Lung surgery benefits emphysema patients for several years

A procedure known as lung-volume reduction surgery (LVRS) appears to improve overall health and quality of life for individuals with end-stage emphysema, and these effects last as long as five years in more than half of this population, according to researchers at Washington University School of Medicine in St. Louis.

The findings appear in the March issue of the Journal of Thoracic and Cardiovascular Surgery. The procedure was developed at the School of Medicine in 1993 by the study’s principal investigator, Joel D. Cooper, M.D., the Evarts A. Graham Professor of Surgery and head of the Division of Cardiothoracic Surgery.

“Evidence of the success of this surgery in patients with severe emphysema is overwhelming, and these latest findings confirm and underscore its potential for treating this critically ill population,” Cooper says. “This publication represents a major, interdisciplinary team effort, which depended on expertise from a variety of areas, including pulmonary medicine, anesthesiology and nurse coordination.”

Emphysema is characterized by destruction and overinflation of the lungs. As the lungs become progressively bloated, they fill the chest cavity and thorax, making it difficult to expand and contract during normal breathing. The disease relentlessly progresses and is responsible for close to 17,000 deaths each year in the United States, according to the National Center for Health Statistics.

In select patients, LVRS provides an alternative to lung transplantation, which until recently was the only option for patients with end-stage lung disease that cannot be controlled with drugs. By removing the most diseased portions of the lung, the procedure provides the lungs with more room to expand within the chest cavity.

Though LVRS is not a cure for emphysema, studies suggest that the surgery increases breathing capacity by more than 50 percent. Such improvements allow otherwise debilitated individuals to resume many normal, daily activities, including moderate exercise. This current study is the first to examine the long-term endurance of patients following surgery.

The research team maintained a detailed database of lung function and quality-of-life assessments for the first 250 patients who underwent LVRS at Washington University’s clinical affiliate, Barnes-Jewish Hospital, between January 1993 and June 2000. Follow-up evaluations were performed six months and one year after surgery and again each year afterward. Patients were followed for an average of 4.8 years.

All participants first were enrolled in a rehabilitation program for about three months prior to surgery and were given medical and dietary programs to make sure they were as healthy as possible for the operation. They also remained on fitness and medical regimens after surgery.

At the conclusion of the study, more than 60 percent of the 250 patients were still alive, and only 18 patients had received a lung transplant since undergoing LVRS. Without surgery, it is estimated that half of the 250 patients would have died within three years and that those still alive after five years would have significantly deteriorated.

Overall, the surviving LVRS patients still had measurable improvements in lung function after five years. For example, patients were tested to see how much air they could blow out in one second, a measurement known as forced expiratory volume. Six months after surgery, 95 percent of patients had improved on this test by an average of 54 percent. After five years, 53 percent of patients still had better scores than before surgery, though they were only 7 percent better.

The team also measured the amount of air left in the lungs after a deep exhale, a value called residual volume. People with healthy lungs have low residual-volume scores because very little air remains in the chest cavity after breathing out. Evaluations six months and one year after surgery revealed that 90 percent of participants had improved residual-volume scores, and that residual-volume values declined an average of 30 percent. After five years, 79 percent still had better residual-volume scores than before surgery, and the average improvement was 14 percent better than pre-surgery scores.

Quality-of-life assessments also were positive: Almost 80 percent of patients still reported better quality-of-life scores five years after surgery than before surgery.

“This procedure is not a cure for emphysema,” Cooper emphasizes. “No matter how successful the operation, emphysema continues to degrade the lungs and progressively impairs breathing. However, our results confirm that LVRS can in fact extend patients’ lives and allow them to continue participating in normal activities of daily living.”

Determining selection criteria is one of the most controversial issues in measuring the effectiveness of LVRS. Cooper’s team therefore analyzed data from patients with potential risk factors. They found that individuals who required surgery to the lower portion of the lungs benefited from the procedure, but their lung function degraded faster than in individuals with damage to the upper portion of the lungs. Other identified risk factors include advanced age, male gender and very low forced expiratory volume.

“We strongly believe that patient selection is one of the keys to success for this procedure,” Cooper says. “With rigorous preoperative preparation and stringent participation criteria, lung-volume reduction surgery appears to improve life expectancy and quality of life for patients who otherwise have very poor prognoses.”