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Looking into Lung Volume Reduction Surgery

When treating COPD and emphysema, there are medical therapies like inhaled corticosteroids and oxygen treatment; then there is surgical therapy like Lung Volume Reduction Surgery (LVRS). While it is not to say one form of therapy is better that the other, LVRS appears so effective, a group of doctors once wrote it was actually unethical to deprive patients of the procedure during randomized trials.

Within the lungs are many tiny air sacs that expand and contract with each breath. COPD toughens these many air sac walls, making the lungs less receptive to the oxygen exchange in each breath; over time, these air sac walls loss all their elasticity and become toughened beyond treatment. In a cutting of dead weight, LVRS means the removal of irreparably damaged lung tissue. Doctors figure once the damaged tissue is removed, the lungs' airflow will increase, structurally easing the patient's breathing difficulties. Specifically, the tissue amount removed results in a 25%-30% reduction in lung volume.

Depending on the area and extent of lung damage, there are 2 surgical approaches when performing the procedure. On the one hand, there is the more technological (and less invasive) thoracoscopy with its video-assisted feed and its 3-5 small incisions on either side of the chest. On the other hand, there is the median sternotomy, a method beginning with an incision through the breastbone--this approach is used when the upper lobe of the lung is most affected. Once at the lungs, both approaches use a stapler and grasper to remove the damaged tissue and reseal the lungs. Sutures, that will dissolve later, are used to re-seal the incision.

The procedure was first introduced in the 1950's, but considering the technical precision needed to safely remove damaged lung tissue--and just damaged lung tissue--LVRS never became a viable option until the 1990's. Indeed, LVRS has been around long enough to survive the evidence-based reviews examining its efficacy and safety--government sponsored trials, even.

In December 1995, Medicare stopped subsidizing LVRS because there was little evidence on its safety or medical worth. The year after, the National Institute of Health (NIH) began the National Ephysema Treatment Trial (NETT), a 7-year randomized study with 17 clinical sites. The study sought to compare the survival and quality of life for patients who underwent LVRS versus those who did not. Of the 1,218 patients selected from 3,777 prospective patients, 608 were randomly assigned medical therapy plus LVRS and 610 were assigned just medical therapy. The study concluded that LVRS increases exercise capacity but usually doesn't confer a survival advantage any greater than medical therapy. LVRS does bring a survival advantage for patients with upper lobe lung damage and very low exercise capacity. Currently, most private insurance plans cover LVRS and, according to the Columbia University Department of Surgery, Medicare now covers the procedure "with condition."

Like NETT, a 2-year Canadian study has just come to a close. Close to the NETT findings, the study concluded that LVRS safely improves pulmonary functioning, increases the length of a six-minute trial walk and a patient's quality of life, but does not extend mortality. However, the study found that procedure's benefits, "peaked during the first 12 months following surgery and begin to diminish after that time." Interestingly, the principal researcher of the study was involved in the aforementioned paper regarding the ethics of withholding LVRS.

Make no mistake, only certain people are right for the procedure. Indeed, undertaking LVRS is a major decision that requires medical consultation. However, for the right patient, it is good to know that there is another safe and viable option in COPD treatment.