Lung Volume Reduction Surgery for Patients with Emphysema
More than 12 million Americans suffer from chronic obstructive pulmonary (lung) disease (COPD). Currently COPD is the third leading cause of death in the United States, and also causes long-term disability. Emphysema, a form of COPD, is a progressive disease most often associated with smoking.
Thoracic surgeons at the University of Wisconsin Hospital and Clinics offer treatment and hope to some patients with severe emphysema through Lung Volume Reduction Surgery (LVRS), one of the few treatment options available for these patients.
Many people who suffer from emphysema have some portions of their lungs that are more affected than others.
During LVRS, surgeons remove small pieces of damaged lung tissue (about 20 to 30 percent in each lung), thereby reducing the lung size and allowing the remaining lung and surrounding muscles to work more efficiently. While LVRS does not cure emphysema, it can improve breathing, overall quality of life and provide an alternative to lung transplantation for appropriate candidates.
UW Health surgeons have been performing LVRS with good to excellent results for the past ten years, making UW Hospital one of the highest volume centers for LVRS nationally. James Maloney, MD, a UW Health thoracic surgeon explains, "LVRS is not widely performed because a patient must meet a very specific set of requirements to be eligible, and it is extremely important it is offered to patients who are most likely to benefit from surgery and are at lower risk for complications."
Who is a candidate for LVRS?
Effectiveness of LVRS depends on the location or size of the diseased lung tissue as well as the patient's ability to exercise and survive surgery. Generally patients who are good candidates for LVRS are:
- Younger than 75 years old
- Have stopped smoking for six months or longer
- Have severe shortness of breath even after medical management
A series of tests is performed to determine if a patient is a candidate for LVRS. These tests include: chest X-ray, pulmonary function tests, arterial blood gas, high resolution CT scan, oxygen titration, six-minute walk, cardiopulmonary exercise test, cardiac stress test and lung perfusion scan.
Prior to surgery, patients must complete 12 weeks of pulmonary rehabilitation, and then another six weeks after surgery. Components of rehabilitation include an assessment phase, training phase which includes exercise and evaluation as well as the development and achievement of personal goals for nutrition, smoking cessation, physical activity, weight loss and stress reduction and a follow-up phase.
How is LVRS performed?
There are three approaches for performing LVRS. According to Dr. Maloney, "There are no studies that have demonstrated an advantage of one particular approach in terms of length of stay or other outcomes." The minimally invasive approach does seem to get patients back to the previous level of activity, including pulmonary rehabilitation, more quickly. As bilateral volume reduction is preferred, the process is then repeated on the contralateral side. There are some patients who have unilateral LVRS or the procedures are staged with time in between.
- Video-Assisted Thoracoscopy: The minimally invasive video-assisted Thorascoscopy (VATS) is the preferred LVRS procedure at our institution. A VATS procedure uses three or four small incisions (1-2 cm) made on both sides of the chest, between the ribs. A small camera is placed through one of the incisions to allow the surgeon to see the lungs. A stapler and grasper are then inserted into the other incisions to remove the most damaged area of the lung.
- Thoracotomy: In this approach, the surgeon makes a larger incision (5-12 inches long) between the ribs. Ribs are separated (not broken) so the surgeon can view the lungs. If both lungs require surgery, two incisions are made.
- Median Sternotomy: In this approach a midline incision is made in the front of the chest. The sternum is divided to expose the lung cavities. Both sides can be addressed with this approach through one incision.
Recovery for LVRS
Time for recovery will vary between patients. Though many see an immediate change, the ultimate benefit might not be seen for three months, as measured by pulmonary function testing.
Ultimately, patients who experience success with the LVRS procedure and rehabilitation will have reduced symptoms, greater tolerance for exercise and ability to complete daily activities, improved quality of life and reduced health care costs. Long term follow-up of the NETT showed that five year survival was improved in appropriately selected patients undergoing surgery as compared to a matched group medically managed.
The number of volume reduction surgeries is limited as they must be performed in CMS or transplant approved programs. Across the country, only approximately 118 LVRS procedures were performed last year, with 10 of them occurring locally in Madison. "Though LVRS is not for all emphysema patients," says Maloney, "we see good to excellent results in 80 to 85 percent of the patients who do receive the procedure."