A perspective on lung volume reduction surgery for pulmonary emphysema

Emphysema is progressive lung disease characterised by pathological hyperinflation. It results in exercise intolerance, dyspnea, impaired quality of life and high mortality. Medical treatment does not alter the progression of emphysema instead the multi-center national emphysema treatment trial (NETT) demonstrated that lung volume reduction surgery (LVRS) is a successful surgical therapy which improves respiratory function, exercise capacity, and quality of life in selected patients with severe emphysema particularly if associated with upper-lobe predominance and low exercise capacity. The surgical technique has evolved from open surgery towards less invasive procedure as video assisted thoracoscopic surgery (VATS) for lung volume reduction. There remains some debate whether LVRS should be one stage bilateral or staged unilateral surgery and its merit in those without clear target areas or with predominantly lower lobe emphysema. The relative merits of perfusion scintigraphy and chest computerised tomography scan (CT) to identify target areas for resection are also debated. There is, in general, an overestimation of the risks associated with the procedure. Individualised scoring systems may allay such fears. However, because of these considerations of morbidity and cost-effectiveness for LVRS, less invasive techniques have been promoted such as endobronchial valves and endobronchial coils, yet their usage is restricted by collateral ventilation (CV), and variable outcomes. LVRS may be considered as a bridge to or even a realistic alternative to lung transplantation in the absence of significant cardiorespiratory failure but even in the elderly with increased risk.