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Lakewood, CA
Los Angeles, CA
Dr. Gelb is Clinical Professor of Medicine, UCLA School of Medicine, and Director, Respiratory Services, Lakewood Regional Medical Center. Dr. McKenna is Clinical Professor of Surgery, UCLA School of Medicine, and Chief, Thoracic Surgery, Cedars-Sinai Medical Center.
Correspondence to: Arthur F. Gelb, MD, FCCP, 3650 E. South St, Suite 308, Lakewood, CA 90712
We were delighted to review the article by Yusen et al in this issue of CHEST (see page 1026), who evaluated 200 consecutive patients who underwent lung volume reduction surgery (LVRS). We previously reviewed the mostly short-term and scant long-term experience following LVRS for emphysema.1 We looked forward to the article by Yusen et al with the enthusiasm usually reserved for attending a smash Broadway show that is completely sold out for 1 year, or dining in a three- or four-star Paris restaurant that is impossible to get reservations. After all, this formidable group is led by Joel D. Cooper, MD, the capo di tutti capo of the LVRS cognoscenti. Also, this is the first peer-reviewed publication that describes their 5-year observational results following LVRS, whereas their 2-year results were published in 1998.2
Needless to say, we were not disappointed. The article describes in great detail the year-by-year impressive clinical and physiologic results in a large cohort of patients, prospectively followed up, undergoing bilateral LVRS for severe emphysema. They evaluated 200 patients 3.7 ± 1.6 years (mean ± SD) after LVRS. Rigid screening criteria emphasized heterogenous anatomic distribution of emphysema with obvious target areas for resection, usually in upper lobes. Additionally, durable physical conditioning and pulmonary rehabilitation prior to surgery was stressed. Those patients selected for LVRS had clinical impairment and physiologic abnormalities similar to patients reported by others.1
All patients underwent sequential, bilateral LVRS using a mediansternotomy incision; 177 patients had upper-lobe-worst emphysema, and 23 patients had lower-lobe-worst emphysema. Incidence of 
1-antitrypsin deficiency was not reported. Patients were restudied at 0.6 months, 3 years, and 5 years after LVRS, and 90% of the evaluable patients completed testing. The 90-day post-LVRS mortality rate was 4.5%, similar to that of previous reports.1
Annual Kaplan-Meier survival rates 1 to 5 years after LVRS were 93%, 88%, 83%, 74%, and 63%. Dyspneic scores were improved 81%, 52%, and 40% at 6 months, 3 years, and 5 years after LVRS; and improvements in quality-of-life questionnaires were 93%, 78%, and 69% at similar time intervals. Compared to baseline values, FEV1 was also significantly improved at 6 months, 3 years, and 5 years after LVRS. Need for supplemental oxygen also improved. The authors noted that changes in residual volume showed poor correlation with change in dyspnea scale and the Medical Outcomes Study Short Form-36 physical function scale score. Results from upper-lobe vs lower-lobe predominant emphysema were not segregated.
We would be most cautious not to overinterpret the significance of the data in Tables 4 and 5 with respect to the percentage of patients improved, and improvement 
12%. While the authors assure us that all pre- and post-LVRS paired tests are statistically significant at the p < 0.001 level, American Thoracic Society criteria for significant bronchodilation when the FEV1 is < 1 L require an absolute increase in FEV1 > 200 mL, not just 12% increase from baseline.3
We4
and Flaherty et al5
have previously used American Thoracic Society criteria to define significant improvement in FEV1 after LVRS. Additionally, we have used the entire cohort for the denominator, and not just evaluable patients, which excludes those patients who have died, or cannot or will not return for testing, or underwent transplantation.
Why are their results so good, especially since lower-lobe-worst emphysema cases were included? Is it because their patients are younger and they have more stringent screening criteria for anticipated surgery, or are they better, more experienced clinicians and surgeons at performing LVRS?
Our previously published 5-year results in older patients,4 which the authors do not cite, and the 3-year data of Flaherty et al5 all seem pale by comparison. The recent long-term data of Bloch et al,6 also not cited, together with their earlier article,7 also emphasized the importance of choosing patients with upper-lobe heterogenous distribution of emphysema. Numerous investigators, including the present group, have also stressed the importance of using quantitative perfusion and CT lung scans to identify potential LVRS candidates with heterogenous distribution of emphysema with upper lobe8 9 10 11 12 13 and especially extent of core-to-rind emphysema.14 15 We have been harping on this for years,16 and again most recently.17 Purists would argue the results reported by Yusen et al must be interpreted with great caution since it was a nonrandomized observational study using patients as their own control. Alternatively, this method may not overestimate the improvement following treatment as compared to randomized trials.18
At first thought, we shudder to think that the forthcoming National Emphysema Treatment Trial results, expected within the next 6 months, will fail to achieve similar results. This may embolden Medicare fiscal visionaries to keep LVRS off the reimbursement plate and relegate it to the same graveyard fate as carotid body resection for relief of dyspnea. "How unfair," the emphysema nonlobby will shout; "treat us like lung cancer patients, who usually live < 3 years following diagnoses and undergo expensive multimodality treatment."
On second thought, if we cannot get it right the first time, let us do a better job the next time and have a second National Emphysema Treatment Trial, with more experienced clinicians and surgeons, younger patients, and stricter screening criteria, and demand that Cooper and his group participate.
References
This article has been cited by other articles:
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  E.W. Russi, K.E. Bloch, and W. Weder Lung volume reduction surgery: what can we learn from the National Emphysema Treatment Trial? Eur. Respir. J., October 1, 2003; 22(4): 571 - 573. [Full Text] [PDF]
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