Book Review

Lung Volume Reduction Surgery

N Engl J Med 2002; 346:541-542February 14, 2002

Article

Lung Volume Reduction Surgery
Edited by Michael Argenziano and Mark E. Ginsburg. 273 pp., illustrated. Totowa, N.J., Humana Press, 2001. $145. ISBN: 0-89603-848-3

Pulmonary emphysema is a common, progressive, disabling disease that carries a high mortality rate. It occupies one end of the spectrum of chronic obstructive pulmonary disease (COPD), with chronic bronchitis at the other end of the spectrum. Invariably, bronchitic disease is much more responsive to medical management than is emphysema. The inexorable progression of emphysema, accompanied by increasing breathlessness, renders the patient desperate for relief. Over the years, surgeons have responded to the call for help by developing operative procedures for different parts of the respiratory apparatus, including the chest wall, diaphragm, pleura, and nervous system. Although these procedures were justified by their advocates on physiological grounds, none proved to be of lasting benefit.

In 1957, Brantigan and Mueller devised a lung-reduction procedure, which involved the removal of overdistended and presumably nonfunctional areas of the lungs. Although many of their patients did improve subjectively, these investigators provided few objective measurements to substantiate the subjective improvements. Moreover, the early mortality rate was unacceptably high. The operation was abandoned.

In 1993, Cooper — prompted by personal observations during lung transplantation for end-stage COPD and by Brantigan's hypothesis that reduction in lung volume would restore the elastic recoil of the lungs, open the small airways, and improve ventilatory mechanics — undertook to remove 20 to 30 percent of each lung in patients with severe COPD, some of whom were on the waiting list for lung transplantation. In 1995, a report by Cooper and his group described remarkable success with wedge resection of emphysematous lung tissue in 20 patients with severe disease. This report sparked a rush of patients with severe emphysema to see thoracic surgeons. However, surgical outcomes were not as positive. Indeed, in 1996 the Health Care Financing Administration reviewed the large increase in the number of wedge resections for pulmonary emphysema and the accompanying high mortality and concluded that the data on efficacy and risk–benefit ratios were insufficient for reimbursement but adequate for a clinical trial. The Health Care Financing Administration then partnered with the National Institutes of Health to conduct a randomized clinical trial that would assess the safety, efficacy, risk–benefit ratio, and cost effectiveness of the procedure. The National Emphysema Treatment Trial began in 1996. While the trial has been under way, several small series have provided additional evidence that some patients do benefit for years from lung-volume–reduction surgery. However, the selection criteria for this group of patients remain uncertain, as do postoperative survival rates, the advantages of the surgery over medical therapy, and the best surgical technique. The literature is now replete with contradictory reports.

The resulting uncertainty and confusion led Argenziano and Ginsburg to put together a multiauthored book about lung-volume–reduction surgery that would help interested parties evaluate the role of this procedure in the treatment of severe emphysema. The panoramic review provided by this book is divided into two parts. Part 1 deals with the pathogenesis, pathophysiology, and medical management of emphysema and includes a chapter on pulmonary rehabilitation. Part 2 is devoted largely to the surgical aspects of lung-volume–reduction surgery, beginning with the history of surgery for emphysema and proceeding to chapters that deal with open-chest and video-assisted techniques, anesthetic management, postoperative management, and survival. This part of the book is rounded off by a general review of clinical results and trials, a chapter on severe emphysema associated with cancer of the lung, and a comparison of lung-volume–reduction surgery and lung transplantation in the treatment of end-stage emphysema.

The book succeeds in providing an overview of both emphysema and lung-volume–reduction surgery, but the coverage is uneven. Thus, the chapters on radiologic assessment and pulmonary rehabilitation in part 1 are comprehensive and focus on emphysema rather than on COPD. In contrast, the chapter on medical management, which has little to offer about emphysema, focuses on chronic bronchitis, at the other end of the COPD spectrum. The chapters in part 2 that cover the technical aspects of lung-volume–reduction surgery and associated support services provide insight into the team approach required for successful surgery but fall short of defining the optimal surgical approach or the selection criteria that might afford patients the best prospects for long-term survival and improved quality of life.

The editors took on a formidable assignment in attempting to satisfy the needs of the diverse population interested in lung-volume–reduction surgery. Some readers may wish for greater depth, such as in the history of lung-volume–reduction surgery. Others may skip over areas with excess detail and accounts of personal experiences. I would like to have seen a section on pathology that approached the critical issue of homogeneity versus heterogeneity on two fronts: topographic, which would relate the appearance of whole-lung sections to the distribution of emphysema on chest films and computed tomographic scans, and microscopical, which would address the distribution of centrilobular emphysema as compared with panacinar emphysema.

Despite such reservations, however, the book succeeds in delivering what the editors had in mind. It provides a broad perspective on lung-volume–reduction surgery as background for understanding current issues surrounding this procedure and its potential role in the treatment of severe emphysema. There are many unsettled questions, such as criteria for the optimal selection of patients, long-term outcomes of medical as compared with surgical therapy, and the preferred surgical technique. This book sets the stage for viewing and dealing with them. Key players, such as the investigators of the National Emphysema Treatment Trial, are in place. The curtain is about to rise. And, I hope, some of the confusion and ambiguity that prompted the publication of this book is about to be dispelled.

Alfred P. Fishman, M.D.
University of Pennsylvania School of Medicine, Philadelphia, PA 19130
fishmana@mail.med.upenn.edu