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Review
, 10 (10), CD001001

Lung Volume Reduction Surgery for Diffuse Emphysema

Affiliations
Review

Lung Volume Reduction Surgery for Diffuse Emphysema

Joseph Em van Agteren et al. Cochrane Database Syst Rev.

Abstract

Background: Lung volume reduction surgery (LVRS) performed to treat patients with severe diffuse emphysema was reintroduced in the nineties. Lung volume reduction surgery aims to resect damaged emphysematous lung tissue, thereby increasing elastic properties of the lung. This treatment is hypothesised to improve long-term daily functioning and quality of life, although it may be costly and may be associated with risks of morbidity and mortality. Ten years have passed since the last version of this review was prepared, prompting us to perform an update.

Objectives: The objective of this review was to gather all available evidence from randomised controlled trials comparing the effectiveness of lung volume reduction surgery (LVRS) versus non-surgical standard therapy in improving health outcomes for patients with severe diffuse emphysema. Secondary objectives included determining which subgroup of patients benefit from LVRS and for which patients LVRS is contraindicated, to establish the postoperative complications of LVRS and its morbidity and mortality, to determine which surgical approaches for LVRS are most effective and to calculate the cost-effectiveness of LVRS.

Search methods: We identified RCTs by using the Cochrane Airways Group Chronic Obstructive Pulmonary Disease (COPD) register, in addition to the online clinical trials registers. Searches are current to April 2016.

Selection criteria: We included RCTs that studied the safety and efficacy of LVRS in participants with diffuse emphysema. We excluded studies that investigated giant or bullous emphysema.

Data collection and analysis: Two independent review authors assessed trials for inclusion and extracted data. When possible, we combined data from more than one study in a meta-analysis using RevMan 5 software.

Main results: We identified two new studies (89 participants) in this updated review. A total of 11 studies (1760 participants) met the entry criteria of the review, one of which accounted for 68% of recruited participants. The quality of evidence ranged from low to moderate owing to an unclear risk of bias across many studies, lack of blinding and low participant numbers for some outcomes. Eight of the studies compared LVRS versus standard medical care, one compared two closure techniques (stapling vs laser ablation), one looked at the effect of buttressing the staple line on the effectiveness of LVRS and one compared traditional 'resectional' LVRS with a non-resectional surgical approach. Participants completed a mandatory course of pulmonary rehabilitation/physical training before the procedure commenced. Short-term mortality was higher for LVRS (odds ratio (OR) 6.16, 95% confidence interval (CI) 3.22 to 11.79; 1489 participants; five studies; moderate-quality evidence) than for control, but long-term mortality favoured LVRS (OR 0.76, 95% CI 0.61 to 0.95; 1280 participants; two studies; moderate-quality evidence). Participants identified post hoc as being at high risk of death from surgery were those with particularly impaired lung function, poor diffusing capacity and/or homogenous emphysema. Participants with upper lobe-predominant emphysema and low baseline exercise capacity showed the most favourable outcomes related to mortality, as investigators reported no significant differences in early mortality between participants treated with LVRS and those in the control group (OR 0.87, 95% CI 0.23 to 3.29; 290 participants; one study), as well as significantly lower mortality at the end of follow-up for LVRS compared with control (OR 0.45, 95% CI 0.26 to 0.78; 290 participants; one study). Trials in this review furthermore provided evidence of low to moderate quality showing that improvements in lung function parameters other than forced expiratory volume in one second (FEV1), quality of life and exercise capacity were more likely with LVRS than with usual follow-up. Adverse events were more common with LVRS than with control, specifically the occurrence of (persistent) air leaks, pulmonary morbidity (e.g. pneumonia) and cardiovascular morbidity. Although LVRS leads to an increase in quality-adjusted life-years (QALYs), the procedure is relatively costly overall.

Authors' conclusions: Lung volume reduction surgery, an effective treatment for selected patients with severe emphysema, may lead to better health status and lung function outcomes, specifically for patients who have upper lobe-predominant emphysema with low exercise capacity, but the procedure is associated with risks of early mortality and adverse events.

Conflict of interest statement

None known.

Figures

Figure 1
Figure 1
Study flow diagram: review update.
Figure 2
Figure 2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Figure 3
Figure 3
Forest plot of comparison: 1 Surgery versus control, outcome: 1.3 Overall mortality (stratified by follow‐up period).
Figure 4
Figure 4
Forest plot of comparison: 1 Surgery versus control, outcome: 1.4 Overall mortality (stratified by risk, to end of follow‐up).
Figure 5
Figure 5
Forest plot of comparison: 1 Surgery versus control, outcome: 1.5 Overall mortality (stratified by subgroup, to end of follow‐up).
Figure 6
Figure 6
Forest plot of comparison: 1 Surgery versus control, outcome: 1.6 Change in SGRQ (end of follow‐up).
Analysis 1.1
Analysis 1.1
Comparison 1 Surgery versus control, Outcome 1 Early mortality (90 days).
Analysis 1.2
Analysis 1.2
Comparison 1 Surgery versus control, Outcome 2 Long‐term mortality (> 36 months).
Analysis 1.3
Analysis 1.3
Comparison 1 Surgery versus control, Outcome 3 Overall mortality (stratified by follow‐up period).
Analysis 1.4
Analysis 1.4
Comparison 1 Surgery versus control, Outcome 4 Overall mortality (stratified by risk, to end of follow‐up).
Analysis 1.5
Analysis 1.5
Comparison 1 Surgery versus control, Outcome 5 Overall mortality (stratified by subgroup, to end of follow‐up).
Analysis 1.6
Analysis 1.6
Comparison 1 Surgery versus control, Outcome 6 Change in SGRQ (end of follow‐up).
Analysis 1.7
Analysis 1.7
Comparison 1 Surgery versus control, Outcome 7 Change in SGRQ (total score, stratified by follow‐up period).
Analysis 1.8
Analysis 1.8
Comparison 1 Surgery versus control, Outcome 8 SGRQ responders (stratified by risk, to end of follow‐up).
Analysis 1.9
Analysis 1.9
Comparison 1 Surgery versus control, Outcome 9 SGRQ responders (stratified by subgroup, to end of follow‐up).
Analysis 1.10
Analysis 1.10
Comparison 1 Surgery versus control, Outcome 10 Difference on SF‐36 (end of follow‐up).
Analysis 1.11
Analysis 1.11
Comparison 1 Surgery versus control, Outcome 11 Walking Distance (Mtrs, end of follow‐up).
Analysis 1.12
Analysis 1.12
Comparison 1 Surgery versus control, Outcome 12 FEV1 (L, end of follow‐up).
Analysis 1.13
Analysis 1.13
Comparison 1 Surgery versus control, Outcome 13 RV (% predicted, end of follow‐up).
Analysis 1.14
Analysis 1.14
Comparison 1 Surgery versus control, Outcome 14 Mean number of emergency‐room visits.
Analysis 1.15
Analysis 1.15
Comparison 1 Surgery versus control, Outcome 15 PA02 (mm Hg, end of follow‐up).
Analysis 1.16
Analysis 1.16
Comparison 1 Surgery versus control, Outcome 16 PAC02 (mm Hg, end of follow‐up).
Analysis 1.17
Analysis 1.17
Comparison 1 Surgery versus control, Outcome 17 TLC (% predicted, end of follow‐up).
Analysis 1.18
Analysis 1.18
Comparison 1 Surgery versus control, Outcome 18 Mean direct medical costs and total healthcare‐related costs according to time after randomisation (USD 000s).

Update of

  • Lung Volume Reduction Surgery for Diffuse Emphysema
    LU Tiong et al. Cochrane Database Syst Rev (4), CD001001. PMID 17054132. - Review
    The evidence summarised in this review is drawn from one large study, and several smaller trials. The findings from the large study indicated that in patients who survive …

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