Lung volume reduction surgery for adults with diffuse emphysema

Review question

Does lung volume reduction surgery improve lung function and quality of life, without leading to an increased chance of death, higher rates of illness after the procedure and higher costs for patients with severe emphysema, and which surgical methods lead to the best results in these patients?

Background

Emphysema causes severe damage to the lungs, which leads to breathing problems. Lung volume reduction surgery (LVRS) may help improve symptoms by removing the most diseased and non-functioning parts of the lung. However, this procedure has been the centre of much controversy with its possible benefit being outweighed by potential harms and costs.

Study characteristics

This review examined the research published up to the 14th of April, 2016, and identified 11 studies involving 1760 participants. 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 a traditional approach to LVRS with a 'non-resectional' surgical approach. All participants completed a mandatory course of pulmonary rehabilitation/physical training before the procedure commenced.

Key results

This review found that people undergoing LVRS were at increased risk of death at three months after the procedure. By the end of follow-up, death rates were lower for participants treated with LVRS than for those given standard medical care. Participants who were characterised by poor lung function with a particular distribution of diseased tissue in their lungs were at higher risk of death at three months and throughout one large study. One study identified a group of participants who responded better to LVRS than other participants, making them especially suitable for this treatment. The benefit of surgery for surviving participants was significant in terms of quality of life, exercise capacity and lung function, but costs of the procedure are relatively high, and patients had a greater chance of adverse events after the procedure.

Quality of the evidence

The quality of the data reported is low to moderate in nature owing to some methodological issues of the trials (lack of blinding, unclear risk of bias). The results presented in this review are largely dominated by one influential study, which accounted for 68% of the participants.

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.

Read the full 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 strategy: 

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.

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