M Hensley1, J L Coughlan, P Gibson. 1. Discipline of Medicine, The University of Newcastle, Division of Medicine, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Australia, 2310. mdmjhe@mail.newcastle.edu.au
Abstract
BACKGROUND: Lung volume reduction surgery (LVRS) has been re-introduced for treating patients with severe diffuse emphysema. OBJECTIVES: To assemble evidence from randomised controlled trials for the effectiveness of LVRS, and identify optimal surgical techniques, those patients who benefit most and those for whom it should be avoided. SEARCH STRATEGY: Randomised controlled trials were identified using the Cochrane Airways Group COPD register using the terms: emphysema AND (emphysema surgery OR lung volume reduction surgery OR LVRS OR volume reduction surgery OR pneumectomy OR reduction pneumoplasty OR lung reduction surgery). The Cochrane Controlled Clinical Trials Register was also searched using these terms. SELECTION CRITERIA: Randomised controlled trials that studied the safety and efficacy of LVRS in patients with diffuse emphysema were included. Studies were excluded if they investigated giant or bullous emphysema. DATA COLLECTION AND ANALYSIS: Two independent reviewers assessed trials for inclusion and extracted data. MAIN RESULTS: Only one randomised trial of LVRS for diffuse emphysema was identified. This compared stapled unilateral thoracoscopic lung reduction coupled with bovine pericardium reinforcement with a unilateral neodymium:yttrium aluminium garnet laser contact reduction. A total of 72 patients were studied. Both arms included post-operative rehabilitation and appeared to be well matched at randomisation. Improvement in FEV1 & FVC at six months was significantly greater in the staple treated group (p < 0.01 & p < 0. 07 respectively), but absolute increases were small. Need for supplemental oxygen was reduced significantly more in the staple treated group; Peto Odds Ratio (OR) 4.05; 95% confidence interval (CI) 1.40, 11.71. Quality of life improved more in the staple treated group (OR 5.36; 95% CI 2.13,13.47). The rate of delayed pneumothorax in the laser treated group was significantly higher (OR 10.46; 95% CI 1.98, 55.30). REVIEWER'S CONCLUSIONS: There is no randomised controlled trial evidence concerning the efficacy of LVRS for diffuse emphysema compared to optimal conservative medical therapy. Stapling is more effective than laser resection and has a lower complication rate. LVRS should not be applied routinely until results of large trials currently underway become available.
BACKGROUND: Lung volume reduction surgery (LVRS) has been re-introduced for treating patients with severe diffuse emphysema. OBJECTIVES: To assemble evidence from randomised controlled trials for the effectiveness of LVRS, and identify optimal surgical techniques, those patients who benefit most and those for whom it should be avoided. SEARCH STRATEGY: Randomised controlled trials were identified using the Cochrane Airways Group COPD register using the terms: emphysema AND (emphysema surgery OR lung volume reduction surgery OR LVRS OR volume reduction surgery OR pneumectomy OR reduction pneumoplasty OR lung reduction surgery). The Cochrane Controlled Clinical Trials Register was also searched using these terms. SELECTION CRITERIA: Randomised controlled trials that studied the safety and efficacy of LVRS in patients with diffuse emphysema were included. Studies were excluded if they investigated giant or bullous emphysema. DATA COLLECTION AND ANALYSIS: Two independent reviewers assessed trials for inclusion and extracted data. MAIN RESULTS: Only one randomised trial of LVRS for diffuse emphysema was identified. This compared stapled unilateral thoracoscopic lung reduction coupled with bovine pericardium reinforcement with a unilateral neodymium:yttrium aluminium garnet laser contact reduction. A total of 72 patients were studied. Both arms included post-operative rehabilitation and appeared to be well matched at randomisation. Improvement in FEV1 & FVC at six months was significantly greater in the staple treated group (p < 0.01 & p < 0. 07 respectively), but absolute increases were small. Need for supplemental oxygen was reduced significantly more in the staple treated group; Peto Odds Ratio (OR) 4.05; 95% confidence interval (CI) 1.40, 11.71. Quality of life improved more in the staple treated group (OR 5.36; 95% CI 2.13,13.47). The rate of delayed pneumothorax in the laser treated group was significantly higher (OR 10.46; 95% CI 1.98, 55.30). REVIEWER'S CONCLUSIONS: There is no randomised controlled trial evidence concerning the efficacy of LVRS for diffuse emphysema compared to optimal conservative medical therapy. Stapling is more effective than laser resection and has a lower complication rate. LVRS should not be applied routinely until results of large trials currently underway become available.