Original article
General thoracic
An Evidence-Based Estimate on the Size of the Potential Patient Pool for Lung Volume Reduction Surgery

https://doi.org/10.1016/j.athoracsur.2012.03.047Get rights and content

Background

Observational and randomized studies have demonstrated that lung volume reduction surgery (LVRS) improves symptoms, lung function, and survival in selected patients with emphysema. In spite of an approximately 3.8 million patient prevalence of the disease in the US, only 119 LVRS procedures were performed nationwide under Medicare during 2008. In order to obtain evidence-based estimate on the size of the patient pool potentially suitable for LVRS, we analyzed the database from our clinical practice that is representative of a substantial segment of the general emphysema population.

Methods

Our pulmonary function test laboratory database between 1996 and 2006 was searched for patients with stage III and IV global initiative for chronic obstructive lung disease (GOLD) who also had lung volumes and carbon monoxide diffusing capacity data. Patients without available chest computed tomographic scans (CT) or with primary diagnoses other than emphysema were excluded. The resultant emphysema cohort was screened using clinical inclusion and exclusion criteria adopted from the National Emphysema Treatment Trial. A suitable clinical profile combined with CT scan evidence of 40% or greater involvement of the lungs and predominantly upper lobe distribution of emphysema were regarded as favorable markers for LVRS.

Results

Pulmonary function test criteria were met by 959 patients and CT scans were available in 588 patients, but 175 patients were excluded because of primary diagnoses other than emphysema. In the remaining 413 patients, 61 or 15% exhibited favorable clinical profiles and anatomy for LVRS.

Conclusions

In a subset of patients that resembles a substantial segment of the general population with advanced emphysema, up to 15% appeared potential candidates for LVRS. Formation of a task force by relevant medical specialty and patient advocate organizations to address the apparent underutilization of LVRS is recommended.

Section snippets

Materials and Methods

The protocol for this study was approved by the BIDMC Institutional Review Board. The data analyzed were obtained from the PFT laboratory, Online Medical Record, and the Picture Archiving and Communications System (Centricity 2.1, General Electric, Milwaukee, WI) databases.

Results

From the 11-year period under review, 959 patients met GOLD stage III and IV spirometric criteria and had available lung volume as well as diffusion capacity data. From this initial cohort 371 patients were excluded from the study because of lack of stored CT scans, leaving 588 patients with digitally archived chest CT scans. Of these, 175 carried primary diagnoses other than emphysema and were not further studied. The remaining 413 patients with a primary diagnosis of emphysema were screened

Comment

Lung volume reduction surgery underwent one of the most rigorous evaluations of an operative procedure in the history of surgery. The process produced robust evidence that the operation improves symptoms, respiratory physiology, and survival in a clearly identifiable subgroup of patients with advanced emphysema. Data from NETT also suggest that the incidence of COPD exacerbations was reduced after LVRS [18]. Moreover, it has been reported that patients in need of surgery for lung cancer,

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