Lung volume reduction surgery (LVRS) for chronic obstructive pulmonary disease (COPD) with underlying severe emphysema

Abstract

Background-Lung volume reduction surgery (LVRS) has recently re-emerged as a surgical option for the treatment of end stage chronic obstructive pulmonary disease (COPD) due to underlying severe emphysema. Advocates of LVRS claim that it represents a significant breakthrough in the management of this challenging group of patients while sceptics point to uncertainty about the eVectiveness of the operation. Methods-A systematic review was conducted of the evidence on the eVects of LVRS in patients with end stage COPD secondary to severe emphysema. Results-The most rigorous evidence on the eVectiveness of LVRS came from case series. Seventy five potentially relevant studies were identified and 19 individual series met the methodological criteria for inclusion. The pattern of results was consistent across individual studies despite a significant degree of clinical heterogeneity. Significant short term benefits occurred across a range of outcomes which appeared to continue into the longer term. Physiological improvements were matched by functional and subjective improvements. Early mortality rates were low and late mortality rates compared favourably with those of the general COPD population. However, the entire research base for the intervention is subject to the limitations of study designs without parallel control groups.Conclusions-LVRS appears to represent a promising option in the management of patients with severe end stage emphysema. However, until the results of ongoing clinical trials are available, the considerable uncertainty that exists around the eVectiveness and cost eVectiveness of the procedure will remain.

Outcomes for COPD pharmacological trials: from lung function to biomarkers

“…This test is now used as a standardised outcome measure in studies of treatment of pulmonary hypertension and has been applied to patients with congestive cardiac failure. Multiple studies also confirm that treatment with lung volume reduction surgery [234,235], rehabilitation [236], oxygen during exercise [237] and a range of bronchodilator drugs [27,238] improve this outcome significantly. As with exercise testing, the walking test is not recommended to be performed during exacerbations of COPD or when the patient has another serious comorbidity.…”

Lung volume reduction surgery versus conservative treatment in severe emphysema

“…A number of studies have been published supporting the assumption of COOPER et al [10] that LVRS offers benefits not achievable by optimal conservative treatment for highly selected patients with severe emphysema. Additionally, the results of these studies have been evaluated in recent reviews [11,27], indicating that significant short-term benefits occurred across a range of outcomes which appeared to continue into the longer term. However, data comparing LVRS to optimal conservative treatment will be lacking [11] until the results of the ongoing National Emphysema Treatment Trial (NETT) [30] are available.…”

“…Additionally, the results of these studies have been evaluated in recent reviews [11,27], indicating that significant short-term benefits occurred across a range of outcomes which appeared to continue into the longer term. However, data comparing LVRS to optimal conservative treatment will be lacking [11] until the results of the ongoing National Emphysema Treatment Trial (NETT) [30] are available. A retrospective study has been published comparing 22 LVRS candidates denied operation because of withdrawal of Medicare funding with 65 LVRS recipients [31].…”

Not only randomized controlled trials, but also case series should be considered in systematic reviews of rapidly developing technologies

“…Quality assessment of case series was based on criteria used in two previous systematic reviews that included case series [10,11], together with published guidance [12]. We developed a list of eight quality items (Table 1) addressing both quality of reporting and risk of bias (principally selection and attrition bias).…”