Surgery - Treating Your Condition: Respiratory Health

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Surgery

Surgeons have several options for treating COPD. But surgery is not for everyone. Ongoing research is providing information about how and when these techniques are best used. The most common types of surgery for this condition are lung volume reduction surgery, bullectomy, and lung transplantation.

Lung volume reduction surgery

This procedure involves surgically removing some areas of the lung damaged by emphysema. The goal is to allow the healthier, more elastic lung tissue to expand and contract more normally and to enable the diaphragm to return to a more normal position, where it can work more effectively.

When this operation was first tried as a treatment for emphysema in the 1950s, many doctors thought it made no sense. What is the use, they wondered, of cutting away damaged parts of one or both lungs? Surprisingly, the surgery helped some patients breathe more easily, but surgeons stopped using it because it caused many complications and deaths.

But since the 1990s, lung volume reduction surgery has made a comeback. Surgeons have modified the operation to make it safer, specifically by closing up the surgical area more tightly to prevent air from leaking out.

This procedure has generated a great deal of interest, and a study of more than 1,200 patients around the country has helped identify who may benefit from the procedure as well as who may end up worse off. The results of the National Emphysema Treatment Trial, published in the New England Journal of Medicine in 2003, showed that the surgery did not increase survival time but did improve exercise tolerance for the overall group of patients. There were some groups for whom the surgery was associated with a higher risk of death compared with drug therapy. One of these high-risk groups consisted of patients with the poorest levels of lung function and disease that was distributed uniformly throughout the lungs. Another high-risk group included patients whose disease was not primarily in the upper regions of the lung and who also had relatively high baseline exercise tolerance. The patients who appeared to benefit most from surgery were those whose disease was predominantly in the upper lobes of the lungs and who also had low baseline exercise tolerance. Although the trial clarified some uncertainties about lung volume reduction surgery, the treatment is still considered somewhat experimental, and the centers that have experience in performing the surgery are mainly large medical centers.

Lung volume reduction surgery can be performed either through an incision several inches long in the chest or with a newer, less invasive procedure called video-assisted thoracoscopy, in which the surgeon makes small incisions on the side of the chest and slips a slender scope and some surgical tools through them. Both procedures require general anesthesia.

Researchers are also investigating new techniques that are not as invasive as lung volume reduction surgery, but still achieve the same goal of reducing the area occupied by damaged lung. Clinical trials are currently under way to see whether one-way valves, stents, or even a type of glue can achieve the same effect.

Bullectomy

This surgery involves removing bullae — large, abnormal air pockets in the lungs that compress and impair the function of the surrounding, healthier lung tissue. The procedure is done infrequently because it is appropriate for very few people with emphysema, who have just one or a few large bullae. People with many small bullae scattered around the lungs are not good candidates for bullectomy, but may benefit from lung volume reduction surgery.

Lung transplantation

This operation is for people with end-stage emphysema who cannot benefit from more conservative surgery. Indeed, about half of all lung transplants are performed on people with emphysema. But because it is such a physically demanding procedure, it can be done only on people who are younger than 60 years old and, therefore, able to withstand the risks. Many candidates for this surgery are people who have A1AT deficiency, as people with this deficiency are more likely to develop severe disease at an earlier age.

Because of the scarcity of organ donors, the preferred technique is a single lung transplant in which the lung with the most diseased tissue is removed and replaced. Some people with A1AT deficiency may need a liver transplant as well, because the disease can also lead to liver damage.

Like all transplant operations, lung transplantation carries a risk of organ rejection, which is the chief cause of complications and death from the procedure. About 8% of patients die from the surgery. But the procedure also has great potential to extend the lives of people with severe emphysema. One year after transplantation, survival rates are 79%, then 61% after three years, and 45% after five years.

Last updated:	May 23, 2007