LVRS : Chirurgie de réduction du volume pulmonaire. Obtenez un deuxième et un troisième avis

(LVRS) can provide clinical and physiologic improvement for more than 2 years.

True or false?

I am not opposed to surgery. I am just opposed to needless surgery. The article below makes a good case for at least considering LVRS. In cases where  the patient is not able to do any exercises to develop the breathing then there seems no rational choice but to use LVRS as an option. But where the patient is able to receive and perform optimal breathing techniques, exercises and nutrition, which can often improve breathing so well that to make LVRS unnecessary then surgery to me is an inappropriate, potentially life threatening quick fix, and an expensive one at that. 

True or false? Bilateral lung volume reduction surgery (LVRS) can provide clinical and physiologic improvement for more than 2 years.

True. This prospective study demonstrates that following bilateral LVRS for emphysema, durable clinical and significant physiologic improvement was achieved in 9 of 26 patients at 3 years, and in 7 of 26 patients at 4 years. Following targeted bilateral stapled LVRS for emphysema, with and without alpha1-antitrypsin deficiency, variable improvement in relief of dyspnea, exercise tolerance, oxygen use, lung function, and mortality has been noted for 2 years following surgery.[1-6]

Beyond 2 years after LVRS, there is very limited experience. The 2-year post-LVRS results are in contrast to the progressive deterioration in lung function in similar patients originally accepted, but denied LVRS by Medicare and followed for two years or more.[6] Furthermore, historical data of patients with severe expiratory airflow limitation due to emphysema and FEV1 less than 0.75 L or 30% predicted indicates survival of 50% to 60% at 3 years.[7,8] Additionally, patients admitted to an intensive care unit for exacerbation of chronic obstructive pulmonary disease have a 1-year mortality rate of 30% irrespective of the need for endotracheal intubation and mechanical ventilation; in patients more than 65 years old, the mortality rate at 1 year doubles.[9]

The present study prospectively evaluates annual clinical as well as physiologic changes in lung function, including mechanisms of expiratory airflow limitation following LVRS for nonalpha1-antitrypsin emphysema. Findings reveal that the improvement in expiratory airflow and hyperinflation is related to the increase in lung elastic recoil pressure and its secondary effect on increasing small airways diameter.

Source: Gelb AF, McKenna RJ, Brenner M, et al.: Lung function 4 years after lung volume reduction surgery for emphysema. Chest. 1999;116:1608-1615.

From an emphysema client that keeps up to date on LVRS results:

"Thanks for the article. I have been keeping up with the subject by talking to people who have undergone  the operation plus the statistical sheets on it. Seems 1/3 gain, 1/3 even, and 1/3 are worse. All agree it is a big deal and they felt close to death. In two cases the most successful moved to the worst category. All agree the prices are terrible and one year later they are still getting bills. Prices are double the original quote. If you  have plenty of money and are on your death bed ---this operation is OK."  DD

References

1. Seneff MG, Wagner DP, Wagner RP, et al. Hospital and 1 year survival of patients admitted in intensive care units with exacerbation of chronic obstructive pulmonary disease. JAMA. 1995;274:1852-1857.
2. Cassina PC, Teschler H, Konietzko, N, et al. Two-year results after lung volume reduction surgery in alpha1-antitrypsin deficiency versus smoker's emphysema. Eur Respir J. 1998;12:1028-1032.
3. Gelb AF, Brenner M, McKenna RJ Jr, et al. Serial lung function and elastic recoil 2 years after lung volume reduction surgery for emphysema. Chest. 1998;113:1497-1506.
4. Cooper JD, Patterson GA, Sundaresan RS, et al. Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg. 1996;112:1319-1330.
5. Roue C, Mal H, Sleiman C, et al. Lung volume reduction in patients with severe diffuse emphysema: a retrospective study. Chest. 1996;110:28-34.
6. Brenner M, McKenna RJ Jr, Chen JC, et al. Survival following bilateral stapled lung volume reduction surgery for emphysema. Chest. 1999;115:390-396.
7. Meyers BF, Yusen RD, Lefrak SS, et al. Outcome of Medicare patients with emphysema selected for, but denied, a lung volume reduction operation. Ann Thorac Surg. 1998;66:331-336.
8. Anthonisen NR. Prognosis in chronic obstructive pulmonary disease: results from multicenter clinical trials. Am Rev Respir Dis. 1989;140:595-599.
9. Burrows B, Earle RH. Course and prognosis of chronic obstructive lung disease: a prospective study of 200 patients. N Engl J Med. 1969;280:397-404.

Emphysema is a progressively debilitating disease that affects more than 2 million Americans. Typically caused by cigarette smoking, it is the fourth leading cause of death in the country.

Severe emphysema causes the lungs to lose their elasticity and become enlarged up to 150 percent the normal size. Hyper-expanded lungs inhibit the flow of air and put pressure on the diaphragm and rib cage.

During lung volume reduction surgery, doctors remove up to one-third of a patient's lungs -- the diseased areas. This creates more space in the chest cavity for the lungs to expand normally, allowing air to move in and out.

The procedure does not cure emphysema, but, when successful, it improves the quality of life of a severely ill person.

The surgery was first attempted in the 1950s, though it soon was abandoned because of a high mortality rate. Medical advances enabled it to stage a comeback in the 1990s.

Death rate too high?

Last fall, however, an article in the New England Journal of Medicine claimed that for a subset of the patient population, the death rate within 30 days of surgery was unacceptably high -- 16 percent.

The article was based on preliminary results from an ongoing, random, national study involving 1,133 patients. The study, which began in 1996, is the result of an unprecedented partnership between Medicare and the National Institutes of Health. Because most people suffering from emphysema are elderly and because the surgery can cost anywhere from $30,000 to $50,000, Medicare wanted to see if that treatment was an improvement over other medical interventions.

Dr. Thomas Kirby, director of thoracic surgery at University Hospitals, calls the finding on the high death rate a red herring. He claims that the study is flawed and the selection criteria wrong.

All that the preliminary results proved, Kirby says, was that high-risk people fare poorly -- something that doctors already knew.

``The key is selecting the right patients for the surgery,'' he said.

Kirby, who operated on Gilliam, says the study was a way for Medicare to save money.

``It's crafty how they picked one aspect to show the public that they saved them from needless surgery at the hands of medical practitioners,'' he said.

Medicare stopped paying for lung volume reduction surgery when it began the study in 1996.

Today, a patient desiring the surgery enrolls in the national study. The patient is then assigned at random to either the surgery group or the control group, whose members are treated with inhaled bronchodilators, steroids and exercise programs.

If a patient doesn't want to be part of the random study, he or she must pay for the surgery or find a private insurance provider who will. Gilliam's husband, for instance, changed jobs until he found one with insurance that picked up the $50,000 tab for his wife's operation.

Dr. Joel Cooper, a Missouri-based surgeon who revived lung volume reduction surgery in the 1990s, also disputes the study's preliminary finding. He dropped out of the study over the finding and other disagreements.

But Dr. Malcolm DeCamp, a lung surgeon at the Cleveland Clinic, says the preliminary finding has been helpful to him.

``Before, there was no compelling data that said this subset of patients fares so much worse,'' DeCamp said. ``We're beginning to define the boundaries within which this technique will be helpful. Unfortunately, the first inkling of results was cast in a very negative way.''

DeCamp explains that emphysema destroys lungs in different ways. In some patients, a part of the lung balloons out like a beach ball, full of air and no blood flow. The rest of the lung is normal. The surgeon can cut off the damaged part of the lung.

But in other patients, he says, emphysema destroys the lung throughout, so that the diseased organ resembles cotton candy rather than a beach ball. For these patients, the surgery is high-risk, with a 16 percent mortality rate.

The Cleveland Clinic is one of 17 hospitals nationwide and the only one in Northeast Ohio participating in the study. Of the 66 patients in the clinic's trial, half were randomly assigned to the surgery group. Of the 33 surgery patients, two died from post-surgery complications. Neither of the dead patients was from the high-risk subgroup.

Kirby says that patients go through a rigorous battery of tests to find out if they are good candidates for the lung surgery. Seventy-five percent of the people he operates on are on oxygen.

``You have to be very sick to qualify,'' he said. ``We turn down 80 percent of those who apply because they're not sick enough. The benefit for those who are not sick enough doesn't outweigh the risks.''

Kirby has done 160 lung volume reduction surgeries since the mid '90s. He lost two of his first 10 patients. Since then, there have been no deaths.

The clinical trials are expected to end later this year, and DeCamp is looking forward to getting more data by next year.

``It's an incredible treasure trove of data,'' he said. ``We will know more about emphysema than we've ever known before. The trial will allow me to be a better counselor to my patients.

``People are so short of breath that there's a sense of desperation on their part. They are ready to accept risks. But no surgeon wants to have operating deaths. The true question here is about patient safety.''

So far, Gilliam, who used to smoke a pack a day and worked in an aerosol factory, is thrilled with the results of her surgery. Now, more than a year later, she no longer uses an oxygen tank. She can exercise on her treadmill for 30 minutes at a time. She is up to 118 pounds.

She says that Kirby gave her no false hopes about curing her emphysema.

``He didn't say this was a cure,'' she said. ``He was very honest.''

Kirby says nobody knows whether the surgery will increase a patient's life expectancy.

``I don't know if that fact is relevant,'' he said. ``People don't want to live the way they do.''

Gilliam certainly didn't. She says she is 75 percent better than before the surgery.

``He (Kirby) gave me my life back,'' she said. ``It's really turned my life around. I wouldn't be alive today or I'd be lying in bed with an oxygen tank, if not for the surgery.''

Single lung transplant study.
"Study objective: Using the negative expiratory pressure (NEP) method, we have previously shown that patients receiving single lung transplantation (SLT) for COPD do not exhibit expiratory flow limitation and have little dyspnea at rest. In the present study, we assessed whether SLT patients exhibit flow limitation, overall hyperinflation, and dyspnea during exercise.

Conclusion: Most SLT patients for COPD exhibit expiratory flow limitation and dynamic hyperinflation during exercise, whereas maximal dyspnea is variable. (CHEST 2000; 118:1248-1254)"

Develop your breathing rapidly and naturally