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• W2036693625 abstract "We were delighted to review the article by Yusen et al in this issue of CHEST (see page 1026), who evaluated 200 consecutive patients who underwent lung volume reduction surgery (LVRS). We previously reviewed the mostly short-term and scant long-term experience following LVRS for emphysema.1Gelb AF McKenna Jr, RJ Brenner M Expanding knowledge of lung volume reduction.Chest. 2001; 119: 1300-1302Abstract Full Text Full Text PDF Scopus (10) Google Scholar We looked forward to the article by Yusen et al with the enthusiasm usually reserved for attending a smash Broadway show that is completely sold out for 1 year, or dining in a three- or four-star Paris restaurant that is impossible to get reservations. After all, this formidable group is led by Joel D. Cooper, MD, the capo di tutti capo of the LVRS cognoscenti. Also, this is the first peer-reviewed publication that describes their 5-year observational results following LVRS, whereas their 2-year results were published in 1998.2Meyers 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: 331-336Abstract Full Text Full Text PDF PubMed Scopus (66) Google ScholarNeedless to say, we were not disappointed. The article describes in great detail the year-by-year impressive clinical and physiologic results in a large cohort of patients, prospectively followed up, undergoing bilateral LVRS for severe emphysema. They evaluated 200 patients 3.7 ± 1.6 years (mean ± SD) after LVRS. Rigid screening criteria emphasized heterogenous anatomic distribution of emphysema with obvious target areas for resection, usually in upper lobes. Additionally, durable physical conditioning and pulmonary rehabilitation prior to surgery was stressed. Those patients selected for LVRS had clinical impairment and physiologic abnormalities similar to patients reported by others.1Gelb AF McKenna Jr, RJ Brenner M Expanding knowledge of lung volume reduction.Chest. 2001; 119: 1300-1302Abstract Full Text Full Text PDF Scopus (10) Google Scholar All patients underwent sequential, bilateral LVRS using a mediansternotomy incision; 177 patients had upper-lobe-worst emphysema, and 23 patients had lower-lobe-worst emphysema. Incidence of α1-antitrypsin deficiency was not reported. Patients were restudied at 0.6 months, 3 years, and 5 years after LVRS, and 90% of the evaluable patients completed testing. The 90-day post-LVRS mortality rate was 4.5%, similar to that of previous reports.1Gelb AF McKenna Jr, RJ Brenner M Expanding knowledge of lung volume reduction.Chest. 2001; 119: 1300-1302Abstract Full Text Full Text PDF Scopus (10) Google Scholar Annual Kaplan-Meier survival rates 1 to 5 years after LVRS were 93%, 88%, 83%, 74%, and 63%. Dyspneic scores were improved 81%, 52%, and 40% at 6 months, 3 years, and 5 years after LVRS; and improvements in quality-of-life questionnaires were 93%, 78%, and 69% at similar time intervals. Compared to baseline values, FEV1 was also significantly improved at 6 months, 3 years, and 5 years after LVRS. Need for supplemental oxygen also improved. The authors noted that changes in residual volume showed poor correlation with change in dyspnea scale and the Medical Outcomes Study Short Form-36 physical function scale score. Results from upper-lobe vs lower-lobe predominant emphysema were not segregated.We would be most cautious not to overinterpret the significance of the data in Tables 4 and 5 with respect to the percentage of patients improved, and improvement ≥ 12%. While the authors assure us that all pre- and post-LVRS paired tests are statistically significant at the p < 0.001 level, American Thoracic Society criteria for significant bronchodilation when the FEV1 is < 1 L require an absolute increase in FEV1 > 200 mL, not just 12% increase from baseline.3American Thoracic Society Lung function testing: selection of reference values and interpretative strategies.Am Rev Respir Dis. 1991; 144: 1202-1218Crossref PubMed Scopus (2562) Google Scholar We4Gelb AF McKenna Jr, RJ Brenner M et al.Lung function 5 years after lung volume reduction surgery for emphysema.Am J Respir Crit Care Med. 2001; 163: 1562-1566Crossref PubMed Scopus (97) Google Scholar and Flaherty et al5Flaherty K Kazerooni EA Curtis JL et al.Short-term and long-term outcome after bilateral lung volume reduction surgery: prediction by quantitative computed-tomography.Chest. 2001; 119: 1337-1346Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar have previously used American Thoracic Society criteria to define significant improvement in FEV1 after LVRS. Additionally, we have used the entire cohort for the denominator, and not just evaluable patients, which excludes those patients who have died, or cannot or will not return for testing, or underwent transplantation.Why are their results so good, especially since lower-lobe-worst emphysema cases were included? Is it because their patients are younger and they have more stringent screening criteria for anticipated surgery, or are they better, more experienced clinicians and surgeons at performing LVRS?Our previously published 5-year results in older patients,4Gelb AF McKenna Jr, RJ Brenner M et al.Lung function 5 years after lung volume reduction surgery for emphysema.Am J Respir Crit Care Med. 2001; 163: 1562-1566Crossref PubMed Scopus (97) Google Scholar which the authors do not cite, and the 3-year data of Flaherty et al5Flaherty K Kazerooni EA Curtis JL et al.Short-term and long-term outcome after bilateral lung volume reduction surgery: prediction by quantitative computed-tomography.Chest. 2001; 119: 1337-1346Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar all seem pale by comparison. The recent long-term data of Bloch et al,6Bloch KE Georgescu C Russi EW et al.Gain and subsequent loss of lung function after lung volume reduction surgery in cases of severe emphysema with different morphologic patterns.J Thorac Cardiovasc Surg. 2002; 123: 845-854Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar also not cited, together with their earlier article,7Hamacher J Bloch KE Stammberger U et al.Two years' outcome of lung volume reduction surgery in different morphologic emphysema types.Ann Thorac Surg. 1999; 68: 1792-1798Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar also emphasized the importance of choosing patients with upper-lobe heterogenous distribution of emphysema. Numerous investigators, including the present group, have also stressed the importance of using quantitative perfusion and CT lung scans to identify potential LVRS candidates with heterogenous distribution of emphysema with upper lobe8Becker MD Berkmen YM Austin JH et al.Lung volumes before and after lung volume reduction surgery: quantitative CT analysis.Am J Respir Crit Care Med. 1998; 157: 1593-1599Crossref PubMed Scopus (65) Google Scholar9Slone RM Pilgram TK Gierada DS et al.Lung volume reduction surgery: comparison of preoperative radiologic features and clinical outcome.Radiology. 1997; 204: 685-693Crossref PubMed Scopus (83) Google Scholar10Kotloff RM Hansen-Flaschen J Lipson D et al.Apical perfusion fraction as a predictor of short-term functional outcome following bilateral lung volume reduction surgery.Chest. 2001; 120: 1609-1615Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar11Maki DD Miller Jr, WT Aronchick JM et al.Advanced emphysema: preoperative chest radiographic findings as predictors of outcome following lung volume reduction surgery.Radiology. 1999; 212: 49-55Crossref PubMed Scopus (26) Google Scholar12Jamadar DA Kazerooni EA Martinez FJ et al.Semi-quantitative ventilation/perfusion scintigraphy and single-photon emission tomography for evaluation of lung volume reduction surgery candidates: description and prediction of clinical outcome.Eur J Nucl Med. 1999; 26: 734-742Crossref PubMed Scopus (48) Google Scholar13Gierada DS Yusen RD Villanueva IA et al.Patient selection for lung volume reduction surgery: an objective model based on prior clinical decisions and quantitative CT analysis.Chest. 2000; 117: 991-998Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar and especially extent of core-to-rind emphysema.14Rogers RM Coxson HO Sciurba FC et al.Preoperative severity of emphysema predictive of improvement after lung volume reduction surgery: use of CT morphometry.Chest. 2000; 118: 1240-1247Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar15Nakano Y Coxson HO Bosan S et al.Core to rind distribution of severe emphysema predicts outcome of lung volume reduction surgery.Am J Respir Crit Care Med. 2001; 164: 2195-2199Crossref PubMed Scopus (76) Google Scholar We have been harping on this for years,16McKenna Jr, RJ Brenner M Fischel RJ et al.Patient selection criteria for lung volume reduction surgery.J Thorac Cardiovasc Surg. 1997; 114: 957-964Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar and again most recently.17Gelb AF McKenna Jr, RJ Lung volume reduction surgery for emphysema: the pros and cons.J Respir Dis. 2002; 23: 475-481Google Scholar Purists would argue the results reported by Yusen et al must be interpreted with great caution since it was a nonrandomized observational study using patients as their own control. Alternatively, this method may not overestimate the improvement following treatment as compared to randomized trials.18Corcato J Shah N Horowitz RI Randomized, controlled trials, observational studies, and the hierarchy of research designs.N Engl J Med. 2000; 342: 1887-1892Crossref PubMed Scopus (2635) Google ScholarAt first thought, we shudder to think that the forthcoming National Emphysema Treatment Trial results, expected within the next 6 months, will fail to achieve similar results. This may embolden Medicare fiscal visionaries to keep LVRS off the reimbursement plate and relegate it to the same graveyard fate as carotid body resection for relief of dyspnea. “How unfair,” the emphysema nonlobby will shout; “treat us like lung cancer patients, who usually live < 3 years following diagnoses and undergo expensive multimodality treatment.”On second thought, if we cannot get it right the first time, let us do a better job the next time and have a second National Emphysema Treatment Trial, with more experienced clinicians and surgeons, younger patients, and stricter screening criteria, and demand that Cooper and his group participate. We were delighted to review the article by Yusen et al in this issue of CHEST (see page 1026), who evaluated 200 consecutive patients who underwent lung volume reduction surgery (LVRS). We previously reviewed the mostly short-term and scant long-term experience following LVRS for emphysema.1Gelb AF McKenna Jr, RJ Brenner M Expanding knowledge of lung volume reduction.Chest. 2001; 119: 1300-1302Abstract Full Text Full Text PDF Scopus (10) Google Scholar We looked forward to the article by Yusen et al with the enthusiasm usually reserved for attending a smash Broadway show that is completely sold out for 1 year, or dining in a three- or four-star Paris restaurant that is impossible to get reservations. After all, this formidable group is led by Joel D. Cooper, MD, the capo di tutti capo of the LVRS cognoscenti. Also, this is the first peer-reviewed publication that describes their 5-year observational results following LVRS, whereas their 2-year results were published in 1998.2Meyers 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: 331-336Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar Needless to say, we were not disappointed. The article describes in great detail the year-by-year impressive clinical and physiologic results in a large cohort of patients, prospectively followed up, undergoing bilateral LVRS for severe emphysema. They evaluated 200 patients 3.7 ± 1.6 years (mean ± SD) after LVRS. Rigid screening criteria emphasized heterogenous anatomic distribution of emphysema with obvious target areas for resection, usually in upper lobes. Additionally, durable physical conditioning and pulmonary rehabilitation prior to surgery was stressed. Those patients selected for LVRS had clinical impairment and physiologic abnormalities similar to patients reported by others.1Gelb AF McKenna Jr, RJ Brenner M Expanding knowledge of lung volume reduction.Chest. 2001; 119: 1300-1302Abstract Full Text Full Text PDF Scopus (10) Google Scholar All patients underwent sequential, bilateral LVRS using a mediansternotomy incision; 177 patients had upper-lobe-worst emphysema, and 23 patients had lower-lobe-worst emphysema. Incidence of α1-antitrypsin deficiency was not reported. Patients were restudied at 0.6 months, 3 years, and 5 years after LVRS, and 90% of the evaluable patients completed testing. The 90-day post-LVRS mortality rate was 4.5%, similar to that of previous reports.1Gelb AF McKenna Jr, RJ Brenner M Expanding knowledge of lung volume reduction.Chest. 2001; 119: 1300-1302Abstract Full Text Full Text PDF Scopus (10) Google Scholar Annual Kaplan-Meier survival rates 1 to 5 years after LVRS were 93%, 88%, 83%, 74%, and 63%. Dyspneic scores were improved 81%, 52%, and 40% at 6 months, 3 years, and 5 years after LVRS; and improvements in quality-of-life questionnaires were 93%, 78%, and 69% at similar time intervals. Compared to baseline values, FEV1 was also significantly improved at 6 months, 3 years, and 5 years after LVRS. Need for supplemental oxygen also improved. The authors noted that changes in residual volume showed poor correlation with change in dyspnea scale and the Medical Outcomes Study Short Form-36 physical function scale score. Results from upper-lobe vs lower-lobe predominant emphysema were not segregated. We would be most cautious not to overinterpret the significance of the data in Tables 4 and 5 with respect to the percentage of patients improved, and improvement ≥ 12%. While the authors assure us that all pre- and post-LVRS paired tests are statistically significant at the p < 0.001 level, American Thoracic Society criteria for significant bronchodilation when the FEV1 is < 1 L require an absolute increase in FEV1 > 200 mL, not just 12% increase from baseline.3American Thoracic Society Lung function testing: selection of reference values and interpretative strategies.Am Rev Respir Dis. 1991; 144: 1202-1218Crossref PubMed Scopus (2562) Google Scholar We4Gelb AF McKenna Jr, RJ Brenner M et al.Lung function 5 years after lung volume reduction surgery for emphysema.Am J Respir Crit Care Med. 2001; 163: 1562-1566Crossref PubMed Scopus (97) Google Scholar and Flaherty et al5Flaherty K Kazerooni EA Curtis JL et al.Short-term and long-term outcome after bilateral lung volume reduction surgery: prediction by quantitative computed-tomography.Chest. 2001; 119: 1337-1346Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar have previously used American Thoracic Society criteria to define significant improvement in FEV1 after LVRS. Additionally, we have used the entire cohort for the denominator, and not just evaluable patients, which excludes those patients who have died, or cannot or will not return for testing, or underwent transplantation. Why are their results so good, especially since lower-lobe-worst emphysema cases were included? Is it because their patients are younger and they have more stringent screening criteria for anticipated surgery, or are they better, more experienced clinicians and surgeons at performing LVRS? Our previously published 5-year results in older patients,4Gelb AF McKenna Jr, RJ Brenner M et al.Lung function 5 years after lung volume reduction surgery for emphysema.Am J Respir Crit Care Med. 2001; 163: 1562-1566Crossref PubMed Scopus (97) Google Scholar which the authors do not cite, and the 3-year data of Flaherty et al5Flaherty K Kazerooni EA Curtis JL et al.Short-term and long-term outcome after bilateral lung volume reduction surgery: prediction by quantitative computed-tomography.Chest. 2001; 119: 1337-1346Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar all seem pale by comparison. The recent long-term data of Bloch et al,6Bloch KE Georgescu C Russi EW et al.Gain and subsequent loss of lung function after lung volume reduction surgery in cases of severe emphysema with different morphologic patterns.J Thorac Cardiovasc Surg. 2002; 123: 845-854Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar also not cited, together with their earlier article,7Hamacher J Bloch KE Stammberger U et al.Two years' outcome of lung volume reduction surgery in different morphologic emphysema types.Ann Thorac Surg. 1999; 68: 1792-1798Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar also emphasized the importance of choosing patients with upper-lobe heterogenous distribution of emphysema. Numerous investigators, including the present group, have also stressed the importance of using quantitative perfusion and CT lung scans to identify potential LVRS candidates with heterogenous distribution of emphysema with upper lobe8Becker MD Berkmen YM Austin JH et al.Lung volumes before and after lung volume reduction surgery: quantitative CT analysis.Am J Respir Crit Care Med. 1998; 157: 1593-1599Crossref PubMed Scopus (65) Google Scholar9Slone RM Pilgram TK Gierada DS et al.Lung volume reduction surgery: comparison of preoperative radiologic features and clinical outcome.Radiology. 1997; 204: 685-693Crossref PubMed Scopus (83) Google Scholar10Kotloff RM Hansen-Flaschen J Lipson D et al.Apical perfusion fraction as a predictor of short-term functional outcome following bilateral lung volume reduction surgery.Chest. 2001; 120: 1609-1615Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar11Maki DD Miller Jr, WT Aronchick JM et al.Advanced emphysema: preoperative chest radiographic findings as predictors of outcome following lung volume reduction surgery.Radiology. 1999; 212: 49-55Crossref PubMed Scopus (26) Google Scholar12Jamadar DA Kazerooni EA Martinez FJ et al.Semi-quantitative ventilation/perfusion scintigraphy and single-photon emission tomography for evaluation of lung volume reduction surgery candidates: description and prediction of clinical outcome.Eur J Nucl Med. 1999; 26: 734-742Crossref PubMed Scopus (48) Google Scholar13Gierada DS Yusen RD Villanueva IA et al.Patient selection for lung volume reduction surgery: an objective model based on prior clinical decisions and quantitative CT analysis.Chest. 2000; 117: 991-998Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar and especially extent of core-to-rind emphysema.14Rogers RM Coxson HO Sciurba FC et al.Preoperative severity of emphysema predictive of improvement after lung volume reduction surgery: use of CT morphometry.Chest. 2000; 118: 1240-1247Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar15Nakano Y Coxson HO Bosan S et al.Core to rind distribution of severe emphysema predicts outcome of lung volume reduction surgery.Am J Respir Crit Care Med. 2001; 164: 2195-2199Crossref PubMed Scopus (76) Google Scholar We have been harping on this for years,16McKenna Jr, RJ Brenner M Fischel RJ et al.Patient selection criteria for lung volume reduction surgery.J Thorac Cardiovasc Surg. 1997; 114: 957-964Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar and again most recently.17Gelb AF McKenna Jr, RJ Lung volume reduction surgery for emphysema: the pros and cons.J Respir Dis. 2002; 23: 475-481Google Scholar Purists would argue the results reported by Yusen et al must be interpreted with great caution since it was a nonrandomized observational study using patients as their own control. Alternatively, this method may not overestimate the improvement following treatment as compared to randomized trials.18Corcato J Shah N Horowitz RI Randomized, controlled trials, observational studies, and the hierarchy of research designs.N Engl J Med. 2000; 342: 1887-1892Crossref PubMed Scopus (2635) Google Scholar At first thought, we shudder to think that the forthcoming National Emphysema Treatment Trial results, expected within the next 6 months, will fail to achieve similar results. This may embolden Medicare fiscal visionaries to keep LVRS off the reimbursement plate and relegate it to the same graveyard fate as carotid body resection for relief of dyspnea. “How unfair,” the emphysema nonlobby will shout; “treat us like lung cancer patients, who usually live < 3 years following diagnoses and undergo expensive multimodality treatment.” On second thought, if we cannot get it right the first time, let us do a better job the next time and have a second National Emphysema Treatment Trial, with more experienced clinicians and surgeons, younger patients, and stricter screening criteria, and demand that Cooper and his group participate." @default.
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