PERFORMING LUNG VOLUME REDUCTION SURGERY: New Treatment for Severe Emphysema
Facing a national shortage of donor lungs for transplantation, many people with end-stage emphysema need alternative treatments not only to breathe easier but to live longer. Lung volume reduction surgery (reduction pneumoplasty) is a promising new operation for this severe emphysema that has been shown to provide significant improvement in lung function, and it may offer patients with advanced pulmonary disease an alternative to lung transplantation.
Stony Brook's University Hospital is the only hospital in Suffolk County that performs lung volume reduction surgery. As of August 1998, Dr. Thomas V. Bilfinger, chief of the thoracic section of our cardiothoracic surgery service, has done 30 such procedures with overall good results, and he continues to evaluate patients with emphysema for this surgery, despite the current policy of the Health Care Financing Administration which does not allow payment for it by Medicare.
An estimated 14 million people in the United States have chronic obstructive pulmonary disease (COPD), in many cases due to emphysema. Chronic bronchitis or asthma also may cause air-flow obstructions in the lungs that characterize COPD.
Emphysema is a disease that enlarges the air sacs (alveoli) in the lung, making it difficult to expel air. Emphysema-enlarged lungs further reduce breathing efficiency by interfering with the ability of the diaphragm muscle to help move air through the lungs. Smoking is the leading cause of emphysema.
In end-stage emphysema, the lungs are also less efficient at exchanging oxygen and carbon dioxide. Inhalers and other therapies no longer give much relief. Until recently, only lung transplantation offered a significant opportunity to improve respiratory function.
But the shortage of donor lungs makes transplantation impossible for most people who could benefit from it. Furthermore, not everyone with end-stage emphysema is a good candidate for a transplant. As a result, there is an ongoing search for alternatives.
The Operation Itself
Recently, advances in surgical technology and techniques have enabled surgeons to pursue the use of lung volume reduction, which was introduced in the 1950s, though results at that time were not satisfactory. Now the procedure is done using either a standard open incision or minimally-invasive approach called "videoscopic" surgery.
In volume reduction, a portion of the diseased lung is removed, and the lung is resealed using a surgical stapling device. The procedure reduces lung volume by 20% to 30%. In many cases, a strip of tissue such as bovine pericardium (the sac surrounding a cow’s heart) or other synthetic material is attached to the lung along the staple line to help prevent air leaks from the site of excision.
One would think that reducing the volume of the lung would make breathing harder. But for some people, less is more. Preliminary results for some patients show improved breathing mechanics, increased efficiency in exchanging oxygen and carbon dioxide, and significantly greater volumes of exhaled air.
Most important, some patients experience improvement in their overall condition, including:
n Less shortness of breath.
n Improved ability to be more active, including exercise.
n Reduced need for supplemental oxygen.
Other patients, however, experience little or no improvement after the procedure. Studies are currently underway to help answer important questions about lung volume reduction concerning which types of patients are most likely to benefit from it, how long the benefits last, what the risks and long-term survival rates are, and what the cost-effectiveness of lung volume reduction is, compared with that of nonsurgical medical therapy for emphysema. Contributing to this effort, we participate in the National Institutes of Health Study Program through Medicare to evaluate the benefits of lung volume reduction surgery.
At present, the early outcomes of the Stony Brook experience with lung volume reduction, together with favorable reports in the medical literature, compell us to offer this new treatment option to selected patients.
A Patient Testimonial
The following account was written by Myrtle Drechsler of West Babylon, NY, and originally appeared in the Florida-based publication, The Pulmonary Paper (June/July 1998):
"I had my lung volume reduction operation at Stony Brook University Hospital on Long Island. Dr. Thomas Bilfinger was my surgeon. Because I already had a double bypass, they operated on only my left lung, going in through the back. This was December 1995.
"I was supposed to go back in the spring for the right lung, but January 1, 1996 Medicare stopped paying for this operation. I felt good enough with only one lung operation that I never did anything about the other. At the time I had the operation I was 71 and was surprised when my HMO said I was a candidate. I had nothing to lose as I was on oxygen 24 hours a day and going downhill rapidly.
"Now I sleep with oxygen and use it on the treadmill. Between two and four days a week, I go to the YMCA for their water exercise program. The program is geared for people with MS and arthritis, so I'm able to keep up with the others. My reading on the oximeter now runs between 92% and 95% (without being on oxygen).
"It is so wonderful not to have to carry the oxygen around. I go to the American Lung Association and different support groups, knitting guilds and my weeks aren't long enough. My advice would be, when you have nothing to lose, go for it. The lung volume reduction surgery was absolutely painless (compared to the heart surgery). It was during the three weeks of rehab after the surgery that I was told I didn't need oxygen. I couldn't believe it!
"I know I have to work at the exercise or I will lose the benefits of the surgery. I thought someone might like to hear my experience."
For more information about lung volume reduction surgery at Stony Brook, please call Dr. Bilfinger at 631-444-1820.
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