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Ann Thorac Surg 2001;71:2081
© 2001 The Society of Thoracic Surgeons

Correspondence

Improved long-term survival seen after lung volume reduction surgery compared to continued medical therapy for emphysema

Bryan F. Meyers, MDa, Roger D. Yusen, MDa, Stephen S. Lefrak, MDa, Joel D. Cooper, MDa

a 3108 Queeny Tower, Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110, USA

e-mail: meyersb{at}msnotes.wustl.edu

To the Editor

We read with interest the prospective, randomized trial by Geddes and associates [1]. We agree with the conclusions: lung volume reduction surgery (LVRS) can improve first second expired volume (FEV1), walking distance, and quality of life in selected emphysema patients who have exhausted nonsurgical alternatives. While the measured benefit from LVRS was less than that reported from many centers, outcomes were likely influenced by the authors’ inclusion of patients with diffuse emphysema and poor exercise capabilities. Geddes and associates reported objective and subjective improvement for LVRS recipients and relentless functional decline for patients managed medically. Conclusions regarding the effect of LVRS on long-term mortality were not possible due to short follow-up and a cross-over design.

Two years ago, we reported in The Annals of Thoracic Surgery our treatment outcome for two groups of emphysema patients [2]. The groups were initially equivalent: Medicare patients selected to receive LVRS. Surgery was performed in 66 patients, but 21 patients were unable to proceed to surgery when the Health Care Financing Administration (HCFA) suspended payment for LVRS. Our report showed the two groups of patients to be functionally comparable at outset. We compared 2-year outcomes and concluded that the improved clinical outcome in the surgical group was attributable to the effects of lung volume reduction surgery. Our results mirrored those of the Geddes article: medically treated patients declined despite optimal medical therapy and LVRS patients improved but experienced a late decline toward preoperative baseline.

In our report, actuarial survival of the medical group did not differ from that of the surgical group. Subsequent follow-up, complete as of July 2000, is relevant to the Geddes paper. At 4 years after initial evaluation, the actuarial survival (Fig 1) of our LVRS patients was 72% and the actuarial survival of the medically treated "control group" was 41% (p = 0.02 by Log rank). Median survival of the surgically treated patients has not been reached, with median follow-up of 4.9 years, while median survival of the medical patients was 3.4 years.



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  		Fig 1. Survival of Medicare patients selected for lung volume reduction surgery at Washington University School of Medicine between 1993 and 1996.

 
The Geddes prospective, randomized trial adds additional scientific validity to previous reports of enhanced function and quality of life after LVRS. Our update of the follow-up of two matched groups of patients indicates that functional improvement produced by LVRS is associated with a significant reduction in long-term mortality as well.

References

  1. Geddes D., Davies M., Koyama H., et al. Effect of lung-volume-reduction surgery in patients with severe emphysema. N Engl J Med 2000;343:239-245.[Medline]
  2. Meyers B.F., Yusen R.D., Lefrak S.S., et al. Outcome of Medicare patients with emphysema selected for, but denied, a lung volume reduction operation. Ann Thorac Surg 1998;66:331-336.[Abstract/Free Full Text]



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