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Ann Thorac Surg 1997;63:827-828
© 1997 The Society of Thoracic Surgeons

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Invited Commentary

Chapman Medical Center 2601 East Chapman Center Orange, CA 92869

See also page 822.

Lung volume reduction surgery (LVRS), the hottest topic in pulmonary medicine and thoracic surgery, illustrates the controversies of developing a new treatment, especially in the era of cost containment and managed care. In 1990, Wakabayashi showed that laser treatment could reduce the symptoms of severe emphysema, but the overall results were unclear [1]. Cooper and colleagues [2], using a technique of resection with staples and bovine pericardium, scientifically documented patient improvement after surgical treatment of emphysema. This, however, led to many questions regarding the mechanism of improvement, the optimal technique (for example, laser, staples, median sternotomy versus thoracoscopy, and unilateral versus bilateral resection), and the duration of palliation.

These uncertainties and the concern regarding the potential cost of operations on the two million Americans with emphysema precipitated the controversial decision by the Health Care Finance Administration to deny coverage for the procedure as of December 8, 1995, with the statement that the procedure has not been shown to be "safe and efficacious." This controversy points out many issues about the development of new operative procedures. How can we contain health care costs without obstructing the development of new procedures? Who should pay for the medical costs of new procedures? Who should regulate and oversee new operative procedures? How should the outcomes of new procedures be evaluated?

In the case of LVRS, a unique and unprecedented approach has been undertaken by the National Institutes of Health, the Health Care Financing Administration, and the medical community. At centers of excellence chosen by the National Institutes of Health, a randomized, prospective study to compare the results of best medical management with and without LVRS will begin in 1997. The surgical treatment will be by both thoracoscopy and median sternotomy to compare the efficacy of these two approaches. The centers have been chosen, and the details of the protocol are to be finalized. If this cooperative effort between the medical community and the government works, it could be a model for the future that will allow medical progress, development of new operative procedures, and coverage for this progress.

Currently, cost considerations are being used to ration health care in the United States. Preferably, the standard of "safe and efficacious" treatment could and should be used to make the decision for coverage of medical care, such as the use of coronary angioplasty, coronary stents, and many cancer treatments, where there is no conclusive scientific proof of safety and efficacy for these treatments compared with controls. These treatments should be held to the same standards that are being applied to LVRS. If all health care were rationed using the standard "safe and efficacious," there would be a large cost saving that could, in part, be used to support research that would allow progress in medical care.

Although there is no published randomized, prospective study comparing medical management versus surgical management of the various operative approaches for LVRS, the current literature [1–5] suggests that LVRS works for select patients with symptoms of severe emphysema. Reports from different centers [1–5] suggest that the results are comparable for the open and video-assisted thoracic surgical approach. This article by Wisser and associates does have the limitations of a small, nonrandomized study, but it suggests that the hospital stay and the postoperative results for the two operative approaches are comparable.

Wisser and co-workers write: "...videoendoscopic volume reduction seems to be less invasive and henceforth is our approach of choice." The data show that the procedure performed on the lung seems to be more important than the incision used to perform the procedure and that the choice of incision for LVRS appears to be based on surgeon preference rather than any apparent difference in outcome.

References

1. Wakabayashi A. Thoracoscopic laser pneumoplasty in the treatment of diffuse bullous emphysema. Ann Thorac Surg 1995;60:936–42.
2. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106–16.[Abstract/Free Full Text]
3. Yusen RD, Lefrak SS, The Washington U Emphysema Group. Evaluation of patients with emphysema for lung volume reduction surgery. Semin Thorac Cardiovasc Surg 1996;1:83–93.
4. McKenna R, Brenner M, Gelb AF, et al. A randomized, prospective trial of stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Cardiovasc Surg 1996;111:310–22.
5. McKenna RJ Jr, Brenner M, Gelb AF, Fischel RJ. Should lung volume reduction surgery be unilateral or bilateral? J Thorac Cardiovasc Surg 1996;112:1331–9.[Abstract/Free Full Text]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by McKenna, R. J. Search for Related Content PubMed Articles by McKenna, R. J., Jr Related Collections Related Article