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Ann Thorac Surg 2000;70:954
© 2000 The Society of Thoracic Surgeons
Discussion
DR MARK D. IANNETTONI (Ann Arbor, MI): I’d like to thank Dr Pompeo for the opportunity to discuss this paper and for sending it to us early. He’s added to the current literature suggesting that if patients are selected properly for lung volume reduction, they can achieve better relief from dyspnea and improved short-term benefit from surgery than from medical therapy.
In regard to the paper itself, the significant improvement that was seen with surgery obviously was better than that seen with medical therapy alone; however, there was a significant improvement with medical therapy as well.
I do have several questions for the authors with regard to the conclusions of their study and the study design. The first is related to patient selection. All of the current literature with respect to lung volume reduction surgery involves patients with nonbullous emphysema, either with or without a gradient. However, in their paper Dr Pompeo and colleagues state that patients with bullous emphysema were included in their study, and this is still one of the true exclusion criteria for lung volume reduction. My question is, what is your definition of bullous emphysema? Additionally, what percentage of your patients had bullous emphysema as their sole disease, and what percentage of these patients had unilateral disease?
The study also had an unusually large number of patients with unilateral disease, 13 of 30. Although only limited information exists at present comparing unilateral with bilateral lung volume reduction, bilateral lung volume reduction in general has proven superior for symptomatic relief and has consistently demonstrated improved mechanical and physiologic results with the same mortality as unilateral lung volume reduction. My second question thus is, did you compare results in your patients having unilateral with those having bilateral lung volume reduction with respect to short-term and long-term function?
My third question relates to the length of pulmonary rehabilitation. The literature in most cases supports the use of at least 12 weeks of active rehabilitation followed by a maintenance period, preferably forever, to sustain the effects not only of medical management. The long-term effects of surgery can be can also improved with the use of a pulmonary maintenance program, however. We have shown that if our patients fail to continue active rehabilitation after surgical intervention, the beneficial effects of surgery can be lost, not only from the physiologic but also from the mechanical aspects, in 6 months. Whereas if they continue in their maintenance program of pulmonary rehabilitation, after 2 years they may maintain their physiologic benefit even though the mechanical benefits may be lost. My question is, do you think that 6 weeks of pulmonary rehabilitation without a maintenance program is adequate to achieve the physical conditioning and the physiologic benefits necessary to make statements about a pulmonary rehabilitation program?
And finally, and possibly most importantly, there was an extremely high crossover rate in your paper; approximately 44% of the patients went from the medical arm to the surgical arm. Were the patients at the beginning of the study told that regardless of what arm they were in they would be offered surgery? That can have an important influence on a perceived benefit of pulmonary rehabilitation and future results, because patient effort and compliance may change if they know they will be optimized to surgery in any event.
The authors are to be congratulated on low morbidity and mortality in a difficult group of patients and the success in showing that our current concepts of what must be done to achieve success in this group of patients should be continually challenged.
I would like to thank the authors and the Society for the opportunity to comment on this important piece of scientific data.
DR POMPEO: Thank you, Dr Iannettoni, for your comments and your pertinent questions. In answer to the first question, regarding unilateral versus bilateral operation, we do take a tailored approach, an intentional tailored approach, performing both unilateral and bilateral procedures. And we do believe that patients with an asymmetric distribution of emphysema in the lungs may benefit either from a unilateral or bilateral operation. This is the reason why we apply criteria that are mainly morphologic. Furthermore, we are going to evaluate the independent effect of surgery in terms of unilateral versus bilateral approaches in a future study.
As to the problem of bullous emphysema, I can say that we excluded patients with giant bullous emphysema—those with bullae occupying at least one-third of the hemithorax surrounded by relatively normal lung. But as everyone knows, emphysema is often mixed. We can have both bullous and nonbullous emphysema in the same lung and patients with these characteristics were included in the study.
To answer your question about the 6-week based rehabilitation program, we can say that our patients came from quite a large country around Rome, and it’s quite difficult for them to comply with a daily outpatient program, one that takes place five days a week. That was the reason why we decided on the relatively short 6-week program. Anyway, we also have seen that some patients, 5 patients exactly, required more than 6 weeks of rehabilitation.
As to the last question, the patients were aware of the possibility of crossing over to surgery. This was the ethical reason that convinced us to prefer a short closeout period of only 6 months to allow unimproved patients to cross over to surgery. The patients, of course, knew the possibility of undergoing reduction pneumoplasty after rehabilitation, but they were randomized to receive rehabilitation before. This may mean that after rehabilitation, as our study shows, results are less stable and most patients will require the operation subsequently. Thank you.
DR WALTER WEDER (Zurich, Switzerland): I want to congratulate you on your paper, and I want to add some more questions along the same lines as those from the previous discussant.
Your FEV1 improved more than 60% despite that fact that almost half of the operations were unilateral. This is outstanding. Morphology must therefore be special in your patients. Were all of your cases marked heterogeneous disease, all upper lobe disease? Did you exclude 
-1 antitrypsin deficiency syndrome, or did you have additionally homogeneous disease as well?
DR POMPEO: This was a highly selected group of patients; we did in fact include only those with heterogeneous disease, diffuse bullous and nonbullous emphysema. That is also a matter of discussion because some groups are excluding bullous emphysema as well. We did not include homogeneous emphysema in our study, which may be one of the reasons why we achieve such a good improvement in FEV1.
Morphology is, of course, a critical point in this kind of surgery, and we do believe and we already have shown that patients with asymmetric emphysema treated unilaterally may have an improvement in FEV1 that compares with that achievable by bilateral operation. Thank you, Dr Weder, for your comments.
Related Article
Ann. Thorac. Surg. 2000 70: 948-953.
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