Several facts were learned about LVRS from various clinical trials. It was shown that surgical LVRS (by sternotomy or thoracoscopy), using stapling devices for the resection of diseased portions of the lung, was superior to laser therapy, having less incidence of air leaks and superior functional benefit.8–
It was also shown that bilateral LVRS in one surgical stage was preferable to sequential unilateral LVRS through two separate surgical events.9–10
It also has been shown that the careful selection of patients is crucial to avoid disaster and to enhance favorable outcomes. Published results from the National Emphysema Treatment Trial (NETT) established several important points. Patients with very low FEV1 (ie, < 20% predicted), with very low carbon monoxide diffusion capacity (ie, < 20% predicted), and with evidence of homogeneously distributed emphysema by CT scanning have excessive 1-month and 6-month mortality rates (25% and 35%, respectively) when undergoing surgery.11
The health-related quality of life for these subjects either did not change, decreased, or ended in death in this subgroup of patients. Therefore, they should not undergo LVRS. In reported data derived from 1,218 patients with severe emphysema, randomized through the NETT study, 580 received surgery, 406 by median sternotomy and 174 via bilateral video-assisted thoracoscopy.12
The 90-day mortality rate was 7.9% in the surgical group. There was no advantage in survival comparing sternotomy to thoracoscopy. The same study defined a subgroup of these patients who had the best outcomes after undergoing surgery. Patients were characterized by a heterogeneous type of emphysema and by predominant disease in both upper lobes, with low baseline exercise capacity (defined as tolerance for < 10 W of workload in a bicycle ergometer for women, and < 40 W for men). These patients derived significantly better survival rates than medically treated subjects, and they showed significant improvement in exercise capacity and better quality-of-life scores compared to medically treated patients. The NETT study has thus defined which patients should avoid LVRS and which patients are most likely to benefit from such a procedure. The surgical approach (sternotomy vs thoracoscopy) probably should be decided by the preference and expertise of the surgeon.