Brantigan et al8first proposed multiple wedge resections of emphysematous tissue > 40 years ago. He hypothesized that this would “resize” the lung, improving elastic recoil, airflow, and lung mechanics. This “resizing” hypothesis has been largely integrated into our current paradigm of emphysema physiology. Using the limited outcome methodologies available at the time, these pioneers reported overall clinical benefit. Despite these positive opinions, extremely high perioperative mortality, in the 25% range, limited its acceptance as part of the medical armamentarium for management of advanced emphysema. Cooper et al,9 utilizing advances in modern anesthesia and surgical practice, revisited these techniques and reported improved spirometry, dyspnea, and 6-min walk results after his “bilateral pneumectomy.” In addition, mortality in these studies was < 5%, which was a significant improvement compared with historical controls. Multiple other groups subsequently reported their observational results, which have consistently demonstrated benefit despite variability in surgical strategy, technique, and selection. Gains in FEV1, exercise tolerance, reduced need for oxygen supplementation, decreased steroid use, and improved quality of life were all reported with benefits persisting up to 5 years after surgery. So what is the problem?