Lung-volume reduction surgery: A vanishing operation?

412 The Journal of Thoracic and Card he article by Lederer and colleagues 1 in this issue of the Journal reports on a small series of patients with end-stage emphysema undergoing lungvolume reduction surgery (LVRS) with good clinical results and amazingly ow morbidity and mortality. The purpose of the article is to correlate improvements n clinical status with the body mass index, airflow obstruction, dyspnea, and xercise capacity (BODE) index, a multidimensional predictor of survival in paients with chronic obstructive pulmonary disease. The authors suggest that the ODE index may eventually prove useful as a surrogate to predict survival not only or patients with chronic obstructive pulmonary disease, but for those with end-stage mphysema undergoing LVRS. Their conclusions regarding the BODE index, owever, must be regarded with caution because of a number of inherent limitations n their study. First, as the authors themselves point out, the study includes a small umber of patients operated on at a single center with a relatively short follow-up. 1 erhaps more importantly, however, the BODE index itself appears to have inherent imitations that could prevent it from proving useful in the subset of patients ndergoing LVRS. The BODE index was designed to assess chronic obstructive ulmonary disease across the spectrum from mild to severe disease. Unfortunately, atients undergoing LVRS do not span this spectrum; all operative candidates have xtremely advanced emphysema and fall toward the severe end. The article of ederer and colleagues exemplifies this finding in that more than 90% of their atients were at the extreme in all four dimensions of the index (percentage of redicted forced expiratory volume in 1 second, 6-minute walk, modified Medical esearch Council dyspnea score, and body mass index). With all patients clustered ogether at one end of the spectrum, the BODE is inherently limited in its ability to iscriminate between patients likely to respond and those likely to have extreme orbidity and mortality. The study also illustrates both the good and the bad effects that have emanated rom the National Emphysema Treatment Trial (NETT). The good is exemplified in he remarkably low morbidity evidenced in the patient population reported in the rticle. The NETT clearly and definitively identified the optimal candidate profile nd thus allowed the selection of patients with the lowest risk-benefit ratio. The uperb results of the patients who were chosen according to the final NETT ecommendations are a testament to the value of this multi-institutional randomized rial. The trial, however, has also had a chilling and detrimental effect on the referral f patients with end-stage emphysema for consideration of LVRS. The first article utlining results from the NETT trial documented poor results in a subset at very igh risk, and thereafter referrals to the trial markedly declined. Many NETT nvestigators believe that this occurred because the public and the medical commuity misinterpreted the conclusions as suggesting that LVRS was too risky to ndertake for any patient. Others believe that the relative inaccessibility of LVRS only 17 NETT sites throughout the country throughout the 7-year duration of the rial) served to dampen the interest of internists and pulmonologists who would have therwise referred patients for this potentially lifesaving intervention. In effect, both atients with end-stage emphysema and their caregivers either forgot about or lost nterest in LVRS during this prolonged period. Whatever the reasons, it is noteorthy that in 2004 (the most recent year for which figures are available) only 254 atients in the entire country underwent LVRS (Current Procedural Terminology ode 32491) paid for under Medicare (data obtained from Centers for Medicare &