Background Lung-volume–reduction surgery has been proposedas a palliative treatment for severe emphysema. Effects on mortality,the magnitude and durability of benefits, and criteria for theselection of patients have not been established.
Methods A total of 1218 patients with severe emphysema underwentpulmonary rehabilitation and were randomly assigned to undergolung-volume–reduction surgery or to receive continuedmedical treatment.
Results Overall mortality was 0.11 death per person-year inboth treatment groups (risk ratio for death in the surgery group,1.01; P=0.90). After 24 months, exercise capacity had improvedby more than 10 W in 15 percent of the patients in the surgerygroup, as compared with 3 percent of patients in the medical-therapygroup (P<0.001). With the exclusion of a subgroup of 140patients at high risk for death from surgery according to aninterim analysis, overall mortality in the surgery group was0.09 death per person-year, as compared with 0.10 death perperson-year in the medical-therapy group (risk ratio, 0.89;P=0.31); exercise capacity after 24 months had improved by morethan 10 W in 16 percent of patients in the surgery group, ascompared with 3 percent of patients in the medical-therapy group(P<0.001). Among patients with predominantly upper-lobe emphysemaand low exercise capacity, mortality was lower in the surgerygroup than in the medical-therapy group (risk ratio for death,0.47; P=0.005). Among patients with non–upper-lobe emphysemaand high exercise capacity, mortality was higher in the surgerygroup than in the medical-therapy group (risk ratio, 2.06; P=0.02).
Conclusions Overall, lung-volume–reduction surgery increasesthe chance of improved exercise capacity but does not confera survival advantage over medical therapy. It does yield a survivaladvantage for patients with both predominantly upper-lobe emphysemaand low base-line exercise capacity. Patients previously reportedto be at high risk and those with non–upper-lobe emphysemaand high base-line exercise capacity are poor candidates forlung-volume–reduction surgery, because of increased mortalityand negligible functional gain.
Source Information
The writing committee for the National Emphysema Treatment Trial (NETT) (Alfred Fishman, M.D., University of Pennsylvania, Philadelphia; Fernando Martinez, M.D., University of Michigan, Ann Arbor; Keith Naunheim, M.D., Saint Louis University, St. Louis; Steven Piantadosi, M.D., Ph.D., and Robert Wise, M.D., Johns Hopkins University, Baltimore; Andrew Ries, M.D., M.P.H., University of California, San Diego, La Jolla; Gail Weinmann, M.D., National Heart, Lung, and Blood Institute, Bethesda, Md.; and Douglas E. Wood, M.D., University of Washington, Seattle) takes responsibility for the content of this article. This article was published at www.nejm.org on May 20, 2003.
Address reprint requests to Dr. Piantadosi at the NETT Coordinating Center, 615 N. Wolfe St., Rm. 5010, Baltimore, MD 21205.
Lung-Volume–Reduction Surgery
Pakhale S. S., Gutierrez C., Piantadosi S., Fishman A., the National Emphysema Treatment Trial Research Group
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N Engl J Med 2003;
349:999-1000, Sep 4, 2003.
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