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Survival following bilateral staple lung volume reduction surgery for emphysema
M Brenner1, R J McKenna, J C Chen
1Division of Pulmonary Medicine, Beckman Laser Institute, UC Irvine Medical Center, Orange, CA 92668, USA. mbrenner@bli.uci.edu
Study Objectives:
Despite numerous reports of short-term response to lung volume reduction surgery (LVRS) for treatment of emphysema, to our knowledge, longer-term survival has not been reported. We describe survival following LVRS in a large cohort of 256 patients treated with bilateral staple LVRS (n = 236 video-assisted thoracic surgery [VATS] approaches, n = 20 median sternotomy) by a single group of physicians over a 3 1/2-year period from April 1994 to November 1997.
Design:
Prospective survival study. Overall survival, survival stratified by preoperative presentation, and acute postoperative response were investigated using Kaplan-Meier methods. The simultaneous effects of preoperative predictors and postoperative response variables on survival were examined using a Cox proportional hazards model.
Setting:
Community hospital and university medical center.
Patients:
We studied 256 consecutive patients with severe emphysema treated with LVRS.
Interventions:
Bilateral staple LVRS by VATS.
Measurements And Results:
Overall survival information was known with certainty for 246 of 256 patients as of February 1, 1998. Median follow-up time was 623 days (range, 0 to 1,545 days). Mean FEV1 was 0.635L+/-0.015 L preoperatively and rose to 1.068L+/-0.029 L postoperatively. By standard analysis methods (missing patients censored at the time of last contact), 1-year survival was 85+/-2.3% compared with 83+/-2.4% 1-year survival with "worst case" analytic methods (assuming all missing patients died). Two-year survival averaged 81+/-2.7% by standard analysis vs 76+/-2.9% by worst case evaluation. Survival was significantly better for patients who were younger (< or = 70 years old, p = 0.02) and with higher baseline FEV1 (> 0.5, p < 0.03) and PO2 (> 54, p < 0.001). Patients who had greatest short-term improvement in FEV1 following surgery (> 0.56 L increase) also had significantly better longer-term survival following LVRS.
Conclusions:
To our knowledge, this is the first longer-term survival analysis of a large series of patients who underwent bilateral staple LVRS for emphysema. Substantial long-term mortality is seen, particularly within identifiable high-risk subgroups. Careful comparison to comparably matched control patients will be needed to definitively assess the benefits and risks of LVRS. This study suggests that prospective, controlled trials may need to stratify patient randomization based on preoperative risk factors to obtain meaningful results.