[Surgery for lung volume reduction]

To define the place of lung volume reduction surgery (LVRS) for non-bullous emphysema, to discuss the mechanisms of postoperative functional improvement and to suggest guidelines for perioperative medical management.

The Medline data base was searched for any article (original papers, editorials, comments, reviews) published in English, French or German, from 1980 to April 1998. The key words were: lung volume reduction surgery, emphysema, respiratory failure, anaesthesia, lung transplantation. The data have been analysed to explain the physiological mechanisms underlying the postoperative improvements and to assess the risk-benefit ratio associated with LVRS. Finally, proposals are suggested for selection criteria and perioperative medical strategies.

Besides pharmacological treatment and lung transplantation, LVRS is considered as an alternative treatment for patients with end-stage pulmonary emphysema. Perioperative management includes selective lung ventilation, continuous peridural analgesia and a general anaesthetic technique that can be easily reversed. Care should be taken to detect and rapidly correct dynamic hyperinflation, pneumothorax, tube malpositioning and major air leaks. In a majority of selected patients (70-80%), resection of 20-30% of lung volume produces significant clinical and physiological improvement (dyspnoea, exercise capacity, FEV1, VO2max), as well as of the quality of life that has been attributed to greater elastic recoil, reduced respiratory workload and better diaphragmatic and right ventricular function. The most common complication is prolonged air leaks. In-hospital mortality varies widely (0-20%, with a median value at 4%), depending in part on the experience of the surgical team and on the selection criteria. Several factors may predict an unfavourable outcome: advanced age, hypercapnia, diffuse emphysema, predominant airway disease and previous thoracic surgery.

According to the favourable preliminary results and an acceptable incidence of perioperative complications, LVRS is presently considered as a new therapeutic option for some patients with respiratory failure. Future clinical studies should be focused on appropriate selection criteria, operative techniques and long term outcome data.