Lung volume reduction surgery in nonheterogeneous emphysema

Patients with a homogeneous type of emphysema have been excluded a priori from LVRS in many centers because of the fear of removing parenchyma, which potentially contributes to gas exchange, and because the observation that heterogeneity of emphysema is a predictor of functional improvement. It is obvious that resection of functionless tissue, such as in heterogeneous emphysema with bullae, can be advised to the patient with a relative low risk. However, as the main positive effect of LVRS is its improvement on respiratory mechanics, it is not surprising that well-selected patients with homogeneous emphysema also benefit from surgery. Their selection has to be done cautiously. It is crucial to exclude patients with a very low functional reserve, such as with diffusing capacity below 20% predicted or with pulmonary hypertension, and with extreme parenchymal loss (vanished lungs) on CT from LVRS. Additionally, cofactors which may potentially interfere with a smooth postoperative course, such as previous recurrent infections, extensive scarring of the lungs, or previous surgery, have to be taken into consideration. When respecting these caveats, LVRS in patients with complete homogeneous emphysema provides a comparable symptomatic and almost the same functional improvement as in patients with heterogeneous emphysema. Although the perioperative mortality is low, patients with homogeneous emphysema have a slightly reduced long-term survival without lung transplantation compared with patients with heterogeneous emphysema. Based on our own experience, we conclude that LVRS can be recommended to selected symptomatic patients with advanced homogenous emphysema associated with severe hyperinflation, if diffusing capacity is not below 20% of predicted values and if the CT scan does not show aspects of vanished lungs.