Low mortality and favourable outcome in lung volume reduction surgery for different emphysema morphologies

A quarter of a century after the National Emphysema Treatment Trial (NETT), lung volume reduction surgery (LVRS) remains an underused procedure with the notion of high mortality and morbidity, mainly recommended for upper lobe predominant heterogeneous emphysema. With advances in patient selection, minimally invasive surgery and improved recovery, this perception may be outdated. This study evaluates 5-year single-centre outcome, including patients beyond traditional NETT criteria (non-upper lobe and non-heterogeneous morphology).

This prospective study included all consecutive LVRS procedures (August 2019 to July 2024). Surgical, functional and quality of life outcomes (COPD Assessment Test (CAT) and St George's Respiratory Questionnaire (SGRQ)) were analysed at 3 and 6 months, and then annually up to 3 years. Subanalysis compared markedly versus non-markedly heterogeneous morphology and isolated versus non-isolated upper lobe disease.

223 procedures were performed in 191 patients with baseline median (interquartile range) forced expiratory volume in 1 s (FEV₁) 31% pred (27-37% pred), residual volume (RV) 219% pred (203-250% pred), 6MWD 358 (291-439) m, CAT score 22 (18-25) and SGRQ score 62 (48-71). 30-day mortality was 0.5% (n=1). Hospital stay was 7 (4-10) days; prolonged air leak occurred in 17.9% and infection in 2.2%. At 3 years (n=42/191), FEV₁ improved to 38% pred (29-48% pred), RV to 173% pred (148-199% pred), CAT score to 20 (17-24) and SGRQ score to 55 (39-68), all statistically significant. Morphology was non-markedly heterogeneous in 57.6% and non-isolated upper lobe in 56%, with no significant difference in morbidity.

This study demonstrates that LVRS performed in a specialised centre results in exceptionally low mortality and morbidity, and meaningful clinical and functional improvement, supporting broader indications beyond classical NETT criteria.