Lung Volume Reduction Surgery

Facing a national shortage of donor lungs for transplantation, many people with end-stage emphysema need alternative treatments not only to breathe easier but to live longer. Lung volume reduction surgery (reduction pneumoplasty) is an operation for certain people with severe emphysema that has been shown to provide significant improvement in lung function, and offers patients with advanced pulmonary disease an alternative to lung transplantation.

An estimated 14 million people in the United States have chronic obstructive pulmonary disease (COPD), in many cases due to emphysema. Chronic bronchitis or asthma also may cause air-flow obstructions in the lungs that characterize COPD.

Emphysema is a disease that enlarges the air sacs (alveoli) in the lung, making it difficult to expel air. Emphysema-enlarged lungs further reduce breathing efficiency by interfering with the ability of the diaphragm muscle to help move air through the lungs. Smoking is the leading cause of emphysema.

Stony Brook University Hospital was the first hospital in Suffolk County to provide lung volume reduction surgery, and Dr. Thomas V. Bilfinger was the first surgeon here to perform this procedure.

In end-stage emphysema, the lungs are also less efficient at exchanging oxygen and carbon dioxide. Inhalers and other therapies no longer give much relief. Until recently, only lung transplantation offered a significant opportunity to improve respiratory function.

But the shortage of donor lungs makes transplantation impossible for most people who could benefit from it. Furthermore, not everyone with end-stage emphysema is a good candidate for a transplant. As a result, there is an ongoing search for alternatives.

A highly publicized national trial, in which Medicare cooperated with the National Institutes of Health, established that selected patients can be helped with an operation. Since that trial a lot of experience has been gained.

It is now clear that only a specific group of patients with most of their emphysema in the upper part of their lungs truly benefit. Further, it has become clear that patients only benefit if there is an entire program covering all aspects of pre- and post-operative conditioning available. Such program is provided at Stony Brook Medicine.

Dr. Bilfinger has been performing lung volume reduction surgery at Stony Brook since 1998, and has established a long record of success with this operation.

The Operation Itself

Recently, advances in surgical technology and techniques have enabled surgeons to pursue the use of lung volume reduction, which was introduced in the 1950s, though results at that time were not satisfactory. Now the procedure is done using either a standard open incision or minimally-invasive approach called “videoscopic” surgery.

In volume reduction, a portion of the diseased lung is removed, and the lung is resealed using a surgical stapling device. The procedure reduces lung volume by 20% to 30%. In many cases, a strip of tissue such as bovine pericardium (the sac surrounding a cow’s heart) or other bio-synthetic material is attached to the lung along the staple line to help prevent air leaks from the site of excision.

One would think that reducing the volume of the lung would make breathing harder. But for some people, less is more. Preliminary results for some patients show improved breathing mechanics, increased efficiency in exchanging oxygen and carbon dioxide, and significantly greater volumes of exhaled air.

Most important, some patients experience improvement in their overall condition, including:

  • Less shortness of breath
  • Improved ability to be more active, including exercise
  • Reduced need for supplemental oxygen

Studies now have shown that a very sophisticated selection process is necessary to find the patients who benefit the most from lung volume reduction surgery. Further, studies have made it clear that a pre- and post-operative conditioning program is as important as the procedure itself in the overall outcome.

The overall care of these patients is very costly, and the government has therefore limited these procedures on Medicare to institutions with lung transplant programs or institutions who originally participated in the evaluation of this procedure.

Stony Brook has offered sophisticated state-of-the-art evaluation since the onset of this procedure, and continues to offer that service including a recommendation for a treatment plan tailored to the individual needs for each patient. This is a multidisciplinary effort with the involvement of several specialists.

A Patient Testimonial

The following account was written by Myrtle Drechsler of West Babylon, NY, and originally appeared in the Florida-based publication, The Pulmonary Paper (June/July 1998):

"I had my lung volume reduction operation at Stony Brook University Hospital on Long Island. Dr. Thomas Bilfinger was my surgeon. Because I already had a double bypass, they operated on only my left lung, going in through the back. This was December 1995.

"I was supposed to go back in the spring for the right lung, but January 1, 1996 Medicare stopped paying for this operation. I felt good enough with only one lung operation that I never did anything about the other. At the time I had the operation I was 71 and was surprised when my HMO said I was a candidate. I had nothing to lose as I was on oxygen 24 hours a day and going downhill rapidly.

"Now I sleep with oxygen and use it on the treadmill. Between two and four days a week, I go to the YMCA for their water exercise program. The program is geared for people with MS and arthritis, so I'm able to keep up with the others. My reading on the oximeter now runs between 92% and 95% (without being on oxygen).

"It is so wonderful not to have to carry the oxygen around. I go to the American Lung Association and different support groups, knitting guilds and my weeks aren't long enough. My advice would be, when you have nothing to lose, go for it. The lung volume reduction surgery was absolutely painless (compared to the heart surgery). It was during the three weeks of rehab after the surgery that I was told I didn't need oxygen. I couldn't believe it!

"I know I have to work at the exercise or I will lose the benefits of the surgery. I thought someone might like to hear my experience."