Surgical options for patients with advanced emphysema

Emphysema affects as many as 1.7 million Americans.(72) It can cause disabling symptoms of dyspnea and exercise limitation and can lead to early death.(15) The mainstays for treatment have been a variety of bronchodilating and anti-inflammatory medications, oxygen supplementation, and, in some instances, a comprehensive pulmonary rehabilitation program. A variety of surgical approaches to improving symptoms and restoring lung function of patients with emphysema have been described over the past 50 to 75 years. Although they were all well intentioned and based on what was considered to be a sound physiologic rationale at the time, with the exceptions of giant bullectomy and, possibly, the recently described lung-volume reduction surgery (LVRS), none of these operations has been found useful. In the early 1900s, an overdistended and stiff chest wall was thought to cause emphysema. Accordingly, early operations were designed to increase the movement of the thoracic cage by disarticulating the ribs from the sternum (costochondrectomy) and performing a transverse sternotomy.(69) Despite initial reports that that approach increased vital capacity by 500 to 700 mL(8, 60) and relieved dyspnea,(39, 45) the procedure was subsequently abandoned because of inconsistent results. As the understanding of emphysema improved, it became clear that chest wall enlargement was the result, rather than the cause, of the condition and operations such as phrenic nerve sectioning (phrenicectomy)(3, 59) and thoracoplasty(39) were designed to decrease the size of the lungs. Those operations were quickly abandoned when they were found to reduce lung function and to worsen symptoms. Instillation of air into the peritoneum was attempted, with some success, based on the rationale that it would improve the curvature and, therefore, the function of the diaphragm.(64) Unfortunately, the discomfort produced by the procedure and the need for repeated installations of gas precluded its widespread acceptance. The large airway obstruction that occurs during exhalation in some patients with emphysema is thought to result from atrophy of airway cartilage. In an attempt to address that problem, a number of procedures were developed to stabilize the trachea externally, using artificial materials,(34, 62) bone chips,(56) and muscle flaps.(34) The inconsistent and unpredictable results observed with those operations led to them being used only rarely today.