Survival following bilateral staple lung volume reduction surgery for emphysema

Study objectives: Despite numerous reports of short-term response to lung v olume reduction surgery (LVRS) for treatment of emphysema, to our knowledge , longer-term survival has not been reported. We describe survival followin g LVRS in a large cohort of 256 patients treated with bilateral staple LVRS (n = 236 video-assisted thoracic surgery [VATS] approaches, n = 20 median sternotomy) by a single group of physicians over a 3-1/2-year period from A pril 1994 to November 1997. Design: Prospective survival study, Overall survival, survival stratified b y preoperative presentation, and acute postoperative response were investig ated using Kaplan-Meier methods, The simultaneous effects of preoperative p redictors and postoperative response variables on survival were examined us ing a Cox proportional hazards model. Setting: Community hospital and university medical center. Patients: We studied 256 consecutive patients with severe emphysema treated with LVRS. Interventions: Bilateral staple LVRS by VATS. Measurements and results: Overall survival information was known with certa inty for 246 of 256 patients as of February 1, 1998. Median follow-up time was 623 days (range, 0 to 1,545 days). Mean FEV1 was 0.635L +/- 0.015 L pre operatively and rose to 1.068 +/- 0.029 L postoperatively, By standard anal ysis methods (missing patients censored at the time of last contact), 1-yea r survival was 85 +/- 2.3% compared with 83 +/- 2.4% 1-year survival with " worst case" analytic methods (assuming all missing patients died). Two-year survival averaged 81 +/- 2.7% by standard analysis vs 76 +/- 2.9% by worst case evaluation. Survival was significantly better for patients who were y ounger (less than or equal to 70 years old, p = 0.02) and with higher basel ine FEV1 (> 0.5, p < 0.03) and Po-2 (> 54, p < 0.001). Patients who had gre atest short-term improvement in FEV, following surgery (> 0.56 L increase) also had significantly better longer-term survival following LVRS. Conclusions: To our knowledge, this is the first longer-term survival analy sis of a large series of patients who underwent bilateral staple LVRS for e mphysema, Substantial long-term mortality is seen, particularly within iden tifiable high-risk subgroups, Careful comparison to comparably matched cont rol patients will be needed to definitively assess the benefits and risks o f LVRS, This study suggests that prospective, controlled trials may need to stratify patient randomization based on preoperative risk factors to obtai n meaningful results.