Ann Thorac Surg 2005;79:416-417
© 2005 The Society of Thoracic Surgeons
INVITED COMMENTARY
Douglas E. Wood, MD
University of Washington, 1959 NE Pacific, Room AA-115, Box 356310, Seattle, WA 98195-6310
Lung volume reduction surgery (LVRS) for emphysema has been the greatest advancement in general thoracic surgery since the development of lung transplantation 20 years ago, providing valuable palliation of the symptoms of end-stage emphysema in select patients. However, a minority of emphysema patients are candidates for LVRS and before realizing the symptomatic improvement, patients must navigate the minefield of surgical morbidity and mortality that can frequently extend the period of convalescence. Even while LVRS was being validated in the recently completed National Emphysema Treatment Trial, surgical and pulmonary investigators and biotechnology companies have been developing innovative strategies to try to mimic the effect of surgical lung reduction less invasively and with less risk. Surgeons with expertise in video-assisted thoracic surgery (VATS) quickly adapted VATS techniques to accomplish LVRS. But thinking even more radically, interventional bronchoscopists, including both thoracic surgeons and pulmonologists, considered whether emphysema palliation might be accomplished endoscopically, possibly becoming an outpatient procedure with minimal risk at much less cost. Some surgeons see this possibility as a threat; concerned that interventional pulmonologists will replace surgical LVRS with endoscopic therapy perhaps, even if LVRS is better. Other surgeons, such as Venuta and colleagues, embrace the prospect of endoscopic management of emphysema and are clear leaders in the development and investigation of these new technologies. They do not see the development of endoscopic lung reduction as a threat to a thoracic surgical procedure, but as an opportunity to benefit a wider spectrum of symptomatic patients who may not be candidates for surgical LVRS or who may be able to achieve palliation with less recovery and less risk.
Bronchoscopic lung volume reduction, if successful, may have a significant impact on the shortcomings of LVRS. An endoscopic approach may open emphysema palliation to many more patients, both because the difference in treatment physiology may broaden the indications to patients not currently considered for LVRS, and the decreased invasiveness may make the procedures more acceptable to patients who are disabled by emphysema, but skeptical or cautious about undergoing emphysema surgery. It seems likely that surgical LVRS will remain the best option for some patients, but that bronchoscopic lung volume reduction may provide benefit to patients with comorbities preventing surgery with different patterns of emphysema not currently considered for LVRS, allowing earlier and staged interventions for emphysema palliation. Obviously investigators in bronchoscopic lung volume reduction encounter a new set of "minefields" that must be overcome for the procedures to be successful (ie, the threat of obstructive pneumonia and the confounding variable of collateral ventilation precluding successful volume reduction, even with aggressive endoluminal blockade). However, outstanding surgical investigators such as Venuta and colleagues will solve these dilemmas and pave the way for all of us to improve our care of patients with emphysema.
