COPD; Alpha-1 antitrypsin deficiency; Bronchitis - chronic; Chronic bronchitis; Emphysema
Surgery -- as a last resort -- may help some patients with COPD. Coverage for such procedures varies among insurance carriers. A major drawback is that patients must be in good enough health to undergo major surgery. By the time COPD is advanced, however, this is usually not the case. As a result, surgery cannot help most COPD patients.
The three available surgical options that are appropriate for some patients with COPD are lung transplantation, lung-volume reduction surgery, and bullectomy.
Three-year survival rates after lung transplantation are about 60% for patients with emphysema or alpha-1 antitrypsin deficiency. Patients may have a transplant of one lung, both lungs, or the lungs plus the heart. The increasingly long waiting time for donor organs and the extraordinary expense are both obstacles to this procedure.
Candidates. The best candidates are under age 65 and have severe heart and lung disease, with a life expectancy of less than 18 months. However, lung transplantation is becoming more out of favor for patients with end-stage COPD because it is unclear whether it provides a "useful" quality of life.
Waiting Time. Up to one-third of patients awaiting lung transplantation die before a suitable donor is available. There were 1,478 lung transplant operations in the United States in 2008, according to the Organ Procurement and Transplantation Network. As of this writing, 1,976 people were waiting for a new lung.
Since 2005, the United Network for Organ Sharing (UNOS) has been assigning lungs for transplants based on an allocation score, rather than time spent on the waiting list. The allocation score takes into account the length of time a patient is likely to survive before and after a transplant. This policy applies to transplant candidates age 12 or older.
Complications. Transplant patients must take drugs that suppress the immune system to prevent the body from rejecting the transplanted organ. Nevertheless, rejection is the primary cause of complications and death. The mortality rate from the procedure itself is about 10%.
Outcomes. About 38% of lung transplants involve both lungs. Transplanting both lungs as opposed to just one significantly improves survival rates in patients under age 60. The average survival in patients who have both lungs transplanted is 6.41 years, compared to 4.59 years in patients with a single-lung transplant.
In lung volume-reduction surgery (LVRS), more than 30% of severely diseased lung tissue is removed, and the remaining parts of the lung are joined together. Breathing improvements after surgery are mainly due to the following factors:
Prognosis. Results of the largest study to date, called the National Emphysema Treatment Trial (NETT), found that patients with upper-lobe disease and poor lung function achieved better 5-year survival rates, improved their exercise ability for 3 years, and had fewer symptoms at 5 years with LVRS than with medical therapy. Those with upper-lobe disease and good ability to exercise did not have a survival advantage with LVRS, but were able to increase their exercise capacity.
When the operation is successful, patients report significant improvement in walking distance, weight, and quality of life. Many patients can engage in daily activities, such as golfing or stair climbing, without having to use supplemental oxygen. Even when candidates are carefully selected, however, about 15% of patients get little or no benefit from the procedure, and about 4% get worse. In successful cases, the improvement is most notable within the first 6 months, after which the condition begins to get worse again. After 3 years, lung function deteriorates to the same level as it was before the procedure. LVRS is substantially more expensive than medical treatment.
Possible Candidates. The procedure is used only in people with severe emphysema, and in some people who have alpha-1 antitrypsin deficiency. It is not used for those with chronic bronchitis. Appropriate candidates with alpha-1 antitrypsin deficiency (even if they have disease in the lower lobe) may do well, but the procedure is only useful in a minority of these patients. Candidates must have the following characteristics:
One year after surgery, lung transplant recipients have much better lung function, greater exercise capacity, and less breathlessness than LVRS patients. However, they are less likely to survive, and the transplant is far more expensive than LVRS.
Patients may not qualify for LVRS if they have:
Other indicators of a poor outlook include severe lung complications and air pockets in diseased areas of the lungs (bullae).
Specific Techniques. At this time, the preferred technique is surgery done on both lungs (bilateral lung volume reduction). Surgeons use either an open approach, making a large cut in the chest area, or video-assisted thoracoscopy (VATS), which is less invasive and involves several small cuts. Either method is effective and has similar complication rates. Lines of staples are typically used to reduce lung volume.
The alternative technique is surgery done on only one lung (unilateral lung volume reduction). Some centers believe this approach may cause fewer complications and the benefits last longer, although not all evidence supports its use over the bilateral method.
Another option for COPD is bullectomy, in which giant air pockets and surrounding lung tissue are removed. It is generally limited to patients with giant bullae (not the typical COPD patient) and those with alpha-1 antitrypsin deficiency.
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