Surgery

010. Surgery

	In selected patients, a surgical approach may be considered for symptom relief 138-148 [evidence level III-2]

None of the current surgical approaches in patients with COPD provides a survival advantage.⁷,¹³⁸ In view of the potential for serious morbidity and mortality, all surgical treatments require careful assessment by an experienced thoracic medical and surgical team.

O10.1 Bullectomy

This operation involves resection of large bullae (larger than 5 cm). The procedure is most successful where there are very large cysts compressing adjacent apparently normal lung.^139-141

O10.2 Lung volume reduction surgery

Lung volume reduction surgery (LVRS) involves resection of the most severely affected areas of emphysematous, nonbullous lung.¹⁴² This can improve lung elastic recoil and diaphragmatic function.¹⁴³ LVRS is still an experimental, palliative, surgical procedure. The National Emphysema Treatment Trial was a large randomised multicentre study which investigated the effectiveness and cost-benefit of this.¹⁴⁴ A total of 1,218 patients with severe emphysema underwent pulmonary rehabilitation and were then randomised to LVRS or continued medical therapy.

There was no overall survival advantage of surgery, but after 24 months there was significant improvement in exercise capacity in the surgical group. Among patients with predominantly upper lobe emphysema and impaired exercise capacity, mortality was significantly lower in the surgical than the medical group. However, high risk patients with diffuse emphysema and well preserved exercise capacity are poor candidates for surgery because of increased mortality and negligible functional gain¹⁴⁹ [evidence level II].

O10.3 Lung transplantation

Lung transplantation is indicated for selected patients with chronic end stage lung disease who are failing maximal medical therapy. However a survival benefit has not been demonstrated in emphysema. For most patients, transplantation is a palliative rather than a curative treatment. The International Society for Heart and Lung Transplantation has listed a number of contraindications¹⁵⁰. The absolute contraindications include malignancy and untreatable advanced dysfunction of another major organ system. Relative contraindications include age older than 65 years, severely limited functional status and other medical conditions that have not resulted in end stage organ damage. The consensus guidelines¹⁵⁰ recommend transplantation be considered in COPD patients with:

  - BODE index of 7 – 10 or at least one of the following:

• History of hospitalisation for exacerbations associated with acute hypercapnia
• Pulmonary hypertension or cor pulmonale or both, despite oxygen therapy
• FEV₁ < 20% and either DLco < 20% or homogeneous emphysema¹⁴⁹

The experience of one Australian lung transplantation centre has recently been reviewed.¹⁵¹ Over a 14 year period, 173 single lung, bilateral lung and heart lung transplants were performed for COPD. Perioperative survival (30 days) was 95% with deaths from infection, cerebrovascular accidents and multiorgan failure. The one, five and ten year survival rates were similar for patients with smoking related emphysema and 1 antitrypsin deficiency at 86%, 57% and 31% respectively. Survival in smoking related emphysema was better following bilateral than single lung transplantation. The commonest cause of late mortality was chronic rejection manifest as the bronchiolitis obliterans syndrome. Overall survival was comparable to international experience and similar to other forms of solid organ transplantation.

O11. Palliation and end of life

O11.1 Opioids

Opioids may have a role for patients with severe intractable dyspnoea¹⁵² [evidence level I]. However, opioids may be associated with drowsiness, nausea, vomiting, dizziness, constipation and, in two of the four multiple dose studies, an opioid withdrawal syndrome.

Content last updated: November 11, 2008 Page last updated: November 13, 2008