Apples, oranges, and lemons: Making sense of lung volume reduction surgery

Abstract

The study reported by Decker and colleagues in this issue of the Journal was undertaken to describe contemporary practice patterns and outcomes of lung volume reduction surgery (LVRS) on a national level, using data obtained from the Society of Thoracic Surgeons (STS) database. The resulting analysis is compared with published results of the National Emphysema Treatment Trial (NETT). The authors, as have many others, question why application of a procedure demonstrated by the NETT to be so effective for selected patients with emphysema has languished, despite the prevalence of chronic obstructive pulmonary disease. The STS database was found to contain 538 patients who underwent LVRS over the 8.5-year span covered by the study. However this database is voluntary, so it may or may not be representative of the majority of cases performed in the United States. It contains aggregate deidentified data that does not permit retrospective data mining or subgroup analysis to be conducted. Postoperative data, including morbidity and mortality, is limited to 30 days and does not include either subjective or objective measures of improvement. In comparison with the NETT trial, which included only patients undergoing bilateral LVRS, the STS database cannot distinguish between unilateral and bilateral procedures that have previously been documented to result in differing postoperative mortality and functional outcome. In addition, the limited data designed to be captured by the STS database are often incomplete. For example, 30-day mortality was missing for 14% of patients so, as the authors indicate, the post-LVRS 30-day mortality of 5.6% might actually range from 4.8% up to 19.6% depending on how many of the patients with unknown status were actually alive at 30 days. Furthermore the NETT trial demonstrated that postoperative mortality