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• What exercise and medication considerations are important in the months leading up to the surgery?
• What are the different techniques for lung reduction surgery?
• What happens to your breathing during the surgery?
• How are the lungs "reduced"?

PARTICIPANTS Byron Thomashow, MD New York Presbyterian Hospital, Columbia University Michael Argenziano, MD New York Presbyterian Hospital, Columbia University

Lung reduction surgery can ease symptoms, but there is a stringent regimen you must follow before you'll even be considered for the surgery.  Here to join us are two specialists who diagnose and operate on patients.   The first is Dr. Byron Thomashow.  He is a pulmonologist at New York Presbyterian Hospital, and a clinical professor of medicine at Columbia University.  Welcome.  We also have Dr. Michael Argenziano, who is a fellow in cardiothoracic surgery at New York Presbyterian Hospital.

Dr. Argenziano, let's begin with you.  A lot of patients, and people who are watching this particular webcast may be wondering how this surgery differs from transplants, and specifically why transplants might not be a good option for someone suffering from COPD.

MICHAEL ARGENZIANO, MD:  To begin, with respect to the differences between lung volume reduction surgery and transplantation, transplantation really only has been an option for a little over a decade now, and involves removal of the diseased lung or lungs, and replacement of those lungs with a donor lung or lungs from another person.

This involves immunosuppression, which is required.  That is, medications which are required to prevent the patient from rejecting the new organs.  Lung volume reduction surgery, on the other hand, involves removal of small parts of the diseased lung, in hopes of allowing other areas of the lung, which are perhaps less diseased, to function more efficiently, and therefore does not require any immunosuppression or addition of new medications.  In fact, in many cases it allows patients to take less medication.

PAUL MONIZ:  Why isn't a lung transplant a good option for some patients, especially patients that are in their sixties and seventies?

MICHAEL ARGENZIANO, MD:  First of all, the main problem you have with any modality which involves transplantation, is donor supply.  There are literally millions of people in this country that suffer from COPD, and there are hundreds of thousands that are probably candidates for a transplant.  However, the number of organs is severely limited by the number of donors that are identified.

Specifically with respect to lung transplantation, the lungs are the organs, which are most delicate and which are most difficult to recover in good shape, or at least in good enough shape to be used for transplantation.  Beyond that, as you've mentioned, COPD is a disease that strikes the elderly population.  For that reason, because the immunosuppressive drugs that we use in transplantation can be problematic and even contraindicated in older patients, they are sometimes not a good combination.  For that reason, most centers will not transplant patients that are older than 65 or 70 years of age.

PAUL MONIZ:  Dr. Thomashow, let's bring you into this.  Months before surgery is actually undertaken, patients have to go under this strict regimen.  What does that regimen consist of?

BYRON THOMASHOW, MD:  We won't even evaluate anyone, whether it is part of the National Emphysema Treatment Trial, which is a randomized study of surgery versus medicine for this procedure, or in patients outside of the trial who are being evaluated, we won't even consider patients unless they've not smoked for at least six months.

The one modality of therapy that has clearly been beneficial in all forms of chronic obstructive lung disease is to stop smoking.  So we will not even begin testing them, unless they have not smoked for six months.

PAUL MONIZ:  Some might wonder, since the lung is already damaged, why does this six-month period make that much of a difference?

BYRON THOMASHOW, MD:  Mainly because of ongoing damage and ongoing risks.  Clearly active smokers are much more at risk than people who have stopped.  With time, when someone stops, there's at least a chance of some healing of the lung function -- indeed, anyone undergoing surgery of any type.  Not anything perhaps as controversial as lung volume reduction surgery, but any surgical procedure, has higher risks if the patients are actively smoking.

PAUL MONIZ:  So, stop smoking.  What about an exercise program?

BYRON THOMASHOW, MD:  It's absolutely crucial.  In part, to get patients in adequate shape for surgery, and in part to determine whether or not surgery has a role.  Because, remember, this operation is only for patients with very advanced disease, only for that subset of emphysema patients whose anatomy on CAT scan suggests that they're candidates.  One would only approach them surgically if on a maximum regimen, they were not able to function in a reasonable manner.

Part of that maximum regimen is an exercise program.  Indeed, it's important to remember that exercise, in some patients, can give them enough improvement to the quality of life that we don't have to consider anything as radical and as risky as an operative procedure.

PAUL MONIZ:  They have to watch their health, make sure they don't get colds or bronchitis or other problems.  They also should stop or reduce the amount of medications they take for their asthma?  Is that right?

BYRON THOMASHOW, MD:  Again, this is not an operation for asthma.

PAUL MONIZ:  Right, but some people have both.

BYRON THOMASHOW, MD:  Many patients, and we try to keep it as pure to the emphysema side as possible.  One of the medicines that many of these patients are on is a type of medicine called a steroid medication.  Steroids have many, many side effects.  They can be an important part of the regimen in patients with asthma or asthmatic bronchitis, particular in the inhaled form.  Inhaled steroids are probably the mainstay of medical regimens in that group now.

But many of the patients who have come to us for evaluation have come to us on fairly high doses of prednisone, a systemic steroid with many risks entailed to that.  Steroids really don't have much of a role in emphysema.

So, yes, we do attempt to get patients down to the lowest doses of steroids as possible.  We make sure that, heading into surgery, if indeed they're candidates, that they don't have an active bronchitic component or an active infection that would just that much more increase the risk. They exercise; they don't smoke.  We keep them in as good health as possible.  Indeed, if you look at the National Emphysema Treatment Trial itself, after the evaluation period, all patients go into an eight-week period of very aggressive rehabilitation.  And only at the end of that time are they reevaluated.  If they're still felt to be candidates, only then does the computer flip a coin to determine if they're randomized into medicine or surgery.  Both groups go right back into a rehabilitation program.

Indeed, one of the concerns, and it's related and it's important, is that while the data seems very clear in the literature over the last decade, pulmonary rehabilitation in patients with advanced chronic obstructive lung disease is of tremendous value.  One of the things which is so frustrating for many of us is that Medicare has no national policy in reimbursement for pulmonary rehabilitation.

Some areas of the country will pay for pulmonary rehabilitation, exercise, and some parts of the country will not.  One of our hopes is since it is part of both arms of this National Emphysema Treatment Trial, that ultimately this trial, whatever the end results are, whatever the ultimate decision in lung volume reduction surgery, it will lead to a national program of rehabilitation.

PAUL MONIZ:  Dr. Argenziano, let's say you are actually chosen for surgery.  Walk us through.  I understand we have some video of an actual surgery.  Maybe you can walk us through that.  Explain how the procedure's done and what we're seeing -- those kinds of things.

MICHAEL ARGENZIANO, MD:  The operation entails, as shown here, the chest is open.  It can be opened in a variety of ways.  Sternotomy is the most common way.  As you can see here, we allow one of the lungs to deflate.  By doing that, we're able to identify areas of the lung that do not deflate as well as others.

PAUL MONIZ:  Now, the lung that is allowed to deflate, is that the damaged lung?  Or both lungs are allowed to deflate and you look for the areas that are damaged?

MICHAEL ARGENZIANO, MD:  In this particular case, both lungs are being operated on, because the disease is usually affecting both sides, but we do one lung at a time.  Here we've identified an area of lung that does not deflate as well as the others.  This is corroborated, of course, with our preoperative workup and CAT scans and other tests.  You see here that we've identified the areas that are more diseased, and we're starting to prepare them for removal.

BYRON THOMASHOW, MD:  I don't mean to interrupt, Mike, but I think, in a normal person, where you're not ventilating the lung, it should be like a pancake.  You shouldn't have the tissue that you're seeing there.  That's all abnormal tissue.

MICHAEL ARGENZIANO, MD:  Right.  These lungs are severely over-inflated, as Byron says.  As you can see here, the stapling device is being applied.  One of the major advances that's allowed this operation to be performed, was Dr. Cooper's introduction of the bovine pericardial strips.  You can see white strips there that line the staple lines.  These have really reduced the major complication of this operation, which is prolonged leakage of air from the very tissue-paper thin lung.

PAUL MONIZ:  You mentioned bovine, is that strictly from cows?

MICHAEL ARGENZIANO, MD:  Right.  Bovine pericardium is pericardium, or the sac, which surrounds the heart from cows, which has been processed, sterilized, and thickened, so that it can act as a buttress.

BYRON THOMASHOW, MD:  A bandage, almost.

MICHAEL ARGENZIANO, MD:  You can see here that the bovine pericardium lines the staple line, and essentially... little micro-tears from occurring at the staple insertion sites.

PAUL MONIZ:  How long does the operation take?

MICHAEL ARGENZIANO, MD:  The operation varies in duration, and generally it takes about two to two and a half hours to actually perform the resections, including preparation and incision.  One of the most important parts of the operation is really the intra-operative evaluation of the lungs.

You see here that we extensively palpate or feel the lung, look at it in different positions before deciding what to resect, because it's critical that we resect the areas that are more diseased.

PAUL MONIZ:  Most people have probably never seen a lung before.  This is not a common organ that's shown even in some of the surgeries.  It looks, having seen it for the first time, almost like an inflated Portobello mushroom or something.

MICHAEL ARGENZIANO, MD:  What you should note about this lung in particular is the dark areas, actually, are very common.  Most of us that live in cities or near cities actually have areas of darkness in our lungs, which just relates to deposition of pollutants in the air.  But what's impressive about these lungs, which is not what you'd find in most lungs that you'd operate on, is that they're very ballooned, as you've said, and very inflated.

Notice now that, after the resection, after the removal of the more diseased parts of the lung, the lungs are much smaller than they were at the beginning of the segment that you're watching.  Here we're pouring water into the chest to test for air leaks, in a similar way that you would check for a leak in a tire.  These are the areas of the lung that have been removed.

PAUL MONIZ:  Now does the lung regenerate, doctor, or can someone live with smaller lungs, if the lungs that are in there are less diseased?

MICHAEL ARGENZIANO, MD:  The lung does not regenerate.  You should know, of course, that plenty of patients undergo much larger resections of lung for cancers and for other problems.  Most patients can tolerate living with as much as half or as little as half as much lung as they're born with. Of course, these patients have such poor function, that it's critical that we choose the areas that are most diseased.  Because if we remove areas that are actually working pretty well, and leave them only with very poorly functioning lung, they may not get off the table.

PAUL MONIZ:  A four-hour operation, about 3,000 have been done across the country.  How successful are these operations?  And what is the reasonable expectation of someone having it?

MICHAEL ARGENZIANO, MD:  The definition of success is important here.  Because when this operation was conceived, initially, and reintroduced by Joel Cooper, the main goal was to relieve patients' symptoms.  This was envisioned as a palliative operation.  That is, one that could ease the symptoms of patients, make their lives a little more palatable and a little more enjoyable, but no one really conceived that this operation would prolong the lives of patients significantly.

However, we have noticed, and we have recently written a paper about our experience, which in fact suggests that, in a select group of patients, this operation can not only improve symptoms, but potentially prolong life.  Now, of course, because we have no adequate control patients, that is, patients who have been randomized to medical therapy, it's impossible to make that conclusion until we get the results from the currently envisioned trial.

PAUL MONIZ:  What about the dangers, Dr. Argenziano?

MICHAEL ARGENZIANO, MD:  The dangers of thoracic surgery in general include things like infections, bleeding, critical events like heart attacks or strokes that can happen around the operation.  But these, really, cumulatively, only make up about 1-2%, in terms of total risk.

The major risk to patients undergoing this operation, is that if it were not that we were targeting areas that were more diseased, most of these patients would not be considered candidates for any sort of thoracic operation.  For instance, if a patient with severe emphysema has a lung cancer that only involves a small portion of the lung, which would normally be easily removed, many of those patients, historically and presently, are denied operation.  They're not considered to be strong enough to withstand an operation like this.

In fact, it's quite revolutionary that we're taking patients with such horrible lung function to the operating room.  Not just operating on them, but actually removing parts of their lung.  It's absolutely counter-intuitive that you'd be able to do this and have the patient survive.  The fact that they do survive attests to the stringent evaluation and identification of patients who have targeted areas that can be removed, with the hopes that other areas of the lung, which are less diseased -- not undiseased, but less diseased -- can re-expand, and function more efficiently.

PAUL MONIZ:  Dr. Argenziano, I'm going to give you the last word on this, since you perform the surgeries.  Give us a perspective for the future here.  What are we looking at in five or ten years, as it relates to lung volume reduction surgery?

MICHAEL ARGENZIANO, MD:  I think the most important thing that's going on now, and forward, is the National Emphysema Treatment Trial.  This is a randomized trial, as Byron has mentioned, which involves 17 centers around the country.  It is sponsored by the NHLBI and HCVA and is run by the National Institutes of Health.  This is a trial in which patients are being evaluated for lung reduction, are being identified as good candidates, and are being randomized either to receive the operation, or maximal medical therapy. These patients are being followed for a period of five to seven years.  We are now three years into the trial, and will soon begin to see the data.  Only with that sort of data will we be able to know for sure whether this is truly an operation that's going to have a future, in both the palliation of symptoms and possibly the prolongation of life.

PAUL MONIZ:  All right, doctor.  Thank you very much for your time.  Dr. Michael Argenziano, we appreciate your time, and Dr. Byron Thomashow as well.  Thanks a lot for being here.

Again, we should point out as we have, that not everyone is selected for this surgery.  Only four in ten patients are selected, and the operation costs about $40,000.  Not all insurance companies cover it.

I'm Paul Moniz.  Thank you very much for joining us.