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• How long do you have to stay in intensive care?  How much pain control is necessary?
• Will any immediate improvements be felt?
• How are lung leakage problems monitored?
• When can the full benefits of the surgery be expected?  What can the patient do to help the process along?

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

If you or someone close to you is planning on having this procedure, you certainly want to know what to expect after it's done, and what reasonable expectations are, in terms of your success rate.

Here to talk about some of the side effects, the healing periods, are two specialists who both diagnose and treat this condition, as well as operate.  We have Dr. Byron Thomashow, who is a pulmonologist at New York Presbyterian Hospital, and a clinical professor of medicine at Columbia University.  Thank you for joining us.  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 patient comes out of the operating room after this four-hour surgery.  What happens post-operatively?

MICHAEL ARGENZIANO, MD:  The patients who undergo lung volume reduction surgery are considered by us to be critically ill immediately post-operatively, because traditionally patients with such severe lung dysfunction really wouldn't even be considered candidates for any kind of surgery.  The fact that we're taking these patients to the operating room and resecting lung really increases our awareness of potential problems.

Post-operatively, the main issues are that we try to keep their fluid levels down.  The lungs don't tolerate a lot of fluid, especially after they've been operated on, especially if they're affected by emphysema.  In addition, the patients have what we call chest tubes, little plastic tubes that come out through their chest wall, that help to drain the air that invariably will leak from the areas of resection.

PAUL MONIZ:  How much pain are they in?  We're talking about lungs that are physically cut.

MICHAEL ARGENZIANO, MD:  Although the lungs are physically cut, believe it or not, there's absolutely no pain associated with the cutting of the lung.  However, there is significant pain associated with the incisions that we make to get to the lung.  The incisions are either a thoracotomy, which is an incision in the side of the chest, between the ribs, and involves cutting a lot of muscle.  The second is a sternotomy, which is an operation that's used, for instance, for heart surgery as well.

Both these operations can be associated with lots of pain, and for that reason, all of our patients receive what we call thoracic epidural catheters.  Catheters that are similar to those that are used in women who are delivering babies, in order to lessen the pain after the surgery.

PAUL MONIZ:  Will a patient see improvement right away?  Perhaps when they wake up?

MICHAEL ARGENZIANO, MD:  Before I move on, I do also want to mention that another option, in terms of approach, is also thoracoscopy.  There are surgeons that are performing this operation, and we have performed it, using thoracoscopes, which are little telescopes that are placed through small incisions in the chest.  In selected patients, this can be an option that can minimize the incisions and therefore the pain.

PAUL MONIZ:  In terms of the success rate, how soon after will a patient notice improvement?

MICHAEL ARGENZIANO, MD:  Because the patients have been under general anesthesia for a prolonged period of time and have had large incisions which cause pain, and therefore restricted motion of the chest, they will often not notice any improvement.  Certainly may feel worse for several days post-operatively.

In fact, we've found that the majority of our patients who have improvement do begin to notice it when they're still in the hospital.  Once they're out of the intensive care unit a few days after the surgery, and up and around, they can already note if they're going to have an improvement.  They are less short of breath.  They are able to walk more than they were before and are more comfortable.

PAUL MONIZ:  Average stay in the hospital?

MICHAEL ARGENZIANO, MD:  The average hospital stay, initially, in our experience, was many weeks, because of problems with air leakage, but in our more recent experience is between one and two weeks.

PAUL MONIZ:  All right, Dr. Thomashow, let's bring you into this.  The patient leaves the hospital and, I would imagine, comes to see you in short order.  What happens to the treatment, and the monitoring?

BYRON THOMASHOW, MD:  If they've had a beneficial result.  As you know, these people go through a very intensive evaluation to see if they're even candidates.  But even if they're candidates, even if they are candidates for the National Emphysema Treatment Trial or candidates for lung volume reduction outside of the trial, even if they're accepted, even if they're randomized to surgery, and even if they go into it, there's no guarantee that the operation is going to work.

It's one of the problems.  We don't really know for sure.  We have guesses now at who is better and who might benefit and who might not, but it's still a very complicated area.  But if they have the surgery, and if they get a benefit, then the response can be really quite dramatic at times.  Patients can come back to you a week or two after the surgery, and will tell you that they are breathing better than they have breathed for years.

A significant number of the patients who get a benefit, and unfortunately that's not all, a significant number of the patients who have a benefit may have reduced oxygen requirements.  We've had patients who no longer need to be on oxygen for periods of time.

PAUL MONIZ:  What percentage of the patients would you say are in the success bracket?

BYRON THOMASHOW, MD:  It's a hard question to absolutely answer.  The data in the literature is not as clear as you'd like it to be.  It's one of the driving forces behind this randomized study.  In our experience, I think it would be fair to say that, assuming you survive the operation, and it carries a life-threatening risk, but assuming you survive the operation, probably around 70% of our patients have had some degree of benefit.

But that benefit can vary tremendously.  Some people can have dramatic improvements in quality of life and function.  Some of the improvements are much milder.  One of the things that has to be weighed in all of this, is that even in those patients who have the most dramatic responses, and we've all seen them, it's not a cure for their disease.  They still have emphysema, and with time the emphysema will progress.  The potential exists even if they get a great response, a year or two or three or four down the line, they will start sliding back to where they started.

We have had had patients who are out, now, five years and are still certainly better than they were when we started.  But we've also had patients who, a year or two out after the operation, even though they seemed to improve initially, are sliding back to where they came from.

PAUL MONIZ:  We should point out, and this is very important, that the mortality rate for this particular operation is fairly high.  What are we talking about?  One in 10 or one in 20 people don't survive?  Or is it less than that.

MICHAEL ARGENZIANO, MD:  The mortality right now, reported from the centers that are doing the most lung reduction, is about 5%.  And is certainly higher than that for all lung surgery that's done in the country, which is certainly less than 1%, but not nearly as high as you might expect if you tried to do lung surgery in patients with this degree of emphysema before the current experience.

We consider a mortality rate of 5% to be, certainly, reasonable in this very sick group of patients.  But we've only been able to achieve that low mortality rate by selecting patients carefully, and by putting together teams, multidisciplinary teams, of pulmonologists, critical care doctors, and surgeons that care for these patients after surgery.

PAUL MONIZ:  So there are certainly a lot of people involved in the team effort to get the patients going.  What does the future hold for patients who may not be able to have this surgery for one reason or another?  What's happening?

BYRON THOMASHOW, MD:  I think it's important to stress that this surgery, even if it works, and even if the National Emphysema Treatment Trial proves that, it's a palliative procedure.  It's not a cure for their disease.  I think we would all agree that radical surgical procedures like lung volume reduction, like transplantation, while they are options, are not ideal options for patients with emphysema.

Ideally, in the best of possible worlds, you wish no one would ever smoke any more, so that perhaps the incidence of the disease would decrease.  That would be more important than anything.

But in those patients with disease that has developed and is significant, there is a potential option that's out there.  I think many of us are skeptical about its benefits in people, but it's going to be looked at, and that's Vitamin-A derivatives.  Retinoic acid.

PAUL MONIZ:  Administered how?  Orally, or --?

BYRON THOMASHOW, MD:  In general, this would be oral.  There was a study done in rats, published in Nature several years ago, which suggested the potential that this might lead to growth of new lung.  Now, there's a large step between that animal model and people.  But there was enough interest that the National Institute of Health is now starting a new study called the Forte Study.  We're one of five centers around the country that's going to be participating in that study, which will look at Vitamin-A derivatives, retinoic acid, in patients with emphysema.

If the preliminary results of this short-term study are suggestive, then perhaps a much longer-term study would be embarked upon.  That, a medical approach to grow new lung, would certainly be preferable than surgical procedures that carry tremendous risk, and unclear long-term benefits.

PAUL MONIZ:  Dr. Argenziano, a final word from you on what you want people watching this webcast to know about lung volume reduction surgery, and reasonable expectations for it.

MICHAEL ARGENZIANO, MD:  People should know that, although there's been a lot of press in this area, it's still an operation in its infancy.  Over the last hundred years, at least 10 other operations have been conceived, most with enthusiasm, for the treatment of emphysema, and each of these has been scrapped after it's been shown that, either it didn't work, or it was associated with too much morbidity and mortality.

We believe that this operation can be performed with low risk of death and side effects, if patients are selected carefully.  We also believe that the operations could be studied more.  What people should know is that this is an option for them if they meet specific criteria.  Over the next few years, as the results of the National Emphysema Treatment Trial are released, we'll know better not only how well the operation works, but also, importantly, for which patients it works.

PAUL MONIZ:  Thank you very much, Dr. Michael Argenziano.  We certainly appreciate your time.  And Dr. Byron Thomashow, your time as well.

It is important to keep in mind, again, that not all patients are selected for this operation.  COPD is the fourth leading cause of death in the United States.  Its chief cause is smoking, so this is yet one more reason to stop, or perhaps not start, if that's an option.

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