Non-transplant surgical interventions for emphysema

Anthony P C Yim 嚴秉泉

HK Pract 2007;29:41-42

Emphysema is one of the very common chronic diseases seen among the elderly population often caused by smoking, and is responsible for billions of dollars in healthcare expenses every year. The commonest symptom of emphysema is chronic dyspnoea which could be very debilitating, and seriously affect one's quality of life. Medical therapy has only limited success. For a long time until recently, emphysema has not been considered a surgical condition except for transplantation which can only benefit a very tiny fraction of patients. In fact, it may be counter-intuitive to imagine that such a disease could have a mechanical solution.

Emphysema is one of the very common chronic diseases seen among the elderly population often caused by smoking, and is responsible for billions of dollars in healthcare expenses every year. The commonest symptom of emphysema is chronic dyspnoea which could be very debilitating, and seriously affect one's quality of life. Medical therapy has only limited success. For a long time until recently, emphysema has not been considered a surgical condition except for transplantation which can only benefit a very tiny fraction of patients. In fact, it may be counter-intuitive to imagine that such a disease could have a mechanical solution. In this issue of The Hong Kong Practitioner, Sihoe and Chan are to be congratulated for giving us an overview on this new, exciting field of surgical intervention for emphysema. The basic pathophysiology of this condition is the loss of elastic recoil, and as the total lung volume increases, the diaphragms are pushed down and cannot function properly. By reducing the lung volume, the respiratory mechanics (including functioning of the diaphragms) is greatly improved. The current options available include lung volume reduction surgery (LVRS) and placement of endobronchial valves (EBV) - the former involves surgical removal of the most emphysematous, functionless lung tissue, and the latter involves bronchoscopic placement of one-way valves in the airway to achieve selective atelectasis or "medical" lung volume reduction. Both options require identification of target areas in the lung - a heterogeneous pattern of emphysema. CT thorax and ventilation perfusion (VQ) scan are useful tests in selecting patients for surgical intervention. The published intermediate and long term results (including those from our unit) for both LVRS and EBV for selected patients are most encouraging.¹

A multi-disciplinary approach is crucial to the success of emphysema surgery. A dedicated team of pulmonologist, physiotherapist, anaesthetist, intensivist and surgeon is important in selecting patients, preparing them for surgery and providing perioperative care. Family physicians also play a critical role in the care of patients with emphysema as they can help to select patients as well as participating in the follow up. They should be kept up to date with the current and emerging treatment modalities for this debilitating condition. Hopefully, by working together, we can bring back quality of life to these unfortunate patients with emphysema.