Lung Volume Reduction Surgery
Lung volume reduction surgery (LVRS) for patients with severe emphysema has been shown in a large prospective, randomized, controlled trial to provide a survival advantage in selected patients with predominantly upper lobe emphysema and low exercise capacity. Patients with an FEV1 of < 20% predicted and either homogeneous emphysema or a Dlco of 20% predicted. However, Mentzer and Swanson have suggested a more aggressive approach. They consider LVRS for patients with severe dyspnea, hypoxia and hypercapnea, and poor lung function (including patients with an FEV1 of < 20% predicted), provided there was heterogeneous emphysema and some potential for the recruitment of relatively preserved lung tissue.
A retrospective analysis of 300 patients undergoing lung cancer surgical resection found that postoperative pulmonary complication rates for patients who had quit smoking > 2 months prior to undergoing the operation were similar to those who had quit within 2 months of the surgery (19% vs 23%, respectively; p > 0.05). Another retrospective study of 288 consecutive patients undergoing pulmonary surgery suggested that smoking abstinence of at least 4 weeks may be associated with reduced perioperative respiratory complications. Prospective, controlled trials are needed to more clearly define the effect that smoking cessation preoperatively might have on reducing perioperative problems. However, smoking cessation should be strongly encouraged at the time of diagnosis of lung cancer because it might reduce the development of metachronous tumors (see the chapter on “Follow-up and Surveillance”). Give up smoking immense with drugs of My Canadian Pharmacy.
As yet, there are no robust data to recommend the routine use of preoperative pulmonary rehabilitation for patients with lung cancer. However, there is some information suggesting that pulmonary rehabilitation might be helpful in preparing patients for LVRS. In the National Emphysema Treatment Trial, all patients underwent pulmonary rehabilitation prior to randomization to either receive medical treatment or undergo LVRS. Pulmonary rehabilitation provided important benefits in dyspnea, quality of life, and exercise ability. Although there was no comparison group for the pulmonary rehabilitation portion of the study, overall, rehabilitation was thought to play an important role in preparing patients for LVRS. The effects of pulmonary rehabilitation should be evaluated in future studies of patients being prepared for both lung cancer resection and LVRS.
In patients with very poor lung function and a lung cancer in an area of upper lobe emphysema, it is recommended that combined LVRS and lung cancer resection be considered if both the FEV1 and the Dlco are > 20% predicted. Grade of recommendation, 1C
It is recommended that all patients with lung cancer be counseled regarding smoking cessation. Grade of recommendation, 1C