Update on lung volume reduction.

Lung-volume reduction surgery was a forgotten chapter in the history of thoracic surgery until it was reincarnated in a new form in 1994. The first report of 20 patients presented startlingly good results with minimal morbidity and mortality and interest in the procedure rapidly disseminated among the thoracic surgical community [1]. Within 2 years over a dozen additional article appeared from other institutions describing small patient series, all of which corroborated the original report describing benefit from the procedure. Lung-volume reduction surgery (LVRS) appeared to be the answer to the prayers of patients with end-stage emphysema who heretofore had little to look forward to other than a slow inexorable decline toward increased breathlessness and death. Not surprisingly, patients in the hundreds flocked to hospitals seeking this surgical redress. Unfortunately, not all clinical results were as beneficial as those that had been published. Most of the published series had low mortalities and significant clinical improvement, but they had short-term follow-up that was often somewhat incomplete. The only early study of significant size in which there was complete mortality data was the Medicare series of 722 patients operated on between October 1995 and January 1996. The 3-, 12-, and 18-month mortalities were 14, 23, and 28%, respectively [2]. Not only did these exceed the previously reported mortality, the report also noted that the number of hospitalizations actually increased rather than decreased following the LVRS procedures. Within the Health Care Finance Administration (HCFA) there was a significant concern regarding these results and the potential morbidity from LVRS on a nationwide basis. These factors as well as questions regarding the durability of