ABSTRACT
Lung volume reduction surgery (LVRS) has been the most controversial
topic in the management of patients with emphysema over the past decade. Given the modest efficacy of medical therapies for emphysema, the limited
availability and drawbacks of lung transplantation and the significant eco-
nomic burden of emphysema (1), the great enthusiasm that the reintroduc-
tion of LVRS (2,3) created in the medical and surgical communities was
justifiable. The early enthusiasm for this procedure was bolstered by a num-
ber of optimistic publications suggesting that LVRS improves lung function
(4), exercise capacity (5-9), dyspnea (7,10), and even survival (11). Unfor-
tunately, these early clinical reports were limited by their nonrandomized design, small study size, incomplete follow-up (12), focus on short-term
results and their use of nonobjective or inconsistent selection criteria. As
a result, the rising popularity of LVRS was paralleled by a growing unease
about its true efficacy, risk-benefit ratio and cost-effectiveness. These con-
cerns were articulated in a number of reviews (13,14), editorials (15-17),
and two federal reports (18,19). Ultimately, this encouraged the development
of the National Emphysema Treatment Trial (NETT) (20), a unique collaborative effort between the National Heart, Lung and Blood Institute of
the National Institutes of Health and the Health Care Financing Adminis-
tration (HCFA). The results of the NETT, published in two key manuscripts
to date have provided significant progress toward answering important
questions about LVRS relating to operative mortality, procedural efficacy,
and subject selection criteria, which could only have been answered
adequately using such a large randomized controlled clinical trial
design (21,22).
