ABSTRACT

Reduction pneumoplasty (RP), conceived by Brantigan in 1959 and modernized by Cooper more recently, entails a 25% to 30% surgical reduction of the lung volume through non-anatomical resection of functionless lung. It can either be carried out unilaterally or bilaterally through conventional open approaches or video-assisted thoracoscopic surgery (VATS). The aim of the operation is to allow a better function of the residual, less damaged lung tissue due to restored configuration towards normal of both the chest wall and diaphragm, improvement in lung elastic recoil with better expiratory flow, improvement in ventilation-perfusion matching and improvement of venous return. Excellent results with low morbidity have been achieved through bilateral reduction surgery (pneumoplasty) performed through median sternotomy or VATS. Similar results have also been achieved by unilateral reduction followed by delayed contralateral treatment through muscle sparing thoracotomy or thoracoscopy that may cause a reduced surgical trauma. However, the clinical outcome is not affected by the type of approach chosen, but rather by the operation itself, which is often performed in fragile and high-risk patients with compromised general and psychological status. On the other hand, comprehensive respiratory rehabilitation may contribute in reducing operative mortality and help optimise the clinical outcome. Nonetheless, it must be kept in mind that RP is a palliative treatment conceived to alleviate the disabling dyspnea of emphysematous patients who are often oxygen- and steroid- dependent and have a severely curtailed quality of life. Selection of surgical candidates is one of the keys for predicting a satisfactory outcome and is still evolving to allow recruitment of more and more patients. Advanced radiologic imaging techniques and detailed functional studies today allow precise identification of the degree and distribution of the damaged lung parenchyma, thus reliably supporting the surgeon in deciding which lung regions are to be targeted for resection without sacrificing functioning and vascularised lung tissue. While short-term clinical improvements have been widely reported after RP, the long-term effects are still under active investigation due to the lack of long-term follow-up data. Thus far, it is accepted that RP may bring about significant subjective and objective improvements as shown by assessment of dyspnea scores, spirometry, blood gas analysis and quality of life questionnaires. Large multi-institutional studies comparing RP with maximized medical therapy, including respiratory rehabilitation with longer follow-up, will probably give more definitive answers in this setting.