Surgical treatment of chronic obstructive pulmonary disease: Which procedure for which disease?

The main treatments for emphysema are preventive measures, medical and oxygen therapy, rehabilitation and surgical procedures. Among the surgical options the lung volume reduction surgery (LVRS) and the lung transplantation are useful interventions, although applicable only to a selected number of patients. Since the late 1950s and 1960s these techniques have been tried out but the high postoperative mortality and the scarce medical treatment made these procedures not beneficial. In recent years, improvement of surgical techniques and of postoperative respiratory and intensive management, as well as new immunosuppressive regimens to treat rejection, have contributed to the amelioration of results and clinical outcome. As regard to results and indications, we can say that LVRS is an efficacious measure to improve respiratory function and clinical condition for a small number of patients; nowadays, the selection of these candidates has been well described. Transplantation appears as the last option for very compromised patients; up to a few years ago this procedure failed to improve life expectancy; on the contrary in the last few years, thanks to a better patient selection and to improvement of surgical techniques and medical treatments, these patients, apart from radical improvement of quality of life, can also experience an amelioration of life expectancy changing the natural history of the disease. These procedures can interestingly interact each other: LVRS can be a bridge to transplantation, but in few and selected cases both procedures can be alternatively considered, while in other cases LVRS has been used to ameliorate lung function in patients after single transplantation with graft failure. The current paper reviews the actual knowledge on LVRS and transplantation, discussing about indications and contraindications, patients selection, pre-operative evaluation, timing and choice of procedures.