Background: Lung volume reduction surgery (LVRS) is an effective treatment for patients with severe emphysema. Most studies favor a bilateral approach over unilateral LVRS. However, there is limited literature comparing the outcomes of sequential bilateral “staged” versus simultaneous bilateral LVRS. Here, we evaluated the safety and effectiveness of these two approaches.
Methods: This retrospective cohort study included patients with severe emphysema who underwent LVRS at two tertiary referral centers. Pre- and postoperative-pulmonary function tests were used to assess outcomes. Descriptive statistics were used to explore associations between variables. For our survival analysis, we created a composite outcome combining overall survival and transplant-free survival, which was analyzed using Kaplan-Meier estimate and log-rank test. Cox proportional-hazard models identified factors associated with the composite outcome.
Results: The study included 81 patients, the majority of whom were male (n=42, 52%) with a median age of 65 years [interquartile range (IQR), 61–69 years]. Most underwent bilateral LVRS (n=60, 74%) while 21 (26%) had a staged approach. Baseline characteristics were similar between groups, except for age, with the bilateral group being significantly younger (P=0.03). Hospital length of stay was comparable between the bilateral {10.9 days [standard deviation (SD): 8.13] and staged LVRS groups [13.5 days (SD: 13.2)]} (P=0.40). Rates of pneumonia (13% vs. 10%, P>0.99) and prolonged air leak (42% vs. 38%, P=0.77) were similar between the bilateral and staged groups, respectively. The only significant difference in surgical complication was subcutaneous emphysema, which occurred more frequently in the staged group (33% vs. 12%, P=0.04). At 5 years, the composite outcome was better in the staged approach {90.0% [95% confidence interval (CI): 73.2–100.0%] over bilateral LVRS [82.8% (95% CI: 73.0–93.9)]} (P=0.044). Univariable analysis revealed that longer hospital stays [hazard ratio (HR): 1.06, 95% CI: 1.01–1.10], need for transfusion during surgery (HR: 4.48, 95% CI: 1.16–17.35), and subcutaneous emphysema (HR: 3.72, 95% CI: 1.05–13.20) were predictors of a worse composite outcome. Regarding pulmonary function tests, the median time from pre- to post-surgical assessment was 6 months for the bilateral group and 22 months for the staged group. Both groups showed significant improvements in pulmonary function from baseline values. In the staged approach, the predicted forced expiratory volume in 1 second increased from 29.1% to 43.7% (P<0.001), while in the bilateral group, it improved from 30.9% to 45.6% (P<0.001). Similarly, the predicted residual volume (RV) improved in the staged group from 227.3% to 160.8% (P<0.001), and in the bilateral group, it improved from 234.0% to 159.4% (P<0.001).
Conclusions: Staged LVRS offered similar hospital length of stay and complication rates as bilateral LVRS. Both approaches led to clinically significant improvements in pulmonary function. Notably, the staged approach showed a better composite outcome of overall survival and transplant-free survival over simultaneous bilateral LVRS.
Keywords: Intraoperative complications; length of stay; pneumonectomy; chronic obstructive pulmonary disease; survival
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Key findings
• Both staged and bilateral lung volume reduction surgery (LVRS) significantly improve pulmonary function tests compared to baseline values.
• The staged LVRS approach offers comparable hospital length of stay and complication rates to the bilateral LVRS approach.
• The staged LVRS approach is associated with a better composite outcome of overall survival and transplant-free survival than the bilateral LVRS approach.
What is known and what is new?
• LVRS is a well-established treatment for patients with advanced emphysema, with most studies favoring a simultaneous bilateral approach due to better overall outcomes. However, there is limited evidence comparing the staged versus simultaneous bilateral LVRS approach.
• This study found that both approaches led to similar improvements in pulmonary function, hospital length of stay, and surgical complication rates. However, the staged approach showed an advantage in the composite outcome of overall survival and transplant-free survival.
What is the implication and what should change now?
• A staged approach may offer survival benefits and allow patients to delay the need for a lung transplant longer compared to the bilateral approach. Since video-assisted thoracoscopic surgery has now replaced sternotomy as the standard for LVRS, there is no need to perform a bilateral operation when morbidity and length of stay are similar for staged unilateral operations. This study casts doubt on whether bilateral LVRS should be the default operation.
Cite this article as: Vaca-Cartagena BF, Lee-Mateus AY, Fernandez-Bussy S, et al. Evaluating the effectiveness of staged versus simultaneous bilateral lung volume reduction surgery in patients with severe emphysema. J Thorac Dis 2025;17(10):7711-7723. doi: 10.21037/jtd-2025-790