Emphysema Surgery: Surgical Lung Volume Reduction and Surgical Treatment of Pulmonary Emphysema

In emphysema (often a consequence of COPD), the tiny air sacs in the lungs are destroyed. Large, flaccid air spaces form. As a result, the air that is inhaled can no longer be fully exhaled (air trapping). This leads to severe lung hyperinflation. The problem is mechanical: The overinflated lungs push the diaphragm flat downward. The diaphragm, our most important respiratory muscle, can no longer function effectively. Emphysema surgery aims to correct this mechanical issue.

Not every patient is a suitable candidate for surgery. The decision regarding surgical indications is made on an interdisciplinary basis by pulmonologists and thoracic surgeons at a specialized center.

The evaluation includes:

• Pulmonary function tests: Measurement of lung capacity.
• Computed tomography (CT) of the chest: To assess the distribution of emphysema (e.g., primarily in the upper lobes).
• Perfusion scintigraphy: Shows which areas still have blood flow.

Surgery is usually indicated when severe symptoms persist despite maximal conservative and medical therapy and the lung tissue is affected heterogeneously (unevenly).

Precision medicine in thoracic surgery: Digital planning of lung volume reduction for the treatment of advanced emphysema.

The Department of Thoracic Surgery employs various procedures, which are selected based on the patient’s findings.

1. Lung Volume Reduction (LVR)

Lung volume reduction (LVRS—Lung Volume Reduction Surgery) is the standard procedure. In this procedure, the most severely damaged, non-functional lung tissue (usually at the tips of the lung lobes) is resected (removed).

• Effect: By reducing lung volume by approximately 20–30%, the adjacent tissue that is still functional can expand again. The diaphragm rises again and can work more effectively.
• Method: Today, the procedure is almost always performed using a minimally invasive technique via video-assisted thoracoscopy (VATS). A large incision in the chest (thoracotomy or sternotomy) is now rarely necessary. This keeps postoperative morbidity low.

2. Bullectomy

Some patients suffer from so-called “giant bullae.” A bulla is a large, air-filled sac that displaces healthy tissue. During a bullectomy, these bullae are surgically removed. This immediately relieves pressure on the thorax and improves ventilation of the remaining lung.

3. Endobronchial valves (non-surgical)

Endoscopic lung volume reduction is an alternative to resection. In this procedure, small valves are inserted into the airways (bronchi) via bronchoscopy. These valves allow air to escape from the diseased areas but prevent new air from entering. This results in a targeted collapse (atelectasis) of the diseased lung lobe. Although this is an invasive procedure—and, strictly speaking, falls under the category of interventional pulmonology—it is often evaluated in the context of emphysema treatment.

Studies have shown that surgical lung volume reduction offers advantages over drug therapy in selected patients:

• Improved lung function (FEV1).
• Increased physical endurance (walking distance).
• Improved quality of life and survival rates for specific types of emphysema.

Since the tissue is often very delicate, modern surgical techniques (e.g., staplers with reinforced non-woven fabric) are used to prevent air leaks (fistulas). Intensive physical therapy and breathing exercises are essential after surgery.

Emphysema surgery is not a cure for the underlying disease COPD, but it is a highly effective therapeutic and palliative measure. Through the surgical removal of overinflated areas, patients literally get “a new lease on life.” Whether lung volume reduction, bullectomy, or valve implantation offers the best results must be determined on a case-by-case basis at a thoracic surgery clinic.

When is lung volume reduction recommended?

Surgical lung volume reduction (LVRS) is indicated in cases of severe emphysema that is unevenly distributed (heterogeneous emphysema), usually concentrated in the upper lobes. Patients must suffer from severe shortness of breath despite optimal medication but still have sufficient residual lung capacity to undergo anesthesia.

How is the surgery performed?

The procedure is usually performed using minimally invasive keyhole surgery (video-assisted thoracoscopy, VATS). A camera and instruments are inserted through small incisions on the side of the chest. The affected areas are resected using special stapling devices. The procedure is gentle and avoids large incisions.

What is the difference between a bullectomy and volume reduction?

In a bullectomy, a single (or a few) giant air bubble (bulla) that is displacing healthy tissue is specifically removed. In lung volume reduction, on the other hand, diffuse, damaged emphysematous tissue (entire areas of a lobe) is removed to reduce overall overinflation.

What are the risks of the surgery?

As with any lung surgery, there are risks. The most common problem is a persistent air leak, since the emphysematous tissue is very fragile. For this reason, negative-pressure drains are often used. Serious complications, such as a pleural empyema (abscess), are rare. Before surgery, doctors also assess whether other risk factors (such as heart disease or cancer) are present.

Are there alternatives to surgery?

Yes, interventional procedures are an option for patients who are too ill for surgery or who have homogeneous emphysema. These include valves that are inserted endoscopically into the bronchi (valve therapy) or coils. These procedures do not require incisions but are performed through the trachea.