Zahid Imran, Sharif Sumera, Routledge Tom, Scarci Marco
Imperial College London, South Kensington Campus, London SW7 2AZ, UK.
Interact Cardiovasc Thorac Surg. 2011 Mar;12(3):480-6. doi: 10.1510/icvts.2010.252213. Epub 2010 Dec 5.
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether lung volume reduction surgery (LVRS) might be superior to medical treatment in the management of patients with severe emphysema. Overall 497 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that LVRS produces superior patient outcomes compared to medical treatment in terms of exercise capacity, lung function, quality of life and long-term (>1 year postoperative) survival. A large proportion of the best evidence on this topic is based on analysis of the National Emphysema Treatment Trial (NETT). Seven studies compared LVRS to medical treatment alone (MTA) using data generated by the NETT trial. They found higher quality of life scores (45.3 vs. 27.5, P<0.001), improved maximum ventilation (32.8 vs. 29.6 l/min, P=0.001) and lower exacerbation rate per person-year (0.27 vs. 0.37%, P=0.0005) with LVRS than MTA. Mortality rates for LVRS were greater up to one year (P=0.01), equivalent by three years (P=0.15) and lower after four years (P=0.06) postoperative compared to MTA. Patients with upper-lobe-predominant disease and low exercise capacity (0.36 vs. 0.54, P=0.003) benefited the most from undergoing LVRS rather than MTA in terms of probability of death at five years compared to patients with non-upper-lobe disease (0.38 vs. 0.45, P=0.03) or upper-lobe-disease with high exercise capacity (0.33 vs. 0.38, P=0.32). Five studies compared LVRS to MTA using data independent from the NETT trial. They found greater six-minute walking distances (433 vs. 300 m, P<0.002), improved total lung capacity (18.8 vs. 7.9% predicted, P<0.02) and quality of life scores (47 vs. 23.2, P<0.05) with LVRS compared to MTA. Even though LVRS has a much greater cost per person over five years ($137,000 vs. $100,200, P<0.001), its improved lung function, greater exercise capacity and better quality of life scores make it a preferable treatment option to MTA, with particular indications for patients with upper-lobe-predominant disease and low exercise capacity.
一篇胸外科最佳证据主题文章是按照结构化方案撰写的。所探讨的问题是，在重度肺气肿患者的治疗中，肺减容手术（LVRS）是否可能优于药物治疗。通过报告的检索共找到497篇论文，其中12篇代表了回答该临床问题的最佳证据。现将作者、期刊、出版日期和国家、所研究的患者群体、研究类型、相关结局和结果制成表格。我们得出结论，与药物治疗相比，LVRS在运动能力、肺功能、生活质量和长期（术后>1年）生存率方面能产生更优的患者结局。关于该主题的大部分最佳证据是基于对国家肺气肿治疗试验（NETT）的分析。七项研究使用NETT试验产生的数据将LVRS与单纯药物治疗（MTA）进行了比较。他们发现，与MTA相比，LVRS的生活质量评分更高（45.3对27.5，P<0.001）、最大通气量改善（32.8对29.6升/分钟，P=0.001）且每人每年的病情加重率更低（0.27对0.37%，P=0.0005）。与MTA相比，LVRS术后一年的死亡率更高（P=0.01），三年时相当（P=0.15），四年后更低（P=0.06）。与非上叶疾病患者（0.38对0.45，P=0.03）或上叶疾病且运动能力高的患者（0.33对0.38，P=0.32）相比，上叶为主型疾病且运动能力低的患者接受LVRS而非MTA在五年死亡概率方面获益最大（0.36对0.54，P=0.003）。五项研究使用独立于NETT试验的数据将LVRS与MTA进行了比较。他们发现，与MTA相比，LVRS的六分钟步行距离更长（433对300米，P<0.002）、总肺容量改善（18.8对预测值的7.9%，P<0.02）且生活质量评分更高（47对23.2，P<0.05）。尽管LVRS五年人均成本高得多（137,000美元对100,200美元，P<0.001），但其改善的肺功能、更大的运动能力和更好的生活质量评分使其成为比MTA更优的治疗选择，对上叶为主型疾病且运动能力低的患者有特别的适应证。
