An operation frozen in 2003
Lung volume reduction surgery, twenty-five years after NETT

Lung volume reduction surgery carries a reputation it earned a quarter of a century ago and has spent twenty-five years failing to shake: dangerous, narrow, a last resort for a small group of patients. That reputation has outlived the operation it describes.

A template set in 2003

The National Emphysema Treatment Trial settled a long argument. It showed that removing the most destroyed regions of an emphysematous lung could improve breathlessness, exercise capacity and quality of life — but it also drew the boundaries narrowly. Benefit was clearest in upper-lobe-predominant disease with low exercise capacity, and a high-risk subgroup suffered enough perioperative mortality to mark the whole procedure as hazardous. The lesson the field took from it was caution. For two decades the template barely moved: upper lobes, a select few, and a wariness that kept referrals low.

The operation moved on; the reputation did not

Those criteria were a snapshot of what was safe in 2003, not a permanent ceiling. Contemporary series tell a different story. The Leuven group's five-year data, published in the European Respiratory Journal this year, report near-zero mortality and durable gains in lung function and quality of life — including in patients who fall outside the classic trial criteria, and across different emphysema morphologies, not only the upper lobes. The change is not a new operation. It is better patient selection, minimally invasive surgery and enhanced recovery — the same shifts that have made other thoracic procedures safer over the same period. I saw this directly when our team spent time with the Leuven unit, and it has changed how we work.

What modern selection looks like

Three things now define how we assess these patients, and each is a deliberate departure from the 2003 template.

• Every patient is discussed at a multidisciplinary meeting that includes the transplant team; I am the only surgeon in our service performing both lung volume reduction and endobronchial valve procedures. Lung volume reduction is never considered in isolation — it sits on a continuum that runs from valves through surgery to transplantation, and the meeting's task is to place each person at the right point on it rather than default them to one option.
• We offer surgery for lower-lobe disease where the emphysema is anatomically located there on HRCT, not only for the upper-lobe pattern the trial favoured. Emphysema does not always sit where the evidence expected it to.
• Every patient has functional imaging with V/Q SPECT-CT — ventilation–perfusion single-photon emission CT with krypton ventilation — with a nuclear-medicine physician experienced in it present at every meeting. A CT scan shows where the lung is destroyed; functional imaging shows where it has stopped working. Choosing the surgical target by physiology, not appearance alone, is in my view the single most important reason modern outcomes look the way they do. It is not a step every centre takes for every patient.

The patients I now take to theatre for lung volume reduction look different from the narrow group the trial defined — and they do well.

Expanded, not unlimited

None of this means lung volume reduction is for everyone. The reason these outcomes hold is precisely that selection is rigorous — that every case passes through an experienced multidisciplinary meeting with the imaging, surgical and transplant expertise to say no as readily as yes. The lesson of the modern data is not that the original criteria were wrong; it is that they were a starting point treated as a limit. Widening selection works only inside that discipline. Loosened without it, the old mortality returns.

What the reputation costs

A reputation is useful until it stops describing reality. Lung volume reduction surgery spent two decades measured against a single trial, and many patients who might have breathed more easily were quietly judged unsuitable by a standard that had already moved on. The work now is unglamorous: to assess each person against what the operation has become, not against what it was in 2003.

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