Bronchoscopic Lung Volume Reduction After Surgical Fissure Completion Is Not Ready for Prime Time.

We read with interest the report in CHEST by Shafiq et al1Shafiq M. Polhemus E. Perkins R. Forth V. Marshall M.B. Bilateral bronchoscopic lung volume reduction after surgical fissure completion.Chest. 2022; 162: e73-e75Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar that described a patient with severe emphysema and hyperinflation despite a left upper lobe bronchoscopic lung volume reduction (BLVR) procedure. The authors describe treating their patient’s persistent hyperinflation with thoracoscopic fissure completion for incomplete right-sided interlobar fissures followed by endobronchial valve (EBV) placement. The authors reported that surgically eliminating collateral ventilation allowed for successful EBV-mediated BLVR, which improved the patient’s functional status and pulmonary physiology. We agree with the authors that this approach has the potential to expand dramatically the pool of patients who would benefit from BLVR that are either not candidates for traditional surgical techniques or have incomplete fissures that result in collateral ventilation that frustrates successful BLVR. Indeed, estimates of the prevalence of incomplete interlobar fissures vary but may be as high as 74% to 90%.2Fishman A. Martinez F. Naunheim K. et al.A randomized trial comparing lung-volume–reduction surgery with medical therapy for severe emphysema.N Engl J Med. 2003; 348: 2059-2073Crossref PubMed Scopus (1715) Google Scholar As Shafiq et al1Shafiq M. Polhemus E. Perkins R. Forth V. Marshall M.B. Bilateral bronchoscopic lung volume reduction after surgical fissure completion.Chest. 2022; 162: e73-e75Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar note, traditional lung volume reduction surgery not only improves pulmonary function, exercise capacity, quality of life, and survival but also is associated with increased perioperative morbidity and death.2Fishman A. Martinez F. Naunheim K. et al.A randomized trial comparing lung-volume–reduction surgery with medical therapy for severe emphysema.N Engl J Med. 2003; 348: 2059-2073Crossref PubMed Scopus (1715) Google Scholar In contrast, bronchoscopic LVR with the use of EBVs is less invasive, allows for reversibility in the event of a complication, and provides similar improvements in pulmonary physiology, quality of life, and exercise capacity.3Labarca G. Uribe J.P. Pacheco C. et al.Bronchoscopic lung volume reduction with endobronchial zephyr valves for severe emphysema: a systematic review and meta-analysis.Respiration. 2019; 98: 268-278Crossref PubMed Scopus (21) Google Scholar The combined thoracoscopic fissure completion and EBV placement approach described by Shafiq et al1Shafiq M. Polhemus E. Perkins R. Forth V. Marshall M.B. Bilateral bronchoscopic lung volume reduction after surgical fissure completion.Chest. 2022; 162: e73-e75Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar has been under active investigation by our group. After having shown the efficacy of such an approach in an animal model,4Majid A. Kheir F. Alape D. et al.Combined thoracoscopic surgical stapling and endobronchial valve placement for lung volume reduction with incomplete lobar fissures.J Bronchol Interv Pulmonol. 2020; 27: 128-134Crossref PubMed Scopus (7) Google Scholar we currently are conducting two prospective trials. The COMPLETE-1 trial5National Institutes of Health Clinical Center. Combined Zephyr valve system with inter-lobar fissure completion for lung volume reduction in emphysema (COMPLETE-1). NCT04801108. ClinicalTrials.gov. National Institutes of Health.https://clinicaltrials.gov/ct2/show/NCT04801108Google Scholar is a randomized controled study that compares medical management to thoracoscopic fissure completion followed by EBV placement for BLVR in patients with incomplete lobar fissures. On the other hand, the SAVED-1 trial6National Institutes of Health Clinical Center. Inter-lobar fissure completion in patients with failed bronchoscopic lung volume reduction (SAVED-1). NCT05257681. ClinicalTrials.gov. National Institutes of Health.https://clinicaltrials.gov/ct2/show/NCT05257681Google Scholar is a prospective observational study that evaluates the potential role of thoracoscopic fissure completion with pleural adhesiolysis in patients with severe emphysema who failed BLVR via the use of EBVs. We have reported our experience with the initial patients enrolled in these trials7Majid A. Ospina-Delgado D. Kheir F. Parikh M. Spector R. Gangadharan S.P. Thoracoscopic surgical stapling as salvage therapy for failed endobronchial valve treatment in patients with incomplete lobar fissures: initial experience.J Bronchol Interv Pulmonol. 2021; 29: e4-e7Crossref Scopus (1) Google Scholar and plan to report our complete results soon. Nevertheless, in our experience, patient outcomes after this procedure are heterogenous, and despite the minimally invasive approach, complications may occur. Moreover, although Shafiq et al1Shafiq M. Polhemus E. Perkins R. Forth V. Marshall M.B. Bilateral bronchoscopic lung volume reduction after surgical fissure completion.Chest. 2022; 162: e73-e75Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar report improvements in their patient’s pulmonary function tests and respiratory symptoms, the existing evidence base for BLVR should not be extrapolated to patients who must undergo thoracoscopic fissure completion before successful EBV placement. For this reason, we urge that patients undergo this combined procedure exclusively in the context of a clinical trial. Financial/nonfinancial disclosures: The authors have reported to CHEST the following: A. M. is the principal investigator of the COMPLETE-1 trial sponsored by Pulmon-X. None declared (B. R., S. G., D. O. D.). Bilateral Bronchoscopic Lung Volume Reduction After Surgical Fissure CompletionCHESTVol. 162Issue 2PreviewAlthough bilateral lung volume reduction surgery has been shown to be safe and effective in carefully selected patients with upper lobe-predominant emphysema and hyperinflation, bronchoscopic lung volume reduction via placement of endobronchial valves is conventionally performed only unilaterally. Furthermore, it is not offered to patients with interlobar collateral ventilation because of the lack of clinical efficacy. We describe two novel management approaches including (1) bilateral bronchoscopic lung volume reduction, and (2) a combined thoracic surgical and interventional pulmonary procedure involving surgical fissure completion followed by endobronchial valve placement, which culminated in safe and effective lung volume reduction of both lungs along with an excellent patient outcome. Full-Text PDF ResponseCHESTVol. 163Issue 1PreviewWe are humbled to receive enthusiastic and very positive feedback–both nationwide and from overseas–on our novel management approach in a patient with severely hyperinflated emphysema that was published in CHEST (August 2022).1 To recap, we described the following two management paradigms that pertain to bronchoscopic lung volume reduction (BLVR) via endobronchial valves: (1) Patients with an incomplete interlobar fissure potentially can undergo minimally invasive surgical fissure completion followed by successful endobronchial valve placement in a single anesthesia session without prolongation of hospital length of stay. Full-Text PDF