Surgery holds hope in fight for breath Operation: A once- discredited procedure might be the best option for some emphysema patients. But its revival raises questions about risks and benefits.

June 10, 1996|By Jonathan Bor | Jonathan Bor,University of Maryland Medical Center Pub Date: 6/10/96 SUN STAFF

A once-discredited operation that was designed to ease the misery of emphysema is winning a new following among doctors who have little else to offer people struggling for every breath.

But even as the procedure is restoring vitality to hundreds of patients -- most of them former smokers -- its revival has raised concerns that it is being performed too widely without conclusive evidence of how well or how often it works.

The federal government in January withdrew Medicare coverage until a clinical trial resolves questions. The suspension, by the Health Care Financing Administration, has stopped federal spending for a procedure that costs $30,000 to $70,000 and could be sought by tens of thousands of patients a year.

"I think it stinks," said Charles Ford, 69, of Baltimore, who is

among many patients and doctors angered by the decision. He was forced to cancel his March 13 surgery date at the University of Maryland Medical Center. "It's definitely a blow to the elderly because they are the ones who are suffering with emphysema."

Known as volume reduction surgery, the operation works on the premise that people who fight for air because their lungs are permanently overinflated might feel better if their lungs were made smaller. Surgeons staple off and remove about 30 percent of the lung, giving the remainder more room to expand and contract.

Patients such as Edward Churchman of Glen Burnie, who was referred last year to a highly regarded program at the UM Medical Center, say the operation has made it possible to do ordinary things like walk down the block.

"I got to the point where I didn't care if I got up in the morning or not," said Churchman, 76, a retired real estate salesman who spent most of his time stationed in front of the television set, tethered to an oxygen machine. "This has revitalized me."

The medical center, which has done about 65 lung reductions, has by far the largest program in metropolitan Baltimore. Johns Hopkins Hospital has performed less than 20 lung reductions, while Sinai Hospital, Union Memorial Hospital and Northwest Hospital Center have each done a few.

The procedure is something of a throwback, pioneered in the 1950s by the late Otto Brantigan, a University of Maryland surgeon who achieved some remarkable successes but sustained unacceptably high death rates. Three years ago, a St. Louis surgeon instigated a revival -- using modern techniques that have generally made the operation safer.

Volume reduction might be the only option besides a lung transplant for many patients who are desperate to escape a condition that makes them feel they are suffocating. For those over 70, it might be the only alternative because they are too old to qualify for a transplant.

Even the most staunch advocates say they have no idea how long the beneficial effects will last and whether it will lengthen life. For the time being, surgeons can make one claim: It helps some patients to breathe more easily.

"Now, our main goal is to make the patients symptomatically better," said Dr. Mark Krasna, UM's director of thoracic surgery. "We are not proposing that this operation will prolong life."

Many patients, however, don't need the promise of longer life. The prospect of taking a deep breath for the first time in years is enticement enough.

Emphysema, which afflicts about 2 million Americans, is a fatal disease that slowly robs people of their ability to breathe. Tobacco smoke is almost always the culprit -- destroying lung tissue needed for the healthy exchange of oxygen and carbon dioxide.

"Breathe in as far as you can. Now live there for the rest of your life," said Dr. Joel D. Cooper, the Washington University surgeon who revived the operation.

Today, doctors marvel at the gutsy ingenuity of Brantigan, who envisioned the simple but radical approach to improving the lungs' mechanics. Cutting their size to make them work better seemed illogical to many doctors, but he figured the approach would literally provide breathing room.

And he was right, to a point.

"Patients got better," said Dr. Jonathan Orens, a UM pulmonary specialist. "They had less shortness of breath and were able to walk better, get out and shop -- things they hadn't been able to do for many years."

On the other hand, six of 33 patients died as a consequence of surgery, a mortality rate of almost 20 percent. Also, Brantigan was loose in measuring improvements or documenting why certain people died -- data needed for a treatment to become established.

Revival after obscurity

The operation drifted into obscurity until Cooper, a well-known transplant surgeon, heard about it from a Canadian colleague in the early 1990s. At first he thought it quaint and mentally filed it away.

Its potential became apparent to him as he observed how nicely a transplanted lung -- so much smaller than the diseased original -- functioned in the chest cavity. At the same time, he realized surgical advances associated with transplants could make the operation less risky.

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