The efficacy-invasiveness trade-off: a retrospective cohort comparison of surgical operation and endobronchial valves for refractory lung bullae disease.

backgroundThe optimal intervention for refractory bullae lung disease remains debated, with a choice between invasive surgical operation (SO) and the minimally invasive endobronchial valve (EBV). A comprehensive comparison of their long-term efficacy, safety, and cost is crucial for clinical decision-making.

objectiveTo compare perioperative outcomes, 1-year efficacy, long-term recurrence-free survival, and economic impact between surgical bullectomy (SO) and endobronchial valve (EBV) placement.

methodsIn this comparative study, 673 patients with refractory bullae disease from two Chinese centers were enrolled (SO: n = 436; EBV: n = 237). This study enrolled patients with refractory bullous disease, defined by HRCT-confirmed bullae > 10 cm in diameter or concomitant symptoms impacting daily life, and an inadequate clinical response to a minimum of 3 months of optimized medical management. After applying propensity score matching (PSM) to control for confounding factors, perioperative outcomes, 1-year efficacy, and long-term recurrence‑free survival were compared between the two groups. Analyses employed analyses of covariance (ANCOVA), mixed-effects models, Kaplan-Meier estimates, Cox regression, and logistic regression.

resultsFollowing PSM, excellent balance in baseline characteristics was achieved between the surgical (SO, n = 237) and endobronchial valve (EBV, n = 237) groups. Regarding perioperative outcomes, EBV was associated with a lower risk of complications (OR = 0.33), shorter operation time (mean difference: -0.72 h), less blood loss (mean: -48.00 ml), and a reduced hospital stay (mean: -7.61d) compared to SO (all p < 0.001). However, total hospitalization costs were significantly higher for EBV (mean increase: ¥104,502). For secondary outcomes, EBV demonstrated lower rates of radiologic lung re-expansion based on the semi-quantitative imaging assessment used in this study (OR = 0.15, p < 0.001) and bulla volume reduction (mean difference: -29.02%, p < 0.001) at 1 year, and was associated with a higher 1-year readmission risk (OR = 3.21, p < 0.001). For the primary outcomes at 1 year, SO demonstrated superior improvement in both lung function (adjusted mean difference in forced expiratory volume in one second (FEV1)%: -9.71%, p < 0.001) and exercise capacity (adjusted mean difference in 6-minute walk distance (6MWD): -53.04 m, p < 0.001). Mixed-effects models confirmed that SO's advantages in FEV1% were significant at all time points, while its 6MWD benefit became fully apparent only by 1 year. Long-term recurrence-free survival was significantly higher in the SO group (2-year rate: 86.5% vs. 70.0%; HR for EBV: 2.48, p < 0.001). Subgroup analysis revealed this survival advantage was most pronounced for giant bullae (≥ 10 cm), where the recurrence risk with EBV was 3.49-fold higher (HR 3.49, p < 0.001), whereas for smaller bullae (< 10 cm) the risk was comparable between groups (HR 1.32, p = 0.426).

conclusionSO was associated with greater improvements in pulmonary function, exercise capacity, and recurrence-free survival in this matched retrospective cohort. However, given the non-randomized design and the potential for residual confounding, these findings should be interpreted cautiously and require further validation in prospective studies. EBV offers a safer, minimally invasive alternative with faster recovery, but is limited by higher costs and an increased recurrence risk. The treatment choice should be individualized, strongly considering the patient's chronic obstructive pulmonary disease (COPD) staging, tolerance for surgical risk, and valuation of long-term efficacy versus initial recovery and cost.