Bullectomy for giant bullae
- Fernando J Martinez, MD, MS
Fernando J Martinez, MD, MS
- Gladys and Roland Harriman Professor of Medicine
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medical College
- Section Editor
- James K Stoller, MD, MS
James K Stoller, MD, MS
- Section Editor — Chronic Obstructive Pulmonary Disease
- Jean Wall Bennett Professor of Medicine, Samson Global Leadership Academy Endowed Chair
- Cleveland Clinic Lerner College of Medicine
- Chairman, Education Institute, Cleveland Clinic
A bulla is defined as an air space in the lung measuring more than one centimeter in diameter in the distended state; the term giant bulla is used for bullae that occupy at least 30 percent of a hemithorax [1-4]. A single giant bulla may be surrounded by normal lung tissue or may be accompanied by a number of smaller adjacent bullae. Bullectomy involves the surgical removal of one or more giant bullae to improve symptoms and respiratory function in patients with bullous emphysema [5,6].
The indications and contraindications for bullectomy, as well as the perioperative management and operative technique of bullectomy will be reviewed here. The evaluation and medical management of giant bullae in patients with chronic obstructive pulmonary disease (COPD) and the roles of lung volume reduction surgery and lung transplantation in the management of advanced COPD are discussed separately. (See "Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging" and "Management of stable chronic obstructive pulmonary disease" and "Evaluation and medical management of giant bullae in COPD" and "Lung volume reduction surgery in COPD" and "Lung transplantation: General guidelines for recipient selection".)
Randomized trials of giant bullectomy have not been performed; however, observations from case series suggest that resection of giant bullae in carefully selected patients is associated with symptomatic and functional improvements lasting for five or more years in 60 to 90 percent of patients [2,3,6-12].
In an observational cohort study of 41 consecutive patients, significant improvements were noted in dyspnea, lung volumes, forced expiratory volume in one second (FEV1), and the FEV1/forced vital capacity (FVC) ratio over baseline and persisted for two years following bullectomy . At five years following surgery, these parameters remained improved compared to prebullectomy values, although the degree of improvement had declined. Patients with diffuse emphysema deteriorated faster than patients without diffuse emphysema.
A systematic review of bullectomy for giant bullae noted that hypoxemia was more likely to improve compared with spirometric parameters or diffusing capacity (DLCO) . Patients with radiographic evidence of compressed lung were most to likely experience improved oxygenation, whereas patients with radiographically diffuse emphysema, a low DLCO, or hypercapnia were less likely to improve, although the exact degree of improvement was not described.
- Thurlbeck WM. Pathophysiology of chronic obstructive pulmonary disease. Clin Chest Med 1990; 11:389.
- Palla A, Desideri M, Rossi G, et al. Elective surgery for giant bullous emphysema: a 5-year clinical and functional follow-up. Chest 2005; 128:2043.
- Neviere R, Catto M, Bautin N, et al. Longitudinal changes in hyperinflation parameters and exercise capacity after giant bullous emphysema surgery. J Thorac Cardiovasc Surg 2006; 132:1203.
- Greenberg JA, Singhal S, Kaiser LR. Giant bullous lung disease: evaluation, selection, techniques, and outcomes. Chest Surg Clin N Am 2003; 13:631.
- Laros CD, Gelissen HJ, Bergstein PG, et al. Bullectomy for giant bullae in emphysema. J Thorac Cardiovasc Surg 1986; 91:63.
- Snider GL. Reduction pneumoplasty for giant bullous emphysema. Implications for surgical treatment of nonbullous emphysema. Chest 1996; 109:540.
- Shah SS, Goldstraw P. Surgical treatment of bullous emphysema: experience with the Brompton technique. Ann Thorac Surg 1994; 58:1452.
- Schipper PH, Meyers BF, Battafarano RJ, et al. Outcomes after resection of giant emphysematous bullae. Ann Thorac Surg 2004; 78:976.
- Nickoladze GD. Functional results of surgery for bullous emphysema. Chest 1992; 101:119.
- Boushy SF, Kohen R, Billig DM, Heiman MJ. Bullous emphysema: clinical, roentgenologic and physiologic study of 49 patients. Dis Chest 1968; 54:327.
- Celli BR, MacNee W, ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004; 23:932.
- Wesley JR, Macleod WM, Mullard KS. Evaluation and surgery of bullous emphysema. J Thorac Cardiovasc Surg 1972; 63:945.
- Kinnear WJ, Tattersfield AE. Emphysematous bullae. BMJ 1990; 300:208.
- Meyers BF, Patterson GA. Chronic obstructive pulmonary disease. 10: Bullectomy, lung volume reduction surgery, and transplantation for patients with chronic obstructive pulmonary disease. Thorax 2003; 58:634.
- Ohta M, Nakahara K, Yasumitsu T, et al. Prediction of postoperative performance status in patients with giant bulla. Chest 1992; 101:668.
- Nakahara K, Nakaoka K, Ohno K, et al. Functional indications for bullectomy of giant bulla. Ann Thorac Surg 1983; 35:480.
- Krishnamohan P, Shen KR, Wigle DA, et al. Bullectomy for symptomatic or complicated giant lung bullae. Ann Thorac Surg 2014; 97:425.
- FitzGerald MX, Keelan PJ, Cugell DW, Gaensler EA. Long-term results of surgery for bullous emphysema. J Thorac Cardiovasc Surg 1974; 68:566.
- Gunstensen J, McCormack RJ. The surgical management of bullous emphysema. J Thorac Cardiovasc Surg 1973; 65:920.
- Martinez FJ, Chang A. Surgical therapy for chronic obstructive pulmonary disease. Semin Respir Crit Care Med 2005; 26:167.
- Brister NW, Barnette RE, Kim V, Keresztury M. Anesthetic considerations in candidates for lung volume reduction surgery. Proc Am Thorac Soc 2008; 5:432.
- Van Bael K, La Meir M, Vanoverbeke H. Video-assisted Thoracoscopic Resection of a Giant Bulla in Vanishing Lung Syndrome: case report and a short literature review. J Cardiothorac Surg 2014; 9:4.
- Huang W, Han R, Li L, He Y. Surgery for giant emphysematous bullae: case report and a short literature review. J Thorac Dis 2014; 6:E104.
- Lewis RJ, Caccavale RJ, Sisler GE. VATS-Argon Beam Coagulator treatment of diffuse end-stage bilateral bullous disease of the lung. Ann Thorac Surg 1993; 55:1394.
- Wakabayashi A, Brenner M, Kayaleh RA, et al. Thoracoscopic carbon dioxide laser treatment of bullous emphysema. Lancet 1991; 337:881.
- Brenner M, Kayaleh RA, Milne EN, et al. Thoracoscopic laser ablation of pulmonary bullae. Radiographic selection and treatment response. J Thorac Cardiovasc Surg 1994; 107:883.
- Wakabayashi A. Thoracoscopic technique for management of giant bullous lung disease. Ann Thorac Surg 1993; 56:708.
- Barker SJ, Clarke C, Trivedi N, et al. Anesthesia for thoracoscopic laser ablation of bullous emphysema. Anesthesiology 1993; 78:44.
- Tsuchida M, Nakayama K, Shinonaga M, et al. Video-assisted thoracic surgery for thorascopic resection of giant bulla. Surg Today 1996; 26:349.
- Boasquevisque CH, Yildirim E, Waddel TK, Keshavjee S. Surgical techniques: lung transplant and lung volume reduction. Proc Am Thorac Soc 2009; 6:66.
- Sagawa M, Maeda T, Yoshimitsu Y, Sakuma T. Saline-cooled radiofrequency coagulation during thoracoscopic surgery for giant bulla. Eur J Cardiothorac Surg 2014; 46:737.
- Chandra D, Soubra SH, Musher DM. A 57-year-old man with a fluid-containing lung cavity: infection of an emphysematous bulla with methicillin-resistant Staphylococcus aureus. Chest 2006; 130:1942.
- Goldstraw P, Petrou M. The surgical treatment of emphysema. The Brompton approach. Chest Surg Clin N Am 1995; 5:777.
- Froeschle P, Krishnadas R, Berrisford R. Video-assisted approach combined with the open Brompton technique for intracavitary drainage of giant bullae. Thorac Cardiovasc Surg 2012; 60:164.
- Lee S, Kim HR, Cho S, et al. Staple line coverage after bullectomy for primary spontaneous pneumothorax: a randomized trial. Ann Thorac Surg 2014; 98:2005.
- Lin KC, Luh SP. Video-assisted thoracoscopic surgery in the treatment of patients with bullous emphysema. Int J Gen Med 2010; 3:215.
- Cho S, Huh DM, Kim BH, et al. Staple line covering procedure after thoracoscopic bullectomy for the management of primary spontaneous pneumothorax. Thorac Cardiovasc Surg 2008; 56:217.
- Moser C, Opitz I, Zhai W, et al. Autologous fibrin sealant reduces the incidence of prolonged air leak and duration of chest tube drainage after lung volume reduction surgery: a prospective randomized blinded study. J Thorac Cardiovasc Surg 2008; 136:843.
- Venuta F, De Giacomo T, Rendina EA, et al. Thoracoscopic pleural tent. Ann Thorac Surg 1998; 66:1833.
- Noppen M, Tellings JC, Dekeukeleire T, et al. Successful treatment of a giant emphysematous bulla by bronchoscopic placement of endobronchial valves. Chest 2006; 130:1563.
- Santini M, Fiorello A, Di Crescenzo VG, et al. Use of unidirectional endobronchial valves for the treatment of giant emphysematous bulla. J Thorac Cardiovasc Surg 2010; 139:224.
- Santini M, Fiorelli A, Vicidomini G, et al. Endobronchial treatment of giant emphysematous bullae with one-way valves: a new approach for surgically unfit patients. Eur J Cardiothorac Surg 2011; 40:1425.
- Tian Q, An Y, Xiao BB, Chen LA. Treatment of giant emphysamous bulla with endobronchial valves in patients with chronic obstructive pulmonary disease: a case series. J Thorac Dis 2014; 6:1674.
- Bhattacharyya P, Sarkar D, Nag S, et al. Transbronchial decompression of emphysematous bullae: a new therapeutic approach. Eur Respir J 2007; 29:1003.
- POTENTIAL BENEFITS
- PREOPERATIVE EVALUATION AND PREPARATION
- Medical optimization
- Pulmonary imaging
- Laboratory studies
- Prophylactic antibiotics
- Venous thromboembolism prophylaxis
- Preoperative pulmonary rehabilitation
- OPEN VERSUS THORACOSCOPIC APPROACH
- OPERATIVE TECHNIQUE
- Extent of surgery
- Strategies to reduce air leak
- POSTOPERATIVE CARE AND FOLLOW-UP
- PERIOPERATIVE MORBIDITY AND MORTALITY
- NOVEL BRONCHOSCOPIC TECHNIQUES
- SUMMARY AND RECOMMENDATIONS