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" 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.
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- 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