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Bullectomy for Symptomatic or Complicated Giant Lung Bullae
Pradheep Krishnamohan, MD, K. Robert Shen, MD, Dennis A. Wigle, MD, Mark S. Allen, MD, Francis C. Nichols, III, MD, Stephen D. Cassivi, MD, William S. Harmsen, MS, and Claude Deschamps, MD Division of General Thoracic Surgery, Department of Surgery and Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
Background. Giant bullae of the lung are rare. Little is known about functional results after surgical treatment. Methods. This study retrospectively reviewed all patients who underwent surgical treatment for giant bullae between December 1988 and December 2010. Results. There were 63 patients (51 men, 12 women) with a median age of 56 years (range, 26 to 85 years). Bullae were a median size of 14 cm (range, 9 to 30 cm). Forty-five patients (71%) had underlying diffuse emphysema. The indication for surgical intervention was symptoms alone in 30 patients (48%) and associated complications in 33 (52%). The operation was a bullectomy in 54 patients, lobectomy in 6, plication in 2, and bilobectomy in 1. Complications occurred in 27 patients (43%), and 2 patients (3.0%) died. At the last follow-up, 19 had died and 44 were alive. Of the 43 patients with shortness of breath preoperatively, 29 (67.4%) were improved. Thirty patients (46.1%) had preoperative and
postoperative pulmonary function tests with improvement from a median forced expiratory volume in 1 second (FEV1) of 1.0 L preoperatively to 1.4 L postoperatively (p [ 0.002). Increasing bulla size (p [ 0.02) and underlying emphysema (p [ 0.01) were adversely associated with postoperative morbidity. Dyspnea improved in 21 of 33 patients (64%) with underlying diffuse emphysema compared with 5 of 7 patients (71%) without emphysema (p [ 0.70). Conclusions. Bullectomy improved pulmonary function in most patients with a symptomatic or complicated giant bulla, or both. However, increasing bulla size and underlying emphysema resulted in increased treatment morbidity. Underlying diffuse emphysema is not a contraindication to bullectomy.
B
Study Design
ullous disease of the lung has often been a therapeutic challenge due to its complex pathophysiology and varied presentations. Although pulmonary emphysema is a disease of high prevalence in the smoking population, giant bullae are rare. Urgent surgical treatment is often prompted by complications such as pneumothorax, prolonged air leak, and more rarely, infection or bleeding. Elective surgical treatment for dyspnea or other symptoms is rarely performed, and the factors affecting the outcome after bullectomy are less well known. We reviewed our experience with surgical treatment for giant pulmonary bullae and analyzed the morbidity, mortality, and the factors affecting functional results and long-term survival.
Material and Methods This study was approved by Mayo Foundation’s Institutional Review Board. Accepted for publication Oct 18, 2013. Presented at the Poster Session of the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013. Address correspondence to Dr Deschamps, Division of General Thoracic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2014;97:425–31) Ó 2014 by The Society of Thoracic Surgeons
All patients who underwent surgical treatment for giant bullae at the Mayo Clinic in Rochester, Minnesota, between December 1988 and December 2010, were reviewed. Eligible patients included those with a giant bulla occupying one-fourth or more of one hemithorax on preoperative imaging. Excluded were patients with generalized emphysema who underwent lung volume reduction surgery, lung transplantation, or operations for bullous disease other than a giant bulla. Medical records were reviewed for demographic information, medical history, radiographic findings, bulla size and location, surgical approach and procedures, postoperative complications, clinical symptoms, and pulmonary function tests at follow-up. Type of bulla was classified according to Reid [1, 2] Type I bullae have a narrow neck, empty sac, and project above the surface like a mushroom. Type II have a broad neck, and the sac usually contains emphysematous lung. Type III bullae protrude slightly above the surface, have no neck, often extend deep to the hilum, and contain emphysematous lung evenly throughout the bulla. The grade of dyspnea was classified according to the New York Heart Association classification [3]: grade I is minimal dyspnea on running or on doing more than ordinary effort, grade II is dyspnea on ordinary effort, grade III is considerable 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.049
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Abbreviations and Acronyms % pred = percent predicted CI = confidence interval COPD = chronic obstructive pulmonary disease CT = computed tomography = diffusion capacity of the lung for DLCO carbon monoxide FEV1 = forced expiratory volume in 1 second FVC = forced vital capacity HR = hazard ratio OR = odds ratio RV = residual volume
dyspnea on doing less than ordinary effort, and grade IV is dyspnea at rest. Postoperative complications included those that occurred within 30 days of the procedure or during the hospitalization. Operative mortality included patients who died within the first 30 days after the operation or during the same hospital admission. Factors affecting morbidity, mortality, and functional results were analyzed. Descriptive statistics for categoric variables are reported as frequency and percentage, and continuous variables are reported as mean (standard deviation) or median (range), as appropriate. Overall change in pulmonary function tests (preoperative to postoperative) was assessed using a signed rank test. Spearman rank correlation was used to assess the correlation between the preoperative bulla size and the change in forced expiratory volume in 1 second (FEV1). Univariate logistic regression was used to test the association between variables and change in dyspnea symptom as well as early postoperative morbidity. Overall survival was estimated using Kaplan-Meier survivorship. The association of demographic factors with survival was assessed using Cox proportional hazards regression. All statistical tests were two-sided with p-values of less than 0.05 considered significant.
Clinical Findings The analysis included 63 patients (51 men, 12 women) who underwent surgical treatment for a giant bulla. Median age was 56 years (range, 26 to 85 years). Patient demographic information is summarized in Table 1. Fiftyfour patients (86%) had a history of cigarette smoking. Median pack-years were 50 (range, 4 to 150). Forty-four patients (70%) had stopped smoking before surgery. Median duration of smoking cessation was 39 months (range, <1 to 450 months). Forty-five patients (71%) had known chronic obstructive pulmonary disease (COPD). Dyspnea was the predominant symptom in 55 patients (87%) and was grade I or II in 32 patients (51%) and grade III or IV in 23 (37%). Conventional chest roentgenograms at presentation showed abnormalities in all patients. Findings on chest roentgenogram included a giant bulla in 24 (38%), air
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Table 1. Demographics and Bulla Characteristics of 63 Patients With a Giant Bulla Variable Age, years Sex Men Women Smoking history Pack years Stopped smoking preoperatively Period of abstinence, months COPD Diabetes mellitus Hypertension Coronary artery disease Bulla size, cm Bulla laterality Right side Left side Bilateral Bulla type I II III Not known
Median (range) or No. (%) (N ¼ 63) 56 (26–85) 51 12 54 50 45 39 45 67 24 11 14
(81) (19) (86) (4–150) (71) (<1–450) (71) (10) (38) (17) (9–30)
36 (57) 19 (30) 8 (13) 3 18 18 24
(5) (29) (29) (38)
COPD ¼ chronic obstructive pulmonary disease.
fluid level in 2 (3%), pneumothorax in 33 (52%), and associated hyperexpansion of lung in 38 (60%). Computed tomography (CT) data were available in all 53 patients and identified a giant bulla in all patients, air fluid level in 5 (8%), crowding of hilum in 18 (29%), compression of adjacent lung parenchyma in 16 (25%), and presence of diffuse emphysema in 45 patients (71%). Bullae were right-sided in 36 patients (57%), left-sided in 19 (30%), and bilateral in 8 (13%). Size (cm) and type of bulla were identified from the CT imaging and the surgeon’s operative report. Bullae were type I in 3 patients (5%), type II in 18 (29%), and type III in 18 (29%). Ten patients had a ventilation/perfusion scan that confirmed the findings noted on CT. Indications for surgical intervention (Table 2) were symptoms only in 30 patients (48%) and included dyspnea, exercise intolerance, cough, hemoptysis. and fever. The operations in 33 patients (52%) were because of complications that included first-time pneumothorax in 19 (29%) and recurrent/persistent pneumothorax in 14 (22%). Eleven patients (17%) had two episodes and 3 (5%) had three episodes. Twenty-four patients (38%) had a persistent air leak after chest tube insertion. Ten patients had preoperative pulmonary rehabilitation. Video-assisted thoracic surgery was performed in 28 patients (44%), thoracotomy in 28 (43%), sternotomy in 6 (10%), and 1 (2%) had video-assisted thoracic surgery and thoracotomy. Surgical procedures included bullectomy in 54 patients (83%), lobectomy in 6 (10%), bulla plication in
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Table 2. Clinical Presentation of Giant Bullae Symptoms Dyspnea None Grade I or II Grade III or more Exercise intolerance Chest pain Fatigability Cough Fever Hemoptysis Pneumothorax 1 episode 2 or more episodes Persistent air leak after tube thoracostomy
No. (%) (N ¼ 63) 8 32 23 37 25 18 18 6 2
(13) (51) (37) (59) (40) (29) (29) (10) (3)
19 (29) 14 (22) 24 (38)
2 (4%), and bilobectomy in 1 (2%). Buttressing of the staple line with reinforcing prosthetic material was done in 42 of the 54 patients (67%) who underwent bullectomy. The 7 patients who had a lobectomy or bilobectomy had a type III bulla. Additional pleural procedures were done in 35 patients and included mechanical pleurodesis in 14 (22%), pleural tent in 10 (16%), parietal pleurectomy in 5 (8%), combined mechanical pleurodesis/pleurectomy in 4 (6%), and talc pleurodesis in 2 (3%). Four patients had bilateral procedures.
Results Postoperative complications (Table 3) occurred in 27 patients (43%) and included prolonged air leak in 19 (30%), atrial fibrillation in 8 (13%), pneumonia in 8 Table 3. Postoperative Complications Complications Air leak Not documented None <7 days 7 days Heimlich valve at dismissal Atrial fibrillation Pneumonia Mechanical ventilation postoperatively Remain intubated from operating room Reintubated postoperatively Bleeding Tracheostomy Bronchoscopy for retained secretions Bronchopleural fistula Seizures Ileus Urinary retention
No. (%) (N ¼ 63) 1 25 18 19 10 8 8
(2) (40) (29) (30) (16) (13) (13)
5 5 3 3 2 1 1 1 1
(8) (8) (5) (5) (3) (2) (2) (2) (2)
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(13%), bleeding in 3 (5%), respiratory failure requiring tracheostomy in 3 (5%), and bronchopleural fistula in 1 (2%). Ten patients (15%) were dismissed with a Heimlich valve. Two patients died (operative mortality, 3%). One patient had an infected bulla and underwent bilateral bullectomy. A prolonged air leak and respiratory failure developed, and he ultimately died of sepsis. The second patient died 12 days after dismissal of unknown cause. Median postoperative length of stay was 7 days (range, 1 to 54 days). Factors associated with an increased odds of a postoperative complication included increasing bulla size (p ¼ 0.017) and underlying diffuse emphysema (p ¼ 0.011; Table 4). Median follow-up was 1.5 years (range, 4 days to 13.0 years). Follow-up data on clinical symptoms were available for 52 patients (82%). Of the 43 patients with shortness of breath preoperatively and who had a follow-up assessment, 29 (67%) were improved (95% confidence interval (CI), 51% to 81%). At the postoperative assessment, 15 patients were asymptomatic, 8 patients had grade I dyspnea, 15 patients had grade II or III, and 5 patients had grade IV. Dyspnea improved in 21 of 33 patients (64%) with underlying diffuse emphysema compared with 5 of 7 patients (71%) without emphysema. Fifteen patients (24%) required intermittent or continuous supplemental home oxygen. One patient subsequently underwent single lung transplantation. Thirty patients (48%) had preoperative and postoperative pulmonary function tests (Table 5). The median preoperative FEV1 was 1.0 L (26% predicted) and improved to a postoperative FEV1 of 1.4 L (43% predicted; p ¼ 0.002). In the 16 patients with preoperative and postoperative assessments, residual volume and the ratio of FEV1 to forced vital capacity (FEV1/FVC) did not change significantly (p ¼ 0.38), nor did the diffusing capacity of the lung for carbon monoxide (DLCO) in 12 patients who were evaluated for it (p ¼ 0.48). The presence of underlying diffuse emphysema did not adversely affect improvement in postoperative dyspnea (odds ratio, 0.7, 95% CI, 0.1 to 4.2; p ¼ 0.70). The preoperative size of bullae had a borderline significant association with postoperative improvement in dyspnea (95% CI, 0.995 to 1.6; p ¼ 0.055). Among 16 patients, there was only a slight negative correlation between the preoperative size of bullae and improvement in postoperative FEV1 (r ¼ –0.14, p ¼ 0.61). At the last follow-up, 46 patients were alive and 17 had died. No recurrent giant bullae or pneumothorax developed during the follow-up period. Overall 5-year survival was 68% (95 % CI, 54% to 87%; Fig 1). Factors associated with a significant decrease in long-term survival included patients who smoked (current or former; hazard ratio, 8.5, 95% CI, 1.1–65.7; p ¼ 0.04) and increasing age (hazard ratio, 1.9 per 10 years; 95% CI, 1.2 to 3.0; p ¼ 0.003; Table 6).
Comment A pulmonary bulla is an air filled space of more than 1 cm in diameter, formed as a result of a destructive process.
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Table 4. Risk Factor Association With Postoperative Complications Variable
Patients (No.)
Early Morbidity No. (%)
OR (95% CI)
51 12
32 (45) 4 (33)
1.6 (0.4–6.2) 1.0 (Reference)
0.46
54 9
26 (48) 1 (11)
7.4 (0.9–63.5) 1.0 (Reference)
0.07
30 27
16 (53) 8 (30)
2.7 (0.9–8.1) 1.0 (Reference)
0.07
43 16
22 (51) 2 (12) . . .
Gender Male Female Smoking Current/Former Never Pack-years >40 years 40 years Emphysema Yes No Age, per 10 years Pack-years, per 10 years Bulla size, per cm a
7.3 1.0 1.4 1.13 1.2
(1.5–36.2) (reference) (0.97–2.0) (0.95–1.35) (1.04–1.4)
p Value
0.01a 0.07 0.16 0.016a
Statistically significant.
CI ¼ confidence interval;
OR ¼ odds ratio.
a patient will be seen for infection, bleeding, or carcinoma associated with the bulla [7]. The goals of surgical therapy for patients with giant bullae are to improve the quality of life for those in whom medical treatment has failed and to resolve complications while preserving lung function [1, 4, 8] Although appropriate selection is considered critical for optimal results in patients seeking improvement in dyspnea and quality of life, no single preoperative test has been found to be an absolute predictor of improvement. Criteria for a favorable prognosis have included bullae occupying more than one-third of the hemithorax, vascular crowding, localized disease, compression of underlying normal lung, relatively good perfusion on the contralateral side, and preoperative FEV1 of less than half of the predicted value [1, 4, 8–10] In contrast, Nakahara and colleagues [11] recommend that preoperative FEV1 be greater than 40% of the predicted value. Compared with those reported criteria, 71% of our patients had diffuse emphysema, and the median preoperative FEV1 in our series was 29% of the predicted value. None of our patients was asymptomatic.
When it has enlarged to significant proportions and occupies a large volume inside the chest cavity, it becomes a giant bulla. The percentage of pleural space occupied by a giant bulla has varied in the literature from not specified to up to 50% [1]. The outer surface of the bulla is made of visceral pleura, but the inner surface consists of fibrous tissue formed by the pleura and underlying destroyed pulmonary tissue [4]. Associated with these changes are varying degrees of emphysema [2]. Giant bullae are different from pulmonary blebs or cysts [5]. The incidence of giant bullae is generally unknown, but the condition is considered rare; in Iceland, for example, the age-standardized incidence rate of giant pulmonary bullae has been reported as 0.21/100,000 per year [6]. Similar to what was reported by Snider [1] in an extensive review, most of our patients were men, former or current smokers, and with disease predominantly on the right side and upper lung fields. Although giant bullae can be asymptomatic, patients are usually referred to the thoracic surgeon because of dyspnea or complications, including pneumothorax and prolonged air leak after chest tube insertion [1, 4]. Rarely,
Table 5. Change in Pulmonary Function in Patients With Giant Bullae After Bullectomy Variablea FEV1, L FEV1 % pred RV, L RV, % pred FEV1/FVC DLCO, % pred a
Patients (No.) 23 21 9 8 16 12
Preoperative 1.0 29 3.7 192 48.2 59
(0.5–3) (16–77) (2.2–8.0) (135–405) (25.2–85.8) (24–81)
Values are expressed as median (range) using Wilcoxon rank sum test.
% pred ¼ % predicted; forced vital capacity;
Follow-Up 1.4 42 3.8 194 52.2 53 b
Change From Preoperative
(0.2–3.5) (11–104) (1.7–6.7) (81–328) (23.4–90.2) (30–88)
0.3 10 –1.3 –45 3.0 4
(–0.8 to 1.4) (–17 to 35) (–1.7 to 1.8) (–89 to 81) (–15.8 to 16.5) (–45 to 25)
p Value 0.002b 0.003b 0.25 0.25 0.38 0.48
Statistically significant.
DLCO ¼ diffusion capacity of the lung for carbon monoxide; RV ¼ residual volume.
FEV1 ¼ forced expiratory volume in 1 second;
FVC ¼
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Fig 1. Kaplan-Meier estimate of overall survival after giant bullectomy.
Snider [1] reports that surgical intervention is most often performed for dyspnea and rarely for pneumothorax. Our series was more evenly divided: up to 52% of our patients were operated on for complications such as pneumothorax or prolonged air leak. A secondary pneumothorax in patients who have severe COPD can be a life-threatening event [12], and there are few alternative therapeutic options to an operation. The air leak associated with a ruptured bulla is often prolonged due to the underlying emphysema and associated diseased elastic network. These pneumothoraces can often be loculated because of previous pleural diseases or interventions, and this may contribute to the development of “tension pouches.” Some pneumothoraces can sometimes be indistinguishable from a bulla on preoperative CT [13]. Although various imaging modalities have been used to try to better predict postoperative results, CT has become [14] and remains [15] the imaging technique of choice for preoperative evaluation of patients with emphysema. All of our patients had a preoperative CT. Findings on CT indicated more than 70% of our patients had underlying diffuse emphysema, and only 25% had compression of the underlying lung. Similar to Schipper and colleagues [16], we have started using pulmonary rehabilitation preoperatively (10 patients in our series) as much to improve conditioning as to assist with patient selection, based on the lung volume reduction surgery experience [17]. Acute bronchitis should be treated aggressively preoperatively with appropriate antibiotics and constitutes a contraindication to elective bullectomy if unresolved [18]. The goal of surgical treatment is to remove the bulla while preserving as much of the underlying pulmonary parenchyma as possible [1, 4, 9], Most of our patients underwent bullectomy, but 11% had a lobectomy or bilobectomy because the emphysematous changes extended to the hilum. Given the expected morbidity of
prolonged air leak in this high-risk population, more than half of the patients in our series required a concomitant pleural obliteration procedure and buttressing of the staple line [12]. Close to 70% of our patients had relief or substantial improvement of their preoperative symptoms, with an operative mortality of 3% and morbidity of 43%. These results are comparable to those reported by others [1, 10–11, 16, 18–20]. A similar improvement in airway obstruction, as demonstrated by an increase in postoperative FEV1 in our series, was also reported by others [1], but Schipper and colleagues [16] and Palla and colleagues [21] have shown that the improvement after bullectomy is time-limited and patients slowly deteriorate over the following years, similar to other emphysematous patients after lung volume reduction surgery [17]. Our relatively short follow-up did not allow us to study our patients long-term. We have shown that the presence of underlying emphysema, as measured by preoperative CT, did not adversely affect the functional results, in contrast to the study from Palla and colleagues [21], who found that patients without underlying emphysema did better. We believe this is relevant to patient selection and suggest that underlying emphysema should not be considered an absolute contraindication for surgical treatment. We also found near statistically significant correlation between larger bulla size and postoperative symptom improvement, similar to the findings reported by others [10, 21]. Long-term survival in our study was less than what was reported by Schipper and colleagues [1] and was adversely affected by age and smoking status. We also had a higher incidence of diffuse emphysema in our series, and this also may have adversely affected longterm survival [22]. Our study is retrospective with a relative short followup period. We do not know the number of patients seen
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Table 6. Risk Factor Association With Long-Term Survival Variable Overall Gender Male Female Smoking Current/former Never Pack-years >40 40 Emphysema Yes No Age, per 10 years Pack-years, per 10 years Bulla size, per cm a
Patients (No.)
Deaths (No.)
Kaplan-Meier Estimate (95% CI) at 5 Years
HR (95% CI)
p Value
63
19
68 (54–87)
.
.
51 12
16 3
61 (43–86) 82 (60–100)
3.2 (0.9–11.2) 1.0 (Reference)
0.07
54 9
18 1
65 (48–87) 83 (58–100)
8.5 (1.1–65.7) 1.0 (Reference)
0.04a
30 27
9 6
81 (62–100) 70 (49–100)
1.5 (0.5–4.3) 1.0 (Reference)
0.43
43 16
15 3
70 (54–91) 57 (30–100) . . .
1.8 1.0 1.9 1.1 1.0
0.33
(0.5–6.4) (Reference) (1.2–3.0) (0.9–1.2) (0.9–1.1)
0.003a 0.38 0.89
Statistically significant.
CI ¼ confidence interval;
HR ¼ hazard ratio.
at our medical center who were never referred to a surgeon or were denied operative treatment after surgical evaluation. The radiologist did not grade the degree of underlying emphysema. Despite those limitations, our goal was to combine all patients operated on for a giant bulla during the study time period to better reflect the spectrum of potential surgical candidates seen by a general thoracic surgeon in clinical practice. In conclusion, giant bullae of the lung can be intimidating, especially when associated with underlying diffuse emphysema or worse, vanishing lung. Several criteria have been identified over the years to help guide therapeutic decisions. In addition, patients who present with pneumothorax or prolonged air leak, or both, after tube thoracostomy face few if any alternatives to surgical intervention. We have found in our population of patients that it is possible to remove a giant bulla of the lung under those circumstances with reasonable morbidity and mortality. Pulmonary function improved in most patients with symptomatic or complicated giant bullae, or both, after bullectomy. In selected cases, a lobectomy might be necessary to remove the giant bulla and be accomplished with favorable outcomes. Increasing bulla size and the presence of diffuse emphysema adversely affected postoperative morbidity. Underlying diffuse emphysema did not adversely affect postoperative functional results and is not considered a contraindication to bullectomy. Increasing age at time of operation and smoking status (current or past) adversely affected long-term survival.
References 1. Snider GL. Reduction pneumoplasty for giant bullous emphysema—implications for surgical treatment of nonbullous emphysema. Chest 1996;109:540–8.
2. Reid L. The pathology of emphysema. Chicago: Year-Book Medical Publishers; 1967:211–40. 3. The Criteria Committee of the New York Heart Association. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston: Little, Brown & Co; 1994:253–6. 4. Mehran RJ, Deslauriers J. Indications for surgery and patient work-up for bullectomy. Chest Surg Clin North Am 1995;5: 717–34. 5. Shamji FM. Classification of cystic and bullous lung disease. Chest Surg Clin North Am 1995;5:701–16. 6. Gunnarsson SI, Johannesson KB, Gudjonsdottir M, Magnusson B, Jonsson S, Gudbjartsson T. Incidence and outcomes of surgical resection for giant pulmonary bullae–a population-based study. Scand J Surg 2012;101:166–9. 7. Hirai S, Hamanaka Y, Mitsui N, Morifuji K, Sutoh M. Primary lung cancer arising from the wall of a giant bulla. Ann Thorac Cardiovasc Surg 2005;11:109–13. 8. Camp PC, Sugarbaker DJ. Surgical interventions for emphysema. Semin Thorac Cardiovasc Surg 2007;19: 157–71. 9. Connolly JE. Results of bullectomy. Chest Surg Clin North Am 1995;5:765–76. 10. FitzGerald MX, Keelan PJ, Cugell DW, et al. Long-term results of surgery for bullous emphysema. J Thorac Cardiovasc Surg 1974;68:566–87. 11. Nakahara K, Nakaoka K, Ohno K, et al. Functional indications for bullectomy of giant bulla. Ann Thorac Surg 1983;35:480–7. 12. Shen KR, Cerfolio RJ. Decision making in the management of secondary spontaneous pneumothorax in patients with severe emphysema. Thor Surg Clin 2009;19:233–8. 13. Keszler P. Surgical pathology of bullae with and without pneumothorax. Eur J Cardiothorac Surg 1988;2:416–24. 14. Morgan MDL, Dennison DM, Strickland B. Value of computed tomography for selecting patients with bullous lung disease for surgery. Thorax 1986;41:855–62. 15. Goldin GJ, Abtin F. Update on radiology of emphysema and therapeutic implications. Thorac Surg Clin 2009;19: 159–67. 16. Schipper PH, Meyers BF, Richard J, et al. Outcomes after resection of giant emphysematous bullae. Ann Thorac Surg 2004;78:976–82.
17. National Emphysema Treatment Trial Research Group. A randomized trial comparing lung volume reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003;348:2059–73. 18. Laros CD, Gelissen HJ, Bergstein PG, et al. Bullectomy for giant bullae in emphysema. J Thorac Cardiovasc Surg 1986;91:63–70. 19. Pearson MG, Ogilvie C. Surgical treatment of emphysematous bullae: late outcome. Thorax 1983;38:134–7.
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20. De Giacomo T, Venuta F, Rendina EA, et al. Video-assisted thoracoscopic treatment of giant bullae associated with emphysema. Eur J Cardiothorac Surg 1999;15:753–7. 21. Palla A, Desideri M, Rossi G, et al. Elective surgery for giant bullous emphysema: a 5-year clinical and functional followup. Chest 2005;128:2043–50. 22. NETT Research Group. Predictors of mortality in patients with emphysema and severe airflow obstruction. Am J Respir Crit Care Med 2006;173:1326–34.
INVITED COMMENTARY Dr Krishnamohan and colleagues [1] present a large retrospective analysis of patients operated on for giant bullous disease. Their mix of patients was fairly evenly distributed between patients with symptoms alone and those with adverse events, predominantly pneumothorax and persistent air leak. Morbidity and mortality were in line with what is expected in this cohort. Nearly half the patients had preoperative and postoperative lung function tests (presumably the patients operated on for symptoms), and they demonstrated the authors’ good surgical insight. The patients all had severe obstruction and hyperinflation with relatively preserved diffusion capacity (median >50% predicted). It was encouraging that forced expiratory volume in 1 second improved significantly postoperatively, but it is curious that residual volume did not decrease. This study’s strengths are its size and excellent results. It suffers from its retrospective nature and the inability to know what happened to the patients with giant bullous disease who were treated nonoperatively. This report highlights the evolving approach to giant bullous disease. Although resectional therapy for giant bullous disease is still uncommon, it may be playing an increasingly important role. Although this report spans
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
a 22-year period, the median follow-up time was only 1.5 years, suggesting that most patients were operated on fairly recently. A combination of the experience with lung volume reduction surgical procedures (LVRS), increasing our knowledge about how to operate on patients with extremely poor lung function, and the fact that most of these operations can now be done in a minimally invasive fashion, may explain this trend. The increasing use of preoperative pulmonary rehabilitation also parallels the LVRS experience and should be used liberally for patients being operated on for dyspnea. William R. Burfeind, Jr, MD Thoracic Surgery St. Luke’s University Health Network 701 Ostrum St, Ste 603 Bethlehem, PA 18015 e-mail: [email protected]
Reference 1. Krishnamohan P, Shen KR, Wigle DA, et al. Bullectomy for symptomatic or complicated giant lung bullae. Ann Thorac Surg 2014;97:425–31.
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Background. Giant bullae of the lung are rare. Little is known about functional results after surgical treatment. Methods. This study retrospectively reviewed all patients who underwent surgical treatment for giant bullae between December 1988 and December 2010. Results. There were 63 patients (51 men, 12 women) with a median age of 56 years (range, 26 to 85 years). Bullae were a median size of 14 cm (range, 9 to 30 cm). Forty-five patients (71%) had underlying diffuse emphysema. The indication for surgical intervention was symptoms alone in 30 patients (48%) and associated complications in 33 (52%). The operation was a bullectomy in 54 patients, lobectomy in 6, plication in 2, and bilobectomy in 1. Complications occurred in 27 patients (43%), and 2 patients (3.0%) died. At the last follow-up, 19 had died and 44 were alive. Of the 43 patients with shortness of breath preoperatively, 29 (67.4%) were improved. Thirty patients (46.1%) had preoperative and
postoperative pulmonary function tests with improvement from a median forced expiratory volume in 1 second (FEV1) of 1.0 L preoperatively to 1.4 L postoperatively (p [ 0.002). Increasing bulla size (p [ 0.02) and underlying emphysema (p [ 0.01) were adversely associated with postoperative morbidity. Dyspnea improved in 21 of 33 patients (64%) with underlying diffuse emphysema compared with 5 of 7 patients (71%) without emphysema (p [ 0.70). Conclusions. Bullectomy improved pulmonary function in most patients with a symptomatic or complicated giant bulla, or both. However, increasing bulla size and underlying emphysema resulted in increased treatment morbidity. Underlying diffuse emphysema is not a contraindication to bullectomy.
B
Study Design
ullous disease of the lung has often been a therapeutic challenge due to its complex pathophysiology and varied presentations. Although pulmonary emphysema is a disease of high prevalence in the smoking population, giant bullae are rare. Urgent surgical treatment is often prompted by complications such as pneumothorax, prolonged air leak, and more rarely, infection or bleeding. Elective surgical treatment for dyspnea or other symptoms is rarely performed, and the factors affecting the outcome after bullectomy are less well known. We reviewed our experience with surgical treatment for giant pulmonary bullae and analyzed the morbidity, mortality, and the factors affecting functional results and long-term survival.
Material and Methods This study was approved by Mayo Foundation’s Institutional Review Board. Accepted for publication Oct 18, 2013. Presented at the Poster Session of the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013. Address correspondence to Dr Deschamps, Division of General Thoracic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2014;97:425–31) Ó 2014 by The Society of Thoracic Surgeons
All patients who underwent surgical treatment for giant bullae at the Mayo Clinic in Rochester, Minnesota, between December 1988 and December 2010, were reviewed. Eligible patients included those with a giant bulla occupying one-fourth or more of one hemithorax on preoperative imaging. Excluded were patients with generalized emphysema who underwent lung volume reduction surgery, lung transplantation, or operations for bullous disease other than a giant bulla. Medical records were reviewed for demographic information, medical history, radiographic findings, bulla size and location, surgical approach and procedures, postoperative complications, clinical symptoms, and pulmonary function tests at follow-up. Type of bulla was classified according to Reid [1, 2] Type I bullae have a narrow neck, empty sac, and project above the surface like a mushroom. Type II have a broad neck, and the sac usually contains emphysematous lung. Type III bullae protrude slightly above the surface, have no neck, often extend deep to the hilum, and contain emphysematous lung evenly throughout the bulla. The grade of dyspnea was classified according to the New York Heart Association classification [3]: grade I is minimal dyspnea on running or on doing more than ordinary effort, grade II is dyspnea on ordinary effort, grade III is considerable 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.049
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Bullectomy for Symptomatic or Complicated Giant Lung Bullae
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Abbreviations and Acronyms % pred = percent predicted CI = confidence interval COPD = chronic obstructive pulmonary disease CT = computed tomography = diffusion capacity of the lung for DLCO carbon monoxide FEV1 = forced expiratory volume in 1 second FVC = forced vital capacity HR = hazard ratio OR = odds ratio RV = residual volume
dyspnea on doing less than ordinary effort, and grade IV is dyspnea at rest. Postoperative complications included those that occurred within 30 days of the procedure or during the hospitalization. Operative mortality included patients who died within the first 30 days after the operation or during the same hospital admission. Factors affecting morbidity, mortality, and functional results were analyzed. Descriptive statistics for categoric variables are reported as frequency and percentage, and continuous variables are reported as mean (standard deviation) or median (range), as appropriate. Overall change in pulmonary function tests (preoperative to postoperative) was assessed using a signed rank test. Spearman rank correlation was used to assess the correlation between the preoperative bulla size and the change in forced expiratory volume in 1 second (FEV1). Univariate logistic regression was used to test the association between variables and change in dyspnea symptom as well as early postoperative morbidity. Overall survival was estimated using Kaplan-Meier survivorship. The association of demographic factors with survival was assessed using Cox proportional hazards regression. All statistical tests were two-sided with p-values of less than 0.05 considered significant.
Clinical Findings The analysis included 63 patients (51 men, 12 women) who underwent surgical treatment for a giant bulla. Median age was 56 years (range, 26 to 85 years). Patient demographic information is summarized in Table 1. Fiftyfour patients (86%) had a history of cigarette smoking. Median pack-years were 50 (range, 4 to 150). Forty-four patients (70%) had stopped smoking before surgery. Median duration of smoking cessation was 39 months (range, <1 to 450 months). Forty-five patients (71%) had known chronic obstructive pulmonary disease (COPD). Dyspnea was the predominant symptom in 55 patients (87%) and was grade I or II in 32 patients (51%) and grade III or IV in 23 (37%). Conventional chest roentgenograms at presentation showed abnormalities in all patients. Findings on chest roentgenogram included a giant bulla in 24 (38%), air
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Table 1. Demographics and Bulla Characteristics of 63 Patients With a Giant Bulla Variable Age, years Sex Men Women Smoking history Pack years Stopped smoking preoperatively Period of abstinence, months COPD Diabetes mellitus Hypertension Coronary artery disease Bulla size, cm Bulla laterality Right side Left side Bilateral Bulla type I II III Not known
Median (range) or No. (%) (N ¼ 63) 56 (26–85) 51 12 54 50 45 39 45 67 24 11 14
(81) (19) (86) (4–150) (71) (<1–450) (71) (10) (38) (17) (9–30)
36 (57) 19 (30) 8 (13) 3 18 18 24
(5) (29) (29) (38)
COPD ¼ chronic obstructive pulmonary disease.
fluid level in 2 (3%), pneumothorax in 33 (52%), and associated hyperexpansion of lung in 38 (60%). Computed tomography (CT) data were available in all 53 patients and identified a giant bulla in all patients, air fluid level in 5 (8%), crowding of hilum in 18 (29%), compression of adjacent lung parenchyma in 16 (25%), and presence of diffuse emphysema in 45 patients (71%). Bullae were right-sided in 36 patients (57%), left-sided in 19 (30%), and bilateral in 8 (13%). Size (cm) and type of bulla were identified from the CT imaging and the surgeon’s operative report. Bullae were type I in 3 patients (5%), type II in 18 (29%), and type III in 18 (29%). Ten patients had a ventilation/perfusion scan that confirmed the findings noted on CT. Indications for surgical intervention (Table 2) were symptoms only in 30 patients (48%) and included dyspnea, exercise intolerance, cough, hemoptysis. and fever. The operations in 33 patients (52%) were because of complications that included first-time pneumothorax in 19 (29%) and recurrent/persistent pneumothorax in 14 (22%). Eleven patients (17%) had two episodes and 3 (5%) had three episodes. Twenty-four patients (38%) had a persistent air leak after chest tube insertion. Ten patients had preoperative pulmonary rehabilitation. Video-assisted thoracic surgery was performed in 28 patients (44%), thoracotomy in 28 (43%), sternotomy in 6 (10%), and 1 (2%) had video-assisted thoracic surgery and thoracotomy. Surgical procedures included bullectomy in 54 patients (83%), lobectomy in 6 (10%), bulla plication in
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Table 2. Clinical Presentation of Giant Bullae Symptoms Dyspnea None Grade I or II Grade III or more Exercise intolerance Chest pain Fatigability Cough Fever Hemoptysis Pneumothorax 1 episode 2 or more episodes Persistent air leak after tube thoracostomy
No. (%) (N ¼ 63) 8 32 23 37 25 18 18 6 2
(13) (51) (37) (59) (40) (29) (29) (10) (3)
19 (29) 14 (22) 24 (38)
2 (4%), and bilobectomy in 1 (2%). Buttressing of the staple line with reinforcing prosthetic material was done in 42 of the 54 patients (67%) who underwent bullectomy. The 7 patients who had a lobectomy or bilobectomy had a type III bulla. Additional pleural procedures were done in 35 patients and included mechanical pleurodesis in 14 (22%), pleural tent in 10 (16%), parietal pleurectomy in 5 (8%), combined mechanical pleurodesis/pleurectomy in 4 (6%), and talc pleurodesis in 2 (3%). Four patients had bilateral procedures.
Results Postoperative complications (Table 3) occurred in 27 patients (43%) and included prolonged air leak in 19 (30%), atrial fibrillation in 8 (13%), pneumonia in 8 Table 3. Postoperative Complications Complications Air leak Not documented None <7 days 7 days Heimlich valve at dismissal Atrial fibrillation Pneumonia Mechanical ventilation postoperatively Remain intubated from operating room Reintubated postoperatively Bleeding Tracheostomy Bronchoscopy for retained secretions Bronchopleural fistula Seizures Ileus Urinary retention
No. (%) (N ¼ 63) 1 25 18 19 10 8 8
(2) (40) (29) (30) (16) (13) (13)
5 5 3 3 2 1 1 1 1
(8) (8) (5) (5) (3) (2) (2) (2) (2)
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(13%), bleeding in 3 (5%), respiratory failure requiring tracheostomy in 3 (5%), and bronchopleural fistula in 1 (2%). Ten patients (15%) were dismissed with a Heimlich valve. Two patients died (operative mortality, 3%). One patient had an infected bulla and underwent bilateral bullectomy. A prolonged air leak and respiratory failure developed, and he ultimately died of sepsis. The second patient died 12 days after dismissal of unknown cause. Median postoperative length of stay was 7 days (range, 1 to 54 days). Factors associated with an increased odds of a postoperative complication included increasing bulla size (p ¼ 0.017) and underlying diffuse emphysema (p ¼ 0.011; Table 4). Median follow-up was 1.5 years (range, 4 days to 13.0 years). Follow-up data on clinical symptoms were available for 52 patients (82%). Of the 43 patients with shortness of breath preoperatively and who had a follow-up assessment, 29 (67%) were improved (95% confidence interval (CI), 51% to 81%). At the postoperative assessment, 15 patients were asymptomatic, 8 patients had grade I dyspnea, 15 patients had grade II or III, and 5 patients had grade IV. Dyspnea improved in 21 of 33 patients (64%) with underlying diffuse emphysema compared with 5 of 7 patients (71%) without emphysema. Fifteen patients (24%) required intermittent or continuous supplemental home oxygen. One patient subsequently underwent single lung transplantation. Thirty patients (48%) had preoperative and postoperative pulmonary function tests (Table 5). The median preoperative FEV1 was 1.0 L (26% predicted) and improved to a postoperative FEV1 of 1.4 L (43% predicted; p ¼ 0.002). In the 16 patients with preoperative and postoperative assessments, residual volume and the ratio of FEV1 to forced vital capacity (FEV1/FVC) did not change significantly (p ¼ 0.38), nor did the diffusing capacity of the lung for carbon monoxide (DLCO) in 12 patients who were evaluated for it (p ¼ 0.48). The presence of underlying diffuse emphysema did not adversely affect improvement in postoperative dyspnea (odds ratio, 0.7, 95% CI, 0.1 to 4.2; p ¼ 0.70). The preoperative size of bullae had a borderline significant association with postoperative improvement in dyspnea (95% CI, 0.995 to 1.6; p ¼ 0.055). Among 16 patients, there was only a slight negative correlation between the preoperative size of bullae and improvement in postoperative FEV1 (r ¼ –0.14, p ¼ 0.61). At the last follow-up, 46 patients were alive and 17 had died. No recurrent giant bullae or pneumothorax developed during the follow-up period. Overall 5-year survival was 68% (95 % CI, 54% to 87%; Fig 1). Factors associated with a significant decrease in long-term survival included patients who smoked (current or former; hazard ratio, 8.5, 95% CI, 1.1–65.7; p ¼ 0.04) and increasing age (hazard ratio, 1.9 per 10 years; 95% CI, 1.2 to 3.0; p ¼ 0.003; Table 6).
Comment A pulmonary bulla is an air filled space of more than 1 cm in diameter, formed as a result of a destructive process.
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Table 4. Risk Factor Association With Postoperative Complications Variable
Patients (No.)
Early Morbidity No. (%)
OR (95% CI)
51 12
32 (45) 4 (33)
1.6 (0.4–6.2) 1.0 (Reference)
0.46
54 9
26 (48) 1 (11)
7.4 (0.9–63.5) 1.0 (Reference)
0.07
30 27
16 (53) 8 (30)
2.7 (0.9–8.1) 1.0 (Reference)
0.07
43 16
22 (51) 2 (12) . . .
Gender Male Female Smoking Current/Former Never Pack-years >40 years 40 years Emphysema Yes No Age, per 10 years Pack-years, per 10 years Bulla size, per cm a
7.3 1.0 1.4 1.13 1.2
(1.5–36.2) (reference) (0.97–2.0) (0.95–1.35) (1.04–1.4)
p Value
0.01a 0.07 0.16 0.016a
Statistically significant.
CI ¼ confidence interval;
OR ¼ odds ratio.
a patient will be seen for infection, bleeding, or carcinoma associated with the bulla [7]. The goals of surgical therapy for patients with giant bullae are to improve the quality of life for those in whom medical treatment has failed and to resolve complications while preserving lung function [1, 4, 8] Although appropriate selection is considered critical for optimal results in patients seeking improvement in dyspnea and quality of life, no single preoperative test has been found to be an absolute predictor of improvement. Criteria for a favorable prognosis have included bullae occupying more than one-third of the hemithorax, vascular crowding, localized disease, compression of underlying normal lung, relatively good perfusion on the contralateral side, and preoperative FEV1 of less than half of the predicted value [1, 4, 8–10] In contrast, Nakahara and colleagues [11] recommend that preoperative FEV1 be greater than 40% of the predicted value. Compared with those reported criteria, 71% of our patients had diffuse emphysema, and the median preoperative FEV1 in our series was 29% of the predicted value. None of our patients was asymptomatic.
When it has enlarged to significant proportions and occupies a large volume inside the chest cavity, it becomes a giant bulla. The percentage of pleural space occupied by a giant bulla has varied in the literature from not specified to up to 50% [1]. The outer surface of the bulla is made of visceral pleura, but the inner surface consists of fibrous tissue formed by the pleura and underlying destroyed pulmonary tissue [4]. Associated with these changes are varying degrees of emphysema [2]. Giant bullae are different from pulmonary blebs or cysts [5]. The incidence of giant bullae is generally unknown, but the condition is considered rare; in Iceland, for example, the age-standardized incidence rate of giant pulmonary bullae has been reported as 0.21/100,000 per year [6]. Similar to what was reported by Snider [1] in an extensive review, most of our patients were men, former or current smokers, and with disease predominantly on the right side and upper lung fields. Although giant bullae can be asymptomatic, patients are usually referred to the thoracic surgeon because of dyspnea or complications, including pneumothorax and prolonged air leak after chest tube insertion [1, 4]. Rarely,
Table 5. Change in Pulmonary Function in Patients With Giant Bullae After Bullectomy Variablea FEV1, L FEV1 % pred RV, L RV, % pred FEV1/FVC DLCO, % pred a
Patients (No.) 23 21 9 8 16 12
Preoperative 1.0 29 3.7 192 48.2 59
(0.5–3) (16–77) (2.2–8.0) (135–405) (25.2–85.8) (24–81)
Values are expressed as median (range) using Wilcoxon rank sum test.
% pred ¼ % predicted; forced vital capacity;
Follow-Up 1.4 42 3.8 194 52.2 53 b
Change From Preoperative
(0.2–3.5) (11–104) (1.7–6.7) (81–328) (23.4–90.2) (30–88)
0.3 10 –1.3 –45 3.0 4
(–0.8 to 1.4) (–17 to 35) (–1.7 to 1.8) (–89 to 81) (–15.8 to 16.5) (–45 to 25)
p Value 0.002b 0.003b 0.25 0.25 0.38 0.48
Statistically significant.
DLCO ¼ diffusion capacity of the lung for carbon monoxide; RV ¼ residual volume.
FEV1 ¼ forced expiratory volume in 1 second;
FVC ¼
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Fig 1. Kaplan-Meier estimate of overall survival after giant bullectomy.
Snider [1] reports that surgical intervention is most often performed for dyspnea and rarely for pneumothorax. Our series was more evenly divided: up to 52% of our patients were operated on for complications such as pneumothorax or prolonged air leak. A secondary pneumothorax in patients who have severe COPD can be a life-threatening event [12], and there are few alternative therapeutic options to an operation. The air leak associated with a ruptured bulla is often prolonged due to the underlying emphysema and associated diseased elastic network. These pneumothoraces can often be loculated because of previous pleural diseases or interventions, and this may contribute to the development of “tension pouches.” Some pneumothoraces can sometimes be indistinguishable from a bulla on preoperative CT [13]. Although various imaging modalities have been used to try to better predict postoperative results, CT has become [14] and remains [15] the imaging technique of choice for preoperative evaluation of patients with emphysema. All of our patients had a preoperative CT. Findings on CT indicated more than 70% of our patients had underlying diffuse emphysema, and only 25% had compression of the underlying lung. Similar to Schipper and colleagues [16], we have started using pulmonary rehabilitation preoperatively (10 patients in our series) as much to improve conditioning as to assist with patient selection, based on the lung volume reduction surgery experience [17]. Acute bronchitis should be treated aggressively preoperatively with appropriate antibiotics and constitutes a contraindication to elective bullectomy if unresolved [18]. The goal of surgical treatment is to remove the bulla while preserving as much of the underlying pulmonary parenchyma as possible [1, 4, 9], Most of our patients underwent bullectomy, but 11% had a lobectomy or bilobectomy because the emphysematous changes extended to the hilum. Given the expected morbidity of
prolonged air leak in this high-risk population, more than half of the patients in our series required a concomitant pleural obliteration procedure and buttressing of the staple line [12]. Close to 70% of our patients had relief or substantial improvement of their preoperative symptoms, with an operative mortality of 3% and morbidity of 43%. These results are comparable to those reported by others [1, 10–11, 16, 18–20]. A similar improvement in airway obstruction, as demonstrated by an increase in postoperative FEV1 in our series, was also reported by others [1], but Schipper and colleagues [16] and Palla and colleagues [21] have shown that the improvement after bullectomy is time-limited and patients slowly deteriorate over the following years, similar to other emphysematous patients after lung volume reduction surgery [17]. Our relatively short follow-up did not allow us to study our patients long-term. We have shown that the presence of underlying emphysema, as measured by preoperative CT, did not adversely affect the functional results, in contrast to the study from Palla and colleagues [21], who found that patients without underlying emphysema did better. We believe this is relevant to patient selection and suggest that underlying emphysema should not be considered an absolute contraindication for surgical treatment. We also found near statistically significant correlation between larger bulla size and postoperative symptom improvement, similar to the findings reported by others [10, 21]. Long-term survival in our study was less than what was reported by Schipper and colleagues [1] and was adversely affected by age and smoking status. We also had a higher incidence of diffuse emphysema in our series, and this also may have adversely affected longterm survival [22]. Our study is retrospective with a relative short followup period. We do not know the number of patients seen
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Table 6. Risk Factor Association With Long-Term Survival Variable Overall Gender Male Female Smoking Current/former Never Pack-years >40 40 Emphysema Yes No Age, per 10 years Pack-years, per 10 years Bulla size, per cm a
Patients (No.)
Deaths (No.)
Kaplan-Meier Estimate (95% CI) at 5 Years
HR (95% CI)
p Value
63
19
68 (54–87)
.
.
51 12
16 3
61 (43–86) 82 (60–100)
3.2 (0.9–11.2) 1.0 (Reference)
0.07
54 9
18 1
65 (48–87) 83 (58–100)
8.5 (1.1–65.7) 1.0 (Reference)
0.04a
30 27
9 6
81 (62–100) 70 (49–100)
1.5 (0.5–4.3) 1.0 (Reference)
0.43
43 16
15 3
70 (54–91) 57 (30–100) . . .
1.8 1.0 1.9 1.1 1.0
0.33
(0.5–6.4) (Reference) (1.2–3.0) (0.9–1.2) (0.9–1.1)
0.003a 0.38 0.89
Statistically significant.
CI ¼ confidence interval;
HR ¼ hazard ratio.
at our medical center who were never referred to a surgeon or were denied operative treatment after surgical evaluation. The radiologist did not grade the degree of underlying emphysema. Despite those limitations, our goal was to combine all patients operated on for a giant bulla during the study time period to better reflect the spectrum of potential surgical candidates seen by a general thoracic surgeon in clinical practice. In conclusion, giant bullae of the lung can be intimidating, especially when associated with underlying diffuse emphysema or worse, vanishing lung. Several criteria have been identified over the years to help guide therapeutic decisions. In addition, patients who present with pneumothorax or prolonged air leak, or both, after tube thoracostomy face few if any alternatives to surgical intervention. We have found in our population of patients that it is possible to remove a giant bulla of the lung under those circumstances with reasonable morbidity and mortality. Pulmonary function improved in most patients with symptomatic or complicated giant bullae, or both, after bullectomy. In selected cases, a lobectomy might be necessary to remove the giant bulla and be accomplished with favorable outcomes. Increasing bulla size and the presence of diffuse emphysema adversely affected postoperative morbidity. Underlying diffuse emphysema did not adversely affect postoperative functional results and is not considered a contraindication to bullectomy. Increasing age at time of operation and smoking status (current or past) adversely affected long-term survival.
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17. National Emphysema Treatment Trial Research Group. A randomized trial comparing lung volume reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003;348:2059–73. 18. Laros CD, Gelissen HJ, Bergstein PG, et al. Bullectomy for giant bullae in emphysema. J Thorac Cardiovasc Surg 1986;91:63–70. 19. Pearson MG, Ogilvie C. Surgical treatment of emphysematous bullae: late outcome. Thorax 1983;38:134–7.
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20. De Giacomo T, Venuta F, Rendina EA, et al. Video-assisted thoracoscopic treatment of giant bullae associated with emphysema. Eur J Cardiothorac Surg 1999;15:753–7. 21. Palla A, Desideri M, Rossi G, et al. Elective surgery for giant bullous emphysema: a 5-year clinical and functional followup. Chest 2005;128:2043–50. 22. NETT Research Group. Predictors of mortality in patients with emphysema and severe airflow obstruction. Am J Respir Crit Care Med 2006;173:1326–34.
INVITED COMMENTARY Dr Krishnamohan and colleagues [1] present a large retrospective analysis of patients operated on for giant bullous disease. Their mix of patients was fairly evenly distributed between patients with symptoms alone and those with adverse events, predominantly pneumothorax and persistent air leak. Morbidity and mortality were in line with what is expected in this cohort. Nearly half the patients had preoperative and postoperative lung function tests (presumably the patients operated on for symptoms), and they demonstrated the authors’ good surgical insight. The patients all had severe obstruction and hyperinflation with relatively preserved diffusion capacity (median >50% predicted). It was encouraging that forced expiratory volume in 1 second improved significantly postoperatively, but it is curious that residual volume did not decrease. This study’s strengths are its size and excellent results. It suffers from its retrospective nature and the inability to know what happened to the patients with giant bullous disease who were treated nonoperatively. This report highlights the evolving approach to giant bullous disease. Although resectional therapy for giant bullous disease is still uncommon, it may be playing an increasingly important role. Although this report spans
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a 22-year period, the median follow-up time was only 1.5 years, suggesting that most patients were operated on fairly recently. A combination of the experience with lung volume reduction surgical procedures (LVRS), increasing our knowledge about how to operate on patients with extremely poor lung function, and the fact that most of these operations can now be done in a minimally invasive fashion, may explain this trend. The increasing use of preoperative pulmonary rehabilitation also parallels the LVRS experience and should be used liberally for patients being operated on for dyspnea. William R. Burfeind, Jr, MD Thoracic Surgery St. Luke’s University Health Network 701 Ostrum St, Ste 603 Bethlehem, PA 18015 e-mail: [email protected]
Reference 1. Krishnamohan P, Shen KR, Wigle DA, et al. Bullectomy for symptomatic or complicated giant lung bullae. Ann Thorac Surg 2014;97:425–31.
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