Median sternotomy for bilateral resection of emphysematous bullae

J THoRAc CARDIOVASC SURG 82:892-897, 1981

Median sternotomy for bilateral resection of emphysematous bullae We report four cases of severe bilateral bullous emphysema treated by bilateral resection of the bullae through median sternotomy. No technical problems were encountered through this approach. which provides maximum benefit with one operation. Reduced postoperative disability associated with median sternotomy together with ability to evaluate and treat both lungs at once are benefits of this surgical approach for patients requiring operation for bullous disease.

Oriane Lima, M.D., Luis Ramos, M.D., Paulo Di Biasi, M.D., Luis Judice, M.D., Niteroi and Rio de Janeiro, Brazil, and Joel D. Cooper, M.D., Toronto, Ontario, Canada

Excision or plication of large, space-occupying bullae in patients with chronic obstructive lung disease may significantly improve exercise tolerance and respiratory reserve.':" Patients with large bilateral bullae present a particular operative challenge owing to the severity of the underlying disability and the potential for postoperative morbidity, including possible complications on the contralateral, nonoperated side.P: 6 It has been demonstrated that both major and minor bilateral pulmonary resections can be accomplished through a median sternotomy; furthermore, postoperative recovery of pulmonary function is more rapid following median sternotomy than following lateral thoracotomy." This report of four cases details our entire experience with median sternotomy employed for bilateral resection of severe emphysematous bullae.

Case reports CAS E 1. A 68-year-old woman was admitted to the Toronto General Hospital in October, 1976, with increasing shortness of breath. The patient's symptoms dated back 5 years, during which time she had noticed the gradual onset of dyspnea on exertion. Her symptoms gradually worsened to the point that she was dyspneic at rest, had nocturnal orthopnea, and could no longer perform even simple kitchen chores. The patient was unable to walk more than a few feet

From the Department of Thoracic Surgery, Santa Cruz Hospital, Niter6i and Rio de Janeiro, Brazil, and the Division of Thoracic Surgery, TorontoGeneral Hospital, Toronto, Ontario, Canada. Received for publication March 10, 1981. Accepted for publication May 2, 1981. Address for reprints: Joel D. Cooper, M.D., 10-226 Eaton North, Toronto General Hospital, 200 Elizabeth St., Toronto, Ontario, Canada M5G IL7.

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at a time and was confined to her home because of the severity of her breathlessness. The patient had worked for 40 years in a jute mill and had smoked one package of cigarettes per day for 20 years. Chest roentgenogram (Fig. I, A) revealed severe bilateral bullous emphysema with hyperlucency of both upper lung fields and compression of both lower lobes. A pulmonary angiogram confirmed the presence of emphysematous bullae in both upper lobes. Pressure in the main pulmonary artery was 75/32 mm Hg with a mean of 50 mm Hg. Angiogram demonstrated downward displacement of the upper lobe vessels on both sides. Pulmonary function studies (Table I) showed marked gas trapping and airway obstruction. Arterial blood gases on room air were pH 7.43, P0 2 50 mm Hg, Pc02 38 mm Hg, and total bicarbonate 26. It was concluded that resection of the emphysematous bullae offered the only possibility for alleviating the patient's disability. Operative procedure. A Robertshaw double-lumen tube was used for the operation. A median sternotomy was employed and the left mediastinal pleura was opened first. There was a large bullae in the left upper lobe. The left pulmonary ligament was divided to improve access to both lobes. The left lower lobe, the lingula, and the anterior segment of the left upper lobe appeared to be free of major bullae and relatively normal. The upper lobe bulla replaced the entire apicoposterior segment. The bulla was incised longitudinally across its center, the wall was everted on either side, and the base of the bulla was closed with a GIA* stapling device repeatedly applied from one end to the other. The knife blade was removed from the stapling device, which then produced four parallel staggered rows of staples. The residual left lung was easily inflated and was found to fill the left side of the chest. An intercostal catheter was placed in the pleural space through a separate stab wound and the mediastinal pleura was closed. *Trademark of Auto Suture Company, Division of United States Surgical Corporation, Norwalk, Conn.

0022-5223/81/120892+06$00.60/0 © 1981 The C. V. Mosby Co.

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..... 1. Case I . A. Preoperative chest x-ray film. There is marked hyperexpansion of the lung fields with compression inferiorly of all major pulmonary vessels. This finding was confirmed by pulmonary angiography. B. Following bilateral upper lobe bullectomy, there is elevation of the diaphragms and hilus with the restoration of a more normal pulmonary vascular pattern.

Table I. Lung function MEF at 50% VC (LIsee) Case J

Predicted Preoperative Postoperative (6 weeks)

4.6 7.5 7.7

2.5 6.4 5.9

1.9 6.2 4.6

3.1

2.0 0.6 1.6

2.7 0.5 0.9

4.2 3.6 2.9

3.1 1.7 1.9

3.7 0.3 1.0 3.1 0.5

2.7 1.3

Case 2

Predicted Preoperative Postoperative (6 months) Case 3

Predicted Preoperative Postoperative (not available)

4.3 4.7

2.1 3.8

1.0 1.6

3.2 3.1

2.4 1.7

5.67 9.0 5.14

3.29 3.36 7.11

1.8 6.16 1.91

3.85 1.7 3.3

3.85 0.88 2.68

Case 4

Predicted Preoperative Postoperative (8 months)

Legend: TLC. Total lung capacity. FRC, Functional residual capacity. RV , Residual volume. VC, Vital capacity. FEV" Forced expiratory volume in I second.

MEF, Maximal expiratory flow.

A satisfactory result, without air leak, was obtained on the left side . The right mediastinal pleura was then opened, and two bullae in the right upper lobe were dealt with in similar fashion . The right-mediastinal pleura was then closed. but the lower portion was left open to provide drainage from the mediastinum to the right pleural space . The patient was elec-

tively ventilated for 48 hours follow ing the operation . After 24 hours no pulmonary air leak was present, and all chest tubes were removed by the third postoperative day . The patient was discharged well on the thirteenth postoperative day. Her exercise tolerance improved to the extent that she could easil y walk several blocks, go shopping , and perform routine

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Fig. 2. Case 2. Preoperative (A) and postoperative (B) chest x-ray films. Major bullae were resected from both upper lobes. household chores. Postoperative pulmonary function studies (Table I) revealed a marked reduction in residual volume and a significant increase in vital capacity. The postoperative x-ray appearance is seen in Fig. I, B. Three years postoperatively, the patient's improved respiratory status has been maintained. CASE 2. A 46-year-old man was admitted to the Thoracic Surgical Department of the Santa Cruz Hospital (Niteroi and Rio de Janeiro, Brazil) on Dec. 3, 1977, with complaints of exertional dyspnea for 2 years with exacerbation of symptoms during the previous 2 months before his hospitalization. In 1960 he had had a post-traumatic right pneumothorax treated without intercostal drainage. Upon admission to the hospital the chest roentgenogram showed a large bulla occupying half of the left hemithorax and several bullae scattered throughout the right lung (Fig. 2, A). The arterial blood gases with the patient breathing room air were pH 7.41, Po 292 mm Hg, and reo, 38 mm Hg. Pulmonary function studies showed significant obstruction (Table I). The lung scan showed perfusion of the left lower lobe and most of the right lung. The pulmonary angiogram showed significant compression of the left lower lobe vessels. The mean pulmonary artery pressure was normal. Operative procedure. The patient underwent median sternotomy (0. L.). A regular Portex tube was used during anesthesia for ventilation. The left mediastinal pleura was opened to permit visualization of a large emphysematous bulla that replaced most of the left upper lobe. There were small bullae along the surface of the left lower lobe. Examination of the right pleural cavity showed several pleural adhesions, a large bulla occupying the major portion of the right upper lobe, and another large pedunculated bulla extending downward from the upper lobe along the right heart border. Smaller bullae were found on the visceral surface of the right middle and lower lobes. The lesions were resected and sutured with 4-0 chromic catgut. Both mediastinal pleura were left open and two intercostal drains were inserted into each pleural cavity. A talc poudrage was performed bilaterally prior to closure.

During the postoperative period ventilatory support was not required. The thoracic drains were removed by the tenth day. The postoperative period was complicated by an upper gastrointestinal hemorrhage from a duodenal ulcer, which was controlled conservatively. The patient was discharged 18 days following operation. Chest roentgenogram 12 weeks later showed bilateral re-expansion of the remaining lung tissue (Fig. 2, B). Pulmonary function studies performed 5 months following operation (Table I) showed only slight improvement in pulmonary function measurements, but recent clinical follow-up (July, 1980) revealed that the patient continues to enjoy marked clinical improvement in his exercise tolerance. The patient's weight increased from 62 kg (preoperative) to 71 kg by the sixth postoperative month. CAS E 3. A 51-year-old man was admitted to the Thoracic Surgical Department at the Santa Cruz Hospital on Aug. 24, 1978, with bilateral bullous emphysema diagnosed originally in 1973. At the time of this admission he complained of having had increasing exertional dyspnea with worsening of symptoms for the previous 6 months, which prevented even moderate effort. A chest x-ray film showed bilateral bullous emphysema with hyperlucency of both upper lung fields and compression of both lower lobes (Fig. 3, A). Pulmonary function studies showed significant airway obstruction (Table I). Arterial blood gases on room air were pH 7.40, Pco, 38 mm Hg, and P0 2 80 mm Hg. Pulmonary angiograms showed downward displacement of the branches of both the right and left pulmonary arteries. Pulmonary artery pressure was normal. Operative procedure. The patient underwent a median sternotomy (0. L.) with a Portex tube used during anesthesia. The left mediastinal pleura was initially opened. There were no pleural adhesions. A large bulla was identified in place of the apicoposterior segments, as well as several smaller bullae and blebs scattered throughout the anterolateral and posterior surfaces of the lower lobe. The upper lobe bulla was incised longitudinally through its center. Several small bronchi were identified and sutured. The wall of the bulla was partly resected, and its margins were used as a buttress for the continuous

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FIg. 3. Case 3. Preoperative (A) and postoperative (B) chest x-ray films. Major bullae were resected from both upper lobes . and small bullae in both lower lobes were plicated .

Fig. 4. Case 4. Preoperative (A) and postoperative (B) chest x-ray films. Total destruction of pulmonary parenchyma required a right upper lobectomy and wedge resection of the superior half of the left upper lobe . The parietal pleura was mobilized from the upper half of the left side of the chest to provide an apicopleural "tent" across the superior surface of the residual left lung. This reduced postoperative air leak and the left pleural space . The postoperative x-ray film, taken 10 months following operation, shows a persistent air space above the pleural tent. mattress suture used to oversew the base of the bulla . The small bullae and blebs were perforated by resection and suturing of the base : The residual left upper lobe and lower lobes were well inflated. Opening the right mediastinal pleura disclosed a large bulla replacing the apicoposterior segments of the right upper lobe and several smaller bullae scattered

throughout the surface of the middle and lower lobes . The bullae were dealt with in similar fashion . Two intercostal drains were placed in each pleural space. Both mediastinal pleurae were left open. A bilateral talc poudrage was performed . The patient was extubated and required no postoperative

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ventilatory assistance. In the postoperative period there was a small air leak on both sides lasting for 2 weeks, after which the tubes were removed. The patient was discharged 5 weeks following operation. At 2 years' follow-up, the patient's excellent clinical improvement has been maintained. A recent follow-up chest x-ray film is shown in Fig. 3, B. CASE 4. A 43-year-old man was admitted to the Toronto General Hospital in January, 1980, with a history of increasing shortness of breath. The patient had had known bullous emphysema for 7 years. He had smoked one package of cigarettes daily for 20 years, having quit completely 7 years prior to admission. In the year prior to admission, he noticed increasing shortness of breath, such that climbing one flight of stairs became difficult. The patient had lost 15 pounds in the past year. He previously had had a spontaneous pneumothorax on the right side and three spontaneous pneumothoraces on the left. The chest x-ray film on admission (Fig. 4, A) showed severe bilateral bullous emphysema involving the upper lobes primarily. A pulmonary angiogram revealed downward displacement of the right middle and lower lobe vessels and similar displacement of the lingula and left lower lobe vessels. Mean pulmonary artery pressure was 17 mm Hg. Arterial blood gases on room air revealed pH 7.42, Pco, 36 mm Hg, and P0 2 86 mm Hg. The alpha, antitrypsin level was normal. The hemoglobin level was 15.3 gm/loo ml. The pulmonary function studies showed a marked increase in functional residual capacity and residual volume, and a firstsecond forced expiratory volume of 0.88 L, and a vital capacity of 1.7 L. Operative procedure. A double-lumen Robertshaw tube was used for ventilation. Through a median sternotomy, the right pleura was initially entered and the right upper lobe was found to be completely replaced with bullous disease, not amenable to surgical plication. A right upper lobectomy was performed without difficulty. The right middle and lower lobes expanded to fill the space and appeared relatively normal. The left pleura was then entered. The lingula appeared relatively normal, but the superior subdivision of the left upper lobe was extensively replaced with emphysematous bullae. A wedge resection of the bullous disease in the left upper lobe was carried out by use of the GIA stapler with the knife blade removed in order to place four parallel staggered rows of staples. Following this resection the re-expanded left lower lobe and lingula were inadequate to fill the pleural space completely, and an apical pleural release was performed; i.e., the apical pleura was dropped down to meet the residual left upper lobe. The pleura was closed on both sides and both pleural spaces were drained with intercostal catheters. Two days after the operation extensive pneumonia developed, initially caused by Hemophilus influenzae and subsequently by Pseudomonas. The patient required a tracheostomy and ventilatory support for several weeks. He was discharged to his home 6 weeks following the operation, at which time his exercise tolerance was noticeably improved over his preoperative status. Table I demonstrates the patient's lung function preoperatively and 8 months following operation. The marked improvement in pulmonary function was paralleled by a marked improvement in exercise tolerance. The patient's preoperative weight of 49 kg increased to 63 kg by the tenth postoperative month. His measured maximum power output increased from

500 kpm preoperatively to 900 kpm 8 months postoperatively (predicted value 1,000 kpm). A recent chest x-ray film is . shown in Fig. 4, B). Discussion Median sternotomy has been used previously for bilateral pulmonary operations, including bilateral pleurodesis for spontaneous pneumothorax, 8. 9 resection of bilateral metastatic tumors to the lungs.!" and other bilateral pulmonary conditions. 7 The benefits of resecting bullae in selected cases has been well estabIished.!: 3. 5, 11 In patients undergoing resection for bullous disease, bilateral bullae are frequently present and staged bilateral thoracotomies have previously been employed in some cases." Fitzgerald and associates" reported on 84 patients undergoing operation for bullous emphysema, and of these, 11 patients subsequently required contralateral thoracotomy for resection of bullae in the other lung. Several reports- 13. 14 have identified postoperative hyperexpansion of preexisting contralateral bullae as a source of morbidity and mortality following unilateral resection of emphysematous bullae. When the sternotomy approach is used to plicate or resect bullae on one side, opening the contralateral pleural space is a minimal addition to the procedure. Median sternotomy with bilateral resection offers the patient the maximum possible improvement, with a morbidity which is significantly less than that associated with the lateral thoracotomy normally used when dealing with just one side. Furthermore, the type of limited resection usually required for bullous disease poses no particular challenge through the sternotomy approach. This is especially true for upper lobe disease. All patients in this limited series have enjoyed marked, sustained clinical improvement, although the pulmonary function studies in some show little longterm improvement over preoperative values. This discrepancy between the clinical improvement and the change in measurable lung function has previously been recognized and may relate to the beneficial effects of bullectomy on increasing the efficiency of ventilation rather than improvement in measured lung volumes alone.

Addendum Since preparation of this manuscript, three more patients have undergone median sternotomy for bilateral bullous resection, and all have had a good result. REFERENCES Delarue NC, Woolf CR, Sanders DE, Pearson FG, Henderson RD, Cooper JD, Nelems JM: Surgical treatment for pulmonary emphysema. Can J Surg 20:222-230, 1977

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2 Wesley JR, Macleod WM, Mullard KS: Evaluation and surgery of bullous emphysema. J THORAC CARDIOVASC SURG 63:945-955, 1972 3 Fitzgerald MX, Keelan PJ, Cugell DW, Gaensler EA: Long-term results of surgery for bullous emphysema. J THORAC CARDIOVASC SURG 68:566-587, 1974 4 Knudson RJ, Gaensler EA: Surgery for emphysema. Ann Thorac Surg 1:332-362, 1965 5 Billig DM: Surgery for bullous emphysema. Chest 70:572-573, 1976 6 Santos GM, Lisboa LO, Lisboa RM, Mattos AD: Tratamento cirurgico da bolha de enfisema hipertensiva bilateral. Rev Bras Cir 36:267-269, 1958 7 Cooper JD, Nelems JM, Pearson FG: Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 26:413-420, 1978 8 Mercier G, Page A, Verdant A, Cossette R, Dontigny L, Pelletier LC: Outpatient management of intercostal tube drainage in spontaneous pneumothorax. Ann Thorac Surg 22:163-165, 1976

9 Kalnins I, Torda TA, Wright JS: Bilateral simultaneous pleurodesis by median sternotomy for spontaneous pneumothorax. Ann Thorac Surg 15:202-206, 1973 10 Takita H, Merrin C, Didolkar MS, Douglass HO, Edgerton F: The surgical management of multiple lung metastases. Ann Thorac Surg 24:359-364, 1977 11 Harris J: Severe bullous emphysema (successful surgical management despite poor preoperative blood gas levels and marked pulmonary hypertension). Chest 70:658-660, 1976 12 Thomas MP, Storer J, Grierson AL: Bilateral giant pulmonary air cysts. Chest 52:291-304, 1967 13 Lopez-Majano V, Kieffer F, Marine DN, Garcia DA, Wagner HN: Pulmonary resection in bullous disease. Am Rev Respir Dis 99:554-564, 1969 14 Dugan DJ, Samson PC: The surgical treatment of giant emphysematous blebs and pulmonary tension cysts. J THORAC SURG 20:729-748, 1950