Bullectomy 

Updated: Feb 21, 2019
Author: Neerja Gulati, MD; Chief Editor: Dale K Mueller, MD 

Overview

Background

Bullectomy is the surgical removal of a bulla, which is a dilated air space in the lung parenchyma measuring more than 1 cm.[1]  A bulla that occupies more than 30% of the hemithorax is referred to as a giant bulla. The most common cause of a lung bulla is chronic obstructive pulmonary disease. Other conditions associated with lung bullae are alpha-1 antitrypsin deficiency, Marfan syndrome, Ehler-Danlos syndrome, cocaine smoking, sarcoidosis, HIV infection, and intravenous (IV) drug abuse.

Bullae increase physiologic dead space and compress surrounding normal lung tissue. Giant bullae also exert pressure on the diaphragm and effect its contractility. The natural history of bullae is one of enlargement causing worsening of dyspnea; however, the rate of expansion is unpredictable. The clinical course of a giant bulla can be complicated by a pneumothorax and fluid accumulation within the bulla.[2]

Indications

Patient selection is one of the most important aspects of successful bullectomy.[1]  The most common indications for bullectomy include the following[3, 4, 5] :

  • Severe dyspnea due to a giant bulla (ie, one occupying 30% or more of the hemithorax)
  • Spontaneous secondary pneumothorax
  • Pain
  • Repeated infection
  • Hemoptysis

Some authors also recommend surgery for bullae that are increasing in size on serial chest radiographs, as well as lesions occupying more than 50% of the hemithorax, even if the patient is asymptomatic.[4, 5]

Contraindications

Contraindications for bullectomy include the following:

  • Significant comorbid conditions
  • Poorly defined bullae on chest imaging
  • Pulmonary hypertension

Forced expiratory volume in 1 second (FEV1) that is less than 35%, hypercapnia, cor pulmonale, and carbon monoxide diffusing capacity less than 40% are associated with an increased risk of surgical intervention.[6]

An increased risk of surgery exists with older age, but advanced age is not a contraindication.[7]

Technical Considerations

Complication prevention

Careful patient selection is the cornerstone of efforts to minimize patient mortality and morbidity. Tenets of complication prevention include the following:

  • Early extubation, which minimizes the duration of positive-pressure ventilation and the risk of barotrauma associated with it [8]
  • Maintenance of low intraoperative tidal volumes, which minimizes barotrauma to the nonoperative lung during surgery
  • Minimal intraoperative fluid resuscitation and postoperative use of fluids, which minimize the risk of pulmonary edema and hypoxemia
  • Pulmonary toileting in the early postoperative period

Outcomes

After bullectomy, surrounding healthy lung tissue expands, and chest mechanics improve by virtue of the remodeling of the thorax and diaphragm. Symptomatic improvement (dyspnea, exercise capacity, need of oxygen) and functional improvement occur.[9, 10, 11, 12, 13, 14, 15, 16]

The greatest benefit is seen in patients with large bullae accompanied by crowding of adjacent structures, upper-lobe predominance, and minimal underlying emphysema.[17]

Preoperative bulla size is the most important determinant of improvement in ventilatory capacity after bullectomy.[18]

Maximal benefit is noted in the first year after surgery. The improvements in symptoms and lung parameters decline a few years after surgery, but the patient's condition remains better than it was in the period before surgical treatment.[11, 12, 13, 16]

Pulmonary rehabilitation and smoking cessation are important in the management of these patients. Decline of lung function after surgery is less in those patients who stopped smoking than in those who continue to smoke.

 

Periprocedural Care

Preprocedural Planning

Preoperative evaluation includes chest radiography, computed tomography (CT) of the thorax, full pulmonary function testing, and, for some patients, ventilation-perfusion scanning and pulmonary angiography.[1, 15]  CT provides detailed information on the location, size, and number of bullae, as well as on adjacent lung, pleural, and mediastinal structures (see the image below).

Computed tomography scan of chest showing bulla in Computed tomography scan of chest showing bulla in left lung. Image courtesy of Richard Lazzaro, MD, New York Methodist Hospital.

Ventilation/perfusion lung scanning provides a functional assessment of the vascular and parenchymal integrity of the lung. Detailed cardiac evaluation is needed because many patients with chronic obstructive pulmonary disease (COPD) have associated heart disease. Medical therapy for COPD should be optimized. Smoking cessation and outpatient pulmonary rehabilitation are usually instituted for all eligible patients preoperatively.[1]

Equipment

Equipment for bullectomy includes the following:

  • Double-lumen endotracheal tube and bronchial blockers for anesthesia
  • Thoracoscope
  • Ports
  • Endoscopic stapler
  • Sponge-holding forceps
  • 24-French chest tubes
  • Sealant material

Patient Preparation

Anesthesia

Patients with lung bullae are at increased risk for perioperative complications due to underlying chronic lung disease. Bullectomy is typically performed with general anesthesia with single-lung ventilation. A double-lumen endotracheal tube is used to provide single-lung ventilation to the lung not being operated on. If single-lung ventilation cannot be achieved, low–tidal volume ventilation during surgery and apneic oxygenation during stapling may be provided. Single-incision thoracoscopic surgery (SITS) with two-lung ventilation has been described.[19]

Close intraoperative monitoring should be done with pulse oximetry, capnography, and measurement of arterial and central venous pressure.[8]

Use of short-acting anesthetic agents is preferred to enable early extubation.[8]  Inhalational agents may have unpredictable uptake and distribution as a consequence of the increased dead space. Use of nitrous oxide is avoided, because of the risk of bulla expansion.

Positioning

The patient is placed in the lateral decubitus position with the nonoperative site in the dependent position and the operated side of the lung unventilated.

 

Technique

Approach Considerations

Careful patient selection is the key to achieving good results.

Early extubation and appropriate invasive and noninvasive monitoring are needed.

Air leakage can be reduced by minimizing the duration of positive-pressure ventilation and applying a secure staple line with or without buttress material/fibrin sealants and creation of a pleural tent.

Chest tube connection to water seal/suction and monitoring for development or worsening of a pneumothorax are needed.

Postoperative pain control, bronchodilators, antibiotics, and pulmonary toileting are needed.

Removal of Lung Bulla

Choice of approach

The choice of surgical technique depends on the size and number of bullae to be removed. The main options are video-assisted thoracic surgery (VATS) and open thoracotomy/sternotomy, with VATS being the less invasive approach.[20, 21, 22, 23, 24]

When an open thoracotomy is performed, the anterolateral or posterolateral approach is generally used for unilateral and median sternotomy for bilateral disease.[15, 25]  

VATS is the preferred approach for patients who are at excessive risk with thoracotomy.[26]  VATS also allows quicker recovery and is associated with less pain than thoracotomy and can be used for bilateral disease.26 Various single-incision thoracoscopic surgical (SITS) approaches have been described.[27, 19]

Operative details

The objectives of concern for surgeon are the following:

  • Amount of lung adjacent to the bulla that should be removed
  • Method of resection
  • Prevention of air leaks

A bulla with a broad stalk is managed with stapler excision or plication. If several bullae exist and it is hard to define healthy tissue, wedge resection is performed. If an entire lobe of lung is affected, lobectomy is performed. (See the images below.)

Flattened bulla. Image courtesy of Richard Lazzaro Flattened bulla. Image courtesy of Richard Lazzaro, MD, New York Methodist Hospital.
Surgical field showing multiple bullae. Image cour Surgical field showing multiple bullae. Image courtesy of Richard Lazzaro, MD, New York Methodist Hospital.
Surgical field showing bullae. Image courtesy of R Surgical field showing bullae. Image courtesy of Richard Lazzaro, MD, New York Methodist Hospital.

The bulla is usually excised with a rim of normal lung parenchyma to avoid leaving open bronchioles. The various techniques include stapler excision, plication, and (less commonly) laser ablation. Additional small bullae and blebs in the residual lung are often excised.

Buttressing of the suture line to prevent an air leak can be done with exogenous material, fibrin sealant, or creation of an apical postoperative pleural tent.

Bovine pericardial strips and other synthetic material (eg, polytetrafluoroethylene [PTFE]) are used to buttress fragile lung tissue. Application of fibrin glue, use of cryoprecipitate, and even reinforcement by the wall of the bulla have been performed to reduce air leaks.[28]

Another surgical technique is the creation of a pleural tent, which reduces the size of the pleural cavity and enables apposition between the sutured surface of the lung and the chest wall.[29]  This is done by dissecting parietal pleura from the chest wall and tailoring it to make a tent for the residual lung.[30, 31, 32, 5, 33, 34, 35]

After resection of the bulla, the lung is examined for air leakage and bleeding. Gentle reexpansion of the residual lung is carried out to check how it fills the pleural cavity. One or two chest tubes are left in the pleural cavity.

The management of drains and tubes is highly variable among surgeons. A retrospective analysis of 838 patients who underwent elective pulmonary resection found that chest tubes on water seal are safe for most patients with an air leak and a pneumothorax. Chest tubes were connected to the drainage system, and –20 cm H2O of suction was added on the day of surgery. The chest tubes were then placed on water seal on the morning of postoperative day 1.

Chest radiographs were obtained daily. All tubes remained on water seal unless they failed water seal. For those who failed water seal (as evidenced, for example, by development of new-onset hypoxia, enlarging pneumothorax, or development of new-onset or enlarging subcutaneous emphysema), chest tubes were then placed to –10 cm H2O of suction. If the problem continued after 24 hours, the tubes were then placed to –20 cm H2O of suction.

Postoperative Care

Early extubation is the goal. Epidural analgesia and opioids are generally used for pain management in the postoperative period.[8]  Epidural analgesia should be used liberally to provide regional pain control and minimize postoperative narcotic use and respiratory suppression.

Early postoperative ambulation on the day of surgery is encouraged. Early ambulation is important because it drives CO2 production, forcing the patient to ventilate and thereby mitigating postoperative atelectasis.

The chest tubes are left in the thoracic cavity until the air leak is resolved and the lung is fully expanded. Patients are monitored for hypoxia and hypercarbia. Chest radiography is performed as needed for pneumothorax.

The patient should receive bronchodilators and prophylactic antibiotic coverage, along with deep venous thrombosis (DVT) prophylaxis.

Complications

The most common pulmonary complications of bullectomy are as follows[9, 11, 34, 15, 35] :

  • Air leakage
  • Postoperative respiratory failure
  • Pneumonia
  • Bleeding

The most common cardiac complications are as follows:

Other complications include the following:

In a series of 43 patients who underwent resection of a giant bulla, prolonged air leakage lasting for more than 7 days was seen in 53%, atrial fibrillation (AF) in 12%, postoperative mechanical ventilation in 9%, and pneumonia in 5%.[11]  Another study described prolonged air leakage lasting for more than 7 days in 46% and subcutaneous emphysema in 53% of patients undergoing VATS. Better results may be expected in patients without underlying diffuse emphysema.[17]

In a series of 41 patients, mortality within the first year was 7.3%, and late mortality was 4.9%.[13]  Causes of death included postoperative pneumonia, acute and chronic respiratory failure, PE, and MI.

 

Questions & Answers