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Ann Thorac Surg 2004;78:976-982
© 2004 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine,St. Louis, MO, USA
b Jacqueline Maritz Lung Center at Barnes-Jewish Hospital, St. Louis, MissouriUSA
Accepted for publication April 1, 2004.
* Address reprint requests to Dr Meyers, One Barnes-Jewish Plaza, 3108 Queeny Tower, St. Louis, MO 63110, USA
meyersb{at}msnotes.wustl.edu
Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentDiscussionReferences |
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METHODS: Forty-three patients underwent resection of giant emphysematous bullae at Barnes-Jewish Hospital between March 1994 and June 2002. All had limiting dyspnea and radiologic evidence of hyperinflated giant bullae compressing adjacent lung parenchyma. Forty-one patients underwent preoperative pulmonary rehabilitation. Twenty-two patients underwent a bilateral procedure and 21 underwent a unilateral procedure. Mean follow-up was 4.5 years.
RESULTS: One early death occurred on postoperative day 20 from heparin-induced thrombocytopenia and pulmonary embolism. Complications included prolonged air leak of more than 7 days in 23 (53%), atrial fibrillation in 5 (12%), postoperative mechanical ventilation in 4 (9%), and pneumonia in 2 (5%). Kaplan-Meier survival at 1, 3, and 5 years was 98%, 92%, and 89%, respectively. Four late deaths occurred at 1.4, 2.8, 3.5, and 5.9 years. Functional measures preoperatively and at 6 months and 3 years postoperatively were a forced expiratory volume in 1 second L (% predicted) of 1.2 ± 0.6 (34%), 1.9 ± 0.9 (55%), and 1.5 ± 0.8 (49%); residual volume L (% predicted) of 5.1 ± 1.2 (262%), 3.6 ± 1.2 (154%), and 4.1 ± 2.2 (209%); 6-minutes walk (ft) of 1230 ± 361, 1393 ± 300, and 1271 ± 423; supplemental O2 used continuously (% patients) of 42%, 9%, and 21%; and O2 used during exercise of 73%, 37%, and 42%, respectively.
CONCLUSIONS: In a contemporary series, giant bullectomy is shown to produce significant immediate functional improvement. This benefit declines with time but persists at least 3 years.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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Surgical treatment of giant bullae by using two-stage endocavitary aspiration (Monaldi procedure) [4, 5], one-stage endocavitary aspiration [6], one-stage endocavitary aspiration with sclerosis and pleurodesis (Brompton technique) [7], plication [8], bullectomy, or lobectomy [9–16] can improve patient symptoms. Many large series that reported results after surgical treatment of giant bullae are now several decades old and may not reflect current treatment or results. A literature review published in 1996 cited 22 studies from 1951 to 1992 that reported on a total of 476 patients, highlighting the rarity of giant bullae [17]. We review here our recent experience and intermediate-term follow-up after the resection of giant bullae.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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Bullectomy candidates in our program are preoperatively evaluated and medically optimized using the same approach as described for LVRS patients. Preoperative evaluation includes a physical examination, pulmonary function testing, arterial blood gas analysis (measured at rest while breathing room air), 6-minute walk testing, and the completion of questionnaires assessing quality of life and dyspnea.
Forty-one of the 43 patients selected for bullectomy were enrolled in a pulmonary rehabilitation program lasting 6 to 8 weeks. One of the two patients not undergoing pulmonary rehabilitation presented when ventilator dependent. The second completed the initial evaluation but became acutely short of breath to such a dramatic degree that a bullectomy was performed urgently.
Patients were reassessed after pulmonary rehabilitation, typically during the week before the planned surgery. This reevaluation included an interval history, physical examination, pulmonary function testing, arterial blood gas, 6-minute walk test, and dyspnea and quality-of-life questionnaires. The postrehabilitation, preoperative data were used as the baseline for comparisons with postoperative data.
Pulmonary function tests were performed with a Medgraphics System 1085 (Medical Graphics Corp., St. Paul, MN) before and after aerosolized albuterol, and the best values for forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were chosen for the data analysis. Lung volumes were determined by plethysmography. Diffusion capacity for carbon monoxide (DLCO) was measured by the single-breath technique. During the 6-minute walk test, supplemental oxygen was administered by nasal cannula as needed to maintain the arterial oxygen saturation at 90% or better.
Dyspnea was evaluated with the Medical Research Council of Great Britain Dyspnea Scale [19]. The scale has 5 integer grades, 0 through 4, which describe the level of activity provoking dyspnea. A 1-point change is considered clinically important. We report patients as better, worse, or no change at each time interval compared with their preoperative baseline score.
Quality of life was assessed by using the physical functioning domain of the Medical Outcomes study 36-Item Short-Form Health Survey [20]. The questionnaire is scored on a scale of 100, with 0 being the worst, 50 the median, and 100 the best.
Postoperative evaluation included pulmonary function testing, room air arterial blood gases, 6-minute walk testing, and dyspnea and quality-of-life questionnaires.
Surgical technique
The procedure was done with a median sternotomy in 25 patients, unilateral thoracotomy in 17, and video-assisted thoracic surgery in 1. Five patients underwent additional procedures concomitant with the bullectomy. Two patients underwent LVRS with their giant bullectomy–one right upper lobe giant bullectomy and left upper lobe LVRS, one right middle lobe giant bullectomy and right lower lobe LVRS. One patient underwent talc pleurodesis, 1 had mechanical pleural abrasion, and 1 had a Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) patch repair of a chronic diaphragmatic rupture as well as a lower lobe decortication.
Forty-one patients underwent a nonanatomic resection and 2 patients an anatomic lobectomy. The nonanatomic resections were right sided in 10 patients, left sided in 9 patients, and bilateral in 22 patients. Of the bilateral resections, 17 were bilateral upper lobe bullectomies, and 1 was a bilateral lower lobe bullectomy. The remaining 4 combined a left upper lobe bullectomy with a right bilobe bullectomy. The anatomic resections were both right upper lobectomies.
Bullectomies and LVRS were done with successive applications of a buttressed stapler. Twenty-four of 43 patients (54%) underwent a pleural tent procedure. If a median sternotomy was used, the mediastinal pleura was closed and two chest tubes per side were brought out in a subxiphoid position. Forty-one of 43 patients (95%) were extubated in the operating room.
Postoperative management
Postoperative pain relief was achieved with a thoracic epidural placed under fluoroscopic guidance and positioned in the midline at the level of the fourth thoracic vertebral body. Postoperative care was provided on a thoracic step-down unit. Early and vigorous chest physiotherapy and ambulation were performed. One of two types of mini-tracheostomy catheters (Cook Cricothyrotomy Catheter, Cook Inc., Bloomington, IN and Portex Mini-Trach Cricothyrotomy Kit, Portex Inc., Keene, NH) was used for secretion management in 3 patients. The decision to place a mini-tracheostomy was subjective, based on the thickness and volume of secretions seen on preoperative bronchoscopy as well as the patient's anticipated or subsequent ability to clear those secretions.
Statistical analysis
Descriptive statistics are expressed as mean ± standard deviation unless otherwise specified. Categorical data are expressed as counts and proportions. Comparisons were done with paired, two-tailed t tests for means of normally distributed continuous variables and the Wilcoxon rank-sum test for skewed data. 
2 or the Fischer exact test were used to analyze differences in proportions among the categorical data. Kaplan-Meier estimate was used to depict survival.
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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-1 antitrypsin deficiency, 1 patient (2%) was ventilator-dependent at the time of surgery, and 1 (2%) patient underwent an urgent operation. Baseline characteristics are shown in Table 1.
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Thirty-four of the 43 patients (79%) suffered nonfatal complications. The most common complication was prolonged air leak (> 7 days) in 23 patients (53%). Seven patients were discharged home with a chest tube and a Heimlich valve. One patient underwent talc pleurodeses to correct the air leak. The remaining air leaks resolved during the hospital stay, without the need for pleurodesis or Heimlich valves. There were no reoperations for repair of an air leak.
Four patients required mechanical ventilation after the procedure. Two patients remained intubated after the operation and 2 were extubated and subsequently reintubated, one on the first postoperative evening and one on postoperative day 7. Of the 2 patients remaining intubated from the operating room, 1 had been preoperatively ventilator dependent for more than a month. Three of these 4 patients were successfully extubated; the fourth was the only hospital mortality. Other complications are shown in Table 2. Some patients had more than one complication.
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0.001). At 6 months, 86% of patients experienced an improved FEV1. At 3 years, the mean FEV1 of 1.5 ± 0.8 l (49% of predicted) remained significantly improved over baseline (p 0.001). At 3 years, 83% of patients continued to have an improved FEV1.
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0.001). This improvement persisted at 2 years, but by 3 years the residual volume of 4.1 ± 2.21 (209% of predicted) was not significantly different from base line (p 
0.05). At 6 months, 1 year, and 3 years, 82%, 83%, and 67% of patients, respectively, had improved residual volumes. The 6-minute walk distance also improved from a postpulmonary rehabilitation baseline of 1230 ± 361 feet to 1444 ± 383 feet at 1 year. By the second and third years, the 6-minute walk distance was not significantly different from the postrehabilitation distance. Arterial blood gas values and supplemental oxygen use are detailed in Table 4. Room air partial pressure of carbon dioxide and oxygen were not different before or after pulmonary rehabilitation, but showed modest improvement during the postoperative follow-up period. Supplemental oxygen requirements at rest and during exercise were reduced at all follow-up times, with some patients returning to increased oxygen use during rest and exercise at 3 years.
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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In 1974 FitzGerald and colleagues reported the largest series to date [10]. They performed 95 procedures in 84 patients with bullous emphysema. Sixty-nine of these procedures were bullectomies. The FitzGerald series reported an operative mortality of 2.1% and a mean follow-up of 7.3 years. They noted that resection of unilateral bullae occupying greater than 70% of the hemithorax produced a doubling of the FEV1 at 1 year that was sustained at 5 years but declined over the next 5 to 10 years. Patients with bullae of less than 30% of the hemithorax showed no improvement, or even a worsening of the FEV1.
Pearson and colleagues reported a series of 11 patients undergoing bullectomy or lobectomy for giant bullae. One patient died, for an operative mortality of 7.7%. They noted significant early (3- to 6-month) improvement in FEV1, FVC, and dyspnea, but by 5 to 10 years, only FVC remained significantly improved. FEV1 and dyspnea grade had declined to no different than preoperative values [12].
The most recent series to include giant bullectomy, by Nickoladze, reported on 46 patients, 18 with bullae of more than 30% of the hemithorax, 16 with bullae less than 30% of the hemithorax operated on for recurrent spontaneous pneumothorax, and 12 with bullae less than 30% of the hemithorax associated with chronic pneumonia. Contrary to previous authors, Nikoladze found no immediate improvement in FEV1 in patients treated surgically for giant bullectomy, although a trend toward improvement was found at 5 years [16]. The other 2 groups, patients treated for small bullae with and without associated chronic pneumonia, had a worse FEV1 postoperatively and no significant change from preoperative status at 5 years.
Since the inception of the LVRS program at Barnes-Jewish Hospital, more than 800 patients have been evaluated on site for potential emphysema surgery. Forty-three of these patients were found to have giant bullae fitting previously published criteria for giant bullectomy [18]. Because of the established expectation of improvement in this group, they were not included in the previously reported LVRS series from this institution [21].
Our complete hospital mortality of 2.3% is low and consistent with the mortalities ranging from 0% to 9% reported by other authors [5, 7, 9–16]. As noted by previous authors, we found significant improvements over the postrehabiliation/presurgery base line for FEV1, residual volume, and DLCO. These improvements declined with time but remained significantly better, in part, at 3 years. In addition, after bullae resection, we noted decreased oxygen use at rest and during exercise. Patients did return to oxygen use over time, but the percentage of patients using oxygen at 3 years after surgery remained well below those requiring oxygen preoperatively.
Although preoperative pulmonary rehabilitation was not commonly employed by other authors, it gave us an opportunity to optimally manage these patients' bullous emphysema, maximize exercise capacity, and improve pulmonary toilet. The design of this study was not able to evaluate the value of undergoing pulmonary rehabilitation versus not. We do, however, believe pulmonary rehabilitation increases the patient's ability to tolerate the operation and facilitates postoperative recovery.
Our most frequent complication was air leak, occurring in half the patients. We approach air leaks initially with prevention. Carefully placed buttressed staple lines are used to perform the bullectomy. Because giant bullae can occupy a large volume of the hemithorax with the underlying lung not able to refill this space, we have a low threshold for creating a pleural tent. Postoperatively, the chest tubes are placed on water-seal, no suction. If the air leak persists, a Heimlich valve is placed to decrease further the resistance to expelling a pneumothorax and the barotrauma on the remaining lung. We are very reluctant to return to the operating room for an air leak, believing that reoperations create more leaks than are repaired. If after 6 to 8 weeks the leak persists, we will consider a thoracoscopic procedure, talc pleurodesis, or if not previously performed, a pleural tent.
For unknown reasons the pattern of emphysematous destruction varies considerably from patient to patient or even from one region of the lung to another. Proximal acinar (centrilobular) emphysema is often times more diffuse, associated with smoking, and has often caused wider spread lung destruction by the time it causes symptoms. Distal acinar (paraseptal) emphysema more severely involves the cortex, sparing the central portions of the lung. Distal acinar emphysema is associated with the development of giant bullae, which can compromise lung function substantially while much relatively normal lung is still present.
Patients suitable for LVRS are those with heterogenous disease having "target" areas for resection, which is most commonly associated with centrilobular emphysema. Giant bullae, with relatively normal but collapsed adjacent lung, may represent the most heterogenous end of a spectrum of disease. Traditionally, giant bullectomy has been performed to alleviate the collapse of "underlying, normal lung tissue." On the other hand, the primary benefit of LVRS has been attributed to the reduction of thoracic hyperinflation and improvement in respiratory mechanics. It is probable that both mechanisms are at work after giant bullectomy.
Furthermore, the adjacent, compressed lung may not be "normal" at all, but just relatively less diseased than the bullae. The patients with this condition have varying severity of emphysema in the remaining lung. This is evidenced by the measurable airflow obstruction in the remaining lung after giant bullectomy. In the long-term follow-up of our series, patients showed a progressive decline in FEV1, an increase in residual volume, and decline in the 6-minute walk test, which is typical for emphysema and suggests that the lung remaining after bullectomy is not normal. Both Pearson and FitzGerald showed a similar decline between 5 and 10 years in FEV1. [10, 12] Even with criteria defining giant bullae, the quality of the underlying lung can make it problematic to define which patients are undergoing bullectomy versus LVRS. In 2 of our patients, giant bullectomies were done concomitantly with lung volume reduction on the ipsilateral and contralateral lung.
A second limitation of this study is that it represents a longitudinal analysis of a shrinking cohort of observable patients. It has been shown by Butler and colleagues that patients lacking follow-up data are more likely to have a poor result [22]. It may be that a component of the observed sustained improvement is due to a loss to follow-up of the sicker (less improved) patients. However, as previously noted, our follow-up at 3 years was 93% complete. We do not believe this limitation has a great impact on our data.
In conclusion, in a contemporary series, giant bullectomy is shown to produce significant immediate functional improvement. This benefit declines with time but persists at least 3 years.
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Discussion |
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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DR SCHIPPER: On the first question, we did not compare the bilateral to the unilateral procedures looking at quality of life. I do not have that data available. Regarding the second question, at Washington University, a giant bullectomy generally generates more paranoia about air leak than lung volume reduction. The resected bullae tend to occupy a larger volume of the chest than what we resect during a lung volume reduction. They can fill 50% to 70% of the hemithorax. After you resect the bullae, you potentially end up with volume issues. It is for this reason that we do pleural tent procedures more often. When using a median sternotomy, the medial parietal pleura is reapproximated to separate the left and right hemithorax, potentially containing a unilateral air leak to one side. And I would point out that even though we did have a fairly significant leak rate, this leak rate was similar to that in the lung volume reduction population, and almost all the leaks got better, eventually.
DR JOHN BENFIELD (Los Angeles, CA): Dr Schipper, this is a very nice paper that recalls a video titled Pulmonary Bullectomy With Selective Bronchial Occlusion that we showed at the American College of Surgeons Clinical Congress in October, 1990. Unfortunately I never wrote a paper about this approach, but I have had about two decades of experience with it and can assure you that it lessens the prolonged air leak problem. Sometime essentially all the leaking stops abruptly as the segmental or subsegmental bronchial branch that feeds a bulla is tied.
DR SCHIPPER: Thank you.
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TopAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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