Bullous disease can occur alone or in conjunction with lung emphysema. Bullae vary in size and the term “giant bulla” is used when lesions exceed one-third of the hemithorax. Giant bullae may impair lung function and cause respiratory symptoms—mainly dyspnea and low exercise tolerance—negatively impacting patient’s quality of life. Bullous disease can lead to complications such as pneumothorax, infection and bleeding. Therefore, surgical treatment of bullous disease through bullectomy is indicated when complications occur or when giant bulla are associated to respiratory symptoms. An increasing giant bulla can also be considered for surgical resection, even when asymptomatic. The surgical aim is to remove the giant bullae, allowing expansion of the remaining lung, in order to restore respiratory function. Patients with large bullae and normal underlying lungs are those who accomplish the best results, but surgery should not be denied to emphysematous patients until a preoperative assessment is made to properly outline risks/benefits.
Uniportal video-assisted thoracic surgery is a feasible and safe method to perform bullectomy, with results at least comparable to other techniques, leading to symptoms resolution, improved lung function and better quality of life. This chapter will focus on this approach and its technical details.
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Conflict of Interest Statement: The author has no conflicts of interest to declare.
Consent: This chapter shows pictures and videos of two cases operated by our group. Written informed consent was obtained from both patients for publication of the selected material.
This video is about the same case shown in Figs. 2, 3, and 4 and shows a bulla at the left lower lobe, as well as its dissection/isolation away from the adjacent structures: the left upper lobe and a major pulmonary arterial branch to the left lower lobe (MP4 730450 kb)
Resection of the bulla using endoscopic staplers, after retracting it up and away from the previously dissected adjacent structures: the left upper lobe and a major pulmonary arterial branch to the left lower lobe (MP4 438932 kb)
Final aspect of the surgical field after bullectomy, bleeding/air leaks checking and subsequent full lung expansion at the end of the procedure (MP4 173892 kb)
Meyers BF, Patterson GA. Chronic obstructive pulmonary disease. 10: Bullectomy, lung volume reduction surgery, and transplantation for patients with chronic obstructive pulmonary disease. Thorax. 2003;58(7):634–8.CrossRefGoogle Scholar
Deslauriers J. History of surgery for emphysema. Semin Thorac Cardiovasc Surg. 1996;8(1):43–51.PubMedGoogle Scholar
Cooper JD. The history of surgical procedures for emphysema. Ann Thorac Surg. 1997;63(2):312–9.CrossRefGoogle Scholar
Klingman RR, Angelillo VA, DeMeester TR. Cystic and bullous lung disease. Ann Thorac Surg. 1991;53(3):576–80.CrossRefGoogle Scholar
Morgan MD, Edwards CW, Morris J, et al. Origin and behaviour of emphysematous bullae. Thorax. 1989;44(7):533–8.CrossRefGoogle Scholar
Ting KY, Klopstock R, Lyons HA. Mechanical properties of pulmonary cysts and bullae. Am Rev Respir Dis. 1963;87:538–44.CrossRefGoogle Scholar
Krishnamohan P, Shen R, Wigle DA, et al. Bullectomy for symptomatic or complicated giant lung bullae. Ann Thorac Surg. 2014;97:425–31.CrossRefGoogle Scholar
Lee KH, Cho SJ, Ryu SM, et al. Fluid-filled giant bulla treated with percutaneous drainage and talc sclerotherapy: a modified Brompton technique. Korean J Thorac Cardiovasc Surg. 2012;45:134–7.CrossRefGoogle Scholar
Taniguchi Y, Fujioka S, Adachi Y, et al. Video-assisted thoracoscopic bullectomy for an infectious giant bulla with the concomitant use of the perioperative intracavity fluid suction. J Thorac Cardiovasc Surg. 2009;137:249–51.CrossRefGoogle Scholar
Potapenkov MA, Shipulin PP. Surgical treatment of complicated bullous pulmonary emphysema. Grud Serdechnososudistaia Khir. 1993;4:39–42.Google Scholar
Hirai S, Hamanaka Y, Mitsui N, et al. Primary lung cancer arising from the wall of a giant bulla. Ann Thorac Cardiovasc Surg. 2005;11:109–13.PubMedGoogle Scholar
Venuta F, Rendina EA, Pescarmona EO, et al. Occult lung cancer in patients with bullous emphysema. Thorax. 1997;52:289–90.CrossRefGoogle Scholar
Shanthaveerappa HN, Mathai MG, Byrd RP Jr, et al. Spontaneous resolution of a giant pulmonary bulla. J Ky Med Assoc. 2001;99:533–6.PubMedGoogle Scholar
Scarlata S, Cesari M, Caridi I, et al. Spontaneous resolution of a giant pulmonary bulla in an older woman: role of functional assessment. Respiration. 2011;81:59–62.CrossRefGoogle Scholar
Palla A, Desideri MT, Rossi G, et al. Elective surgery for giant bullous emphysema – a 5-year clinical and functional follow-up. Chest. 2005;128:2043–50.CrossRefGoogle Scholar
Pearson MG, Ogilvie C. Surgical treatment of emphysematous bullae: late outcome. Thorax. 1983;38:134–7.CrossRefGoogle Scholar
Greenberg JA, Singhal S, Kaiser LR. Giant bullous lung disease: evaluation, selection, techniques, and outcomes. Chest Surg Clin N Am. 2003;13:631–49.CrossRefGoogle Scholar
De Giacomo T, Venuta F, Rendina EA, et al. Video-assisted thoracoscopic treatment of giant bullae associated with emphysema. Eur J Thorac Surg. 1999;12:753–7.CrossRefGoogle Scholar
Kayawake H, Chen F, Date H. Surgical resection of a giant emphysematous bulla occupying the entire hemithorax. Eur J Cardiothorac Surg. 2013;43:e136–8.CrossRefGoogle Scholar
Schipper PH, Meyers BF. Surgery for bullous disease. In: Person FG, Patterson GA, Cooper JD, editors. Thoracic & esophageal surgery. Philadelphia: Churchill Livingstone Elsevier; 2008. p. 631–52.CrossRefGoogle Scholar
Van Bael K, La Meir M, Vanoverbeke H. Video-assisted thoracoscopic resection of a giant bulla in vanishing lung syndrome: a case report and short literature review. J Cardiothorac Surg. 2014;9:4.CrossRefGoogle Scholar
Monaldi V. Endocavitary aspiration: its practical applications. Tubercle. 1947;28:223–8.CrossRefGoogle Scholar
Shah SS, Goldstraw P. Surgical treatment of bullous emphysema: experience with the Brompton technique. Ann Thorac Surg. 1994;58:1452–6.CrossRefGoogle Scholar
Santini M, Fiorelli A, Vicidomini G, et al. Endobronchial treatment of giant emphysematous bullae with one-way valves: a new approach for surgically unfit patients. Eur J Cardiothorac Surg. 2011;40:1425–31.CrossRefGoogle Scholar
Gonzalez-Rivas D, Bonome C, Fiera E, et al. Non-intubated video-assisted thoracic surgery: the future of thoracic surgery? Eur J Cardiothorac Surg. 2016;50:925–6.CrossRefGoogle Scholar
Ng CSH, Ho JYK, Zhao Z-R. Spontaneous ventilation anaesthesia: the perfect match for thoracoscopic bullectomy? Eur J Cardiothorac Surg. 2016;50:933.CrossRefGoogle Scholar
Mazzella A, Izzo A, Amore D, et al. Ann Ital Chir. 2016;87(ePub pii):S2239253X16024816.PubMedGoogle Scholar
Sagawa M, Maeda T, Yoshimitsu Y, et al. Saline-cooled radiofrequency coagulation during thoracoscopic surgery for giant bulla. Eur J Cardiothorac Surg. 2014;46:737–9.CrossRefGoogle Scholar
Venuta F, De Giacomo T, Rendina EA, et al. Thoracoscopic pleural tent. Ann Thorac Surg. 1998;66:1833–4.CrossRefGoogle Scholar
Pompili C, Xiumè F, Hristova R, et al. Regulated drainage reduces the incidence of recurrence after uniportal video-assisted thoracoscopic bullectomy for primary spontaneous pneumothorax: a propensity case-matched comparison of regulated and unregulated drainage. Eur J Cardiothorac Surg. 2016;49:1127–31.CrossRefGoogle Scholar