SURGERY FOR BULLOUS DISEASE

RENDY AGUSTIAN
STASE BEDAH THORAKS RSUP PERSAHABATAN
2021
 DEFINITION
Bleb:
• A subpleural collection of air (<2cm) contained within the layers of the
visceral pleura
• Alveolus ruptures  air subsequently leaks out, dissects through interstitial
tissues to surface of lung (contained by thin fibrous tissues of visceral
pleura)
Emphysema:
• Usual cause of a primary spontaneous pneumothorax
• An abnormal and permanent enlargement of air spaces distal to the
terminal nonrespiratory bronchioles
• Arises from the destruction of the alveolar walls, no obvious fibrosis
• Departitioning of the distal lung architecture

Bulla:
• An air-filled space (≥1-2 cm in distended diameter), within lung parenchyma
• Forms as a result of destructive process of emphysema
• A thin outer fibrous wall consisting of visceral pleura and an inner wall of
variable thickness, consisting of the remnants of disintegrating
emphysematous lung
Giant bullae:
• One or more bullae enlarge to occupy more than one third of the
hemithorax
 CLASSIFICATION

Patients with bullae have traditionally been divided into two

groups:
• Those in whom the rest of the lung is structurally normal (20% of
patients)
• Those in whom the rest of the lung exhibits changes of emphysema (80%
of patients)
Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
 CLASSIFICATION OF EMPHYSEMA

ACINAR classification of emphysema.

A, Normal acinus. B, Proximal acinar/centrilobular emphysema. C, Panacinar/panlobular emphysema. D,
Distal acinar/periacinar/paraseptal emphysema. AD, alveolar duct; AS, alveolar sac; RB, respiratory
 Associated with certain specific
pathological cases:

Cyst: a space lined by

epithelium, wall < 2 to 3
mm
Cavity: a space lined by
epithelium, wall > 3 mm

Grippi, MA (ed.). Fishman’s Pulmonary Diseases and Disorders 5th edition. US: McGraw-Hill, 2015.
 ETIOLOGY
Direct effects of the injected drug,
An inflammatory or
granulomatous inflammation from
destructive insult to the
additives (talc), septic emboli, or simply
alveolus, resulting in
the fact that many abusers are also
destruction of its walls
smokers

LoCicero III, J (ed.). Shields’ General Thoracic Surgery 8th edition. Philadelphia: Wolters Kluwer, 2019.
 PATHOPHYSIOLOGY
Initially formed by the local
destruction of pulmonary tissue
 space gradually enlarges, its
compliance increases  air
flows preferentially to the bulla,
and it continues to expand 
ORIGINAL THEORY: surrounding lung, with its
develop, pressurize, and preserved elastic recoil, retracts
compress adjacent lung from the bullae
parenchyma secondary to  Under this theory, the bulla
the development of one- has no compressive effect, but
way valves rather redirects airflow from
 PROVEN INCORRECT normal lung to itself, creating
restriction and hypoventilation
of the normal lung
Bullae had little or no
elastic properties and
behaved like a paper bag,
increasing in volume
without large increases in
pressure until filled to
capacity, then greatly
increasing in pressure
with little change in
volume
 INDICATIONS FOR OPERATION
The most accepted criteria for giant bullectomy follow:

• Isolated bullae occupying 30% or more of a hemithorax

• Evidence of relatively nonventilated (compressed) and
nonemphysematous underlying lung parenchyma
• Dyspneic patient
Asymptomatic patient: preventive surgery is justified if the bulla
occupies more than 50% of a hemithorax, adjacent lung is
collapsed, or the bulla has enlarged over a period of years

Symptomatic patient: giant bulla and otherwise preserved

underlying lung stands to benefit from surgical treatment of the
bulla
 A patient whose degree of dyspnea is
out of proportion to the size of a bulla
raises the question of underlying
emphysema.

These scales can help quantitate a

subjective complaint and assist in the
evaluation of treatment outcomes

Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
 PREOPERATIVE EVALUATION
Determination of the overall medical status of the patient
• Age, presence of comorbid diseases, past surgical and medical
history, smoking history

Cardiac status
• Determine fitness for a thoracic procedure
• Presence of right-sided heart failure or cor pulmonale

Pulmonary function testing

• Relation between size of bulla, underlying emphysema and
FEV1

Chest radiography

Computed tomography

Radioisotope Scanning

Pulmonary Angiography
Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Greenberg JA, Singhal S, Kaiser LR. Giant bullous lung disease: evaluation, selection,
Livingstone, 2008. techniques, and outcomes. Chest Surg Clin N Am. 2003;13(4):631-649.
Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition.
Philadelphia: Churchill Livingstone, 2008.
Grippi, MA (ed.). Fishman’s Pulmonary Diseases and Disorders 5th
edition. US: McGraw-Hill, 2015.
OTHER INDICATIONS FOR CONTRA Hypoxemia and cor
OPERATION
Hemoptysis / Pulmonary INDICATIONS pulmonale – early on
for
hemorrhage – rare
SURGERY
Preoperative hypercapnia
Chest pain – rare
Relative: chronic bronchitis
• Substernal & squeezing, radiating to the arms, and
exercise related
with cough, sputum
• Air trapping in a bulla, with distention of the production, and recurrent
visceral or mediastinal parietal pleura infections

Pneumothorax
• Giant bullae vs a large pneumothorax on
radiography
• Treatment consists of re-expanding the lung,
closing the fistula, and preventing recurrence
• Accomplished by observation, needle aspiration,
tube thoracostomy, thoracoscopy, or thoracotomy
Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd
edition. Philadelphia: Churchill Livingstone, 2008.
 OTHER CONSIDERATIONS
Smoking • Cessation prior to surgery

• 10x risk in bullous disease + smokers, present in considerably younger age

• Characteristic radiographic features:
• An opacity in or adjacent to the bulla
• A focal or diffuse thickening of the wall of the bulla with an irregular
Lung cancer inner surface
• Secondary signs including sudden enlargement or shrinkage of the bulla,
straightening of the thin curvilinear shadow of the bulla, fluid retention
within the bulla, and pneumothorax

• Resemble single or multiple cavitating abscesses

• An infected bulla may be distinguished from a lung abscess:
• Knowledge of preexisting bullous disease in the involved lung
• Other bullae in the same or contralateral lung
Infected bullae • Very rapid appearance of the air-fluid levels and extensive apparent
cavitation after only a few days of illness
• Relatively slight involvement of surrounding lung
• Initial absence of any pleural reaction
 SURGICAL TREATMENTS
Surgery for giant bullae seeks to REMOVE THE
VOLUME OCCUPIED by the bulla while preserving
as much underlying lung and lung function as
possible.

Resecting the wall of the bulla, as in

bullectomy, with either a thoracotomy or
median sternotomy or through a
thoracoscope

Removing the air within the bulla,

effectively collapsing it, as in endocavitary
drainage
 Standard operation for
bullous lung disease

Nonanatomical wedge
resection of the bullous
lung tissue

Open vs VATS

Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
 PREDICTORS
A number of predictors of short-term improvement after bullectomy have been
identified

The size of the bulla

• A large bulla occupying 50% or more of the lung volume is associated with
significant improvements in FEV1 postoperatively

The state of the underlying lung apart from the bulla

• CT evidence of relatively normal underlying lung with adequate perfusion—and
which has been significantly compressed by the expanding bulla—is a predictor
of good functional outcome after bullectomy

Demonstration of asymmetric regional distribution of lung function

• A demonstration of poor contribution to overall lung function by the bullous part
(typically by VQ scan) is linked to better improvement in functional parameters
after bullectomy
 CONCLUSION
• Preoperative workup for giant bullectomy includes cardiac risk assessment, pulmonary function testing,
chest CT scan, and sometimes quantitative ventilation-perfusion scanning.

• Pulmonary function testing values are difficult to interpret without a chest CT.

• The best candidates for surgical benefit have dyspnea, an isolated bulla larger than 30% of the hemithorax,
and a collapsed but otherwise normal underlying lung.

• Giant bullectomy in the setting of diffuse emphysema in the remaining lung is not a contraindication to
surgery but may be better considered in the context of lung volume reduction surgery.

• Operative techniques include stapled bullectomy, excision, ligation, plication, and endo-cavitary drainage.
These are accomplished with thoracoscopy, thoracotomy, or median sternotomy.

• Most patients can expect symptomatic and functional improvement. The duration of this improvement is
dependent on the progression of emphysema in the remaining lung parenchyma.
 REFERENCES
Patterson, GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia:
Churchill Livingstone, 2008.

LoCicero III, J (ed.). Shields’ General Thoracic Surgery 8th edition. Philadelphia:
Wolters Kluwer, 2019.

Grippi, MA (ed.). Fishman’s Pulmonary Diseases and Disorders 5th edition. US:
McGraw-Hill, 2015.

Greenberg JA, Singhal S, Kaiser LR. Giant bullous lung disease: evaluation, selection,
techniques, and outcomes. Chest Surg Clin N Am. 2003;13(4):631-649. doi:10.1016/s1052-
3359(03)00095-4