Surgery for Bullous Disease

1. A R D I A N S Y A H
Cardiothoracic and Vascular Surgery Trainee
University of Indonesia

2. • 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)
• Usual cause of a primary spontaneous pneumothorax
Bleb:
• 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
Emphysema:
• An air-filled space (≥1 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
Bulla:
• One or more bullae enlarge to occupy more than one third of the hemithorax
Giant bullae:

3. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
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)

4. 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 bronchiole; TB, terminal bronchiole

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

6. LoCicero III, J (ed.). Shields’ General Thoracic Surgery 8th edition. Philadelphia: Wolters Kluwer, 2019.
An inflammatory or destructive
insult to the alveolus, resulting in
destruction of its walls
Direct effects of the injected drug, granulomatous
inflammation from additives (talc), septic emboli, or
simply the fact that many abusers are also smokers

7. ORIGINAL THEORY:
develop, pressurize, and
compress adjacent lung
parenchyma secondary to
the development of one-
way valves
 PROVEN INCORRECT
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 
surrounding lung, with its
preserved elastic recoil, retracts
from the bullae
 Under this theory, the bulla
has no compressive effect, but
rather redirects airflow from
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

8. • Isolated bullae occupying 30% or more of a hemithorax
• Evidence of relatively nonventilated (compressed) and nonemphysematous
underlying lung parenchyma
• Dyspneic patient
The most accepted criteria for giant bullectomy follow:
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

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

10. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
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

11. • Age, presence of comorbid diseases, past surgical and medical
history, smoking history
Determination of the overall medical status of the patient
• Determine fitness for a thoracic procedure
• Presence of right-sided heart failure or cor pulmonale
Cardiac status
• Relation between size of bulla, underlying emphysema and
FEV1
Pulmonary function testing
Chest radiography
Computed tomography
Radioisotope Scanning
Pulmonary Angiography

12. 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.
Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia:
Churchill Livingstone, 2008.

13. 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.

14. Hemoptysis / Pulmonary hemorrhage – rare
• Substernal & squeezing, radiating to the arms, and
exercise related
• Air trapping in a bulla, with distention of the
visceral or mediastinal parietal pleura
Chest pain – rare
• 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
Pneumothorax
CONTRA
INDICATIONS
for
SURGERY
Hypoxemia and cor
pulmonale – early on
Preoperative hypercapnia
Relative: chronic bronchitis
with cough, sputum
production, and recurrent
infections

15. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd
edition. Philadelphia: Churchill Livingstone, 2008.

16. Smoking • Cessation prior to surgery
Lung cancer
• 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
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
Infected bullae
• 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
• 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

17. 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

18. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
Standard operation for
bullous lung disease
Nonanatomical wedge
resection of the
bullous lung tissue
Open vs VATS

19. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.

20. • A large bulla occupying 50% or more of the lung volume is associated with
significant improvements in FEV1 postoperatively
The size of 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
The state of the underlying lung apart from the bulla
• 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
Demonstration of asymmetric regional distribution of lung function
A number of predictors of short-term improvement after bullectomy have been
identified

21. • 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 benef t 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.

22. 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