From the Guidelines
Thoracoscopic bullectomy and pleurodesis are primarily indicated for patients with recurrent spontaneous pneumothorax, especially after a second ipsilateral pneumothorax, first contralateral pneumothorax, bilateral spontaneous pneumothorax, persistent air leak, spontaneous haemothorax, or professions at risk. The indications for these procedures are based on the statistical and perceived risk of recurrence, as outlined in the BTS guidelines for the management of spontaneous pneumothorax 1.
Key Indications
- Second ipsilateral pneumothorax
- First contralateral pneumothorax
- Bilateral spontaneous pneumothorax
- Persistent air leak (>5–7 days of tube drainage; air leak or failure to completely re-expand)
- Spontaneous haemothorax
- Professions at risk (e.g. pilots, divers) The procedure involves video-assisted thoracoscopic surgery (VATS) to remove the bullae (bullectomy) followed by creation of pleural adhesions (pleurodesis) using mechanical abrasion, talc, or chemical agents like doxycycline or tetracycline.
Procedure Details
- Surgical chemical pleurodesis is best achieved with 5 g sterile talc, with a success rate of 91% 1
- Talc slurry inserted under medical supervision via intercostal tube drainage tends to be less favoured than thoracoscopic talc poudrage, but both methods have been shown to be effective
- The overall success rate for talc pleurodesis reviewed by meta-analysis is 91% 1 The combined approach of bullectomy and pleurodesis is effective because it addresses both the source of air leak (bullae) and prevents recurrence by creating pleural adhesions. Patients typically require chest tube placement for 2-4 days postoperatively, and complete recovery usually takes 2-4 weeks. The recurrence rate after this procedure is significantly lower compared to conservative management with chest tube drainage alone.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Indications for Thoracoscopic Bullectomy and Pleurodesis
The indications for thoracoscopic bullectomy and pleurodesis include:
- Symptomatic or complicated bullous emphysema, such as compression of giant bullae (>30% of hemithorax) or related complications like infection, rupture, or bleeding 2
- Complicated spontaneous pneumothorax, including recurring or persistent cases 3, 4, 5
- Primary spontaneous pneumothorax with bullae or blebs 5, 6
- Patients with bullae of > 2 cm in diameter, who have a greater risk of treatment failure with simple talc pleurodesis 3
Patient Selection
Patient selection for thoracoscopic bullectomy and pleurodesis is based on:
- Presence of symptoms related to bullous emphysema or spontaneous pneumothorax
- Size and location of bullae or blebs
- Presence of complications like infection, rupture, or bleeding
- Pulmonary function tests, which may be compromised in some patients 2
Surgical Procedure
The surgical procedure for thoracoscopic bullectomy and pleurodesis involves:
- Video-assisted thoracoscopic surgery (VATS) for bullectomy and pleurodesis 2, 5, 6
- Talc pleurodesis under local anesthesia or neuroleptanalgesia 3, 4
- Electrocauterization of the upper surface of the parietal pleura for pleurodesis 6
- Endoscopic stapling or thoracoscopic ligation using an endoloop technique for bullectomy 5