When is a bullectomy (surgical removal of a bulla) recommended?

Bullectomy Recommendations

Bullectomy is recommended for patients with giant bullae that occupy at least one-third of the hemithorax and compress adjacent normal lung parenchyma, resulting in significant improvements in lung mechanics, symptoms, functional performance, and health status. 1

Indications for Bullectomy

Bullectomy should be considered in the following scenarios:

• Giant bullae occupying ≥1/3 of the ipsilateral hemithorax with compression of relatively normal adjacent lung tissue 1, 2
• Patients with incapacitating dyspnea related to large bullae 2
• Complications related to bullous disease such as infection or pneumothorax 2
• Bullae causing significant physiological compromise 1

Patient Selection Criteria

Proper patient selection is crucial for successful outcomes:

• Size of bulla: Should occupy at least 1/3 of the hemithorax, ideally 2/3 3
• Presence of relatively normal surrounding lung parenchyma 1
• Preoperative lung function showing clear reduction 3
• Patient experiencing significant dyspnea 3

Preoperative Evaluation

A thorough preoperative assessment should include:

• CT scan: Most important imaging study to assess the extent of bullous disease and quality of surrounding lung tissue 2
• Pulmonary function tests: Including lung volumes by whole body plethysmography, spirometry, diffusion capacity 2
• Arterial blood gas analysis 2
• Smoking cessation and pulmonary rehabilitation prior to surgery 2

Surgical Approaches

Several surgical approaches can be considered:

1. Video-Assisted Thoracoscopic Surgery (VATS): Preferred minimally invasive approach with quicker recovery and less pain compared to thoracotomy 2

2. Transaxillary minithoracotomy: A minimally invasive procedure with a 5-6 cm incision at the axillary margin, showing low recurrence rates (0.4%) 1

3. Open thoracotomy: Traditional approach using single lung ventilation, with limited posterolateral excision or stapling of bullae 1

4. Bronchoscopic bullectomy: Emerging alternative for patients with poor lung function, involving implantation of an endobronchial valve (EBV) 4

Expected Outcomes

Properly selected patients can expect:

• Improved lung mechanics and gas exchange 3
• Significant improvements in symptoms and functional performance 1
• Enhanced health status 1
• Better exercise capacity 5
• Reduced dyspnea 6

The functional improvement is directly proportional to the size of the bullae removed - larger bullae removal correlates with greater functional improvement 6.

Contraindications and Cautions

Bullectomy may not be beneficial in:

• Patients with generalized bullous changes throughout the lung (diffuse emphysema) 3
• Cases requiring lobectomy (should be avoided whenever possible) 2
• Patients with significant comorbid conditions 5

Postoperative Management

Optimal postoperative care includes:

• Aggressive tracheobronchial toilet and vigorous chest physiotherapy 2
• Adequate pain control (initially via epidural infusion, later oral opioids) 2
• Early ambulation and pulmonary rehabilitation 2
• Monitoring for air leaks, which are a common complication 1

Special Considerations

For patients with COPD who have bullous disease but are not candidates for traditional surgical approaches due to poor lung function, bronchoscopic bullectomy with endobronchial valve placement may be considered as an alternative 4.

For patients with chronic respiratory failure due to COPD who have not improved despite maximal surgical and medical therapy, lung transplantation remains an option if no significant comorbidities exist 5.