What is bulle plication?

Bullae Plication: Overview and Clinical Context

Bullae plication is a surgical technique used to manage giant bullae in patients with advanced COPD/emphysema, involving the folding and suturing of the bulla wall to reduce its volume and decompress adjacent compressed lung parenchyma. 1

What is Bullae Plication?

Bullae plication represents an alternative or adjunctive surgical approach to bullectomy for managing large emphysematous bullae. 1 The procedure involves:

• Folding the bulla wall upon itself rather than excising it completely, which can preserve more lung tissue and potentially reduce air leak complications 1
• Suturing the plicated tissue to maintain the reduced volume and allow re-expansion of compressed adjacent lung parenchyma 1
• Decompressing functional lung tissue that has been compressed by the space-occupying bulla 1

Patient Selection Criteria

Patients who harbor giant bullae (isolated gas-filled cavities occupying one-third of the ipsilateral hemithorax) surrounded by relatively normal parenchyma can obtain significant improvements in lung mechanics, symptoms, functional performance, and health status from bullectomy or plication procedures. 1

Ideal Candidates Include:

• Patients with giant bullae (≥1/3 of hemithorax) causing compression of adjacent functional lung tissue 1
• Preserved lung function in non-bullous regions on imaging 1
• Symptomatic patients with dyspnea, reduced exercise capacity, or recurrent infections 1
• Patients with advanced COPD who may benefit from lung volume reduction approaches as complement to medical therapy 1

Surgical Approach Considerations

Plication vs. Bullectomy:

• Plication may reduce air leak complications compared to complete bullectomy, as it avoids creating large raw surfaces on the lung 1
• Both techniques aim to decompress functional lung tissue and improve respiratory mechanics 1
• Minimally invasive surgical techniques (thoracoscopic approaches) should be evaluated to reduce complication rates and improve perioperative outcomes compared with conventional open techniques 1

Important Surgical Considerations:

• 90% of patients who undergo lung volume reduction surgery experience significant air leaks after thoracotomy that result in prolonged hospital stay and morbidity 1
• Plication techniques may theoretically reduce this complication rate, though specific comparative data is limited 1

Clinical Outcomes and Evidence

The benefits of bullae surgery (including plication) are well-established for giant bullae, with significant improvements in lung mechanics, symptoms, functional performance, and health status. 1

Expected Benefits:

• Improved lung mechanics through decompression of functional parenchyma 1
• Symptom relief including reduced dyspnea 1
• Enhanced functional performance and exercise capacity 1
• Better health status and quality of life 1

Critical Pitfalls to Avoid

• Do not confuse bullae plication with lung volume reduction surgery (LVRS) for diffuse emphysema—these are distinct procedures with different indications 1
• Avoid operating on patients without giant bullae or those with diffuse emphysema without predominant bullous disease, as outcomes are less predictable 1
• Ensure adequate preoperative assessment of surrounding lung parenchyma to confirm preserved function in non-bullous regions 1
• Be prepared for prolonged air leaks postoperatively, which remain common even with plication techniques 1

Relationship to Other Lung Volume Reduction Approaches

Studies are needed to evaluate whether minimally invasive surgical techniques can reduce complication rates and improve perioperative outcomes and costs compared with conventional surgical techniques for bullae management. 1

• Bronchoscopic lung volume reduction techniques have not received regulatory approval for COPD due to limited efficacy and concerns about pneumonia and exacerbations 1
• Traditional LVRS for non-bullous emphysema has different indications and cost-effectiveness considerations ($98,000 per quality-adjusted life-year) 1
• Bullae plication/bullectomy remains the most appropriate surgical approach specifically for giant bullae 1