Which procedure has more complications, bullectomy or bullae plication, and which one is better?

Bullae Plication vs Bullectomy: Complication Rates and Optimal Choice

Bullae plication demonstrates superior outcomes with fewer complications compared to bullectomy, particularly in patients with severely impaired lung function, achieving better postoperative results while avoiding the sacrifice of potentially functional lung tissue. 1

Complication Profile Comparison

Bullae Plication Advantages

• Plication reduces air leak complications compared to complete bullectomy by avoiding the creation of large raw surfaces on the lung parenchyma 2
• In patients with severely impaired lung function, plication achieved better results than lobectomy or extensive resection, with improved symptomatic outcomes in the majority of cases 1
• The technique preserves all surrounding functional pulmonary parenchyma, which is critical for optimal outcomes 3

Bullectomy Complication Rates

• Standard bullectomy via open thoracotomy carries an overall morbidity of 3.7%, primarily from sputum retention and postoperative infection 4, 5
• When performed via VATS, bullectomy shows complication rates of approximately 22% (2 of 9 patients with prolonged air leak >7 days or wound infection) 6
• Increasing bulla size and underlying emphysema are adversely associated with postoperative morbidity following bullectomy (p=0.02 and p=0.01 respectively) 7
• Overall complication rates for bullectomy reach 43% in some series, with a 3% mortality rate 7

Clinical Decision Algorithm

When to Choose Plication

• Patients with severely impaired lung function (preoperative FEV1 26-45% predicted) benefit more from plication than resection 5, 1
• Presence of diffuse emphysema in surrounding lung tissue favors plication to minimize tissue sacrifice 1
• High-risk surgical candidates who cannot tolerate extensive resection 3
• Goal is to avoid lobectomy whenever possible, as limited procedures spare functional parenchyma 3

When Bullectomy is Preferred

• Giant bullae >30% of hemithorax with clear compression of adjacent healthy lung tissue 5, 2, 3
• Complicated bullous disease with infection, rupture, or bleeding 3, 6
• Recurrent pneumothorax requiring definitive treatment, where bullectomy combined with pleurodesis achieves recurrence rates <0.5% 4, 5
• Younger patients with preserved lung function in non-bullous regions 2

Technical Considerations

Surgical Approach

• Both procedures can be performed via VATS or open thoracotomy 4, 6
• VATS reduces hospital stay by 3.66 days and decreases complications (99/1000 vs 138/1000 with thoracotomy) 4
• However, VATS carries slightly higher recurrence rates (31/1000 vs 15/1000) compared to open thoracotomy 4
• For high-risk occupations (pilots, divers), thoracotomy with pleurodesis should be considered for lowest recurrence risk 4

Adjunctive Measures

• Pleurodesis should be added to either procedure to prevent recurrence, with pleurectomy showing advantage over pleural abrasion (0.4% vs 2.3% recurrence) 4, 5
• Additional suturing reinforcement can prevent air leak complications 6
• Modified Monaldi-type drainage procedures are effective alternatives in extremely high-risk patients 3

Critical Pitfalls to Avoid

• Never sacrifice potentially functional lung tissue - this is the most important principle distinguishing plication from aggressive resection 3
• Avoid lobectomy whenever possible as limited resections produce superior results 3, 1
• Do not confuse bullae plication with lung volume reduction surgery (LVRS) for diffuse emphysema - these are distinct procedures with different indications 2
• Ensure adequate preoperative assessment of surrounding lung parenchyma to confirm preserved function in non-bullous regions 2
• Be prepared for prolonged air leaks postoperatively even with plication techniques, though they occur less frequently than with bullectomy 2, 6

Expected Outcomes

Functional Improvement

• Both techniques improve lung mechanics, symptom relief, and quality of life 2
• Median FEV1 improvement from 1.0L to 1.4L postoperatively (p=0.002) 7
• Dyspnea improvement in 67.4% of symptomatic patients 7
• Even patients with underlying diffuse emphysema show 64% improvement in dyspnea 7

Postoperative Management

• Aggressive tracheobronchial toilet and chest physiotherapy minimize complications 3
• Adequate pain control via epidural initially, then oral opioids 3
• Early ambulation and pulmonary rehabilitation are essential 3