Bullectomy for Symptomatic or Complicated Giant Lung Bullae

Application and clinical effects in lung bullae resection of CT 3-dimensional reconstruction

BACKGROUND

To investigate the value and clinical effect of computed tomography (CT) 3-dimensional reconstruction technology in lung bullae resection.

METHODS

Ninety-eight patients who underwent thoracoscopic surgical resection of lung bullae in our hospital from February 2019 to February 2023 were selected and divided into 2 groups according to the principle of voluntary participation in the clinical trial, of which 43 cases underwent preoperative spiral CT for thin-layer enhancement or planar CT scanning of lung bullae (control group), and 43 cases were imaged with MimicsMedical 21 software for 3-dimensional reconstruction to develop a surgical plan (observation group). To compare the surgery-related indexes, postoperative complications, pain, and analgesic use between the 2 groups, we measured serum creatine phosphokinase and myoglobin levels.

RESULTS

The amount of surgical bleeding, drainage volume, hospital stay, and postoperative visual analog scale score of the research group were lower than those of the control group (P < .05), and the duration of analgesic medication was shorter than that of the control group (P < .05), and the levels of serum creatine phosphokinase and myoglobin were lower than those of the control group at 1 and 3 days postoperatively, and the differences were statistically significant (P < .05).

CONCLUSION

Preoperative CT 3-dimensional reconstruction technique can clearly show the anatomical structures around the lung bullae and has its application value for precise lung bullae.

Giant pulmonary bulla causing respiratory compromise in a very low-birthweight infant

Acquired cystic lung disease in premature infants is a serious respiratory complication, and pulmonary interstitial emphysema (PIE) has been widely reported. We report a rare case of giant pulmonary bulla in an infant treated with bullectomy where chest computed tomography was useful in directing treatment.

Results of the surgical treatment of pulmonary bleb and bullous disease: A retrospective study

Objective

Bullous lung disease is characterised by the development of bullae within the lung parenchyma. Smoking is considered as a main risk factor of bullae formation. The clinical manifestation varies from asymptomatic bullae to severe respiratory distress. The exact medical approach is still controversial. Here, we aimed to evaluate the patient clinical characteristics and the indication of surgery in the patients.

Methods

This study was an analytic cross-sectional study in Razi hospital, Rasht, Iran, in 2016-2020. A total of 110 patients with newly diagnosed lung bullae underwent evaluation based on a checklist, which assessed the variables as clinical characteristics, bullae features, the medical treatment, and its complication. Eventually, statistical analysis was performed by using SPSS v21.0.

Results

: A total of 110 patients were enrolled. All the patients were smokers. In 72.9%, the primary presentation was respiratory distress, which needed surgical resection with no recurrence over 8 months. The clinical manifestation varies from asymptomatic bullae in 4.3% and pneumonia in 34.3% to respiratory distress in 61.4%. There was no statistical correlation between clinical manifestation and all the studied variables excluding respiratory distress (p value: 0.659). Seventy patients underwent surgical treatment, in which 20 cases were complicated by air leak that was managed by the chest tube in 16 patients and the Heimlich valve in four patients. No evidence of recurrence was detected.

Conclusion

The main risk factor of bulla formation is smoking. Because of various clinical presentations, the appropriate medical approach is of paramount importance.

Thoracoscopic giant lung bullaectomy: our initial experience

Background

Giant lung bullae (GLB) are rare, and the only currently available management involves either an open surgical resection (thoracotomy) or the newer minimally invasive resection consisting of video-assisted thoracoscopic surgery (VATS). The aim of our study was to evaluate the possible influence of GLBs pulmonary attachment on patient's post-operative complications.

Methods

A retrospective analysis included all consecutive patients with GLBs who underwent bullae's surgical resection from 7/2007 to 12/2018. GLBs patient's individual characteristics, including demographics, comorbidities, and clinical pre-operative, surgical intra-operative and post-operative data were evaluated.

Results

20 patients with GLBs, 15 males and 5 females with average age of 48.9 years (range, 22–67 years) underwent 21 surgical procedures. The GLBs were located in the right lung in 12 patients, in the left lung in seven patients, and in both lungs in one patient. Fifteen patients (75%) were symptomatic on admission and underwent urgent surgery. Five asymptomatic patients (25%) were operated on electively. Thirteen from 21 surgical procedures (61.9%) were VATS bullectomy, while the other eight were thoracotomies (38.1%). Complications included pneumonia successfully treated with intravenous antibacterial therapy in two thoracotomy patients and in one VATS patient (three patients, 14.2%) and a prolonged air leak in two thoracotomy and four VATS patients (six patients, 28.5%). Out of 21 GLBs, eight had a wide attachment with lung parenchyma (wide-based bullae's) and 13 had a short attachment (short-based bullae's). Two re-operated patients, with prolonged air leak complicated with empyema, had a wide-based GLBs. The median hospital stay was nine days. All patients completed the 24-month follow-up.

Conclusions

Minimally invasive video-assisted thoracoscopic surgery as an open thoracotomy surgery is a safe and effective for giant lung bullae (GLB). Patients with wide-based GLBs were more likely to develop postoperative prolonged air leak that requiring re-operation.

Unexpected Histopathological Diagnosis of Placental Transmogrification of the Lung after Bullectomy for Recurrent Spontaneous Pneumothorax: A Case Report and Literature Review

We report a 33-year-old man who presented with recurrent right pneumothorax. Computed tomography (CT) showed the presence of a large bulla with a maximum diameter of 8 cm in the right middle lobe; he subsequently underwent bullectomy. Histopathology revealed that pulmonary parenchyma adjacent to the bulla represented nodular proliferation of clear cells characterized by a papillary structure resembling placental chorionic villi. Immunohistochemically, clear cells were positive for CD10, suggesting placental transmogrification of the lung (PTL). We reviewed 36 surgical cases of PTL, and only 2 cases (5.6%), including our case, were operated for spontaneous pneumothorax. Bullous lesions secondary to PTL tend to appear as unilateral large cystic masses in non-upper lobes, which is atypical for primary spontaneous pneumothorax (PSP). Although PTL is considered a very rare cause of secondary pneumothorax, we must carefully differentiate this condition.

Loss of consciousness during air travel: A case of lung bullae

A giant lung bulla occupies at least a third of the lung space. We present a middle-aged man who lost consciousness during an air flight for 30 minutes, without any respiratory symptoms. An incidental finding on chest x-ray revealed a giant bulla and a chest computed tomography imaging confirmed the diagnosis and ruled out a tension pneumothorax. A giant lung bulla is an uncommon cause of loss of consciousness and may be suspected if it occurs during air travel.

Surgical Interventions for COPD

Chronic obstructive pulmonary disease (COPD) treatment is aimed at managing the disease rather than cure, with a focus on improving quality of life and decreasing exacerbations. Interventional therapies, including lung volume reduction surgery, bullectomy, lung transplantation, and bronchoscopic lung volume reduction treatment using endobronchial valves, are treatment options for patients with COPD who are symptomatic due to hyperinflation despite optimal medical management. We will review the current literature to provide a comprehensive summary of the currently available scientific data, discuss typical treatment-related side effects, and evidence-based management approach and recommendations for patient selection in clinical practice.

Surgical treatment of giant bullae on the background of cystic lesion and vascular malformation. Case report

Bullae formation on a cystic background is still not described thoroughly. This clinical case aims to improve this situation and describes the combination of multiple cysts with vascular malformation, giant bullae (2/3 of the left hemithorax and 1/2 of the right hemithorax) with suppuration in a 50-year-old smoker. Before surgery, treatment for chronic obstructive lung disease (COPD) was administered without a positive outcome. Bullectomy was subsequently conducted and histopathological data revealed vascular malformation causing microinfarctions in pulmonary parenchyma, cystic degeneration and tuberculosis. Although it became possible to establish a final diagnosis due to histology, the need for surgical treatment was clear from clinical and x-ray evidence. Such instances as the one presented in this case report should assist with improving our knowledge about bullae in combination with cysts in the lungs because they provide additional context in a clinical setting.

Chartis System Corrected a Misjudged Location of a Giant Bulla Facilitating a Successful Bronchoscopic Bullectomy with Valves: A Case Report

The recommended standard treatment for giant bullae is surgical bullectomy. However, with a relatively high risk for perioperative morbidity and mortality, it is unsuitable for some patients. Recently, bronchoscopic bullectomy with one-way valves has shown efficacy and safety in some cases. Locating the giant bulla and confirming the negative collateral ventilation are essential for the bronchoscopic bullectomy with valves. Here, we report a case with a giant bulla using the Chartis System to correct the previous mislocation by the high-resolution computed tomography (HRCT), thus helping to achieve a great efficacy in the bronchoscopic bullectomy with valves. Our case suggests that bronchoscopic bullectomy with valves could be an effective and safe choice. Chartis system can be helpful in determining the location of a bulla when difficulty is encountered using HRCT.

Intraoperative extracorporeal carbon dioxide removal support for minimally invasive surgical treatment of vanishing lung syndrome

Vanishing lung syndrome is a rare disease that could be treated successfully in selected cases with bullectomy. Protective ventilation is very important during surgery to achieve optimal post-operative results and to prevent complications. Hypercapnia and respiratory acidosis are the main disadvantages of this ventilator strategy. The use of extracorporeal CO₂ removal device has been introduced to support protective and ultra-protective ventilation during respiratory failure in complex cases. In thoracic surgery the intraoperative use of this device is still not widespread. We report a successful case of a giant left lung bullectomy with intraoperative support with Pro-Lung CO₂ removal device for the management of hypercapnia during single lung ventilation.

[Indications and results of surgical resection of bubbles arising from pulmonary emphysema]

La chirurgie d'exérèse des bulles ou bullectomie, principal moyen thérapeutique dans la prise en charge des bulles d'emphysème pulmonaire, est généralement réservée aux patients dont les bulles sont compliquées ou, sont à l'origine d'une dyspnée invalidante. Le but de notre étude était de déterminer les indications de la bullectomie et d'évaluer les résultats de cette chirurgie dans notre service. Nous avons mené une étude rétrospective descriptive de 24 patients (23 hommes et 1 femme), dont la moyenne d'âge était de 49 ans, et qui ont bénéficié d'une bullectomie entre 2004 et 2013. Les données recueillies étaient les facteurs favorisant la survenue d'un emphysème bulleux, les circonstances de découverte de la bulle, les données des examens radiologiques, les données de l'évaluation fonctionnelle respiratoire et cardiovasculaire, les données de la technique de la bullectomie, les données de l'évaluation clinique et fonctionnelle post opératoire. Le taux de morbidité était de 37,5%. La principale complication était la fuite aérienne persistante (7 cas). Un patient est décédé au 2^e jour post opératoire suite à une insuffisance respiratoire aiguë. La durée moyenne de suivi était de 26 mois. Durant ce suivi, nous avons observé une amélioration de la dyspnée chez tous les patients et nous n'avons noté aucune complication. La bullectomie est une technique chirurgicale efficace, fiable et sûre qui peut permettre aux patients d'avoir une meilleure qualité de vie pendant quelques années.

A successful surgical repair of intraoperative pneumothorax and the diffuse dissection of visceral pleura during liver transplantation surgery via trans-diaphragmatic approach

BACKGROUND

Pneumothorax during surgery under general anesthesia is a life-threatening situation for the patient because it can progress easily to the tension pneumothorax due to positive pressure ventilation unless appropriate treatments such as inserting a drainage tube in the thoracic cavity are initiated. The authors experienced a case of intraoperative pneumothorax and the diffuse dissection of visceral pleura during liver transplantation surgery, and achieved successful repair by a trans-diaphragmatic approach without changing patient's body position.

CASE PRESENTATION

A 66-year-old male with multiple liver and renal cysts caused by autosomal dominant polycystic kidney disease (ADPKD) was admitted to the authors' hospital for treating the infection of the liver cysts. The infection was unable to be controlled by conservative treatments. Therefore, the patient was planned to undergo living-donor liver transplantation. Intraoperatively, the liver was found to swell markedly and to firmly adhere to the right diaphragm. After the extraction of the liver, because the right diaphragm swelled markedly, pneumothorax was suspected. Chest tube was inserted immediately, and the small incision was made in the right diaphragm. Thoracoscopic observation revealed that (1) the visceral pleura of the bottom of the right lung widely expanded like a giant cyst due to the dissection from the lung parenchyma and (2) a large air leakage from a pin hole appeared in the dissected pleura. After the completion of the liver transplantation, the thoracoscopic leakage-closing operation was performed through the right diaphragm incision. Because the dissection of visceral pleura was too wide to perform plication or cystectomy by a stapler or sutures, the dissected pleura was opened, and absorbable fibrin sealant patches and fibrin glue were put or injected between the lung parenchyma and the pleura. Although, after being observed postoperatively, prolonged minor air leakage disappeared by a conservative drainage treatment, and the cyst on the bottom of the right lung disappeared on chest computed tomography (CT).

CONCLUSIONS

Although intraoperative pneumothorax and broad dissection of visceral pleura during laparotomy is a complicated situation, the authors successfully repaired air leakage via a trans-diaphragmatic approach without changing the patient's body position.

Intrabullous Adhesion Pexia (IBAP) by Percutaneous Pulmonary Bulla Centesis: An Alternative for the Surgical Treatment of Giant Pulmonary Bulla (GPB)

Background and Objective

Most patients with giant pulmonary bulla (GPB) are treated by surgery; however, there is a subset for whom surgery is not a viable option, such as those with contraindications, or those unwilling to undergo operation. Therefore, an alternative minimally invasive method is desired for this subpopulation. The aim of this study was to explore an alternative procedure for treating GPB.

Methods

This was a prospective, nonrandomized, single-arm, unblinded study evaluating the efficacy and safety of intrabulla adhesion pexia (IBAP) procedure in GPB patients. The study was conducted between December 2004 and April 2017.

Results

There were 38 cases in 36 patients (33 males and 3 females) with the target GPB cavities varying in size (range, 10 cm × 7 cm × 5 cm to 15 cm × 8 cm × 30 cm (anteroposterior diameter × medial-lateral diameter × superoinferior diameter)). After IBAP treatment, the closure ratio of GPB in one month was 86.84% (33/38), while the dyspnea index significantly decreased from 4.11 ± 1.11 to 2.24 ± 1.15 (P < 0.01). In addition, the mean FEV1 (L) increased from 1.06 ± 0.73 to 1.57 ± 1.13 (P < 0.01), while RV (L) decreased from 2.77 ± 0.54 to 2.36 ± 0.38 (P < 0.01) and TLC (L) decreased from 6.46 ± 1.21 to 5.86 ± 1.08 (P < 0.01). Moreover, PaO₂ (mmHg) increased from 52.18 ± 8.31 to 68.29 ± 12.34, while the 6 MWD increased by 129.36% from 131.58 ± 105.24 to 301.79 ± 197.90 (P < 0.01). Collectively, these data indicated significant improvement in pulmonary function and exercise tolerance after IBAP treatment. Furthermore, no deaths occurred during IBAP treatment, and no cases of aggravated GPB relapse were reported during the 12-month follow-up period.

Conclusions

IBAP is a promising strategy for the treatment of GPB. Our findings demonstrated that IBAP had a noteworthy therapeutic effect, desirable safety, and ideal long-term efficacy for GPB.

Dangers of flying high and diving low! An unusual case of dyspnea

Giant bullae are bullae that occupy at least 30 percent of a hemi thorax. This condition can rarely be idiopathic and not usually suspected in young patients with no risk factors. We describe a case of a giant solitary pulmonary bulla in a healthy young female with no known risk factors. 23-year-old female presented to the Emergency department with dyspnea and pleuritic right sided chest pain. She started experiencing these symptoms when she was on a 7-h flight and later experienced similar symptoms when she went scuba diving. Lung exam revealed decreased breath sounds on the right and she was saturating well on room air. Chest X-ray done showed a large bleb at the right lung apex. CT angiogram done was negative for pulmonary embolism, but confirmed a large bulla involving the right upper lobe. She had no history of lung diseases, marfanoid features, cigarette smoking, drug use or family history of similar condition. She underwent VAT assisted mini thoracotomy with resection of the right apical bulla and tube thoracostomy. Surgical pathology showed a pulmonary bleb with pleural fibrosis and prominent adhesions with parietal pleura and no evidence of malignancy. She was advised to avoid air travel and diving for 3 months and is doing well. Idiopathic giant pulmonary bullae have rarely been reported. It is a rare cause of dyspnea and chest pain in young adults. This may be suspected when patients develop symptoms with air travel and deep sea diving.

Management of long-term persistent air leakage developed after bullectomy for giant bullous lung disease associated with neurofibromatosis type 1

Persistent air leakage is a serious and sometimes fatal complication of bullous lung disease surgery. A 32-year-old man with lung involvement of neurofibromatosis type I underwent bullectomy for huge bullae and recurrent pneumothorax. Persistent postoperative air leakage developed and the lung was totally collapsed. The initial surgery failed, but a second trial employing a novel suture technique on half-absorbed polyglycolic acid (PGA) felt successfully resolved the massive air leakage. Pneumothorax did not recur and the patient remained stable without dyspnea. Thus, a suture technique employing half-absorbed PGA felt was an effective option for managing persistent air leakage.