Bullectomy for Symptomatic or Complicated Giant Lung Bullae

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THORACIC

GENERAL

Bullectomy for Symptomatic or Complicated GiantLung BullaePradheep Krishnamohan, MD, K. Robert Shen, MD, Dennis A. Wigle, MD,Mark S. Allen, MD, Francis C. Nichols, III, MD, Stephen D. Cassivi, MD,William S. Harmsen, MS, and Claude Deschamps, MDDivision of General Thoracic Surgery, Department of Surgery and Division of Biomedical Statistics and Informatics, Department ofHealth Sciences Research, Mayo Clinic, Rochester, Minnesota

Background. Giant bullae of the lung are rare. Little isknown about functional results after surgical treatment.

Methods. This study retrospectively reviewed all pa-tients who underwent surgical treatment for giant bullaebetween December 1988 and December 2010.

Results. There were 63 patients (51 men, 12 women)with a median age of 56 years (range, 26 to 85 years).Bullae were a median size of 14 cm (range, 9 to 30 cm).Forty-five patients (71%) had underlying diffuse emphy-sema. The indication for surgical intervention wassymptoms alone in 30 patients (48%) and associatedcomplications in 33 (52%). The operation was a bullec-tomy in 54 patients, lobectomy in 6, plication in 2, andbilobectomy in 1. Complications occurred in 27 patients(43%), and 2 patients (3.0%) died. At the last follow-up, 19had died and 44 were alive. Of the 43 patients withshortness of breath preoperatively, 29 (67.4%) wereimproved. Thirty patients (46.1%) had preoperative and

Accepted for publication Oct 18, 2013.

Presented at the Poster Session of the Forty-ninth Annual Meeting of TheSociety of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013.

Address correspondence to Dr Deschamps, Division of General ThoracicSurgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail:[email protected].

� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

postoperative pulmonary function tests with improve-ment from a median forced expiratory volume in 1 second(FEV1) of 1.0 L preoperatively to 1.4 L postoperatively(p [ 0.002). Increasing bulla size (p [ 0.02) and under-lying emphysema (p [ 0.01) were adversely associatedwith postoperative morbidity. Dyspnea improved in 21 of33 patients (64%) with underlying diffuse emphysemacompared with 5 of 7 patients (71%) without emphysema(p [ 0.70).Conclusions. Bullectomy improved pulmonary func-

tion in most patients with a symptomatic or complicatedgiant bulla, or both. However, increasing bulla size andunderlying emphysema resulted in increased treatmentmorbidity. Underlying diffuse emphysema is not acontraindication to bullectomy.

(Ann Thorac Surg 2014;97:425–31)� 2014 by The Society of Thoracic Surgeons

ullous disease of the lung has often been a thera-

Bpeutic challenge due to its complex pathophysiologyand varied presentations. Although pulmonary emphy-sema is a disease of high prevalence in the smokingpopulation, giant bullae are rare. Urgent surgical treat-ment is often prompted by complications such as pneu-mothorax, prolonged air leak, and more rarely, infectionor bleeding. Elective surgical treatment for dyspnea orother symptoms is rarely performed, and the factorsaffecting the outcome after bullectomy are less wellknown. We reviewed our experience with surgical treat-ment for giant pulmonary bullae and analyzed themorbidity, mortality, and the factors affecting functionalresults and long-term survival.

Material and Methods

This study was approved by Mayo Foundation’s Institu-tional Review Board.

Study DesignAll patients who underwent surgical treatment for giantbullae at the Mayo Clinic in Rochester, Minnesota, be-tween December 1988 and December 2010, werereviewed. Eligible patients included those with a giantbulla occupying one-fourth or more of one hemithorax onpreoperative imaging. Excluded were patients withgeneralized emphysema who underwent lung volumereduction surgery, lung transplantation, or operations forbullous disease other than a giant bulla.Medical records were reviewed for demographic in-

formation, medical history, radiographic findings, bullasize and location, surgical approach and procedures,postoperative complications, clinical symptoms, andpulmonary function tests at follow-up. Type of bulla wasclassified according to Reid [1, 2] Type I bullae have anarrow neck, empty sac, and project above the surfacelike a mushroom. Type II have a broad neck, and the sacusually contains emphysematous lung. Type III bullaeprotrude slightly above the surface, have no neck, oftenextend deep to the hilum, and contain emphysematouslung evenly throughout the bulla. The grade of dyspneawas classified according to the New York Heart Associa-tion classification [3]: grade I is minimal dyspnea onrunning or on doing more than ordinary effort, grade IIis dyspnea on ordinary effort, grade III is considerable

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Table 1. Demographics and Bulla Characteristics of 63Patients With a Giant Bulla

VariableMedian (range) orNo. (%) (N ¼ 63)

Age, years 56 (26–85)SexMen 51 (81)Women 12 (19)

Smoking history 54 (86)Pack years 50 (4–150)Stopped smoking preoperatively 45 (71)Period of abstinence, months 39 (<1–450)

COPD 45 (71)Diabetes mellitus 67 (10)Hypertension 24 (38)Coronary artery disease 11 (17)Bulla size, cm 14 (9–30)Bulla lateralityRight side 36 (57)Left side 19 (30)Bilateral 8 (13)

Bulla typeI 3 (5)II 18 (29)III 18 (29)Not known 24 (38)

COPD ¼ chronic obstructive pulmonary disease.

Abbreviations and Acronyms

% pred = percent predictedCI = confidence intervalCOPD = chronic obstructive pulmonary

diseaseCT = computed tomographyDLCO = diffusion capacity of the lung for

carbon monoxideFEV1 = forced expiratory volume in 1 secondFVC = forced vital capacityHR = hazard ratioOR = odds ratioRV = residual volume

426 KRISHNAMOHAN ET AL Ann Thorac SurgBULLECTOMY FOR GIANT LUNG BULLAE 2014;97:425–31

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dyspnea on doing less than ordinary effort, and grade IVis dyspnea at rest.

Postoperative complications included those thatoccurred within 30 days of the procedure or during thehospitalization. Operative mortality included patientswho died within the first 30 days after the operation orduring the same hospital admission. Factors affectingmorbidity,mortality, and functional results were analyzed.

Descriptive statistics for categoric variables are re-ported as frequency and percentage, and continuousvariables are reported as mean (standard deviation) ormedian (range), as appropriate. Overall change in pul-monary function tests (preoperative to postoperative) wasassessed using a signed rank test. Spearman rank corre-lation was used to assess the correlation between thepreoperative bulla size and the change in forced expira-tory volume in 1 second (FEV1).

Univariate logistic regression was used to test the as-sociation between variables and change in dyspneasymptom as well as early postoperative morbidity.Overall survival was estimated using Kaplan-Meier sur-vivorship. The association of demographic factors withsurvival was assessed using Cox proportional hazardsregression. All statistical tests were two-sided withp-values of less than 0.05 considered significant.

Clinical FindingsThe analysis included 63 patients (51 men, 12 women)who underwent surgical treatment for a giant bulla. Me-dian age was 56 years (range, 26 to 85 years). Patientdemographic information is summarized in Table 1. Fifty-four patients (86%) had a history of cigarette smoking.Median pack-years were 50 (range, 4 to 150). Forty-fourpatients (70%) had stopped smoking before surgery.Median duration of smoking cessation was 39 months(range, <1 to 450 months). Forty-five patients (71%) hadknown chronic obstructive pulmonary disease (COPD).Dyspnea was the predominant symptom in 55 patients(87%) and was grade I or II in 32 patients (51%) and gradeIII or IV in 23 (37%).

Conventional chest roentgenograms at presentationshowed abnormalities in all patients. Findings on chestroentgenogram included a giant bulla in 24 (38%), air

fluid level in 2 (3%), pneumothorax in 33 (52%), andassociated hyperexpansion of lung in 38 (60%). Computedtomography (CT) data were available in all 53 patientsand identified a giant bulla in all patients, air fluid level in5 (8%), crowding of hilum in 18 (29%), compression ofadjacent lung parenchyma in 16 (25%), and presence ofdiffuse emphysema in 45 patients (71%). Bullae wereright-sided in 36 patients (57%), left-sided in 19 (30%),and bilateral in 8 (13%). Size (cm) and type of bulla wereidentified from the CT imaging and the surgeon’s oper-ative report. Bullae were type I in 3 patients (5%), type IIin 18 (29%), and type III in 18 (29%). Ten patients had aventilation/perfusion scan that confirmed the findingsnoted on CT.Indications for surgical intervention (Table 2) were

symptoms only in 30 patients (48%) and includeddyspnea, exercise intolerance, cough, hemoptysis. andfever. The operations in 33 patients (52%) were becauseof complications that included first-time pneumothoraxin 19 (29%) and recurrent/persistent pneumothorax in 14(22%). Eleven patients (17%) had two episodes and 3 (5%)had three episodes. Twenty-four patients (38%) had apersistent air leak after chest tube insertion.Ten patients had preoperative pulmonary rehabilita-

tion. Video-assisted thoracic surgery was performed in 28patients (44%), thoracotomy in 28 (43%), sternotomy in 6(10%), and 1 (2%) had video-assisted thoracic surgery andthoracotomy. Surgical procedures included bullectomy in54 patients (83%), lobectomy in 6 (10%), bulla plication in

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Table 2. Clinical Presentation of Giant Bullae

Symptoms No. (%) (N ¼ 63)

DyspneaNone 8 (13)Grade I or II 32 (51)Grade III or more 23 (37)

Exercise intolerance 37 (59)Chest pain 25 (40)Fatigability 18 (29)Cough 18 (29)Fever 6 (10)Hemoptysis 2 (3)Pneumothorax

1 episode 19 (29)2 or more episodes 14 (22)

Persistent air leak after tube thoracostomy 24 (38)

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2 (4%), and bilobectomy in 1 (2%). Buttressing of thestaple line with reinforcing prosthetic material was donein 42 of the 54 patients (67%) who underwent bullectomy.The 7 patients who had a lobectomy or bilobectomy had atype III bulla. Additional pleural procedures were done in35 patients and included mechanical pleurodesis in 14(22%), pleural tent in 10 (16%), parietal pleurectomy in 5(8%), combined mechanical pleurodesis/pleurectomy in 4(6%), and talc pleurodesis in 2 (3%). Four patients hadbilateral procedures.

Results

Postoperative complications (Table 3) occurred in 27patients (43%) and included prolonged air leak in 19(30%), atrial fibrillation in 8 (13%), pneumonia in 8

Table 3. Postoperative Complications

Complications No. (%) (N ¼ 63)

Air leakNot documented 1 (2)None 25 (40)<7 days 18 (29)�7 days 19 (30)

Heimlich valve at dismissal 10 (16)Atrial fibrillation 8 (13)Pneumonia 8 (13)Mechanical ventilation postoperatively

Remain intubated from operating room 5 (8)Reintubated postoperatively 5 (8)

Bleeding 3 (5)Tracheostomy 3 (5)Bronchoscopy for retained secretions 2 (3)Bronchopleural fistula 1 (2)Seizures 1 (2)Ileus 1 (2)Urinary retention 1 (2)

(13%), bleeding in 3 (5%), respiratory failure requiringtracheostomy in 3 (5%), and bronchopleural fistulain 1 (2%). Ten patients (15%) were dismissed with aHeimlich valve. Two patients died (operative mortality,3%). One patient had an infected bulla and underwentbilateral bullectomy. A prolonged air leak and res-piratory failure developed, and he ultimately died ofsepsis. The second patient died 12 days after dismissalof unknown cause.Median postoperative length of stay was 7 days (range,

1 to 54 days). Factors associated with an increased odds ofa postoperative complication included increasing bullasize (p ¼ 0.017) and underlying diffuse emphysema(p ¼ 0.011; Table 4).Median follow-up was 1.5 years (range, 4 days to 13.0

years). Follow-up data on clinical symptoms were avail-able for 52 patients (82%). Of the 43 patients with short-ness of breath preoperatively and who had a follow-upassessment, 29 (67%) were improved (95% confidenceinterval (CI), 51% to 81%). At the postoperative assess-ment, 15 patients were asymptomatic, 8 patients hadgrade I dyspnea, 15 patients had grade II or III, and 5patients had grade IV. Dyspnea improved in 21 of 33patients (64%) with underlying diffuse emphysemacompared with 5 of 7 patients (71%) without emphysema.Fifteen patients (24%) required intermittent or continuoussupplemental home oxygen. One patient subsequentlyunderwent single lung transplantation.Thirty patients (48%) had preoperative and post-

operative pulmonary function tests (Table 5). The medianpreoperative FEV1 was 1.0 L (26% predicted) andimproved to a postoperative FEV1 of 1.4 L (43% predicted;p ¼ 0.002). In the 16 patients with preoperative andpostoperative assessments, residual volume and the ratioof FEV1 to forced vital capacity (FEV1/FVC) did notchange significantly (p ¼ 0.38), nor did the diffusingcapacity of the lung for carbon monoxide (DLCO) in 12patients who were evaluated for it (p ¼ 0.48). Thepresence of underlying diffuse emphysema did notadversely affect improvement in postoperative dyspnea(odds ratio, 0.7, 95% CI, 0.1 to 4.2; p ¼ 0.70). Thepreoperative size of bullae had a borderline significantassociation with postoperative improvement in dyspnea(95% CI, 0.995 to 1.6; p ¼ 0.055). Among 16 patients, therewas only a slight negative correlation between thepreoperative size of bullae and improvement inpostoperative FEV1 (r ¼ –0.14, p ¼ 0.61).At the last follow-up, 46 patients were alive and 17 had

died. No recurrent giant bullae or pneumothorax devel-oped during the follow-up period. Overall 5-year survivalwas 68% (95 % CI, 54% to 87%; Fig 1). Factors associatedwith a significant decrease in long-term survival includedpatients who smoked (current or former; hazard ratio, 8.5,95%CI, 1.1–65.7; p¼ 0.04) and increasing age (hazard ratio,1.9 per 10 years; 95% CI, 1.2 to 3.0; p ¼ 0.003; Table 6).

Comment

A pulmonary bulla is an air filled space of more than 1 cmin diameter, formed as a result of a destructive process.

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Table 4. Risk Factor Association With Postoperative Complications

Variable Patients (No.)Early Morbidity

No. (%) OR (95% CI) p Value

GenderMale 51 32 (45) 1.6 (0.4–6.2) 0.46Female 12 4 (33) 1.0 (Reference)

SmokingCurrent/Former 54 26 (48) 7.4 (0.9–63.5) 0.07Never 9 1 (11) 1.0 (Reference)

Pack-years>40 years 30 16 (53) 2.7 (0.9–8.1) 0.07�40 years 27 8 (30) 1.0 (Reference)

EmphysemaYes 43 22 (51) 7.3 (1.5–36.2) 0.01a

No 16 2 (12) 1.0 (reference)Age, per 10 years . 1.4 (0.97–2.0) 0.07Pack-years, per 10 years . 1.13 (0.95–1.35) 0.16Bulla size, per cm . 1.2 (1.04–1.4) 0.016a

a Statistically significant.

CI ¼ confidence interval; OR ¼ odds ratio.

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When it has enlarged to significant proportions and oc-cupies a large volume inside the chest cavity, it becomes agiant bulla. The percentage of pleural space occupied by agiant bulla has varied in the literature from not specifiedto up to 50% [1]. The outer surface of the bulla is made ofvisceral pleura, but the inner surface consists of fibroustissue formed by the pleura and underlying destroyedpulmonary tissue [4]. Associated with these changesare varying degrees of emphysema [2]. Giant bullae aredifferent from pulmonary blebs or cysts [5]. Theincidence of giant bullae is generally unknown, but thecondition is considered rare; in Iceland, for example,the age-standardized incidence rate of giant pulmonarybullae has been reported as 0.21/100,000 per year [6].Similar to what was reported by Snider [1] in anextensive review, most of our patients were men, formeror current smokers, and with disease predominantly onthe right side and upper lung fields.

Although giant bullae can be asymptomatic, patientsare usually referred to the thoracic surgeon because ofdyspnea or complications, including pneumothorax andprolonged air leak after chest tube insertion [1, 4]. Rarely,

Table 5. Change in Pulmonary Function in Patients With Giant B

Variablea Patients (No.) Preoperative

FEV1, L 23 1.0 (0.5–3) 1FEV1 % pred 21 29 (16–77)RV, L 9 3.7 (2.2–8.0) 3RV, % pred 8 192 (135–405) 1FEV1/FVC 16 48.2 (25.2–85.8) 52DLCO, % pred 12 59 (24–81)

a Values are expressed as median (range) using Wilcoxon rank sum test. b

% pred ¼ % predicted; DLCO ¼ diffusion capacity of the lung for carbonforced vital capacity; RV ¼ residual volume.

a patient will be seen for infection, bleeding, or carcinomaassociated with the bulla [7]. The goals of surgical therapyfor patients with giant bullae are to improve the qualityof life for those in whom medical treatment has failedand to resolve complications while preserving lungfunction [1, 4, 8]Although appropriate selection is considered critical for

optimal results in patients seeking improvement in dys-pnea and quality of life, no single preoperative test hasbeen found to be an absolute predictor of improvement.Criteria for a favorable prognosis have included bullaeoccupying more than one-third of the hemithorax,vascular crowding, localized disease, compression ofunderlying normal lung, relatively good perfusion on thecontralateral side, and preoperative FEV1 of less than halfof the predicted value [1, 4, 8–10] In contrast, Nakaharaand colleagues [11] recommend that preoperative FEV1

be greater than 40% of the predicted value. Comparedwith those reported criteria, 71% of our patients haddiffuse emphysema, and the median preoperative FEV1

in our series was 29% of the predicted value. None ofour patients was asymptomatic.

ullae After Bullectomy

Follow-Up Change From Preoperative p Value

.4 (0.2–3.5) 0.3 (–0.8 to 1.4) 0.002b

42 (11–104) 10 (–17 to 35) 0.003b

.8 (1.7–6.7) –1.3 (–1.7 to 1.8) 0.2594 (81–328) –45 (–89 to 81) 0.25.2 (23.4–90.2) 3.0 (–15.8 to 16.5) 0.3853 (30–88) 4 (–45 to 25) 0.48

Statistically significant.

monoxide; FEV1 ¼ forced expiratory volume in 1 second; FVC ¼

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Fig 1. Kaplan-Meier estimate of overallsurvival after giant bullectomy.

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Snider [1] reports that surgical intervention ismost oftenperformed for dyspnea and rarely for pneumothorax.Our series was more evenly divided: up to 52% of ourpatients were operated on for complications such aspneumothorax or prolonged air leak. A secondarypneumothorax in patients who have severe COPD can bea life-threatening event [12], and there are few alternativetherapeutic options to an operation.

The air leak associated with a ruptured bulla is oftenprolonged due to the underlying emphysema and asso-ciated diseased elastic network. These pneumothoracescan often be loculated because of previous pleural dis-eases or interventions, and this may contribute to thedevelopment of “tension pouches.” Some pneumo-thoraces can sometimes be indistinguishable from a bullaon preoperative CT [13].

Although various imaging modalities have been usedto try to better predict postoperative results, CT hasbecome [14] and remains [15] the imaging technique ofchoice for preoperative evaluation of patients withemphysema. All of our patients had a preoperative CT.Findings on CT indicated more than 70% of our patientshad underlying diffuse emphysema, and only 25% hadcompression of the underlying lung.

Similar to Schipper and colleagues [16], we have startedusing pulmonary rehabilitation preoperatively (10 patientsin our series) as much to improve conditioning as toassist with patient selection, based on the lung volumereduction surgery experience [17]. Acute bronchitisshould be treated aggressively preoperatively withappropriate antibiotics and constitutes a contraindicationto elective bullectomy if unresolved [18].

The goal of surgical treatment is to remove the bullawhile preserving as much of the underlying pulmonaryparenchyma as possible [1, 4, 9], Most of our patientsunderwent bullectomy, but 11% had a lobectomy orbilobectomy because the emphysematous changesextended to the hilum. Given the expected morbidity of

prolonged air leak in this high-risk population, more thanhalf of the patients in our series required a concomitantpleural obliteration procedure and buttressing of thestaple line [12].Close to 70% of our patients had relief or substantial

improvement of their preoperative symptoms, with anoperative mortality of 3% and morbidity of 43%. Theseresults are comparable to those reported by others[1, 10–11, 16, 18–20]. A similar improvement in airwayobstruction, as demonstrated by an increase in post-operative FEV1 in our series, was also reported by others[1], but Schipper and colleagues [16] and Palla andcolleagues [21] have shown that the improvement afterbullectomy is time-limited and patients slowly deterio-rate over the following years, similar to other emphyse-matous patients after lung volume reduction surgery [17].Our relatively short follow-up did not allow us to studyour patients long-term.We have shown that the presence of underlying

emphysema, as measured by preoperative CT, did notadversely affect the functional results, in contrast to thestudy from Palla and colleagues [21], who found thatpatients without underlying emphysema did better. Webelieve this is relevant to patient selection and suggestthat underlying emphysema should not be consideredan absolute contraindication for surgical treatment. Wealso found near statistically significant correlationbetween larger bulla size and postoperative symptomimprovement, similar to the findings reported by others[10, 21].Long-term survival in our study was less than what was

reported by Schipper and colleagues [1] and wasadversely affected by age and smoking status. We alsohad a higher incidence of diffuse emphysema in ourseries, and this also may have adversely affected long-term survival [22].Our study is retrospective with a relative short follow-

up period. We do not know the number of patients seen

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Table 6. Risk Factor Association With Long-Term Survival

Variable Patients (No.) Deaths (No.)Kaplan-Meier Estimate(95% CI) at 5 Years HR (95% CI) p Value

Overall 63 19 68 (54–87) . .

GenderMale 51 16 61 (43–86) 3.2 (0.9–11.2) 0.07Female 12 3 82 (60–100) 1.0 (Reference)

SmokingCurrent/former 54 18 65 (48–87) 8.5 (1.1–65.7) 0.04a

Never 9 1 83 (58–100) 1.0 (Reference)Pack-years

>40 30 9 81 (62–100) 1.5 (0.5–4.3) 0.43�40 27 6 70 (49–100) 1.0 (Reference)

EmphysemaYes 43 15 70 (54–91) 1.8 (0.5–6.4) 0.33No 16 3 57 (30–100) 1.0 (Reference)

Age, per 10 years . 1.9 (1.2–3.0) 0.003a

Pack-years, per 10 years . 1.1 (0.9–1.2) 0.38Bulla size, per cm . 1.0 (0.9–1.1) 0.89

a Statistically significant.

CI ¼ confidence interval; HR ¼ hazard ratio.

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at our medical center who were never referred to a sur-geon or were denied operative treatment after surgicalevaluation. The radiologist did not grade the degree ofunderlying emphysema. Despite those limitations, ourgoal was to combine all patients operated on for a giantbulla during the study time period to better reflect thespectrum of potential surgical candidates seen by a gen-eral thoracic surgeon in clinical practice.

In conclusion, giant bullae of the lung can be intimi-dating, especially when associated with underlyingdiffuse emphysema or worse, vanishing lung. Severalcriteria have been identified over the years to help guidetherapeutic decisions. In addition, patients who presentwith pneumothorax or prolonged air leak, or both, aftertube thoracostomy face few if any alternatives to surgicalintervention.

We have found in our population of patients that it ispossible to remove a giant bulla of the lung under thosecircumstances with reasonable morbidity and mortality.Pulmonary function improved in most patients withsymptomatic or complicated giant bullae, or both, afterbullectomy. In selected cases, a lobectomy might benecessary to remove the giant bulla and be accomplishedwith favorable outcomes. Increasing bulla size and thepresence of diffuse emphysema adversely affected post-operative morbidity. Underlying diffuse emphysema didnot adversely affect postoperative functional results andis not considered a contraindication to bullectomy.Increasing age at time of operation and smoking status(current or past) adversely affected long-term survival.

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� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

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INVITED COMMENTARY

Dr Krishnamohan and colleagues [1] present a largeretrospective analysis of patients operated on for giantbullous disease. Their mix of patients was fairlyevenly distributed between patients with symptomsalone and those with adverse events, predominantlypneumothorax and persistent air leak. Morbidity andmortality were in line with what is expected in thiscohort. Nearly half the patients had preoperative andpostoperative lung function tests (presumably thepatients operated on for symptoms), and theydemonstrated the authors’ good surgical insight. Thepatients all had severe obstruction and hyperinflationwith relatively preserved diffusion capacity (median>50% predicted). It was encouraging that forcedexpiratory volume in 1 second improved significantlypostoperatively, but it is curious that residual volumedid not decrease. This study’s strengths are its sizeand excellent results. It suffers from its retrospectivenature and the inability to know what happened tothe patients with giant bullous disease who weretreated nonoperatively.

This report highlights the evolving approach to giantbullous disease. Although resectional therapy for giantbullous disease is still uncommon, it may be playing anincreasingly important role. Although this report spans

a 22-year period, the median follow-up time was only1.5 years, suggesting that most patients were operatedon fairly recently. A combination of the experience withlung volume reduction surgical procedures (LVRS),increasing our knowledge about how to operate onpatients with extremely poor lung function, and the factthat most of these operations can now be done in aminimally invasive fashion, may explain this trend. Theincreasing use of preoperative pulmonary rehabilita-tion also parallels the LVRS experience and should beused liberally for patients being operated on fordyspnea.

William R. Burfeind, Jr, MD

Thoracic SurgerySt. Luke’s University Health Network701 Ostrum St, Ste 603Bethlehem, PA 18015e-mail: [email protected]

Reference

1. Krishnamohan P, Shen KR, Wigle DA, et al. Bullectomy forsymptomatic or complicated giant lung bullae. Ann ThoracSurg 2014;97:425–31.

0003-4975/$36.00http://dx.doi.org/10.1016/j.athoracsur.2013.11.005