Video-assisted thoracoscopic treatment of giant bullae associated with emphysema

Symptomatic unilateral idiopathic giant bullous emphysema : a case report

Background

Idiopathic Giant Bullous Emphysema (or Vanishing Lung Syndrome) is a rare condition which is usually associated with male gender, active smoking and underlying emphysematous disease. We present an unusual case of a giant bulla occurring in the absence of these risk factors.

Case presentation

A 54-year-old woman presented to the respiratory outpatient clinic with gradually worsening left sided chest discomfort, which was most marked during a recent flight. She had no significant dyspnoea or other symptoms. She had a remote 5-pack-year smoking history. Chest X-Ray revealed a large hyperlucent area in the left upper lobe. CT Thorax found this to be an isolated bulla occupying more than one-third of the hemithorax. The remaining lung parenchyma was normal. A diagnosis of Idiopathic Giant Bullous Emphysema was made. The patient was referred for VATS (Video-assisted thoracoscopic surgery) bullectomy which was carried out without complication. Her symptoms resolved completely following the operation.

Conclusions

This is an unusual case of a solitary giant bulla occurring without major risk factors or underlying lung disease. VATS bullectomy was shown to be an effective therapeutic option, allowing re-expansion of compressed lung tissue and complete resolution of symptoms.

[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.

Treatment of a giant pulmonary emphysematous cyst with primary bronchoalveolar papillary carcinoma in a Shih Tzu dog

OBJECTIVE

To report the surgical treatment of a pulmonary emphysematous cyst concurrent with primary pulmonary bronchoalveolar papillary carcinoma in a dog.

STUDY DESIGN

Clinical case report.

ANIMALS

12-year-old 6.4 kg spayed female Shih Tzu dog.

METHODS

The dog presented for surgical treatment of pulmonary emphysema. Radiography revealed that more than half of the left caudal lung lobe was enlarged and hyperlucent and computed tomography (CT) confirmed the presence of an emphysematous space. Thoracoscopic lung lobectomy was attempted but was converted to an intercostal thoracotomy due to poor visualization and pleural adhesions. A left caudal total lung lobectomy was performed using a self-cutting endoscopic stapler.

RESULTS

The dog recovered uneventfully and a postoperative histopathologic diagnosis of pulmonary cystic bronchoalveolar papillary carcinoma was made. Re-evaluation using a CT scan with contrast study on postoperative days 27 and 177 revealed no evidence of residual, metastatic, or recurrent lesions. The dog has been doing well since surgery during the 11 month follow-up period.

CONCLUSION

This case report suggests a potential relationship between pulmonary emphysematous diseases and primary lung tumors in dogs.

Veno-venous extracorporeal membrane oxygenation support during lung volume reduction surgery for a severe respiratory failure patient with emphysema

The use of extracorporeal membrane oxygenation (ECMO) in adults has increased in popularity and importance for the support of patients with cardiac or pulmonary failure, but rarely been described as a means of support during anaesthesia and surgery. We report the case of a patient who required lung volume reduction because of emphysema where veno-venous ECMO was required both during surgery and for the first four days postoperatively. We describe the anaesthetic management of this patient who had severe respiratory failure, review other alternatives and discuss why ECMO was particularly suited to this case.

Video-assisted thoracoscopic surgery in the treatment of patients with bullous emphysema

Purpose:

Surgical operation for bullous emphysema is indicated for patients with symptoms related to the compression of giant bullae (usually >30% of hemithorax) or other related complications, such as infection, rupture, or bleeding. Video-assisted thoracoscopic surgery (VATS) has been widely applied in the diagnosis and treatment of patients with intrathoracic diseases, including bullous emphysema.

Materials and methods:

We retrospectively reviewed nine patients with symptomatic or complicated bullous emphysema, who were treated by bullectomy using VATS in the past two years. Eight males and one female were included, with ages ranging from 39 to 82 (median 62) years. Eight (89%) were heavy smokers. Pulmonary function tests were performed preoperatively in only three patients because of their compromised condition on admission.

Results:

Bullae resection and pleurodesis was performed using VATS in the eight patients. The operating time ranged from 35 to 75 (median 50) minutes. Two patients had minor postoperative complications (one prolonged air leak for more than seven days and one wound infection), which recovered with conservative treatment. The chest tube was successfully removed 5–14 days postoperatively. Either symptomatic relief or improved pulmonary function was noted in these patients postoperatively. One patient complained of intermittent dyspnea during follow-up, but the imaging study was essentially normal.

Conclusion:

Bullectomy for patients with bullous emphysema can be performed safely and effectively using VATS. Additional pleurodesis or suturing reinforcement can prevent the complication of air leak.

Novel method of thoracoscopic surgery for giant bulla without residual cavity

A giant bulla is generally resected by thoracoscopic surgery. Resection using an automated stapling device is popular, however, a number of cartridges may be consumed and a cavity is sometimes left remaining, especially when resecting wide-based lesions. To establish a thoracoscopic surgical procedure that results in no residual cavity, we developed a method in which the roof of the bulla is resected first, followed by resection of the pulmonary parenchyma, including the base of the bulla, using a stapling device. Exposure of the base by first removing the roof facilitates determination of the resection line. Between 2003 and 2005, the procedure was attempted in 6 patients, which included one bilateral case. Conversion to a minithoracotomy was required in one patient because of bulla thickening. The operating time ranged from 80 to 150 min (median, 135 min) in the other 6 cases. Postoperative chest drainage ranged from 2 to 13 days (median, 3 days), and postoperative hospital stay was 5 to 18 days (median, 6 days). No adverse events occurred. We found this procedure to be simple and useful for complete resection of giant bullae.

Video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery is finding an ever-increasing role in the diagnosis and treatment of a wide range of thoracic disorders that previously required sternotomy or open thoracotomy. The potential advantages of video-assisted thoracoscopic surgery include less postoperative pain, fewer operative complications, shortened hospital stay and reduced costs. The following review examines the surgical and anesthetic considerations of video-assisted thoracoscopic surgery, with an emphasis on recently published articles.

Decompression of Giant Bulla in Acute Pneumonia: Surgical Palliation Prior to Definitive Management

Giant bullae can be complicated by respiratory tract infection in the setting of emphysema. Herein we describe a technique of palliative decompression of the bullae that gives time to treat acute pulmonary infection prior to definitive surgical treatment.

State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature

BACKGROUND

Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable.

METHODS

Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n = 910), wedge resections (n = 261), lobectomies (n = 221), pneumonectomies (n = 6), the diagnosis and treatment of pleural diseases (n = 200), the treatment of pneumothorax (n = 170), giant bullae (n = 57), lung volume reduction surgery (LVRS) for emphysema (n = 41), the diagnosis and treatment of mediastinal diseases (n = 133), the treatment of esophageal diseases (n = 39), and 30 other miscellaneous procedures.

RESULTS

A review of the literature indicates that videothoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications.

CONCLUSIONS

Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.