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Gunnarsson SI, Johannesson KB, Gudjonsdottir M, Magnusson B, Jonsson S, Gudbjartsson T. Incidence and outcomes of surgical resection for giant pulmonary bullae--a population-based study. Scand J Surg 2013; 101:166-9. [PMID: 22968239 DOI: 10.1177/145749691210100305] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Giant pulmonary bullae (GPB) are rare and there is little information on incidence, long-term prognosis, and outcome of treatment. OBJECTIVES To assess the incidence of GPB in the Icelandic population and to evaluate the outcome of surgical treatment. METHODS Twelve consecutive patients (11 males; mean age 60 ± 15.7 years) underwent resection for GPB in Iceland between 1992 and 2009. All were heavy smokers and had bullae occupying > 30% of the involved lung. There were 8 bilateral and 3 unilateral bullectomies and one lobectomy. Pulmonary function tests were performed preoperatively, and at one month and 5.4 years postoperatively. Age-standardized incidence rate (ASR) was calculated, complications and operative mortality were registered, and overall survival was estimated. Mean follow-up time was 8.2 years. RESULTS The ASR for GPB was 0.40 and 0.03 per 100,000 per year for men and women, respectively. There was no operative mortality, but prolonged air leakage (75%) and pneumonia (17%) were the most common postoperative complications. One month postoperatively, mean FEV1 increased from 1.0 ± 0.48 L (33% predicted) to 1.75 ± 0.75 L (57.5% predicted) (p < 0.01), but FVC remained unchanged. RV decreased from 3.9 ± 0.8 L (177% predicted) to 3.0 ± 1.0 L (128% predicted) (p < 0.05), but TLC and DLCO did not change after operation. At long-term follow-up the FEV1 and FVC had declined to near-baseline values. Five-year and 10-year survival were 100% and 60%, respectively. CONCLUSIONS The ASR of GPB in Iceland was 0.21 per 100,000 per year. In this small series, bullectomy was found to be a safe procedure that significantly improved pulmonary function. The functional improvement then declined over time. Prolonged air leakage was a common postoperative complication that prolonged hospital stay.
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Affiliation(s)
- S I Gunnarsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
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Mineo TC, Ambrogi V, Pompeo E, Mineo D. New simple classification for operated bullous emphysema. J Thorac Cardiovasc Surg 2007; 134:1491-7. [PMID: 18023671 DOI: 10.1016/j.jtcvs.2007.04.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2007] [Revised: 04/03/2007] [Accepted: 04/11/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Optimal results in bullectomy depend on both the size of the resected bulla volume and the reexpansion of the adjacent collapsed healthy pulmonary parenchyma. We hypothesized that the bigger the bulla is compared with residual volume, the greater are the possible benefits. We suggested a new prognostic classification according to bulla volume and its relationship with residual volume. METHODS We retrospectively reviewed 121 patients with emphysematous bulla (>200 mL) who, from 1996 to 2006, underwent unilateral single (n = 64), unilateral multiple (n = 16), bilateral 1-stage (n = 9), and bilateral 2-stage (n = 32) bullectomies. Bulla volume and residual volume were measured by computed tomography and body plethysmography, respectively. Six-month postoperative decrement of residual volume values and their persistence below the baseline for 5 years were considered primary outcomes. Logistic regression was used to select significant variables. The receiver operating characteristic curve was used to identify the cutoff point for a possible classification system. RESULTS There was no postoperative mortality. Significant postoperative improvements in respiratory function were found and correlated with bulla size. Residual volume improved in 75 patients (62%) and persisted in 20 patients (35% of the patients followed for > 5 years). Logistic regression selected bulla/residual volume ratio as the most predictive variable for both outcomes (P < .0001). The best cutoff individuated by the receiver operating characteristic curve analysis was 20% to achieve a high probability of residual volume improvement and 30% to minimize residual volume recurrence. CONCLUSIONS Bullectomy provides good results, but more significant and long-lasting improvements are achievable with a greater ratio bulla/residual volume: scant for less than 20%, good but temporaneous for 20% to 30%, and good and long-lasting results for more than 30%.
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Affiliation(s)
- Tommaso Claudio Mineo
- Thoracic Surgery Division and Emphysema Center, Policlinico Tor Vergata University, Rome, Italy
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Palla A, Desideri M, Rossi G, Bardi G, Mazzantini D, Mussi A, Giuntini C. Elective surgery for giant bullous emphysema: a 5-year clinical and functional follow-up. Chest 2005; 128:2043-50. [PMID: 16236853 DOI: 10.1378/chest.128.4.2043] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND So far, very few studies in the literature have reported data on the long-term follow-up of patients who have undergone surgery for giant bullous emphysema (GBE), and much still needs to be known on the late fate of these patients. AIMS To evaluate patients who have undergone elective surgery due to GBE, early and late mortality following surgery, the early and late reappearance of bullae, and the early and late modifications of clinical and functional data. SUBJECTS AND METHODS Forty-one consecutive patients (36 men; mean [+/- SD] age, 48.4 +/- 14.8 years) who underwent elective surgery for GBE were enrolled in a prospective study, and were studied both before and after undergoing bullectomy for a 5-year-follow-up period. Analyses were performed on the whole population and on two subgroups of patients who were divided on the basis of the absence of underlying diffuse emphysema (group A; n = 23) or the presence of underlying diffuse emphysema (group B; n = 18). RESULTS The early mortality rate was 7.3% (within the first year), and the late mortality rate was 4.9% (overall mortality rate at 5 years, 12.2%; mortality rate in group B, 27.8%). Bullae did not reappear and residual bullae did not become enlarged in any patients at the site of the bullectomy. During the follow-up, the dyspnea score was reduced significantly soon after bullectomy and up to the fourth year of follow-up; intrathoracic gas volume also was reduced significantly (average, 0.7 L). The same was true for the FEV1 percent predicted and the FEV1/vital capacity ratio, which kept increasing until the second year; then, from the third year of follow-up these values were reduced, yet remained above the prebullectomy values until the fifth year of follow-up. When considered separately, the patients in group B appeared to be the most impaired, clinically and functionally (eg, FEV1 showed a similar significant increase up to the second year in both groups after surgery, while a different mean annual decrease was appreciable from the second to the fifth year of follow-up: group A, 25 mL/year; group B, 83 mL/year. Furthermore, patients in group B were the only ones who contributed to the mortality rate, on the whole showing a behavior similar to that of patients who had undergone lung volume reduction surgery. CONCLUSIONS In patients with GBE who were enrolled in the study prospectively and were investigated yearly during a 5-year-follow-up period, elective surgery appears to have been fairly safe, and allowed clinical and functional improvement for at least 5 years. Better results may be expected in patients without underlying diffuse emphysema.
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Affiliation(s)
- Antonio Palla
- Sezione di Malattie dell'Apparato Respiratorio, Dipartimento Cardio-Toracico, U.O. Fisiopatologia Respiratoria, Via Paradisa 2, Pisa 56100, Italy.
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Greenberg JA, Singhal S, Kaiser LR. Giant bullous lung disease: evaluation, selection, techniques, and outcomes. ACTA ACUST UNITED AC 2004; 13:631-49. [PMID: 14682599 DOI: 10.1016/s1052-3359(03)00095-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patient selection remains one of the most important aspects of successful surgery for bullous disease. Operation is indicated for patients who have incapacitating dyspnea with large bullae that fill more than 30% of the hemithorax and result in the compression of healthy adjacent lung tissue. Operation is also indicated for patients who have complications related to bullous disease such as infection or pneumothorax. Patients who have bullous disease in the presence of diffuse lung disease (emphysematous or nonemphysematous) should be evaluated on an individual basis and surgery should be performed on patients in whom even a small increase in pulmonary function might be of major benefit. Smoking cessation and outpatient pulmonary rehabilitation are required of all patients preoperatively. Patients should undergo PFTs including lung volumes by whole body plethysmography, spirometry, diffusion capacity, and arterial blood gas. CT remains the most important preoperative evaluation because it is useful assessing the extent of bullous disease and the quality of the surrounding lung tissue. The authors favor a minimally invasive technique through VATS whenever possible because it might allow for a quicker recovery and might be associated with less pain than is seen following thoracotomy. Modified Monaldi-type drainage procedures are also effective, especially in high-risk patients who cannot tolerate excisional procedures. Special care must be taken to avoid sacrifice of any potentially functional lung tissue. Lobectomies should be avoided whenever possible. The best results are seen in limited resections of large bullae that spare all surrounding functional pulmonary parenchyma. Postoperative complications are minimized through aggressive tracheobronchial toilet and vigorous chest physiotherapy. Adequate pain control in maintained throughout the postoperative period, initially by way of epidural infusion of morphine or fentanyl and later through oral opioids. Early ambulation and pulmonary rehabilitation also help minimize complications.
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Affiliation(s)
- Jacob A Greenberg
- Brigham and Women's Hospital, 75 Francis Street, c/o Surgery Education Office, Boston, MA 02115, USA
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Brenner M, Yusen R, McKenna R, Sciurba F, Gelb AF, Fischel R, Swain J, Chen JC, Kafie F, Lefrak SS. Lung volume reduction surgery for emphysema. Chest 1996; 110:205-18. [PMID: 8681630 DOI: 10.1378/chest.110.1.205] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
There has been dramatic resurgence of interest in surgical treatment of emphysema, particularly "lung volume reduction" procedures. Recent studies have demonstrated improvements in pulmonary function, lung mechanics, exercise tolerance, and quality of life in selected patients following volume reduction procedures. However, considerable uncertainty remains regarding overall benefit, optimal patient selection, operative techniques, and duration of response. This summarizes current approaches to lung volume reduction surgery, available clinical outcome information, selection criteria, and physiologic mechanisms of response, and discusses the potential role for surgical volume reduction in treatment of emphysema. Recent data appear to support the efficacy of bilateral staple lung volume reduction surgery in patients with severe symptomatic heterogeneously distributed emphysema. Further studies will be needed to determine relative value of different operative techniques and benefit in patients with other clinical presentations.
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Affiliation(s)
- M Brenner
- Pulmonary and Critical Care Medicine Division, UC Irvine Medical Center, Orange 92668, USA
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Snider GL. Reduction pneumoplasty for giant bullous emphysema. Implications for surgical treatment of nonbullous emphysema. Chest 1996; 109:540-8. [PMID: 8620733 DOI: 10.1378/chest.109.2.540] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
A review of the literature on reduction pneumoplasty for giant bullous emphysema was undertaken to identify current criteria for this surgical treatment and in the hope of obtaining insights into evaluating reduction pneumoplasty for nonbullous emphysema. Twenty-two retrospective case series, published since 1950, were retrieved by a computer search of the literature and a search of the Index Medicus prior to 1966. Reduction pneumoplasty is most effective when bullae are larger than one third of a hemithorax with evidence of compression of adjacent lung tissue and an FEV1 of less than 50% predicted; the presence of emphysema in nonbullous lung and the amount of compression are best judged by CT. The rationale for reduction pneumoplasty for nonbullous emphysema is supported by the similar early functional changes after reduction pneumoplasty for bullous and nonbullous-improvement of blood gas values and lung mechanics. A single study showing that decline of lung function after surgery for bullous emphysema was less in those who stopped smoking than in those who continued to smoke supports the need for preoperative and maintained smoking cessation in patients receiving reduction pneumoplasty. After 4 decades, the duration of improvement in lung function, whether worsening of emphysema occurs in remaining lung, and late morbidity and mortality after reduction pneumoplasty for bullous emphysema are not well defined. A registry with an unoperated-on comparison group could more rapidly accumulate such data after reduction pneumoplasty for nonbullous emphysema.
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Affiliation(s)
- G L Snider
- Boston VA Medical Center, Boston University School of Medicine, USA
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Brenner M, Kayaleh RA, Milne EN, Bella LD, Osann K, Tadir Y, Berns MW, Wilson AF. Thoracoscopic laser ablation of pulmonary bullae: Radiographic selection and treatment response. J Thorac Cardiovasc Surg 1994. [DOI: 10.1016/s0022-5223(94)70345-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ohta M, Nakahara K, Yasumitsu T, Ohsugi T, Maeda M, Kawashima Y. Prediction of postoperative performance status in patients with giant bulla. Chest 1992; 101:668-73. [PMID: 1541130 DOI: 10.1378/chest.101.3.668] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
To predict the postoperative improvement in performance status after bullectomy, preoperative pulmonary function and dyspneic grade were evaluated in 20 patients with giant bulla. The patients were divided into two groups, based on postoperative performance status: group 1 consisted of 15 patients with improved status after surgery; and group 2 of five patients with worsened status after temporary improvement. To determine correlation with the groups, preoperative functional measurements such as %VC, FEV1%, MMF, PEFR, RV/TLC, delta N2, LCI, and PNCD were then analyzed by the multivariate statistic method; results of delta N2 and FEV1% showed significant correlation with the groups. Prediction of the groups based on the two measurements agreed with the actual results except in one patient. These results show that postoperative improvement in performance status of patients with giant bulla can be predicted on the basis of preoperative pulmonary function.
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Affiliation(s)
- M Ohta
- First Department of Surgery, Osaka University Medical School, Japan
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Cohen E, Kirschner PA, Benumof JL. Case 1--1990. A 59-year-old, oxygen-dependent man with severe giant bullous emphysema is admitted for pulmonary angiography and pulmonary bulla resection. JOURNAL OF CARDIOTHORACIC ANESTHESIA 1990; 4:119-29. [PMID: 2131843 DOI: 10.1016/0888-6296(90)90458-r] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- E Cohen
- Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY 10029
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Molins L. Tratamiento quirurgico de la bulla gigante en el paciente con enfermedad pulmonar obstructiva cronica. Arch Bronconeumol 1989. [DOI: 10.1016/s0300-2896(15)31745-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Laros C, Gelissen H, Bergstein P, Van Den Bosch J, Vanderschueren R, Westermann C, Knaepen P. Bullectomy for giant bullae in emphysema. J Thorac Cardiovasc Surg 1986. [DOI: 10.1016/s0022-5223(19)38482-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nakahara K, Nakaoka K, Ohno K, Monden Y, Maeda M, Masaoka A, Sawamura K, Kawashima Y. Functional indications for bullectomy of giant bulla. Ann Thorac Surg 1983; 35:480-7. [PMID: 6847283 DOI: 10.1016/s0003-4975(10)60419-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Nineteen patients with giant bulla were followed for more than 1 year after bullectomy. They were divided into two groups according to their postoperative symptoms. Group 1 consisted of 16 patients who had no problems in their postoperative clinical course, while Group 2 included 3 patients who complained of severe dyspnea at 5 to 6 years of follow-up. Prior to operation, the forced expiratory volume in 1 sec over vital capacity (FEV1%) was 66.8 +/- in Group 1 and 27.6 +/- 5.4% in Group 2. Differences in preoperative and postoperative FEV1% were statistically significant within Group 1 and between the two groups. Postoperative FEV1% (Y) correlated significantly with preoperative FEV1% (X) (Y = 0.74X + 25.4; r = 0.836; p less than 0.001). Thus, we were able to predict the postoperative FEV1% from the preoperative value. Regional ventilation over volume was computed from the washout curve of xenon 133 after reaching equilibrium with rebreathing in a closed circuit (V/V dynamic). Group 2 had significantly lower regional ventilation over volume in all regions, both before and even after bullectomy, compared with normal subjects or Group 1 patients. Preoperative V/V dynamic was below 0.5 in all regions of Group 2. Furthermore, postoperative V/V dynamic (Y) correlated significantly with preoperative V/V dynamic (X) in the upper region (Y = 0.46X + 0.40; r = 0.638; p less than 0.02) and in the lower region (Y = 0.72X + 0.33; r = 0.869; p less than 0.001). We conclude that functional indications of bullectomy for giant bulla are that FEV1% should be greater than 40%, and that regional V/V dynamic should be greater than 0.5. On the other hand, symptomatic and functional improvement following bullectomy was reduced in patients whose FEV1% was less than 35% in whose V/V dynamic was remarkably disturbed in all regions of the involved hemithorax.
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Abstract
The major clinical use of ventilation-perfusion (V/Q) scintigraphy is for the diagnosis of pulmonary embolism (PE). Accurate diagnosis of PE is essential since effective treatment is available but involves some risk to the patient. The scintigraphic characteristics of PE are segmental perfusion defects in lung that is normally ventilated and normal on the radiograph. The inherent shortcoming of perfusion scintigraphy is its lack of specificity. Combining a ventilation study with perfusion imaging improves the diagnostic specificity of lung scintigraphy. Xenon-133 is currently the most commonly used radionuclide for routine ventilation studies; a long washout technique is more sensitive than single-breath imaging when this radionuclide is used. We obtain preperfusion xenon-133 ventilation studies with a 4-min rebreathing equilibrium phase and a long 5-min washout phase to obtain maximum information. It is imperative that V/Q studies be interpreted with a current high quality chest radiograph. Interpretation of V/Q studies for PE is perhaps best done by assigning a probability diagnosis, since rarely is absolute specificity possible. This article details the criteria we use for these probability determinations.
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Tenholder MF, Jones PA, Matthews JI, Hooper RG. Bullous emphysema. Progressive incremental exercise testing to evaluate candidates for bullectomy. Chest 1980; 77:802-5. [PMID: 7398395 DOI: 10.1378/chest.77.6.802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Various tests of both function and anatomy have been used in patients being considered for surgical resection of giant pulmonary bullae. A young patient had an excellent response to removal of a large bulla in the right lung. In addition to roentgenographic evaluation, ventilation perfusion scanning, and routine preoperative pulmonary function studies, we performed progressive incremental exercise testing to determine both preoperative and postoperative ventilatory and cardiac measurements. We feel that progressive incremental exercise pulmonary function adds another dimension to the selection and follow-up of patients being considered for operative bullectomy.
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Sung DT, Payne WS, Black LF. Surgical management of giant bullae associated with obstructive airway disease. Surg Clin North Am 1973; 53:913-20. [PMID: 4717258 DOI: 10.1016/s0039-6109(16)40096-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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