Outcomes After Resection of Giant Emphysematous Bullae

Transcription

1 ORIGINAL ARTICLES: Outcomes After Resection of Giant Emphysematous Bullae Paul H. Schipper, MD, Bryan F. Meyers, MD, Richard J. Battafarano, MD, PhD, Tracey J. Guthrie, RN, BSN, G. Alexander Patterson, MD, and Joel D. Cooper, MD Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, and Jacqueline Maritz Lung Center at Barnes-Jewish Hospital, St. Louis, Missouri Background. Giant emphysematous bullae represent a rare form of emphysematous lung destruction. Surgical resection has traditionally been indicated when there is hyperexpansion of the chest, compromised pulmonary function, and evidence of underlying, relatively normal compressed lung. We review our experience and intermediate-term follow-up after the resection of giant bullae. Methods. Forty-three patients underwent resection of giant emphysematous bullae at Barnes-Jewish Hospital between March 1994 and June All had limiting dyspnea and radiologic evidence of hyperinflated giant bullae compressing adjacent lung parenchyma. Forty-one patients underwent preoperative pulmonary rehabilitation. Twenty-two patients underwent a bilateral procedure and 21 underwent a unilateral procedure. Mean follow-up was 4.5 years. Results. One early death occurred on postoperative day 20 from heparin-induced thrombocytopenia and pulmonary embolism. Complications included prolonged air leak of more than 7 days in 23 (53%), atrial fibrillation in 5 (12%), postoperative mechanical ventilation in 4 (9%), and pneumonia in 2 (5%). Kaplan-Meier survival at 1, 3, and 5 years was 98%, 92%, and 89%, respectively. Four late deaths occurred at 1.4, 2.8, 3.5, and 5.9 years. Functional measures preoperatively and at 6 months and 3 years postoperatively were a forced expiratory volume in 1 second L (% predicted) of (34%), (55%), and (49%); residual volume L (% predicted) of (262%), (154%), and (209%); 6-minutes walk (ft) of , , and ; supplemental O 2 used continuously (% patients) of 42%, 9%, and 21%; and O 2 used during exercise of 73%, 37%, and 42%, respectively. Conclusions. In a contemporary series, giant bullectomy is shown to produce significant immediate functional improvement. This benefit declines with time but persists at least 3 years. (Ann Thorac Surg 2004;78:976 82) 2004 by The Society of Thoracic Surgeons Emphysema is an abnormal enlargement of the air spaces distal to the terminal nonrespiratory bronchioles that arises from the destruction of the alveolar walls. A bulla is defined as an air-filled space 1 cm or greater in diameter within the lung parenchyma that forms as a result of this destructive process. Rarely, one or more bullae enlarge to such a degree that they occupy more than one third of the hemithorax. The term giant bulla is then applied. These easily distensible reservoirs are preferentially filled during inspiration, causing the collapse of adjacent, more normal, lung parenchyma [1 3]. Because of the alveolar destruction, bullae lack any meaningful alveolar capillary interface and the thoracic volume they occupy is wasted. The resulting hyperinflation of the chest interferes with normal respiratory mechanics, increasing the work of breathing with associated exercise limitation and dyspnea. Surgical treatment of giant bullae by using two-stage Accepted for publication April 1, Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13 15, Address reprint requests to Dr Meyers, One Barnes-Jewish Plaza, 3108 Queeny Tower, St. Louis, MO 63110; meyersb@msnotes. wustl.edu. endocavitary aspiration (Monaldi procedure) [4, 5], onestage endocavitary aspiration [6], one-stage endocavitary aspiration with sclerosis and pleurodesis (Brompton technique) [7], plication [8], bullectomy, or lobectomy [9 16] can improve patient symptoms. Many large series that reported results after surgical treatment of giant bullae are now several decades old and may not reflect current treatment or results. A literature review published in 1996 cited 22 studies from 1951 to 1992 that reported on a total of 476 patients, highlighting the rarity of giant bullae [17]. We review here our recent experience and intermediate-term follow-up after the resection of giant bullae. Patients and Methods Patients Since 1993, we have maintained a prospective database on all patients undergoing surgery for emphysema. The onset of this data collection effort was stimulated by the interest generated by our lung volume reduction surgery (LVRS) program. The database includes pulmonary function testing, exercise testing, and quality-of-life measurements. Data were collected preoperatively and postoper by The Society of Thoracic Surgeons /04/$30.00 Published by Elsevier Inc doi: /j.athoracsur

2 Ann Thorac Surg SCHIPPER ET AL 2004;78: RESECTION OF GIANT EMPHYSEMATOUS BULLAE 977 atively at 6 months, 1 year, and yearly intervals thereafter whenever possible. Although nearly all of the patients in the database had LVRS procedures, 43 giant bullectomies were recorded between March 1994 and June Mean follow-up was 4.5 years (range 20 days to 9.4 years). The selection criteria for giant bullectomy have been reviewed elsewhere [18] and include hyperexpansion of the chest on computed tomographic (CT) scan or chest roentgenogram, compromised pulmonary function as assessed by pulmonary function testing, disability measured by 6-minute walk testing, and evidence on the CT scan of underlying, relatively normal, underinflated lung. Bullectomy candidates in our program are preoperatively evaluated and medically optimized using the same approach as described for LVRS patients. Preoperative evaluation includes a physical examination, pulmonary function testing, arterial blood gas analysis (measured at rest while breathing room air), 6-minute walk testing, and the completion of questionnaires assessing quality of life and dyspnea. Forty-one of the 43 patients selected for bullectomy were enrolled in a pulmonary rehabilitation program lasting 6 to 8 weeks. One of the two patients not undergoing pulmonary rehabilitation presented when ventilator dependent. The second completed the initial evaluation but became acutely short of breath to such a dramatic degree that a bullectomy was performed urgently. Patients were reassessed after pulmonary rehabilitation, typically during the week before the planned surgery. This reevaluation included an interval history, physical examination, pulmonary function testing, arterial blood gas, 6-minute walk test, and dyspnea and quality-of-life questionnaires. The postrehabilitation, preoperative data were used as the baseline for comparisons with postoperative data. Pulmonary function tests were performed with a Medgraphics System 1085 (Medical Graphics Corp., St. Paul, MN) before and after aerosolized albuterol, and the best values for forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV 1 ) were chosen for the data analysis. Lung volumes were determined by plethysmography. Diffusion capacity for carbon monoxide (Dlco) was measured by the single-breath technique. During the 6-minute walk test, supplemental oxygen was administered by nasal cannula as needed to maintain the arterial oxygen saturation at 90% or better. Dyspnea was evaluated with the Medical Research Council of Great Britain Dyspnea Scale [19]. The scale has 5 integer grades, 0 through 4, which describe the level of activity provoking dyspnea. A 1-point change is considered clinically important. We report patients as better, worse, or no change at each time interval compared with their preoperative baseline score. Quality of life was assessed by using the physical functioning domain of the Medical Outcomes study 36- Item Short-Form Health Survey [20]. The questionnaire is scored on a scale of 100, with 0 being the worst, 50 the median, and 100 the best. erative evaluation included pulmonary function testing, room air arterial blood gases, 6-minute walk testing, and dyspnea and quality-of-life questionnaires. Surgical Technique The procedure was done with a median sternotomy in 25 patients, unilateral thoracotomy in 17, and video-assisted thoracic surgery in 1. Five patients underwent additional procedures concomitant with the bullectomy. Two patients underwent LVRS with their giant bullectomy one right upper lobe giant bullectomy and left upper lobe LVRS, one right middle lobe giant bullectomy and right lower lobe LVRS. One patient underwent talc pleurodesis, 1 had mechanical pleural abrasion, and 1 had a Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) patch repair of a chronic diaphragmatic rupture as well as a lower lobe decortication. Forty-one patients underwent a nonanatomic resection and 2 patients an anatomic lobectomy. The nonanatomic resections were right sided in 10 patients, left sided in 9 patients, and bilateral in 22 patients. Of the bilateral resections, 17 were bilateral upper lobe bullectomies, and 1 was a bilateral lower lobe bullectomy. The remaining 4 combined a left upper lobe bullectomy with a right bilobe bullectomy. The anatomic resections were both right upper lobectomies. Bullectomies and LVRS were done with successive applications of a buttressed stapler. Twenty-four of 43 patients (54%) underwent a pleural tent procedure. If a median sternotomy was used, the mediastinal pleura was closed and two chest tubes per side were brought out in a subxiphoid position. Forty-one of 43 patients (95%) were extubated in the operating room. erative Management erative pain relief was achieved with a thoracic epidural placed under fluoroscopic guidance and positioned in the midline at the level of the fourth thoracic vertebral body. erative care was provided on a thoracic step-down unit. Early and vigorous chest physiotherapy and ambulation were performed. One of two types of mini-tracheostomy catheters (Cook Cricothyrotomy Catheter, Cook Inc., Bloomington, IN and Portex Mini-Trach Cricothyrotomy Kit, Portex Inc., Keene, NH) was used for secretion management in 3 patients. The decision to place a mini-tracheostomy was subjective, based on the thickness and volume of secretions seen on preoperative bronchoscopy as well as the patient s anticipated or subsequent ability to clear those secretions. Statistical Analysis Descriptive statistics are expressed as mean standard deviation unless otherwise specified. Categorical data are expressed as counts and proportions. Comparisons were done with paired, two-tailed t tests for means of normally distributed continuous variables and the Wilcoxon ranksum test for skewed data. 2 or the Fischer exact test were used to analyze differences in proportions among the categorical data. Kaplan-Meier estimate was used to depict survival.

3 978 SCHIPPER ET AL Ann Thorac Surg RESECTION OF GIANT EMPHYSEMATOUS BULLAE 2004;78: Table 1. Demographic Data of Patients Operated On for Giant Bullae Characteristic Frequency (n 43) No. % Gender Female 5 (12%) Male 38 (88%) Race Caucasian 35 (81%) African-American 7 (16%) Hispanic 1 (2%) Smoker 43 (100%) Pack years (Range pack years) Results Baseline The mean age at surgery was years. All 43 patients had smoked tobacco products: 42 (98%) were cigarette smokers, 1 (2%) was a pipe smoker. Forty of the 43 patients (95%) had quit for at least 1 month at the time of surgery. One of the 43 patients (2%) had -1 antitrypsin deficiency, 1 patient (2%) was ventilator-dependent at the time of surgery, and 1 (2%) patient underwent an urgent operation. Baseline characteristics are shown in Table 1. Hospital Course There was one early death on postoperative day 20 of heparin-induced thrombocytopenia, left subclavian vein thrombosis, and multiple pulmonary emboli. The hospital mortality was 2.3% (1/43). Mean length of stay was days (range 4 to 31 days). Thirty-four of the 43 patients (79%) suffered nonfatal complications. The most common complication was prolonged air leak ( 7 days) in 23 patients (53%). Seven patients were discharged home with a chest tube and a Heimlich valve. One patient underwent talc pleurodeses to correct the air leak. The remaining air leaks resolved during the hospital stay, without the need for pleurodesis or Heimlich valves. There were no reoperations for repair of an air leak. Four patients required mechanical ventilation after the procedure. Two patients remained intubated after the operation and 2 were extubated and subsequently reintubated, one on the first postoperative evening and one on postoperative day 7. Of the 2 patients remaining intubated from the operating room, 1 had been preoperatively ventilator dependent for more than a month. Three of these 4 patients were successfully extubated; the fourth was the only hospital mortality. Other complications are shown in Table 2. Some patients had more than one complication. Follow-Up The mean follow-up was 4.5 years (range 20 days to 9.4 years). At 3 years, follow-up was 93% complete; 2 of 28 Table 2. erative Complications Event Frequency (n 43) No. % Prolonged air leak ( 7 days) 23 (53%) Heimlich valve at discharge 7 (16.2%) Talc pleurodesis 1 (2.3%) Atrial fibrillation 5 (11.6%) Mechanical ventilation 4 (9.3%) Remained intubated from OR 2 (4.7%) Reintubated 2 (4.7%) Massive subcutaneous emphysema 3 (7.0%) Mini-tracheostomy for secretion 3 (7.0%) retention Hemothorax 3 (7.0%) Pneumonia 2 (4.7%) DVT 1 (2.3%) Reoperation for bleeding 1 (2.3%) C. difficile colitis 1 (2.3%) Methemoglobinemia 1 (2.3%) Heparin-induced thrombocytopenia 1 (2.3%) Seizure 1 (2.3%) Ileus 1 (2.3%) DVT deep vein thrombosis. evaluable patients (7%) were known to be alive but were lost to pulmonary function testing. Kaplan-Meier survival at 1 year was 98%, 3 years, 92%; and 5 years, 89%. Figure 1 shows survival after procedure. Four late deaths occurred at 1.4, 2.8, 3.5, and 5.9 years. Three of these deaths were from pneumonia and one was from idiopathic pulmonary fibrosis. Functional Results The results of pulmonary function testing and the 6-minute walk test are shown in Table 3. From baseline evaluation to postpulmonary rehabilitation no significant change occurred in FEV 1, residual volume, or Dlco. However, 6-minute walk distance increased significantly postpulmonary rehabilitation. At 6 months postoperatively, FEV 1 significantly improved, from a mean of l (34% of predicted) to l (55% of predicted) Fig 1. Kaplan-Meier survival after giant bullectomy.

4 Table 3. Pulmonary Function and Exercise Test Results Before and After Surgery Evaluation Baseline Post-Rehabilitation 6 Months 1 Year 2 Years 3 Years N Days from surgery Mean SD FEV 1 L (% Predicted) (32%) a (34%) (55%) c (55%) c (53%) c (49%) c RV L (% Predicted) (268%) a (262%) (154%) c (140%) c (199%) b (209%) a Dlco ml/min/mm Hg a c c b b Six-Minute Walk (ft) c c c a a a p 0.05 for paired analyses with postrehabilitation scores. b p 0.05 for paired analyses with postrehabilitation scores. c p 0.05 for paired analyses with postrehabilitation scores. FEV 1 Forced expiration volume in 1 second; RV residual volume; Dlco diffusion capacity for carbon monoxide. Table 4. Alveolar Gas Exchange and Oxygen Supplementation Requirements Before and After Surgery Evaluation Baseline Post-Rehabilitation 6 Months N Paco 2 (mm Hg) a Pao 2 (mm Hg) Supplemental Oxygen Used continuously (% of patients) 36% 42% 9% 7% 15% 21% Used during exercise (% of patients) 70% 73% 37% 39% 33% 42% a Pao 2 measured on room air at rest. Paco 2 partial pressure of carbon dioxide in the arterial blood, Pao 2 partial pressure of oxygen in the arterial blood. 1 Year 2 Years 3 Years Ann Thorac Surg SCHIPPER ET AL 2004;78: RESECTION OF GIANT EMPHYSEMATOUS BULLAE 979

5 980 SCHIPPER ET AL Ann Thorac Surg RESECTION OF GIANT EMPHYSEMATOUS BULLAE 2004;78: Fig 2. Modified Medical Research Council Dyspnea Scale respondent s score change after surgery. (p 0.001). At 6 months, 86% of patients experienced an improved FEV 1. At 3 years, the mean FEV 1 of l (49% of predicted) remained significantly improved over baseline (p 0.001). At 3 years, 83% of patients continued to have an improved FEV 1. At 6 months, the mean residual volume of l (154% of predicted) was significantly reduced from the baseline value of (262% of predicted) (p 0.001). This improvement persisted at 2 years, but by 3 years the residual volume of (209% of predicted) was not significantly different from base line (p 0.05). At 6 months, 1 year, and 3 years, 82%, 83%, and 67% of patients, respectively, had improved residual volumes. The 6-minute walk distance also improved from a postpulmonary rehabilitation baseline of feet to feet at 1 year. By the second and third years, the 6-minute walk distance was not significantly different from the postrehabilitation distance. Arterial blood gas values and supplemental oxygen use are detailed in Table 4. Room air partial pressure of carbon dioxide and oxygen were not different before or after pulmonary rehabilitation, but showed modest improvement during the postoperative follow-up period. Supplemental oxygen requirements at rest and during exercise were reduced at all follow-up times, with some patients returning to increased oxygen use during rest and exercise at 3 years. Medical Research Council dyspnea scores are shown in Figure 2. At 6 months postoperatively, 86% of patients Fig 3. The SF-36 Physical Functioning (PF) Scale scores from before bullectomy (Baseline) and after surgery. reported relief from dyspnea, 10% reported no change, and 4% reported worse dyspnea. By 3 years, 81% still reported improved dyspnea, 11% described no change, and 8% thought their dyspnea was now worse. Health related quality of life as measured by the SF-36 Physical Functioning Scale showed marked improvement from a baseline preoperative score of 27.8 to a 6-month postoperative score of At 6 months, 83% of patients reported an improved quality of life. This improvement persisted to 3 years. The SF-36 Physical Functioning Score is detailed in Figure 3. Comment In 1949 Jerome Head and Edward Avery [5] reported 9 patients with giant bullae treated with endocavitary drainage in the manner of Monaldi [4]. In 8 of these 9 patients, they were able to largely eliminate the bullae, reexpand underlying relatively normal lung, and produce symptomatic improvement. Several authors have since reported on the use of surgery to treat this disease. In 1974 FitzGerald and colleagues reported the largest series to date [10]. They performed 95 procedures in 84 patients with bullous emphysema. Sixty-nine of these procedures were bullectomies. The FitzGerald series reported an operative mortality of 2.1% and a mean follow-up of 7.3 years. They noted that resection of unilateral bullae occupying greater than 70% of the hemithorax produced a doubling of the FEV 1 at 1 year that was sustained at 5 years but declined over the next 5 to 10 years. Patients with bullae of less than 30% of the hemithorax showed no improvement, or even a worsening of the FEV 1. Pearson and colleagues reported a series of 11 patients undergoing bullectomy or lobectomy for giant bullae. One patient died, for an operative mortality of 7.7%. They noted significant early (3- to 6-month) improvement in FEV 1, FVC, and dyspnea, but by 5 to 10 years, only FVC remained significantly improved. FEV 1 and dyspnea grade had declined to no different than preoperative values [12]. The most recent series to include giant bullectomy, by Nickoladze, reported on 46 patients, 18 with bullae of more than 30% of the hemithorax, 16 with bullae less than 30% of the hemithorax operated on for recurrent spontaneous pneumothorax, and 12 with bullae less than 30% of the hemithorax associated with chronic pneumonia. Contrary to previous authors, Nikoladze found no immediate improvement in FEV 1 in patients treated surgically for giant bullectomy, although a trend toward improvement was found at 5 years [16]. The other 2 groups, patients treated for small bullae with and without associated chronic pneumonia, had a worse FEV 1 postoperatively and no significant change from preoperative status at 5 years. Since the inception of the LVRS program at Barnes- Jewish Hospital, more than 800 patients have been evaluated on site for potential emphysema surgery. Fortythree of these patients were found to have giant bullae fitting previously published criteria for giant bullectomy

6 Ann Thorac Surg SCHIPPER ET AL 2004;78: RESECTION OF GIANT EMPHYSEMATOUS BULLAE 981 [18]. Because of the established expectation of improvement in this group, they were not included in the previously reported LVRS series from this institution [21]. Our complete hospital mortality of 2.3% is low and consistent with the mortalities ranging from 0% to 9% reported by other authors [5, 7, 9 16]. As noted by previous authors, we found significant improvements over the postrehabiliation/presurgery base line for FEV 1, residual volume, and Dlco. These improvements declined with time but remained significantly better, in part, at 3 years. In addition, after bullae resection, we noted decreased oxygen use at rest and during exercise. Patients did return to oxygen use over time, but the percentage of patients using oxygen at 3 years after surgery remained well below those requiring oxygen preoperatively. Although preoperative pulmonary rehabilitation was not commonly employed by other authors, it gave us an opportunity to optimally manage these patients bullous emphysema, maximize exercise capacity, and improve pulmonary toilet. The design of this study was not able to evaluate the value of undergoing pulmonary rehabilitation versus not. We do, however, believe pulmonary rehabilitation increases the patient s ability to tolerate the operation and facilitates postoperative recovery. Our most frequent complication was air leak, occurring in half the patients. We approach air leaks initially with prevention. Carefully placed buttressed staple lines are used to perform the bullectomy. Because giant bullae can occupy a large volume of the hemithorax with the underlying lung not able to refill this space, we have a low threshold for creating a pleural tent. eratively, the chest tubes are placed on water-seal, no suction. If the air leak persists, a Heimlich valve is placed to decrease further the resistance to expelling a pneumothorax and the barotrauma on the remaining lung. We are very reluctant to return to the operating room for an air leak, believing that reoperations create more leaks than are repaired. If after 6 to 8 weeks the leak persists, we will consider a thoracoscopic procedure, talc pleurodesis, or if not previously performed, a pleural tent. For unknown reasons the pattern of emphysematous destruction varies considerably from patient to patient or even from one region of the lung to another. Proximal acinar (centrilobular) emphysema is often times more diffuse, associated with smoking, and has often caused wider spread lung destruction by the time it causes symptoms. Distal acinar (paraseptal) emphysema more severely involves the cortex, sparing the central portions of the lung. Distal acinar emphysema is associated with the development of giant bullae, which can compromise lung function substantially while much relatively normal lung is still present. Patients suitable for LVRS are those with heterogenous disease having target areas for resection, which is most commonly associated with centrilobular emphysema. Giant bullae, with relatively normal but collapsed adjacent lung, may represent the most heterogenous end of a spectrum of disease. Traditionally, giant bullectomy has been performed to alleviate the collapse of underlying, normal lung tissue. On the other hand, the primary benefit of LVRS has been attributed to the reduction of thoracic hyperinflation and improvement in respiratory mechanics. It is probable that both mechanisms are at work after giant bullectomy. Furthermore, the adjacent, compressed lung may not be normal at all, but just relatively less diseased than the bullae. The patients with this condition have varying severity of emphysema in the remaining lung. This is evidenced by the measurable airflow obstruction in the remaining lung after giant bullectomy. In the long-term follow-up of our series, patients showed a progressive decline in FEV 1, an increase in residual volume, and decline in the 6-minute walk test, which is typical for emphysema and suggests that the lung remaining after bullectomy is not normal. Both Pearson and FitzGerald showed a similar decline between 5 and 10 years in FEV 1. [10, 12] Even with criteria defining giant bullae, the quality of the underlying lung can make it problematic to define which patients are undergoing bullectomy versus LVRS. In 2 of our patients, giant bullectomies were done concomitantly with lung volume reduction on the ipsilateral and contralateral lung. A second limitation of this study is that it represents a longitudinal analysis of a shrinking cohort of observable patients. It has been shown by Butler and colleagues that patients lacking follow-up data are more likely to have a poor result [22]. It may be that a component of the observed sustained improvement is due to a loss to follow-up of the sicker (less improved) patients. However, as previously noted, our follow-up at 3 years was 93% complete. We do not believe this limitation has a great impact on our data. In conclusion, in a contemporary series, giant bullectomy is shown to produce significant immediate functional improvement. This benefit declines with time but persists at least 3 years. References 1. Morgan MDL, Edward CW, Morris J, Matthews HR. Origin and behaviour of emphysematous bullae. Thorax 1989;44: Ting EY, Klopstock R, Lyons HA. Mechanical properties of pulmonary cysts and bullae. Am Rev Respir Dis 1963;87: Pride NB, Hugh-Jones P, O Brien EN, Smith LA. Changes in lung function following the surgical treatment of bullous emphysema. Q J Med 1970;36: Monaldi V. Endocavitary aspiration: its practical applications. Tubercle 1947;November: Head JR, Avery EE. Intracavitary suction (Monaldi) in the treatment of emphysematous bullae, and blebs. J Thorac Surg 1949;18: MacArthur AM, Fountain SW. Intracavitary suction and drainage in the treatment of emphysematous bullae. Thorax 1977;32: Shah SS, Goldstraw P. Surgical treatment of bullous emphysema: experience with the Brompton technique. Ann Thorac Surg 1994;58: Benfield JR, Cree FM, Pellett JR, Barbee R, Mendenhall JT, Hickey RC. Current approach to the surgical management of emphysema. Arch Surg 1966;93: Wesley JR, Macleod WM, Mullard KS. Evaluation of surgery

7 982 SCHIPPER ET AL Ann Thorac Surg RESECTION OF GIANT EMPHYSEMATOUS BULLAE 2004;78: of bullous emphysema. J Thorac Cardiovasc Surg 1972;63: FitzGerald MX, Keelan PJ, Cugell DW, Gaensler EA. Longterm results of surgery for bullous emphysema. J Thorac Cardiovasc Surg 1974;68: Potgieter PD, Benatar SR, Hewitson RP, Ferguson AD. Surgical treatment of bullous lung disease. Thorax 1981;36: Pearson MG, Ogilvie C. Surgical treatment of emphysematous bullae: late outcome. Thorax 1983;38: Laros CD, Gelissne HJ, Bergstein PGM, et al. Bullectomy for giant bullae in emphysema. J Thorac Cardiovasc Surg 1986; 91: Morgan MDL, Denison DM, Strickland B. Value of computed tomography for selecting patients with bullous lung disease for surgery. Thorax 1986;41: Connolly JE, Wilson A. The current status of surgery for bullous emphysema. J Thorac Cardiovasc Surg 1989;97: Nickoladze GD. Functional results of surgery for bullous emphysema. Chest 1992;101: Snider GL. Reduction pneumoplasty for giant bullous emphysema implications for surgical treatment of nonbullous emphysema. Chest 1996;109: Gaensler EA, Jederlinic PJ, FitzGerald MX. Patient work-up for bullectomy. J Thorac Imag 1986;1: American Thoracic Society. Surveillance for respiratory hazards in the occupational setting. Am Rev Respir Dis 1982; 126: Ware J Jr, Sherbourne C. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;20: Ciccone AM, Meyers BF, Guthrie TJ, et al. Long-term outcome of bilateral lung volume reduction in 250 consecutive patients with emphysema. J Thorac Cardiovasc Surg 2003; 125: Butler CW, Snyder M, Wood DE, Curtis R, Albert RK, Benditt JO. Underestimation of mortality following lung volume reduction surgery resulting from incomplete followup. Chest 2001;119: DISCUSSION DR DANIEL L. MILLER (Atlanta, GA): I enjoyed your presentation. The majority of the time when we think of giant bullectomy, we usually think of a unilateral procedure, but because of your experience with lung volume reduction, most of your cases were bilateral. Did you look at the difference in overall quality of life and pulmonary function between the bilateral procedure and the unilateral procedure? You had a very high air leak rate of 53% with the use of bovine pericardial strips. Would you comment please on the reason for that high leak rate? DR SCHIPPER: On the first question, we did not compare the bilateral to the unilateral procedures looking at quality of life. I do not have that data available. Regarding the second question, at Washington University, a giant bullectomy generally generates more paranoia about air leak than lung volume reduction. The resected bullae tend to occupy a larger volume of the chest than what we resect during a lung volume reduction. They can fill 50% to 70% of the hemithorax. After you resect the bullae, you potentially end up with volume issues. It is for this reason that we do pleural tent procedures more often. When using a median sternotomy, the medial parietal pleura is reapproximated to separate the left and right hemithorax, potentially containing a unilateral air leak to one side. And I would point out that even though we did have a fairly significant leak rate, this leak rate was similar to that in the lung volume reduction population, and almost all the leaks got better, eventually. DR JOHN BENFIELD (Los Angeles, CA): Dr Schipper, this is a very nice paper that recalls a video titled Pulmonary Bullectomy With Selective Bronchial Occlusion that we showed at the American College of Surgeons Clinical Congress in October, Unfortunately I never wrote a paper about this approach, but I have had about two decades of experience with it and can assure you that it lessens the prolonged air leak problem. Sometime essentially all the leaking stops abruptly as the segmental or subsegmental bronchial branch that feeds a bulla is tied. DR SCHIPPER: Thank you.