Bullectomy for giant bullae

INTRODUCTION — Giant bullae occupy at least 30 percent of a hemithorax (image 1) and may be surrounded by normal lung tissue or accompanied by a number of smaller adjacent bullae [1-4]. Bullectomy involves the surgical removal of one or more giant bullae to improve symptoms and respiratory function in patients with bullous emphysema [5,6].

The indications and contraindications for bullectomy, as well as the perioperative management and operative technique of bullectomy will be reviewed here. The evaluation and medical management of giant bullae in patients with chronic obstructive pulmonary disease (COPD) and the roles of lung volume reduction surgery and lung transplantation in the management of advanced COPD are discussed separately. (See "Chronic obstructive pulmonary disease: Diagnosis and staging" and "Stable COPD: Initial pharmacologic management" and "Evaluation and medical management of giant bullae" and "Lung volume reduction surgery in COPD" and "Lung transplantation: General guidelines for recipient selection".)

DEFINITION — A bulla is defined as an air space in the lung measuring more than one centimeter in diameter in the distended state; the term giant bulla is used for bullae that occupy at least 30 percent of a hemithorax (image 1) [1-4]. A single giant bulla may be surrounded by normal lung tissue or may be accompanied by a number of smaller adjacent bullae.

PATIENT SELECTION

Potential benefits — Randomized trials of giant bullectomy have not been performed; however, observations from case series suggest that resection of giant bullae in carefully selected patients is associated with symptomatic and functional improvements lasting for five or more years in 60 to 90 percent of patients [2,3,6-13].

In an observational cohort study of 41 consecutive patients, significant improvements were noted in dyspnea, lung volumes, forced expiratory volume in one second (FEV₁), and the FEV₁/forced vital capacity (FVC) ratio over baseline and persisted for two years following bullectomy [2]. At five years following surgery, these parameters remained improved compared to prebullectomy values, although the degree of improvement had declined. Patients with diffuse emphysema deteriorated faster than patients without diffuse emphysema.

A review of 22 published case series of bullectomy for giant bullae noted that hypoxemia was more likely to improve compared with spirometric parameters or diffusing capacity (DLCO) [6]. Patients with radiographic evidence of compressed lung were most to likely experience improved oxygenation, whereas patients with radiographically diffuse emphysema, a low DLCO, or hypercapnia were less likely to improve, although the exact degree of improvement was not described.

The degree of improvement in the arterial tension of oxygen (PaO₂) reported in a separate series of 43 patients was modest (approximately 8 mmHg) [8]. However, the proportion of patients requiring supplemental oxygen decreased from 42 percent before to 9 percent one year after bullectomy [8]. Over the next three years, there was a gradual increase in the percent requiring continuous oxygen up to 21 percent.

Improvements in exercise tolerance following giant bullectomy were noted in other case series [3,8]. In a series of 12 patients, improvements were noted in aerobic exercise capacity and dynamic inspiratory capacity (ie, a decrease in dynamic hyperinflation) relative to baseline values [3]. A modest reduction in the partial arterial pressure of carbon dioxide (mean of 43 to 40 mmHg) was noted in one series, although the improvement was no longer present at three years [8]. (See "Dynamic hyperinflation in patients with COPD".)

The physiologic mechanisms by which resection of a giant bulla is thought to improve lung function include [6,7,14]:

●Reducing the size mismatching between the hyperinflated lungs and the chest cavity can restore the outward circumferential pull on the bronchioles, thus improving expiratory airflow and decreasing air trapping

●Removing the space occupying effect of the bulla and reducing air trapping help to restore the diaphragm to a more domed shape, which is more efficient

●Reinflation of compressed areas decreases the physiologic dead space that was caused by compression of normal lung by the inflated bulla and improves matching of ventilation and perfusion

●Reducing airway resistance, air trapping, and physiologic dead space decreases the work of breathing

The rationale of lung volume reduction surgery in diffuse bullous emphysema is discussed separately. (See "Lung volume reduction surgery in COPD", section on 'Rationale of LVRS'.)

Indications — The most common indications for bullectomy are:

●Severe dyspnea due to a giant bulla (ie, occupying approximately 30 percent or more of the hemithorax) that is refractory to medications and pulmonary rehabilitation.

●Spontaneous secondary pneumothorax [2,3,15]. Patients who present with a spontaneous secondary pneumothorax associated with a giant bulla have a high rate of recurrent pneumothorax and generally require pleurodesis even if a bullectomy is not indicated, such as a patient with diffuse bullous emphysema. (See "Treatment of secondary spontaneous pneumothorax in adults".)

●Mediastinal shift and/or herniation due to a giant bulla have been mentioned as additional clinical indications, although outcomes data are lacking [2].

An important challenge for the clinician is to select the patient for bullectomy who can benefit the most with the lowest morbidity and mortality. One factor that suggests that bullectomy may be particularly beneficial is a bulla that occupies greater than approximately 30 percent of the hemithorax [6,9,15]. Radiographic evidence that the bulla is compressing adjacent normal (rather than emphysematous) pulmonary parenchyma (ie, radiographic signs of atelectasis or adjacent vascular crowding) is also a favorable factor [6]. Other specific characteristics in favor of bullectomy are described in the table (table 1).

Limited information is available regarding the use of pulmonary function test (PFT) parameters to guide the decision to perform bullectomy [16]. The majority of patients who undergo bullectomy have a forced expiratory volume in one second (FEV₁) that is below 80 percent predicted, but greater than or equal to 40 percent predicted [2]. In a series of 18 patients, a better clinical response to bullectomy was noted in those with an FEV₁ greater than 40 percent predicted [17]. In contrast, the mean FEV₁ in a series of 43 patients who benefited from bullectomy was 34 percent predicted [8], and the median FEV₁ was 26 percent in a more recent series [18], suggesting that this criterion is not absolute in otherwise carefully selected patients.

In general, patients who will benefit from bullectomy have PFT evidence of air trapping (eg, total lung capacity [TLC] >100 percent predicted, residual volume [RV] >150 percent predicted) [2,8].

The difference in lung volume measurements obtained by the body plethysmography and helium dilution techniques can be compared to estimate the volume of nonventilated lung. A larger nonventilated volume suggests that the patient is likely to derive greater benefit from bullectomy. Chest computed tomography (CT) scanning provides a direct visual assessment of the extent to which normal lung is compressed by bullae and complements the physiologic measures. (See "Overview of pulmonary function testing in adults", section on 'Lung volumes'.)

Contraindications — Contraindications or unfavorable conditions for bullectomy include the following, among others (table 1):

●Ongoing cigarette smoking

●Significant comorbid disease

●Poorly defined bullae on chest imaging

●Pulmonary hypertension

●Comorbid conditions that make the surgical risk prohibitive (eg, heart failure, unstable coronary artery disease).

As no randomized trials of bullectomy have been performed, most of the contraindications derive from case series and experience with lung volume reduction surgery. (See "Lung volume reduction surgery in COPD".)

Age over 50 has been associated with increased morbidity and mortality in some older studies [5,19]. However, in a series of 41 patients undergoing bullectomy, patients up to age 77 were included [2]. No increase in risk was associated with older age, although results were not stratified based on age. In a separate series of 43 patients, the mean age was 56, and age was not a risk factor for mortality [8]. Thus, we now view age over 60 as a less favorable feature, but not a contraindication.

A markedly reduced forced expiratory volume in one second (FEV₁) (eg, less than 500 mL or less than 40 percent of predicted) is associated with an increased risk for perioperative morbidity and mortality [7,14,20] in some, but not all, series [18]. Hypercapnia and cor pulmonale are also associated with markedly increased risk and are considered relative contraindications [6,9,14,20]. As an example, significant cor pulmonale was associated with 33 percent mortality in one report [20].

A diffusing capacity for carbon monoxide (DLCO) less than 40 percent predicted is considered a contraindication to bullectomy, as it suggests a greater degree of diffuse underlying emphysema and is associated with a greater likelihood of postoperative air leaks and a poor outcome [21]. A cohort study of 63 patients suggested that presence of underlying emphysema was not associated with lesser symptomatic response [18]. (See "Evaluation and medical management of giant bullae", section on 'Pulmonary function tests'.)

In the systematic review of giant bullectomy, patients with chronic sputum production or frequent lung infections were less likely to improve than those without these clinical characteristics [6].

PREOPERATIVE EVALUATION AND PREPARATION — Much of the preoperative evaluation for bullectomy (eg, arterial blood gases, pulmonary function tests, radiographic imaging) is performed while determining whether the patient fits the indications and contraindications for bullectomy. The details of this evaluation are described separately. (See "Evaluation and medical management of giant bullae" and 'Indications' above.)

Medical optimization — Patients with giant bullae who are referred for bullectomy typically have a baseline degree of respiratory insufficiency and are at increased risk for perioperative complications. Current cigarette smokers should be advised to stop smoking. (See "Overview of smoking cessation management in adults" and "Pharmacotherapy for smoking cessation in adults" and "Behavioral approaches to smoking cessation".)

Underlying COPD should be treated aggressively with an appropriate combination of an inhaled glucocorticoid, long-acting anticholinergic agent, and long-acting beta-agonist to achieve the best possible baseline level of function. Inhaled agents are normally administered the morning of surgery. Inhaled bronchodilator agents (eg, ipratropium and albuterol) can be delivered through the circuit of the ventilator during surgery, as needed. For the rare patient using theophylline, this medication is discontinued the evening before surgery as it interacts with many of the drugs used perioperatively. (See "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Perioperative medication management'.)

Baseline pulse oximetry values and requirement for supplemental oxygen should be noted.

Preoperative assessment for coronary artery disease is prudent given the increased risk among patients with COPD. Uncontrolled coronary heart disease would be a contraindication to bullectomy. Cardiac testing typically includes an electrocardiogram and should include an echocardiogram to assess pulmonary artery pressures and left ventricular function, as these patients are at increased risk for cor pulmonale. Right-sided cardiac catheterization is usually performed in patients with elevated pulmonary artery pressures by echocardiogram or clinical evidence of cor pulmonale. (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Pulmonary hypertension due to lung disease and/or hypoxemia (group 3 pulmonary hypertension): Epidemiology, pathogenesis, and diagnostic evaluation in adults".)

Pulmonary imaging — If the radiographic evaluation that identified the giant bulla(e) was performed more than six months previously, a repeat CT scan is usually obtained to exclude any new pulmonary pathology (eg, pulmonary nodules, pleural disease). (See "Evaluation and medical management of giant bullae", section on 'Imaging'.)

Laboratory studies — Baseline laboratory studies obtained prior to bullectomy generally include a complete blood count, electrolytes, blood urea nitrogen, creatinine, and arterial blood gases.

Prophylactic antibiotics — Antimicrobial prophylaxis for wound infections is administered within 60 minutes prior to the skin incision, following guidelines for noncardiac thoracic surgery. The choice of antimicrobial therapy is discussed separately. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Thoracic surgery'.)

Venous thromboembolism prophylaxis — Given the nature of the surgical procedure and the affected patient population, venous thromboembolism prophylaxis should follow usual guidelines, as described separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

Preoperative pulmonary rehabilitation — Although the absence of systematically collected data limit conclusions, several investigative groups advocate the preoperative use of pulmonary rehabilitation [8,18].

ANESTHESIA — Bullectomy is typically performed under general anesthesia. Intravenous agents are typically used for induction of anesthesia, as severe bullous disease may make the uptake and distribution of inhalational agents unpredictable [22]. Short-acting rather than longer-acting anesthetic agents are used to enable early extubation. A thoracic epidural catheter is usually placed for administration of epidural anesthetic agents during and/or after surgery whether the procedure is performed via thoracotomy or video-assisted thoracoscopy. (See "Evaluation of perioperative pulmonary risk", section on 'General anesthesia versus neuraxial or regional anesthesia' and "Anesthesia for patients with chronic obstructive pulmonary disease".)

After induction of anesthesia, appropriate positioning, and sterile draping, a double-lumen endotracheal tube (or other endotracheal tube that will allow isolation of ventilation to one lung) is placed to administer one lung ventilation to the nonoperative lung and to enable deflation of the operative lung [22]. For patients with bilateral giant bullae, deeper advancement of the bronchial cuff of the double lumen tube can achieve bilateral upper lobar blockade along with single lung isolation, avoiding hyperinflation of bullae on the nonoperative side [23]. Once the bulla has been excised, the clamp or bronchial blocker is removed from that side of the endotracheal tube, and mechanical ventilation is resumed to the deflated lung. A gradual reinflation is preferred to aggressive efforts at reinflation. The technique of one lung ventilation for lung resectional surgery is discussed separately. (See "Lung isolation techniques" and "One lung ventilation: General principles".)

Standard monitoring during the procedure includes blood pressure, pulse oximetry, capnography, core temperature, and continuous electrocardiography. Arterial and central venous pressure monitoring are frequent, but not universal [22].

OPEN VERSUS THORACOSCOPIC APPROACH — Either an open or a video-assisted thoracoscopic approach may be appropriate depending on patient and institution specific factors. Traditionally, a thoracotomy was preferred for bullectomy; however, thoracic surgeons are performing an increasing number of procedures via video-assisted thoracoscopy as a first line approach (picture 1) [4,8,24,25]. (See "Overview of minimally invasive thoracic surgery".)

The data in support of using VATS for bullectomy come from case series of elective resection of giant bullae and resection of a giant bulla in the management of a secondary spontaneous pneumothorax [26-30]. Some series have included patients with very limited lung function who have traditionally been considered at high risk for thoracotomy [29]. VATS is a less invasive procedure than open thoracotomy and has been used in conjunction with staplers, electrocautery, laser, and combinations of these techniques [26-31]. (See 'Techniques' below.)

When an open thoracotomy is performed, the posterolateral approach is generally used for unilateral bullous disease, while median sternotomy may be used for resection of bilateral bullae [8].

OPERATIVE TECHNIQUE — Once the giant bulla has been accessed, the next several steps include deciding how much of the lung adjacent to the bulla to remove, whether to use an automatic stapler or other method of resection, and how to reduce or prevent air leaks.

Extent of surgery — A key decision for the surgeon is determining the amount of lung to resect in addition to the main bulla, as patients frequently have adjacent smaller bullae. This decision involves balancing removal of diseased tissue to optimize reexpansion of compressed tissue, avoiding resection of healthy lung tissue, and achieving a suture line that is least likely to have prolonged air leakage.

The specific characteristics of the bulla influence the decision regarding the amount of lung tissue adjacent to the giant bulla to be removed [6,15]. For the rare single bulla that is well-demarcated and has a clear, narrow pedicle, a simple stapled nonanatomic resection is typically performed. When the bulla is broad based or when numerous bullae are in close proximity and merge indistinctly, a broad nonanatomic stapled wedge resection is usually necessary.

Lobectomy and segmentectomy (resection of an anatomic lung segment (figure 1)) are used less commonly, as they generally involve resection of a greater amount of lung tissue and are associated with less favorable outcomes [3,6,8,19]. However, when a lobe is nearly completely replaced by bullous disease and the lobar fissures are well-formed, a lobectomy may be performed rather than a simple bullectomy to reduce the likelihood and severity of postoperative air leakage [19].

Techniques — Ablation or excision of giant bulla(e) is most commonly achieved by stapler excision, but can also be achieved by other surgical methods, such as plication and laser or talc ablation.

●Staple excision – The most common method resects the bulla using an automatic stapler, which may or may not be buttressed with material (natural, synthetic) to help reduce the incidence of air leak. (See 'Strategies to reduce air leak' below.)

The initial step is to compress the lung along the line of the proposed incision, using a standard lung clamp or similar instrument [32]. After compression of the lung, an automatic stapler is advanced and fired, dividing the tissue.

●Plication – Plication involves sewing tucks or folds into the bulla to obliterate the air space and is occasionally used for bullae that are on a narrow pedicle of lung tissue [15].

●Ablation techniques – Investigational techniques to ablate a giant bulla via video-assisted thoracoscopic surgery (VATS) have included the use of laser, radiofrequency energy, and other methods to destroy or shrink the bullae. None of these has been successful enough for widespread use [26-30].

An experimental technique using saline-cooled radiofrequency coagulation was used in two patients to shrink the wall of the bulla under thoracoscopic guidance [33]. Radiofrequency coagulation enabled gradual reduction in the size of the bulla and clear delineation of the border between the bulla and underlying lung. Further study of this technique is needed before widespread adoption.

●Modified Monaldi procedure – The modified Monaldi procedure, or the Brompton technique, consists of a limited thoracotomy to identify the bulla, insufflate it with talc, and drain it for several days with a Foley catheter under water seal to collapse the bulla [7,34-36]. Talc is also instilled into the pleural cavity to achieve pleurodesis. This approach has been suggested for patients with poor respiratory reserve [36].

At the end of the procedure, the operated lung is inspected for air leaks and bleeding. Two chest tubes are placed in the pleural cavity, one apical and one basal and the pleura and chest wall are closed in standard fashion [32].

Strategies to reduce air leak — A common complication of bullectomy is air leak, which prolongs chest tube duration, increases the likelihood of associated infection, and increases the length of hospital stay. Several techniques have been developed to reduce postoperative air leak. These techniques include buttressing the staple line with natural or synthetic materials, applying fibrin sealant (also known as fibrin "glue") to areas of air leak intraoperatively, and creating a "pleural tent".

●When stapler excision of a bulla is performed, the staple line may be buttressed with bovine pericardial strips and/or other materials (eg, polytetrafluoroethylene strips) to reduce the incidence of postoperative air leaks. Buttressing is particularly important when the underlying lung is fragile and emphysematous. In a randomized trial of 1414 patients undergoing bullectomy for primary spontaneous pneumothorax, staple line coverage with absorbable cellulose mesh and fibrin glue was compared with mechanical abrasion of the parietal pleura; no difference was noted in the proportion of patients experiencing air leakage >5 days [37]. Whether this applies to giant bullectomy is unclear. A cohort series of nine patients undergoing VATS bullectomy and mechanical pleurodesis noted a prolonged air leak in only one patient [38]. A retrospective cohort study compared differing methods of buttressing in 112 patients undergoing thoracoscopic bullectomy for primary spontaneous pneumothorax [39]. There was no significant difference in perioperative outcomes; however, the postoperative recurrence rate was significantly higher for the oxidized regenerated cellulose mesh compared with polyglycolic acid sheet group (22.8 versus 3.6 percent).

●For patients with visible air leakage after resection of a giant bulla, application of fibrin sealant to the staple line may reduce the severity of the air leak, although data assessing this technique are limited [40,41]. (See "Overview of topical hemostatic agents and tissue adhesives".)

●A pleural tent is a surgical technique designed to reduce the size of the pleural cavity and enable apposition between the stapled surface of the lung and the chest wall, usually in the case of upper lobectomy [8]. To create a pleural tent, the parietal pleura is dissected free from the chest wall and tailored to make a tent (or cap) to cover the divided surface of the lung [42].

POSTOPERATIVE CARE AND FOLLOW-UP — Postoperative management entails careful attention to respiratory status and pain control, treatment of bronchoconstriction, monitoring for development or worsening of a pneumothorax, and prevention of deep venous thrombosis and pulmonary embolism. A discussion of general postoperative management issues is provided separately. (See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Postoperative strategies'.)

Immediately postoperatively, patients are assessed for anemia due to excessive intraoperative blood loss, cardiac ischemia, electrolyte abnormalities, hypercapnia, hypoxemia, and inadequate lung reexpansion (eg, due to massive air leak associated with suboptimal function of chest tubes). If these factors are all acceptable, the patient can be extubated. The majority of patients are extubated in the operating room to minimize the duration of positive pressure ventilation [32].

Nebulized bronchodilator therapy is administered every four to six hours, but may be increased to every one to two hours for patients with increased cough, wheeze, or dyspnea. Nebulizer treatments are continued for 24 to 48 hours and then transitioned back to the patient's usual regimen. (See "Overview of the management of postoperative pulmonary complications", section on 'Bronchospasm'.)

Due to the high proportion of patients with air leaks, careful attention to the proper function of the chest tubes is key to prevent development of a pneumothorax and consequent respiratory insufficiency. Brief kinking or blockage of a chest tube can lead to rapid accumulation of a pneumothorax and cardiopulmonary decompensation. A chest radiograph is obtained daily to confirm full lung re-expansion. Chest tubes are generally left in place until the lung is fully re-expanded, and there is no evidence of air leak. However, some patients with slow air leaks may be transitioned to a mini chest tube with a unidirectional flutter valve (ie, Heimlich valve) to enable discharge prior to complete resolution of the air leak. The procedure for chest tube removal is described separately. (See "Thoracostomy tubes and catheters: Management and removal" and "Alveolopleural fistula and prolonged air leak in adults".)

Management of postoperative pain usually involves a combination of regional and systemic agents to enable early mobilization of the patient and effective cough [32]. (See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Postoperative strategies' and "Approach to the management of acute pain in adults".)

Postextubation respiratory insufficiency can result from bronchoconstriction from the underlying COPD, atelectasis, pneumothorax, pneumonia, or hypoventilation due to postoperative pain or analgesic medication. For awake patients with a rising PaCO₂ despite prompt attention to these factors, noninvasive positive pressure ventilation may be used to avoid re-intubation. (See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications".)

Prevention of deep venous thrombosis and pulmonary embolism is discussed separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

PERIOPERATIVE MORBIDITY AND MORTALITY

Mortality — The perioperative mortality reported in case series of bullectomy for giant bulla(e) ranges from 0 to 7 percent for bullectomy via open thoracotomy [2,3,8]. In these series, patients with diffuse emphysema had a higher mortality rate than those with relatively normal lung parenchyma aside from the giant bulla(e). As an example, in a series of 41 patients undergoing bullectomy, the first year mortality rate of 7 percent was entirely attributable to patients with diffuse emphysema [2]. Causes of death include postoperative pneumonia, acute and chronic respiratory failure, pulmonary embolism, and myocardial infarction [6,8,26-28,30].

Complications — Prolonged air leakage is the most common complication following bullectomy, although the reported incidence varies [8]. In one series of 43 patients, air leakage for longer than seven days occurred in 53 percent [8]. In another series, prolonged air leak occurred in 7 percent [2]. The mean forced expiratory volume in one second (FEV₁) values for patients in the two series were 32 and 64 percent predicted, respectively, suggesting a greater degree of underlying diffuse emphysema in the first study. This may explain the difference in postoperative air leakage. A subsequent cohort series of 63 patients reported prolonged air leak in 30 percent [18].

Other complications include atrial fibrillation (12 percent), postoperative mechanical ventilation (9 percent), pneumonia (5 percent), and postoperative incisional pain [8].

USE OF BRONCHOSCOPIC TECHNIQUES — Bronchoscopic approaches have been used in a few patients with giant bullae who were not considered candidates for surgery. One technique, which was developed as a nonoperative method for lung volume reduction in emphysema, involves the placement of one-way endobronchial valves via bronchoscopy to deflate the bulla [43-50]. The success of this technique may depend on the amount of collateral ventilation between the bulla and adjacent lung [46]. One group has combined endobronchial valve placement with percutaneous bulla drainage in an urgent clinical setting [51]. Another technique uses transbronchoscopic needle aspiration and deflation of the giant bulla followed by instillation of autologous blood to prevent air leakage [52]. (See "Bronchoscopic treatment of emphysema", section on 'Endobronchial valves'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic obstructive pulmonary disease".)

SUMMARY AND RECOMMENDATIONS

●Definitions – A bulla is defined as an air space in the lung measuring more than one centimeter in diameter in the distended state; the term giant bulla is used for bullae that occupy at least 30 percent of a hemithorax. A single giant bulla may be present, or a giant bulla may be accompanied by a number of smaller adjacent bullae. (See 'Introduction' above.)

●Patients with persistent dyspnea – For selected patients with a giant bulla and persistent dyspnea despite optimal medical therapy and pulmonary rehabilitation, we suggest bullectomy (Grade 2B). Clinical and laboratory features that guide patient selection are presented in the table (table 1). The patient's values and preferences should be used to guide the decision. Patients who highly value a potential reduction in dyspnea and are willing to accept the risk of perioperative mortality may choose bullectomy over medical management, whereas others may not wish to accept the risk of perioperative mortality. (See 'Indications' above and 'Complications' above.)

●Patients with secondary spontaneous pneumothorax – For most patients with a giant bulla and a secondary spontaneous pneumothorax, we recommend video-assisted thoracoscopic surgery (VATS) with pleurodesis, due to the high risk of recurrent pneumothorax (Grade 1B). For patients with minimal surrounding diffuse emphysema, a bullectomy is typically performed at the time of pleurodesis. However, for patients with diffuse bullous emphysema, pleurodesis may be performed without bullectomy. (See 'Indications' above and "Treatment of secondary spontaneous pneumothorax in adults".)

●Contraindications – Contraindications for bullectomy include a bulla smaller than 30 percent of the hemithorax, cigarette smoking within the previous six months, advanced emphysema in the non-bullous adjacent lung, and significant comorbidities. Patient with upper lobe emphysema may be considered for lung volume reduction surgery. (See 'Contraindications' above and "Lung volume reduction surgery in COPD".)

●Open versus thoracoscopic approach – Both thoracotomy and video-assisted thoracoscopic surgery (VATS) approaches have been used in the resection or ablation of giant bullae. The choice between these approaches usually depends on the expertise and preference of the operating team. (See 'Open versus thoracoscopic approach' above.)

●Operative technique – The most frequently used operative technique for bullectomy is a broad stapled wedge resection along the border of the giant bulla, resecting as little normal or near normal adjacent tissue as possible. The staple line may be buttressed with bovine pericardial strips and/or other materials (eg, polytetrafluoroethylene strips) to reduce the incidence of postoperative air leaks. (See 'Operative technique' above.)

●Postoperative management – Postoperative management entails careful attention to respiratory status and pain control, treatment of bronchoconstriction, monitoring for development or worsening of a pneumothorax, and prevention of deep venous thrombosis and pulmonary embolism. (See 'Postoperative care and follow-up' above.)

●Perioperative morbidity – Postoperative complications include prolonged air leak, atrial fibrillation, postoperative mechanical ventilation, pneumonia, and postoperative incisional pain. Persistent air leak is the most common complication. (See 'Perioperative morbidity and mortality' above.)

●Perioperative mortality – Reported operative mortality ranges from 0 to 7 percent. Causes of death include postoperative pneumonia, acute and chronic respiratory failure, pulmonary embolism, and myocardial infarction. (See 'Perioperative morbidity and mortality' above.)