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J Thorac Cardiovasc Surg 2009;137:249-251
© 2009 The American Association for Thoracic Surgery

Brief Communication

Video-assisted thoracoscopic bullectomy for an infectious giant bulla with the concomitant use of the perioperative intracavity fluid suction

^a Operating Room Division, Tottori University Hospital, Yonago, Japan
^b Division of General Thoracic Surgery, Tottori University Hospital, Yonago, Japan

Received for publication January 29, 2008; revisions received February 14, 2008; accepted for publication February 22, 2008.

^_* Address for reprints: Yuji Taniguchi, MD, Division of General Thoracic Surgery, Tottori University Hospital, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504 Japan. (Email: kuichi{at}med.tottori-u.ac.jp).

Bullectomy by video-assisted thoracoscopic surgery (VATS) is an effective treatment for giant bullae.¹ However, once an infection comorbidly develops in a bulla, a bullectomy is not easy to perform. We completed a VATS bullectomy with excellent vision by perioperatively inserting a balloon catheter into the bullae and aspirating the fluid contents therein.

Clinical Summary

A 69-year-old man who had received follow-up for bilateral giant bullae had a temperature of 39.0°C to 40.0°C, and a small amount of fluid was detected in the giant bulla on the right ( Figure 1, A). He was admitted to our hospital because of infectious giant bulla on the right side.

View larger version (86K): [in this window] [in a new window]   Figure 1. A, Chest x-ray film at the time of hospitalization. B, Chest x-ray film before surgery.

The operation was performed in the lateral decubitus position with the patient under general anesthesia. We used a double-lumen endobronchial tube with protection of the contralateral lung from infectious fluid. First, a trocor (Thoracoport, Norwalk, Conn) was inserted at the midaxillary line in the sixth intercostal space. Observations with a thoracoscope showed the anterior side of the thoracic cavity to be occupied by a thickened white bulla wall, a large portion of which had adhered to the chest wall. The adhesion was dissected from the chest wall to the fourth rib, and a trocor was inserted at the midaxillary line in the fourth intercostal space. About 5 mm of the bulla wall was resected using a radio knife inserted through the trocor. A 12F balloon catheter (Biocath Foley Catheter; C. R. Bard Inc, Murray Hill, NJ) was immediately inserted into the bulla through this orifice, and the balloon was inflated to aspirate the content fluid of the bulla. After 750 mL of fluid was aspirated, the bulla shrank significantly, providing better vision. The bulla was easily dissected from the chest wall without the fluid contents flowing into the thoracic cavity. Thereafter, the catheter was not removed, and the bulla was resected with an endoscopic staple while the bulla was raised ( Figure 2). The operation lasted 3 hours 14 minutes, and the amount of perioperative bleeding was 100 mL. The postoperative course was excellent, with a decrease in fever, and the patient was discharged on day 11 after the operation.

View larger version (127K): [in this window] [in a new window]   Figure 2. The bulla was resected with a balloon catheter inserted into the bulla while the bulla was raised.

For an infectious giant bulla, the administration of an antibiotic often becomes the initial choice of treatment. The reasons are that postoperative thoracic empyema or postoperative pneumonia may occur with surgery, and treatment with an antibiotic can reduce a bulla size.² It is also believed that the bulla size decreases because it is not connected to the bronchus.³

On the basis of this theory, Nomori and associates⁴ reported that an excellent result can be obtained by simply opening an infectious giant bulla without resection by VATS. However, there is also a report in which an infectious giant bulla that was not connected to the bronchus has been observed to reconnect during the follow-up.² Therefore, the risk of a future occurrence of pneumothorax or thoracic empyema cannot be ruled out with an opening of an infectious bulla. We therefore believe a bullectomy is desirable as a surgical remedy for infectious bullae.

Reports in which preoperative percutaneous intracavity suction was performed on giant bullae with no infection, followed by bullectomy on another day, are occasionally seen.⁵ However, there are few reported cases in which intracavity suction therapy is performed for infectious giant bullae. We speculate that the reason thereof is the avoidance of empyema or pneumothorax after preoperative catheter insertion in a case without adhesion to the chest wall.⁴ In the present case, the perioperative finding showed adhesion of the bulla wall to the chest wall. This concurs with the report by Nomori and associates,⁴ stating that infectious giant bullae adhere to the chest wall. Therefore, the insertion of a catheter immediately after minimal dissection from the chest wall of adhesion prevents intracavity fluid from flowing into the thoracic cavity. Moreover, the insertion of a balloon catheter enables raising of the bulla after suction to ensure excellent vision, which facilitates resection.

It is believed that a VATS bullectomy, less invasive than thoracotomy, using a balloon catheter can thus be an effective surgical procedure for cystic lesions in the thoracic cavity as well as for infectious giant bullae. However, in a complicated case such as chronic inflammation or malignancy, VATS should be converted to thoracotomy.

References

1. Divisi D, Battaglia C, Francescantonio WD, Torresini G, Crisci R. Giant bullous emphysema resection by VATS. Analysis of laser and stapler techniques. Eur J Cardiothorac Surg 2002;22:990-994.[Abstract/Free Full Text]
   
2. Nonaka M, Kadokura M, Kataoka D, Yamamoto S, Tanio N, Iyano K, et al. Surgically treated infectious giant bulla (in Japanese with English abstract). Jpn J Thorac Surg 2000;53:880-882.
   
3. Stone DJ, Schwartz A, Feltman JA. Bullous emphysema: a long-term study of the natural history and the effects of therapy. Am Rev Respir Dis 1960;82:493-507.
   
4. Nomori H, Horio H, Fuyuno G, Kobayashi R, Morinaga S, Suemasu K. Opening of infectious giant bulla with use of video-assisted thoracoscopic surgery. Chest 1997;112:1670-1673.[Abstract/Free Full Text]
   
5. Verma RK, Nishiki M, Mukai M, Fujii T, Kuranishi F, Yoshioka S, et al. Intracavitary drainage procedure for giant bullae in compromised patients. Hiroshima J Med Sci 1991;40:115-118.[Medline]
   

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