Video-assisted Thoracoscopic Resection of a Giant Bulla in Vanishing Lung Syndrome: case report and a short literature review

Journal of Cardiothoracic Surgery, Jan 2014

A 36-year-old Caucasian man was admitted to our hospital with acute onset of left-sided chest pain. Computed Tomography confirmed the presence of a giant bulla on the apex of the lower lobe of the left lung. A video-assisted thoracic surgery (VATS) with bullectomy was performed using two linear endostaplers. Additionally pleurectomy was performed. No serious complications occurred in the postoperative course, as the patient showed good lung re-expansion and no prolonged air leakage. VATS bullectomy is a suitable and eminent technique to approach giant bullous emphysema and definitely fulfils a role in its treatment.

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Video-assisted Thoracoscopic Resection of a Giant Bulla in Vanishing Lung Syndrome: case report and a short literature review

Journal of Cardiothoracic Surgery Video-assisted Thoracoscopic Resection of a Giant Bulla in Vanishing Lung Syndrome: case report and a short literature review Kobe Van Bael 0 Mark La Meir 0 Hans Vanoverbeke 0 0 Department of Cardiothoracic Surgery, ASZ Aalst , Merestraat 80, B-9300 Aalst , Belgium A 36-year-old Caucasian man was admitted to our hospital with acute onset of left-sided chest pain. Computed Tomography confirmed the presence of a giant bulla on the apex of the lower lobe of the left lung. A video-assisted thoracic surgery (VATS) with bullectomy was performed using two linear endostaplers. Additionally pleurectomy was performed. No serious complications occurred in the postoperative course, as the patient showed good lung re-expansion and no prolonged air leakage. VATS bullectomy is a suitable and eminent technique to approach giant bullous emphysema and definitely fulfils a role in its treatment. Giant bulla; Pulmonary emphysema; Vanishing lung syndrome; Thoracoscopic resection; Bullectomy; VATS - Background Giant bullous emphysema (GBE) involves the presence of emphysematous areas with complete destruction of lung tissue producing an airspace bigger than 1cm in diameter. An anatomical classification is made based on single or multiple bullae and the absence or presence of diffuse emphysema [1]. Obviously the bullous area does not participate in broncho-alveolar oxygenation and can cause dyspnoea, hypoxia, symptomatic chest pain or pressure, haemoptysis etc. It can result in spontaneous pneumothorax, pneumothorax provoked by mechanical ventilation, infection and even slow progression to malignancy. Some literature differentiates GBE from bullous emphysema where the latter has been associated with more diffusely abnormal lung tissue (in the context of chronic obstructive pulmonary disease) and where GBE has bullae with structural normal intervening lung parenchyma. GBE, sometimes referred to as Vanishing Lung Syndrome (VLS) as a clinical syndrome, was first described by Burke in a typical patient: a young male cigarette smoker with a large bullae in the upper lobe associated with paraseptal emphysema [2]. Roberts described radiographic criteria for this entity: the presence of a giant bullae in one or more upper lobes (mostly unilateral), often asymmetrical, occupying at least one-third of the hemithorax and compressing surrounding normal lung parenchyma [3]. High resolution computerized tomography (HRCT) is the best imaging technique to determine most accurately the extent and distribution of bullous disease. CT also allows assessment of coexisting problems such as bronchiectasis, co-infected cysts, pulmonary artery enlargement and pneumothorax [4,5]. Centrilobular emphysema is mostly seen on HRCT in cigarette smokers and can be of major importance pre-operatively. The condition has clearly been associated with smokers, alpha-1 antitrypsin deficiency and marijuana abuse [6]. Some reports also mention Marfan and Ehlers-Danlos syndrome as possible causes. Surgery is indicated to treat the complications related to GBE or on preventive basis when lesions occupy more than one third of the hemithorax, when there is a compression of healthy adjacent lung tissue and when size of a bulla shows to have been increased at follow-up. Generally resection of small bullae has no effect on lung function [7,8]. Also auto-bullectomy has been reported [9]. The case described below illustrates the successful approach of a bullectomy via VATS for GBE. Case presentation A 36-year-old Caucasian male patient was admitted to the emergency department with acute onset of left thoracic chest pain. The pain suddenly appeared without physical activity, cough or trauma. Medical history of this patient revealed a chronic low back pain, surgery for left epicondylitis lateralis humeri and no specific cardiovascular risk factors except for active smoking. Physical examination showed a man with diminished breath sounds on the left apex over the left anterior chest without palpable subcutaneous emphysema and with normal oxygen saturation. There were no other abnormal clinical findings. A routine chest X-ray was performed and suggested an apical pneumothorax on the left side, though HRCT showed a massive bulla of the left lung, with a 10 cm diameter, occupying the whole upper left hemithorax, with signs of centrilobular emphysema also on the right side [Figure 1A-C]. The initial arterial blood gas analysis without oxygen showed pH 7.38, pO2 94 mmHg, and pCO2 43 mmHg. Carboxyhemoglobine status was 6.4% and other blood results were normal. The patient underwent VATS with bullectomy. Surgery was performed under general anaesthesia with double lumen endotracheal intubation and discontinuing ventilation on the left side in half lateral position. Two 12 mm trocars and one 5 mm trocar were used. The giant bulla was located at the apex of the lower lobe with total compression of the left upper lobe and pleural irritation (...truncated)


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Kobe Van Bael, Mark La Meir, Hans Vanoverbeke. Video-assisted Thoracoscopic Resection of a Giant Bulla in Vanishing Lung Syndrome: case report and a short literature review, Journal of Cardiothoracic Surgery, 2014, pp. 4, 9, DOI: 10.1186/1749-8090-9-4