Surgical Treatment of Emphysematous Blebs and Bullae

¹ Division of Surgery, Mayo Clinic, Rochester, Minnesota.

The preceding cases are examples chosen from a number of similar cases that have come to my attention in recent years. As indicated, it was possible in some cases to obtain a satisfactory result by simple repair of a small surface defect; in others segmental resection, lobectomy or pneumonectomy was necessary. Before exploratory thoracotomy was performed, it was not possible in any case to determine the extent of operation that would be necessary. Since in some cases extensive pulmonary resection, even total pneumonectomy, is required, it is, of course, important to determine as accurately as possible the status of the opposite lung. The fact that these patients have been maintaining respiratory requirements with one lung, even in the presence of tension pneumothorax on the opposite side, is quite good evidence of the condition of the functioning lung. However, in some cases there may be blebs or bullae in the better lung. The most conservative surgical procedure possible should always be chosen since there is always some likelihood that the factors that have led to the development of the lesion for which operation is being performed may lead to the development of other blebs and bullae in the future. So far as we know at present this has not occurred in any of our patients as yet but the possibility must be recognized and as much functioning pulmonary tissue should be preserved as is possible under the circumstances of the individual case.

It is an interesting fact to me that these patients can have a huge air-filled cavity with bronchial communication and yet so rarely become infected. It is amazing that some of our patients have apparently gone three or four years with a complete and even a tension pneumothorax with open bronchial communication without development of a pleural infection. In some cases there may be a little clear pleural fluid; in others, none. In some instances it has been necessary to decorticate the lung before it would expand satisfactorily. In others re-expansion occurred readily when the defect was closed or the involved segment of lung was removed.

Pulmonary cysts of alveolar origin occur fairly commonly. They deserve more attention than they have received. They are not necessarily a part of a generalized pulmonary disease. They are the most frequent cause of spontaneous pneumothorax. In many instances they are amenable to corrective surgical measures with great benefit to the patient.