The current status of surgery for bullous emphysema.

The great majority of cases of emphysema are generalized with diffuse involvement of all portions of the lung: Clearly, surgery has little to offer in such cases. In contrast, there is an uncommon variant involving primarily the upper lobes and the superior portions of the lingula and lower lobes, which spares the relatively normally functioning lower lobes. A number of diagnostic tests are available to identify compression of uninvolved lower lobe tissue, the most reliable of which identify pulmonary vasculature that is crowded together. We suggest that whole lung tomograms or pulmonary angiograms provide the most convincing evidence of compression of normal tissue. In properly selected patients with compression or displacement of normal lung, thoracotomy with simple excision of the bullae is tolerated by even the most ill patients if care is taken to carefully support the patient postoperatively with assisted ventilation and prolonged chest tube suction. There were no deaths in 19 patients and the results were rewarding, often spectacular, and surprisingly enduring. It is likely that some patients with operable bullous emphysema are not being studied or offered operation because of a lack of knowledge about the benefits possible with bullectomy.