What Is a Bullectomy? Surgical Removal of Lung Bullae

Bullectomy is a surgical procedure that removes bullae, which are large air-filled sacs that form in damaged lung tissue, most often in people with emphysema. By cutting away these non-functional spaces, the operation allows compressed healthy lung to re-expand, and in well-selected patients the results can be dramatic: airflow improves by roughly a quarter to a third and breathlessness drops within weeks. The reality beneath that headline, though, is more layered than “remove the bulla, fix the lung,” because who benefits, how long the improvement lasts, and what can go wrong all depend on details that surgeons weigh carefully before recommending the operation.

How Bullae Form and Why They Matter

A bulla is not simply an air bubble that inflates inside the lung. Research suggests that bullae develop when surrounding lung tissue retracts and collapses away from a structurally weak region, leaving behind an over-distended, thin-walled sac that traps air but performs no gas exchange.¹ The trapped air takes up space in the chest without doing useful work, and the bulla presses on adjacent lung that could otherwise expand. Depending on size, a single bulla can occupy a third, a half, or even an entire side of the chest cavity. The bigger it gets, the more the healthy tissue next to it gets squeezed, making breathing progressively harder. Patients often describe a frustrating combination of being unable to take a deep breath and feeling that their lungs are overfull at the same time.

Who Benefits Most From the Operation

Not everyone with a bulla is a good candidate. Decades of surgical experience have identified a profile that predicts the best outcomes. Patients tend to do best when the bulla occupies more than a third of one side of the chest and the forced expiratory volume in one second (a common measure of how much air you can push out quickly) is less than half of what’s expected for someone of the same age and size.² Other favorable signs include a large amount of gas trapped in the bulla that can be removed, a reasonably preserved ability to transfer oxygen from air into blood, and normal carbon dioxide levels in the bloodstream. That last point matters because high baseline carbon dioxide often signals that the remaining lung is too damaged to compensate after surgery.

The logic is intuitive once you see it: the ideal patient has a big, useless air pocket compressing a meaningful amount of still-functional lung. Remove the pocket, and the good lung springs back. If the underlying lung is itself severely destroyed, taking out the bulla doesn’t give it anywhere useful to expand into.

Predicting Postoperative Improvement

Surgeons don’t rely on intuition alone. Preoperative pulmonary function testing has proven remarkably good at forecasting who will improve and who won’t. In one series evaluating patients with giant bullae, two measurements taken before surgery accurately predicted the postoperative outcome in all but one patient.³ Separately, a study tracking patients before and after bullectomy found a strong linear relationship between preoperative airflow and the airflow measured afterward, meaning surgeons could estimate how much improvement to expect from the prebullectomy numbers alone.⁴

High-resolution CT scanning is another essential piece of the puzzle. It maps the exact location, size, and number of bullae and shows whether they are unilateral or bilateral. In one series of patients prepared for bilateral bullectomy, all had apical bullae visible on both sides on preoperative scans, which guided the surgical approach.⁵ Taken together, CT imaging and breathing tests give the surgical team a reasonably clear picture of whether the operation is worth the risk for a given patient.

Open Surgery Versus Minimally Invasive Approaches

Bullectomy has traditionally been performed through a thoracotomy, a large incision that spreads the ribs apart for direct access to the lung. That approach remains necessary in certain cases, especially when the bulla is enormous or when complications arise. Over the past two decades, though, video-assisted thoracoscopic surgery (VATS) has become the more common route. VATS uses small incisions and a camera, which generally means less postoperative pain, shorter hospital stays, and faster recovery.

In a series comparing the two techniques for giant bullae, about 62% of procedures were completed thoracoscopically while the remainder required open thoracotomy.⁶ Complications occurred in both groups, including pneumonia in about 14% of patients overall and prolonged air leak in roughly 29%. The pneumonia cases were spread across both surgical approaches, which is a reminder that the underlying lung disease creates risk regardless of how the surgeon gains access.

Anesthesia in a Fragile Lung

One of the less appreciated challenges of bullectomy is keeping the patient safe while they are under anesthesia. The operation typically requires one-lung ventilation, where the anesthesiologist deflates the side being operated on so the surgeon has room to work, while the remaining lung handles all the breathing. In patients whose lung function is already severely impaired, that can be a precarious balancing act. A recent case report detailing management of a patient with stage IV COPD and bilateral giant bullae described an anesthetic plan that included pressure-controlled ventilation, acceptance of higher-than-normal carbon dioxide levels (so-called permissive hypercapnia), and backup measures including continuous positive airway pressure and pulmonary vein clamping in case oxygen levels dropped dangerously.⁷ These extreme-sounding contingencies are instructive: they illustrate that for patients at the sicker end of the spectrum, the anesthetic management is as critical as the surgery itself.

Why Staple Line Reinforcement Matters

When a bulla is removed, the remaining lung edge is sealed shut with surgical staples. That staple line is the most vulnerable spot for two problems: air leaking immediately after surgery, and new bullae forming at the staple site months or years later. Both issues have generated a significant amount of research into reinforcing the staple line with various materials.

Covering the staple line with an absorbable mesh has been shown to shorten the duration of postoperative chest drainage. In one comparison, patients whose staple lines were covered averaged one day of chest tube drainage versus three days in patients who had stapling alone, and prolonged air leaks lasting more than a week occurred only in the uncovered group.⁸ A separate study found that covering the staple line and surrounding tissue with a polyglycolic acid sheet significantly reduced the risk of recurrent pneumothorax: roughly 97% of covered patients stayed recurrence-free compared to about 84% without coverage.⁹ And when researchers compared fleece-coated fibrin glue, sprayed fibrin glue solution, and bare stapling, the recurrence rates were about 1%, 7%, and 10% respectively, a large spread that strongly favored the fleece-coated option.¹⁰

The concern about the staple line isn’t just theoretical. CT follow-up after bullectomy has shown that new bullae tend to form right at the staple site, and their presence there carries a dramatically higher risk of recurrence. In one study, patients who developed new bullae at the staple line had a hazard of recurrent pneumothorax more than 26 times higher than those who did not.¹¹ Separate pathological examinations have confirmed that even with an oxidized cellulose covering, bulla regeneration can occur underneath the thickened pleura at the staple line.¹² In short, reinforcement helps, but it does not eliminate the problem entirely.

What Happens Right After Surgery

The immediate postoperative gains in lung function are among the most satisfying results in thoracic surgery. In one study of bullectomy patients, the forced expiratory volume increased by about 29%, maximal inspiratory pressure rose by roughly 39%, and residual volume (the air stuck in the lungs after a full breath out) fell by about 30%.¹³ That drop in residual volume is key: it means the lungs are no longer hyperinflated, the diaphragm sits in a mechanically better position, and each breath becomes more efficient.

A population-based study found a similar pattern. Mean forced expiratory volume nearly doubled at one month after surgery for giant bullae, jumping from about 33% of predicted to roughly 58% of predicted.¹⁴ A series tracking 41 patients who underwent preoperative pulmonary rehabilitation showed improvement from about 34% predicted to 55% predicted at six months, alongside a steep drop in the need for supplemental oxygen. Before surgery, 42% of patients used continuous oxygen; at six months that had fallen to 9%.¹⁵ Quality-of-life measures and exercise tolerance, as measured by the six-minute walk test, also improved alongside these functional gains across multiple studies.¹⁶

How Long the Improvement Lasts

Here is where the picture becomes less cheerful. Because most bullectomy patients have underlying COPD or emphysema, the disease process that caused the bulla in the first place continues after surgery. One five-year follow-up found that airflow and lung-volume reductions remained significantly better than prebullectomy values through the fourth year, but from the third year onward the measurements began to slide back toward baseline.¹⁷ The dyspnea scores, though, stayed improved through all five years, suggesting that even as the numbers on a breathing test drifted downward, patients still felt meaningfully better than before the operation.

The population-based study mentioned earlier paints a starker long-term picture: forced expiratory volume eventually declined to near-baseline values at extended follow-up, although five-year survival was 100% and ten-year survival was 60%.¹⁸ Similarly, a retrospective analysis of bullectomy and lung volume reduction surgery found that clinical benefit gradually declined over 12 to 24 months, most likely due to COPD progression, although patients still had measurably better airflow than before surgery two years out.¹⁹

The takeaway is that bullectomy buys meaningful time and comfort, but it is not a cure for the underlying lung disease. How much time depends on how aggressively the emphysema progresses and how well the patient manages their condition after surgery.

Complications Worth Knowing About

The most common complication is a persistent air leak, meaning air continues escaping from the lung into the chest cavity through the surgical site for more than a week. In one large series covering bullectomy and lung volume reduction surgery, persistent air leak occurred in 60% of patients, making it essentially a frequent accompaniment to the surgery rather than a rare event.²⁰ Heart rhythm disturbances followed at about 52%, and air collecting under the skin (subcutaneous emphysema) occurred in about 22% of cases.

Risk factors for prolonged air leak have been studied specifically. A multivariable analysis identified patient age, overall health status, bilateral procedures, and the diameter of the bullae as independent predictors of a leak lasting more than a week.²¹ Postoperatively, the standard management involves a chest tube connected to drainage. One trial comparing vacuum-assisted drainage to non-vacuum drainage found no significant difference between the two approaches in terms of chest tube duration, air leak duration, or fluid volume drained.²² That finding suggests the choice between suction and water seal is less critical than surgeons sometimes debate.

Endobronchial Valves as a Nonsurgical Alternative

For patients too sick to undergo general anesthesia and surgery, a bronchoscopic approach using endobronchial valves has emerged as an alternative. These tiny one-way valves are placed through a scope into the airway feeding the bulla, blocking air from entering while allowing trapped air and mucus to drain out. Over weeks, the bulla deflates. In one case, a patient with diffuse emphysema and severely impaired lung function had a large bulla in the right middle lobe treated with Zephyr valves; CT scanning showed complete resolution of the bulla after about five weeks, and airflow improved by 30% at seven months.²³

A small case series treating five COPD patients with giant bullae via endobronchial valves tempered the enthusiasm somewhat. Only one of the five showed sustained improvement at six months, and the procedure seemed to work best when the bulla occupied a well-defined anatomical segment and there was no collateral ventilation between lung lobes allowing air to sneak around the valve.²⁴ Patient selection here is even more critical than for surgical bullectomy, and the technique remains reserved for highly selected cases.

Bullectomy in Children

Giant pulmonary bullae occasionally occur in children, though for different reasons than in adults. While adult bullae almost always arise from smoking-related emphysema, pediatric bullae can be congenital or follow infection. A report describing two pediatric cases illustrates the range of outcomes. One child had an uneventful bullectomy through a posterolateral thoracotomy and was discharged improved. The second, a 12-year-old girl with a giant multiseptated bulla that had caused two years of exertional breathlessness and significant weight loss, underwent the same approach, but the lung remained collapsed despite increased ventilatory pressure during surgery.²⁵ That second outcome underscores a risk particular to long-standing bullae in growing lungs: if the underlying lung has been compressed for years, it may not have the structural integrity to re-expand once the bulla is removed. The clinical stakes are high because children have decades of life ahead and limited options for lung transplant.

The Role of Pulmonary Rehabilitation

Surgery alone does not produce the best possible results. Preoperative pulmonary rehabilitation, a structured program of exercise training, breathing techniques, and education, is widely used to optimize patients before bullectomy. In the series of 41 patients who underwent rehabilitation before surgery, the six-minute walk distance at six months after the operation was about 13% higher than the preoperative value, and the proportion of patients needing supplemental oxygen during exercise dropped from 73% before surgery to 37%.²⁶ By three years, the walk distance had drifted back close to baseline and oxygen use had crept up to 42%, reflecting the gradual erosion of benefit noted in other studies. Even so, the rehabilitation investment appears to set patients up for a stronger recovery in those critical first months and years.