Awake Thoracoscopic Bullaplasty

Staple excision of emphysematous bullae through general anesthesia is the standard surgical treatment of bullous emphysema. We have developed a new surgical technique entailing thoracoscopic bullaplasty performed in fully awake patients through sole epidural anesthesia. Methods This prospective nonrandomized trial included 35 patients undergoing awake thoracoscopic bullaplasty between 2002 and 2009. Preoperative work-up included computed tomography with algorithm for quantitative measurement of the bulla volume. Outcome measures included technical feasibility and patient’s satisfaction with the anesthesia, scored into 4 grades (1=unsatisfactory;4=excellent); ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2), and postoperative assessment of standard clinical measures at 6, 12 and 36 months. Results There were 29 men and 6 women with a median age of 60 years. Median volume of the bulla was 688mL. Awake bullaplasty was successfully completed in 34 patients. Perioperatively, PaO2/FiAO2 decreased significantly (ANOVA,P<0.0001) though remaining satisfactory (>300mmHg) whereas PaCO2 increased intraoperatively (ANOVA, P<0.0001) but returned to baseline values 1h after surgery (P=0.20). There was no mortality while 4 patients had air leaks longer than 7 days. Mean hospital stay was 4.9±2.2 days. Comparisons between pre- to 6-month changes in outcome measures showed improvements (P<0.0001) in FEV1 (+0.37L), residual volume (-1.16L), dyspnea index (-2) and SMWT (+71m). These improvements lasted for up to 36 months and in no patient did operated bullae recur. Conclusion Our study suggests that awake thoracoscopic bullaplasty was well tolerated and easily performed in the majority of the patients and significant clinical improvements lasted for up to 36 months.