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 [Figure 2A]. Bullectomy was done with two 60 mm Endo-GIA (Gastro-Intestinal Anastomosis) linear endoscopic stapling devices (Covidien®, Norwalk, CT, USA) without extra suture reinforcement [Figure 2B and C]. Subsequently an extensive stripping of the parietal pleura was carried out [Figure 2D].
Anatomopathologic examination of the pleural wall of the giant bulla showed signs of chronic inflammatory infiltrates without any malignancy.
The lung expanded well and the pleural cavity was drained with two chest tubes (thoracic drainage systems Pleur-evac) connected to a water seal under 10 cm H20 suction. No air leak was noted, tubes were removed on second post-operative day.
Patient developed a bronchopneumonia of the right lower lobe, which was treated with intravenous antibiotics and quickly resolved. After five days the patient could leave the hospital in a good general condition.
Three months later the patient was free of complaints. Auscultation and spirometry were perfectly normal. No restrictive syndrome was observed with FEV1 of 78% (reversible), FVC of 82% and normal lung volumes.
Chest radiography showed good expansion of the left lung without pneumothorax or residual pleural effusion [Figure 3]. The patient ceased tobacco consumption since surgery, supported by Vareniciline (Champix®, Pfizer, New York, USA). One year follow-up revealed no recurrence, no intercostal pain syndrome and preserved pulmonary function.