Surgical pathology of bullae with and without pneumothorax

Experience with 2030 patients admitted for an actual episode of spontaneous pneumothorax, and with 370 patients hospitalized for bullous emphysema is thoroughly analyzed. Out of these groups, 400 patients (318 and 82 respectively) underwent an open thoracotomy. Macroscopic operative findings were divided into 8 groups. Descriptions of the aspect, size and site of bullae, respiratory function, mortality and follow-up data, are presented. Pathogenesis of the localised apical disease in comparison to the extended and diffuse types is outlined. Attention is drawn to the high operative risk in generalized emphysema and airway obstruction when associated with tension bullae and/or pneumothorax. More than 30% of the patients could not be included in either the juvenile type, isolated apical disease, or in the category of bullae associated with generalized emphysema. Reasons for an early rupture of apical subpleural blebs and the high resistance to check valve pressure of bullae following alveolar disruption are discussed. The observations lead to the conclusion that surgical pathology and treatment problems in bullous emphysema and in spontaneous pneumothorax have a lot in common and their arbitrary separation is not justified.