Objectives There exists only limited historical guidance on patient selection for giant bullectomy in emphysema which is now 20-years-old (1). Operative mortality was reported at about 10%, and patients with FEV₁<50% predicted were excluded. Developments in video assisted thoracic surgery (VATS) and experience with lung volume reduction surgery have reduced our selection threshold. We have reviewed our results in the last decade and their implications for patient selection.

Methods Between June 1997 and November 2009, 55 patients (45 males:10 females; median age 61 years (range 39–76 years)) with significant dyspnoea associated with giant emphysematous bullae underwent surgery. Their median preoperative FEV₁ was 31% predicted (range 9–93%). Twenty nine patients had FEV₁<50%pred and fifteen <25%pred. Eight patients were in type I respiratory failure three patients had alpha-1-antitrypsin deficiency. All were cigarette smokers and four had significant cannabis use. In all patients there was evidence of hyperinflation and a bulla occupying >30% of the hemithorax. All operations were performed by stapled VATS bullectomy and in the high risk patients six operations were performed under sedation with spontaneous ventilation and two using intraoperative extracorporeal membrane oxygenation (ECMO).

Results Median hospital stay was 9 days (range 3–64 days). Prolonged air leak (lasting over 48 h) was observed in 21 patients (38%). Three patients (6%) required postoperative ventilation. 30-day mortality was 3.6% (two patients). One-year survival was 94.5% (52 patients). Symptomatic improvement in dyspnoea was reported in 73% patients.

Conclusions VATS bullectomy should be considered for symptom relief even in patients with severe airflow obstruction and borderline respiratory failure.