Functional outcomes after bullectomy in Group III bullous emphysema: a single-center 24-month follow-up study

Abstract

Background

Bullous emphysema is a distinct form of chronic obstructive pulmonary disease (COPD), characterized by the presence of large air-filled spaces that compress adjacent lung parenchyma and impair ventilation. Surgical resection of bullae (bullectomy) aims to restore lung expansion and improve respiratory function. The objective of this study was to evaluate functional outcomes following bullectomy in patients with Group III bullous emphysema according to the De Vries and Wolf classification by assessing pulmonary function, exercise capacity, and postoperative complications during a 24-month follow-up period.

Methods

This retrospective study included 38 patients who underwent bullectomy between 2008 and 2023. Demographic and clinical parameters, pulmonary function tests [forced vital capacity (FVC), forced expiratory volume in one second (FEV1), total lung capacity (TLC), residual volume (RV), diffusing capacity of the lung for carbon monoxide (DLCO)], 6-minute walk test (6MWT), and dyspnea score [modified Medical Research Council dyspnea scale (mMRC)] were assessed preoperatively and at 6, 12, and 24 months postoperatively. Postoperative complications were also recorded.

Results

The mean patient age was 47 years. Active smokers accounted for 55.2% of the cohort. A statistically and clinically meaningful improvement was observed in FEV1, FVC, 6MWT, and mMRC scores at all postoperative time points (P<0.001), while TLC and RV showed significant reductions. The most common complication was prolonged air leak (39.4%), followed by cardiac arrhythmias (28.9%). No mortality was observed.

Conclusions

Bullectomy was associated with significant improvements in functional parameters and quality of life during a 24-month follow-up period in carefully selected patients with Group III bullous emphysema.

Highlight box.

Key findings

• Bullectomy was associated with significant improvements in forced expiratory volume in one second, forced vital capacity, exercise capacity, and dyspnea during a 24-month follow-up period in patients with Group III bullous emphysema.

What is known and what is new?

• Surgical treatment of giant bullae is well established; however, evidence regarding patients with diffuse emphysematous changes remains limited.

• This study demonstrates sustained functional improvement during a 24-month follow-up in patients with Group III disease according to the De Vries and Wolf classification.

What is the implication, and what should change now?

• Carefully selected patients with Group III bullous emphysema may benefit from bullectomy despite underlying diffuse emphysema.

• Further prospective studies with larger cohorts and longer follow-up are required to confirm these findings.

Introduction

Bullous emphysema represents a specific morphological manifestation of chronic obstructive pulmonary disease (COPD), characterized by the formation of large air-filled spaces resulting from progressive destruction of alveolar structures. These bullae may occupy a considerable portion of the thoracic cavity, compress adjacent functional lung tissue, and significantly impair ventilation. The resulting mechanical disadvantage leads to reduced gas exchange efficiency, increased work of breathing, and progressive dyspnea, often accompanied by decreased exercise tolerance. In advanced cases, hyperinflation and diaphragmatic dysfunction further exacerbate respiratory compromise (1).

Surgical treatment, primarily bullectomy, aims to remove the bulla and enable re-expansion of the preserved lung tissue. This improves alveolar ventilation and reduces the mechanical inefficiency of breathing (2).

Although the presence of diffuse emphysema has historically been considered a relative contraindication, growing evidence suggests that selected patients may still derive significant benefit from surgical intervention.

The aim of this study was to evaluate the functional benefit of bullectomy in patients with Group III bullous emphysema according to the De Vries and Wolf classification, by assessing pulmonary function, exercise capacity and clinical outcomes during a 24-month follow-up period after the operation. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1214/rc).

Methods

Study design and population

This retrospective study included 38 consecutive patients who underwent bullectomy between 2008 and 2023.

All patients were classified as group III according to the De Vries and Wolf classification (3). Group III disease was defined as the presence of multiple bullae associated with moderately diffuse emphysematous changes.

Patient selection was based on radiological evidence of compression of adjacent functional lung parenchyma and clinically significant symptoms, including dyspnea and reduced exercise tolerance. This subgroup was selected because it represents a clinically challenging population in whom the role of bullectomy remains controversial. While the benefit of surgery is well established in patients with localized giant bullae, evidence regarding patients with associated diffuse emphysema is more limited.

Inclusion criteria were the presence of giant bullous emphysema classified as Group III according to the De Vries and Wolf classification predominantly involving the upper lobes and eligibility for elective surgical treatment. Baseline COPD severity was assessed according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria using preoperative spirometric parameters.

Exclusion criteria included secondary spontaneous pneumothorax requiring emergency intervention, active pulmonary infection, pulmonary malignancy, previous ipsilateral thoracic surgery, and incomplete preoperative functional assessment.

Demographic data, smoking status, and comorbidities were obtained from institutional medical records. Written informed consent was obtained from all patients. The study was approved by the Ethics Committee of the Faculty of Medicine, University of Belgrade (MFUB/25.02.2016. No. 29/II-21). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Preoperative assessment

All patients underwent a standardized preoperative evaluation, including pulmonary function testing [forced vital capacity (FVC), forced expiratory volume in one second (FEV₁), total lung capacity (TLC), residual volume (RV), diffusing capacity of the lung for carbon monoxide (DLCO)], chest computed tomography (CT), and ventilation/perfusion scintigraphy.

Preoperative pulmonary rehabilitation was performed in all patients and active smokers were required to stop smoking at least 4 weeks before surgery. Patients received antibiotic prophylaxis and further antibiotic therapy according to a standardized protocol.

Surgical technique

All procedures were performed through a minimal anterolateral thoracotomy. Although video-assisted thoracoscopic surgery (VATS) has become increasingly adopted in modern thoracic practice, this approach was not routinely implemented during the early years of the study period. In addition, the presence of large bullae, diffuse emphysematous changes, and anticipated smoking-related pleural adhesions favored an open approach, providing optimal exposure and operative control.

The procedure consisted of non-anatomical resection of bullous lesions with preservation of viable lung tissue. Resection was achieved using linear stapling devices, followed by reinforcement of the staple line with fibrin sealant to minimize postoperative air leakage. Staple-line reinforcement materials were not routinely used because of economic limitations.

Chest tubes were routinely placed at the end of the procedure and removed following cessation of air leak and radiographic confirmation of adequate lung expansion.

Postoperative management

All patients received standardized postoperative care, including respiratory physiotherapy, thromboprophylaxis, and antibiotic therapy when indicated.

Follow-up and outcome measures

Patients were evaluated preoperatively and at 6, 12, and 24 months postoperatively. Outcome measures included pulmonary function parameters, exercise capacity [6-minute walk test (6MWT)], dyspnea score [modified Medical Research Council dyspnea scale (mMRC)], postoperative complications, and mortality.

Statistical analysis

Statistical analysis was performed using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA). Normality of distribution was assessed using the Shapiro-Wilk test.

Continuous variables were presented as mean ± standard deviation or median (interquartile range), depending on data distribution. Categorical variables were expressed as frequencies and percentages.

Longitudinal changes over time were analyzed using repeated measures analysis of variance (ANOVA) or the Friedman test, as appropriate. Pairwise comparisons were performed using the paired Student’s t-test or Wilcoxon signed-rank test.

Comparisons between independent groups were conducted using the Student’s t-test or Mann-Whitney U test, while categorical variables were analyzed using the Chi-square test or Fisher’s exact test.

A P value <0.05 was considered statistically significant. No correction for multiple comparisons was applied.

Results

Patient characteristics

A total of 38 patients were included in the study. All 38 patients completed follow-up assessments at 6, 12, and 24 months. No patients were lost to follow-up and no missing outcome data were recorded during the study period. Patient selection and follow-up are summarized in Figure 1.

Figure 1.

STROBE flow diagram showing patient selection, follow-up, and inclusion in the final analysis. STROBE, STrengthening the Reporting of OBservational studies in Epidemiology.

Most patients were men aged 40–60 years, with active smokers representing the largest subgroup. The male gender was represented by 55.2% (21 patients), and the female gender by 44.8% (17 patients). The mean age was 47 years (range 34–62). Active smokers represented 55.2%, ex-smokers 28.9% and non-smokers 15.7%, which indicates pronounced smoking habits in our population (Table 1).

Table 1. Demographic characteristics of the respondents.

Clinical parameter	Number of patients (n=38)	Percentage (%)
Gender
Male	21	55.2
Female	17	44.8
Age (mean)	34–62 (47)
Smoke history
Active smokers	21	55.2
Ex-smokers	11	28.9
Non-smokers	6	15.7

In total, 44.8% of patients had significant comorbidities before surgery: 12 patients (31.5%) had cardiomyopathy [New York Heart Association (NYHA) class I, NYHA class II], 7 patients (18.4%) had arterial hypertension, and 4 patients (10.5%) had type II insulin-dependent diabetes mellitus.

Preoperative outcomes

Preoperatively, all patients underwent spirometry, diffusion capacity testing (DLCO), 6MWT and chest CT (Table 2)

Table 2. Preoperative respiratory function.

Clinical parameter	Bullectomy (n=38)
	Minimum	Maximum	Mean	Standard deviation
FVC (L)	2.68	4.42	3.81	0.37
FVC (%)	65	86	79.15	5.74
FEV1 (L)	1.89	2.71	2.19	0.18
FEV1 (%)	52	64	59.62	4.39
TLC (L)	4.93	7.21	5.64	0.75
TLC (%)	113	139	119.5	7.59
RV (L)	2.84	4.94	3.37	0.54
RV (%)	124	186	145.9	12.1
RV/TLC ratio	0.38	0.61	0.60	0.05
RV/TLC (% predicted)	116	139	129	7
DLCO (L)	5.1	6.9	5.89	0.36
DLCO (%)	56	74	64.5	3.8
6MWT (m)	340	442	396	27.4
Dyspnea (mMRC)	1	2	1.93	0.22
BMI (kg/m2)	17	28	24.05	3.15

6MWT, 6-minute walking test result; BMI, body mass index; DLCO, diffusing lung capacity of the lungs for carbon monoxide; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; mMRC, modified Medical Research Council dyspnea scale; RV, residual volume; TLC, total lung capacity.

In 95.6% of patients, the preoperative CT findings revealed bullous emphysema, which predominates in the upper lobes (stage III according to the De Vries and Wolff classification). Operated side: right 20 (52.6%), left 18 (47.4%).

Postoperative outcomes

The most common complication was air leakage (>7 days), observed in 39.4% of patients. Cardiac arrhythmias occurred in 28.9% of cases. No procedure-related mortality was recorded. Pneumonia and atelectasis were less frequent (13.1% and 10.5%).

No perioperative or late mortality was recorded.

The average duration of chest drainage was approximately between 8–11 days postoperatively and the mean length of hospital stay was approximately between 10–14 days.

Postoperative complications and postoperative hospitalization are shown in Tables 3,4.

Table 3. Postoperative complications.

Postoperative complication	Bullectomy (n=38)
Reoperation	0 (0.0)
Mechanical ventilation	0 (0.0)
Reintubation	0 (0.0)
Subcutaneous emphysema	7 (18.4)
Air leakage >7 days	15 (39.4)
Arrhythmia	11 (28.9)
Pneumonia	5 (13.1)
Atelectasis	4 (10.5)
Empyema	0 (0.0)
Mortality	0 (0.0)

Data are presented as number (%).

Table 4. Postoperative drainage and hospital stay.

Clinical parameter	Bullectomy (n=38)
Drain ex. postop day
Mean ± SD	8.2±3.1
Min–max	5–15
Hospitalization stay
Mean ± SD	10.3±4.3
Min–max	5–19

Drain ex. postop day: the mean amount of time until drain removal postoperatively; hospitalization stay: the mean number of days spent in hospital. max, maximum; min, minimum; SD, standard deviation.

Pulmonary function outcomes

Statistically and clinically meaningful improvements in pulmonary function were observed following surgery. FEV₁ and FVC increased significantly and remained stable over time at 6, 12, and 24 months compared to baseline (P<0.001).

Mean FEV₁ increased from 2.19±0.18 L preoperatively to 2.56±0.16 L at 6 months (P<0.001), 2.53±0.16 L at 12 months (P<0.001), and 2.45±0.17 L at 24 months (P=0.001). Mean FVC increased from 3.81±0.37 L preoperatively to 4.32±0.42 L at 6 months (P<0.001), 4.20±0.45 L at 12 months (P<0.001), and 4.05±0.47 L at 24 months (P=0.003).

TLC demonstrated a significant reduction throughout follow-up, indicating decreased hyperinflation and improved lung mechanics. RV decreased significantly at 6 and 12 months after surgery. Although RV remained lower than baseline at 24 months, the difference did not reach statistical significance (P=0.06).

DLCO showed no statistically significant changes throughout follow-up. Mean DLCO was 5.95±0.34 preoperatively, 6.02±0.43 at 6 months (P=0.41), 5.98±0.45 at 12 months (P=0.67), and 5.91±0.47 at 24 months (P=0.78). Likewise, DLCO percentage predicted remained stable during follow-up without statistically significant differences.

Our results show that mean FEV₁ increased by 370 mL at 6 months and by 340 mL at 12 months, corresponding to a 15–25% improvement over preoperative values.

The observed improvements were considered clinically meaningful. Temporal changes in pulmonary function parameters (FEV₁, FVC, TLC, and RV) are presented in Figure 2.

Figure 2.

Pulmonary function outcomes (FEV₁, FVC, TLC, RV). Error bars represent standard deviations. FEV₁, forced expiratory volume in one second; FVC, forced vital capacity; RV, residual volume; TLC, total lung capacity.

Functional capacity and symptoms

Exercise capacity improved significantly, with an increase in 6MWT distance of approximately 50–55 meters at follow-up assessments. Dyspnea severity, measured by the mMRC scale, decreased significantly after surgery and remained improved throughout the follow-up period. Changes in exercise capacity and dyspnea scores during follow-up are shown in Figures 3,4.

Figure 3.

Changes in exercise capacity (6MWT) during follow-up after bullectomy. Error bars represent standard deviations. 6MWT, 6-minute walk test; Pre-op, preoperative.

Figure 4.

Changes in dyspnea severity (mMRC score) during follow-up after bullectomy. Error bars represent standard deviations. mMRC, modified Medical Research Council dyspnea scale; Pre-op, preoperative.

Average body mass index (BMI) was the only parameter that did not change significantly 6 months after surgery but increased significantly after 24 months (from 24.05 to 26.03).

Long-term outcomes

After 12 and 24 months, the clinical benefit decreased, but most lung function parameters remained significantly improved from baseline (Tables 5-7).

Table 5. Clinical outcome 6 months after surgery.

Clinical parameter		Bullectomy (n=38)	P
FVC (L)	Pre	3.81 (0.37)	<0.001*
	Post	4.32 (0.42)
FEV1 (L)	Pre	2.19 (0.18)	<0.001*
	Post	2.56 (0.16)
TLC (L)	Pre	5.64 (0.75)	0.004*
	Post	4.89 (0.68)
RV (L)	Pre	3.37 (0.54)	0.006*
	Post	2.89 (0.46)
DLCO (L)	Pre	5.89 (0.36)	0.41
	Post	6.02 (0.43)
BMI (kg/m2)	Pre	24.05 (3.15)	0.35
	Post	25.21 (3.01)
6MWT (m)	Pre	396.27 (27.43)	<0.001*
	Post	448.27 (15.04)
Dyspnea (mMRC)	Pre	1.93 (0.22)	<0.001*
	Post	0.51 (0.50)

Data expressed as mean (SD). Pre, baseline; post, 6 months postoperatively. *, P<0.05 was considered statistically significant. 6MWT, 6-minute walking test result; BMI, body mass index; DLCO, diffusing lung capacity of the lungs for carbon monoxide; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; mMRC, modified Medical Research Council dyspnea scale; RV, residual volume; TLC, total lung capacity.

Table 6. Clinical outcome 12 months after surgery.

Clinical parameter		Bullectomy (n=38)	P
FVC (L)	Pre	3.81 (0.37)	<0.001*
	Post	4.20 (0.45)
FEV1 (L)	Pre	2.19 (0.18)	<0.001*
	Post	2.53 (0.16)
TLC (L)	Pre	5.64 (0.75)	0.003*
	Post	4.86 (0.71)
RV (L)	Pre	3.37 (0.54)	0.01*
	Post	2.87 (0.53)
DLCO (L)	Pre	5.89 (0.36)	0.67
	Post	5.98 (0.45)
BMI (kg/m2)	Pre	24.05 (3.15)	0.02*
	Post	25.85 (3.03)
6MWT (m)	Pre	396.27 (27.43)	<0.001*
	Post	448.95 (16.06)
Dyspnea (mMRC)	Pre	1.93 (0.22)	<0.001*
	Post	0.51 (0.50)

Data expressed as mean (SD). Pre, baseline; post, 12 months postoperatively. *, P<0.05 was considered statistically significant. 6MWT, 6-minute walking test result; BMI, body mass index; DLCO, diffusing lung capacity of the lungs for carbon monoxide; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; mMRC, modified Medical Research Council dyspnea scale; RV, residual volume; TLC, total lung capacity.

Table 7. Clinical outcome 24 months after surgery.

Clinical parameter		Bullectomy (n=38)	P
FVC (L)	Pre	3.81 (0.37)	0.003*
	Post	4.05 (0.47)
FEV1 (L)	Pre	2.19 (0.18)	0.001*
	Post	2.45 (0.17)
TLC (L)	Pre	5.64 (0.75)	0.005*
	Post	4.92 (0.52)
RV (L)	Pre	3.37 (0.54)	0.06
	Post	3.04 (0.51)
DLCO (L)	Pre	5.89 (0.36)	0.78
	Post	5.91 (0.47)
BMI (kg/m2)	Pre	24.05 (3.15)	0.001*
	Post	26.03 (2.92)
6MWT (m)	Pre	396.27 (27.43)	<0.001*
	Post	446.84 (21.17)
Dyspnea (mMRC)	Pre	1.93 (0.22)	<0.001*
	Post	0.51 (0.50)

Data expressed as mean (SD). Pre, baseline; post, 24 months postoperatively. *, P<0.05 was considered statistically significant. 6MWT, 6-minute walking test result; BMI, body mass index; DLCO, diffusing lung capacity of the lungs for carbon monoxide; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; mMRC, modified Medical Research Council dyspnea scale; RV, residual volume; TLC, total lung capacity.

A majority of patients (65.4%) reported improved quality of life at the end of follow-up.

Incident PH findings occurred in 3 patients (7.8%): Interstitial pneumonia in 2 patients and Pulmonary aspergilloma in 1 patient.

Discussion

Most previous studies indicate that the presence of diffuse emphysema worsens the reported benefits and increases morbidity (4). The present study demonstrates that bullectomy was associated with sustained clinical and functional improvements during the 24-month follow-up period in carefully selected patients with bullous emphysema, even in the presence of moderately diffuse disease.

Careful preoperative patient selection is important, particularly in patients with upper-lobe predominant bullous disease and whose FEV₁ exceeds 40% of the predicted value (5). In our series, 95.6% of patients had bullous changes of the upper lobes, which confirms that the anatomical localization significantly affects the postoperative outcome.

An important factor contributing to favorable outcomes in the present study was careful patient selection. The majority of patients demonstrated upper-lobe predominant disease with preserved surrounding lung parenchyma available for re-expansion following bullectomy. Furthermore, baseline DLCO values remained above levels generally associated with poor postoperative functional recovery, supporting the rationale for surgical intervention in this population.

Postoperative complications were within the expected range, the most common complication was prolonged air leak (>7 days) in 39.4% of patients. The rate of prolonged air leakage (39.4%) is in the middle range of published series (20–50%) (1).

Pneumonia is considered the second most common pulmonary complication. In our analysis, 13.1% of patients developed pneumonia. In our group, prophylactic antibiotic therapy began 1 hour before surgery and continued until the thoracic drains were removed.

Cardiac arrhythmias occurred in 28.9% of patients and were successfully managed with medical therapy alone. The incidence of major cardiovascular complications, including myocardial infarction and pulmonary embolism, was comparable to that reported after other thoracic surgical procedures.

Although postoperative complications were relatively common, particularly prolonged air leak and transient cardiac arrhythmias, these events were managed successfully using standard institutional protocols and no procedure-related mortality occurred. Therefore, postoperative morbidity should be carefully considered when evaluating the risk-benefit profile of bullectomy in this patient population.

The length of hospitalization (average ~10.3 days) is relatively favorable compared to earlier series that state a length of about 9–14 days depending on the technique (6).

In our series, no mortality was recorded in the immediate postoperative period, which is very favorable and in accordance with modern publications, which indicates a good selection of patients and adequate perioperative care (1,4,7).

Our patients demonstrated sustained improvements in FEV₁ and FVC, accompanied by reductions in hyperinflation (TLC and RV) and significant improvement in 6MWT performance.

As literature reviews point out, in large bullae that compress the surrounding lung parenchyma, the greatest benefits lie in reducing hyperinflation, tissue re-expansion and improving diaphragmatic function (8).

The increase in FEV1 and FVC by 0.3–0.4 L in the first 6 months after surgery (P<0.001) and the increase in 6MWT by about 50–55 meters coincide with the results reported in the literature (9-12).

The greatest increase in FEV₁ and FVC was recorded in the first 12 months, with a gradual stabilization after 2 years. In parallel, the decrease in TLC and RV indicates a decrease in hyperinflation and re-expansion of the functional parenchyma (4,8).

The decrease in TLC remained significant throughout follow-up, whereas RV demonstrated significant improvement during the first 12 months, with partial attenuation of benefit at 24 months. This finding is consistent with the progressive nature of diffuse emphysema and COPD, where ongoing parenchymal destruction may gradually reduce the initial functional gains achieved by surgery. The decrease in TLC and RV after bullectomy, by an average of 750 mL and 510 mL, indicates decompression of healthy lung parenchyma, which is consistent with previous reports describing that lung volume reduction leads to improved elastic recoil and reduced hyperinflation (13).

The attenuation of RV improvement at 24 months may reflect the progressive nature of the underlying emphysematous process rather than failure of the surgical procedure itself. Despite this finding, other functional parameters, including FEV₁, FVC, TLC, exercise capacity, and dyspnea scores, remained significantly improved compared with baseline values.

Improvements in lung function after bullectomy may last 3–5 years, but patients with diffuse emphysema may experience a faster decline in function, possibly due to progression of the underlying lung disease. Previous studies have reported that the effect of bullectomy remains stable for at least 2 years, with a gradual decrease in functional gain only after 24–36 months, which is in line with our finding—although FEV₁ and FVC values after 2 years are slightly lower than in the early postoperative period, they are still statistically significantly higher compared to preoperative ones (14). One-year decrease in FEV₁ in our analysis was 80 mL but not significant. Previous studies with a 3-year follow-up showed the stability of functional gain in majority of patients, which was also confirmed in this study, where even after 24 months, a statistically significantly higher FEV₁ (P=0.001) was recorded compared to the initial values, which confirms sustained benefit throughout the 24-month follow-up period (15-17).

In our series, 6MWT performance remained significantly improved throughout the 24-month follow-up period. An increase in 6MWT distance (average 50–52 m) represents a clinically significant improvement in exercise tolerance. Similar results have been reported in previous studies of surgical lung volume reduction, which have also demonstrated improvements in exercise capacity following surgery (18). The improvement in 6MWT distance and reduction in dyspnea were consistent with clinically meaningful functional improvement and improved patient-reported quality of life.

Although VATS has become increasingly adopted in modern thoracic practice, all procedures in this study were performed via a minimal anterolateral thoracotomy. This approach reflects the extended study period, during which VATS was not routinely implemented in the earlier years, as well as the need for optimal exposure and control in patients with large bullae and underlying diffuse emphysema. In addition, the predominance of smokers in our cohort suggests a higher likelihood of pleural adhesions and altered parenchymal integrity, which may further limit the feasibility of a minimally invasive approach and favor an open technique. Furthermore, direct access provided by thoracotomy allows more precise parenchymal handling and secure management of the staple line, which may be particularly relevant in reducing the risk and duration of postoperative air leakage. Nevertheless, VATS remains a valuable and less invasive option in selected patients, particularly in cases with limited disease extent and favorable anatomical conditions.

The long inclusion period [2008–2023] represents a potential source of temporal bias, as perioperative management, imaging quality, surgical techniques, and postoperative care evolved over time. However, patient selection criteria, preoperative assessment, operative principles, and follow-up evaluations remained consistent throughout the study period according to institutional protocols. Nevertheless, the influence of temporal changes cannot be completely excluded.

This study has several limitations, including its retrospective design, relatively small sample size, and lack of a control group, which should be considered when interpreting the results. In addition, multiple longitudinal comparisons were performed without adjustment for multiplicity. Consequently, the possibility of type I error cannot be completely excluded and the reported P values should be interpreted with caution. Longer-term follow-up beyond 24 months is also lacking.

The single-center nature of the study may also limit the generalizability of the findings to other institutions and patient populations. Therefore, multicenter prospective studies are warranted to validate these results.

These findings support a more individualized approach to surgical decision-making in patients with bullous emphysema, rather than strict exclusion based on the presence of diffuse disease. Therefore, we suggest that in the future prospective studies with larger cohorts and a follow-up of 5–10 years be performed in our population to assess long-term stability and survival.

Conclusions

The present study demonstrates that bullectomy is associated with significant improvements in pulmonary function, exercise capacity, and dyspnea during a 24-month follow-up period in carefully selected patients with Group III bullous emphysema. Improvements in FEV₁, FVC, TLC, and functional capacity were maintained throughout follow-up, whereas the reduction in RV showed partial attenuation over time. Although postoperative complications were relatively common, they were manageable and no mortality was observed. Further prospective studies with larger cohorts and longer follow-up are required to confirm these findings.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study protocol was approved by the Ethics Committee of the Faculty of Medicine, University of Belgrade (MFUB/25.02.2016. No. 29/II-21). Written informed consent was obtained from all patients.

Data Sharing Statement

Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1214/dss

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DOI: 10.21037/jtd-2026-1214