Secondary spontaneous pneumothorax associated with emphysema and ruptured bullae at the azygoesophageal recess

Purpose  With secondary spontaneous pneumothorax (SSP) associated with emphysema, lesions responsible for pneumothorax can be located anywhere along the lung surface. Among such lesions, ruptured bullae at the azygoesophageal recess (AER) have received little attention thus far. Methods  We conducted a retrospective study of 38 right SSP patients with emphysema who underwent surgery. Among them, we reviewed the clinical characteristics and technical problems of patients with surgically proven ruptured bullae at the AER. Results  Ruptured bullae at the AER were found in 10 of 38 patients. They accounted for 26.3% of all 38 patients and for 66.7% of 15 patients whose bullae at the AER were identified by preoperative computed tomography (CT). On CT, all the bullae were relatively large and oriented in a predominantly vertical axis. At surgery, they were confirmed as white, thin-walled structures originating from the mediastinal part of the apical segment of the right lower lobe. Surgery typically consisted of stapling bullectomy with video-assisted thoracic surgery. Technical problems in surgical treatment included poor mobilization of the base of the bulla and a restricted working space. Conclusion  Bullae at the AER are common and possibly lead to rupture. The presence of a bulla at the AER seen by CT can be predictive of rupture. Although the AER is a unique location, video-assisted bullectomy is the method of choice for treating these lesions.