Pneumonectomy and Pleurectomy Articles

Surgery: Extrapleural Pneumonectomy, Pleurectomy/Decortication
Mee Lee Chun, B.A., Kemp H. Kernstine, M.D., PhD
Peer Review Status: Internally Peer Reviewed

Extrapleural Pneumonectomy

The surgical technique for an extrapleural pneumonectomy (pleuropneumonectomy) entails making a posterolateral thoracotamy incision along the course of the sixth rib anteriorly to the costochondral margin. After the 6th rib is resected, a dissection plane is created between the parietal pleura and endothoracic fascia. It is important to avoid injury to the superior and inferior vena cavae, the subclavian vessels, internal thoracic vessels, and the recurrent laryngeal nerves. A nasogastric tube should be placed to help identify the esophagus and reduce its likelihood for damage.

The diaphragm is removed en bloc with the specimen being divided in a radial fashion leaving 2-3 cm of uninvolved diaphragm from the chest wall. The diaphragm is then bluntly dissected away from the parietal peritoneum, leaving the peritoneum behind. The caval, aortic, and esophageal hiatuses are left intact.

The pericardium is opened anteromedially to the phrenic nerve to expose the hilar vessels. The vessels and main stem bronchus are transected along with the subcarinal nodes.

After the lung and tumor are removed, a vascular pedicle of pericardial fat is loosely sutured to the bronchial stump. To prevent cardiac herniation through the pericardial defect a fenestrated patch of Gortex is sutured into place. Gortex is also used to reconstruct the diaphragm and if necessary, reconstruct the chest wall as well.

The mortality for an extrapleural pneumonectomy has been as high as 10-20% and the morbidity exceeding 30% [3]. With new surgical and anesthetic techniques, the mortality is approximately 5% and the morbidity less than 10-15% [2,3]. The most frequent complications from the procedure are postoperative bleeding, respiratory failure, pneumonia, deep venous thrombosis, pulmonary emboli, empyema, and gastrointestinal ulcers [2]. Following surgery, the median survival is 19-21 months [2].

Chest wall pain and restrictive pulmonary symptoms may be relieved with a pleurectomy/decortication [1]. Pleural instillation of chemotherapeutic agents does not appear to improve survival, even in early stage disease. The entire diseased pleura is removed without resecting the underlying lung. The operative approach is similar to that used for an extrapleural pneumonectomy. Instead of resection, tumor is stripped from the lung, diaphragm and vessels. The ease at which the visceral pleura can be peeled from the parietal pleura varies greatly. Large resections of the visceral pleura as well as involved lung may be necessary. Once the tedious task of removing all gross tumor is completed, defects in the diaphragm and pericardium are repaired as necessary. Pleural instillation of chemotherapy may then be performed.

Pleurectomy/Decortication

Pleurectomy/decortication can be technically more difficult and complex than the extrapleural pneumonectomy. However, the mortality of pleurectomy/decortication is 1.5%-5% by an experienced surgeon [3]. Extrapleural pneumonectomy may appear to be better in removing more of the tumor by the en bloc resection. When performed at an early stage, pleurectomy/decortication is just as effective in removing all gross tumor as the extrapleural pneumonectomy [3]. In cases where there is tumor invasion of the lung parenchyma, pleurectomy/decortication is not an option.

Sources:

1. Sugarbaker, David J. et al. "Surgical Staging and Work-up of Patients with Diffuse Malignant Pleural Mesothelioma." Seminars in Thoracic and Cardiovascular Surgery. Vol 9, No 4 (October), 1997: pp 356-60.

2. Sugarbaker, David J. et al. "Extrapleural Pneumonectomy in the Setting of Multimodality Therapy for Diffuse Malignant Pleural Mesothelioma." Seminars in Thoracic and Cardiovascular Surgery. Vol 9, No 4 (October), 1997: pp 373-82.

3. Rusch, Valerie W. "Pleurectomy/decortication in the Setting of Multimodality Treatment for Diffuse Malignant Pleural Mesothelioma." Seminars in Thoracic and Cardiovascular Surgery. Vol 9, No 4 (October), 1997: pp 367-72.

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Surgical treatment of mesothelioma: Pleurectomy.
-Roberts JR.
Department of Cardiac and Thoracic Surgery, Vanderbilt Hospital, Nashville, TN, USA.
bob.roberts@mcmail.vanderbilt.edu

Malignant diffuse mesothelioma is the most common type of mesothelioma, with a median survival ranging from 8.5 to 18 months after diagnosis. Good performance status, absence of chest pain, age < 50 years, and epithelial histology are all associated with improved survival. Several investigators have described staging systems for this tumor and have emphasized the importance of thoracoscopy in the diagnosis and staging of the disease. Pleurectomy is the most common surgery employed to manage patients with diffuse mesothelioma, and this procedure is associated with minimal postoperative morbidity and mortality. Because mesothelioma usually recurs locally after surgery, efforts at optimizing local control have included both intraoperative phototherapy and chemotherapy. However, neither of these techniques has demonstrated any significant benefit to date and thus should not be considered as standards of care. No studies have compared pleurectomy to extrapleural pneumonectomy (EPP) in randomized trials. However, nonrandomized series suggest a significant improvement in disease-free survival for those undergoing EPP versus pleurectomy. Other data suggest that EPP may improve local control but may predispose the patient to distant metastases. A randomized comparison of these techniques may be beneficial in identifying the most effective procedure for patients with malignant diffuse mesothelioma.

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PMID: 10619505 [PubMed - indexed for MEDLINE]