Overview

Definition:
-Pleurectomy/decortication involves surgical removal of the parietal pleura (pleurectomy) and often the visceral pleura along with adherent tumor (decortication)
-It is primarily performed for malignant pleural mesothelioma, aiming for macroscopic tumor clearance, symptom relief, and potentially improved survival in select cases.
Epidemiology:
-Malignant pleural mesothelioma is a rare but aggressive malignancy, strongly associated with asbestos exposure
-Incidence varies globally, with higher rates in regions with historical heavy industrial use of asbestos
-It predominantly affects older males
-The latency period from exposure to diagnosis is often decades.
Clinical Significance:
-This procedure represents a critical surgical intervention for malignant pleural mesothelioma, a challenging disease with limited treatment options
-It is employed as part of a multimodality treatment strategy, aiming to palliate symptoms like dyspnea and chest pain, control local disease, and in specific, carefully selected patients, offer a chance for long-term survival
-Understanding its indications, techniques, and outcomes is vital for surgical residents preparing for DNB and NEET SS examinations.

Indications

Patient Selection:
-Careful patient selection is paramount
-Suitable candidates typically have early-stage epithelial or biphasic mesothelioma (T1-T2 N0-N1 M0), good performance status (ECOG 0-1), adequate pulmonary reserve, and no distant metastases or significant comorbidities.
Goals Of Surgery:
-The primary goals are symptom palliation (dyspnea, pain), macroscopic tumor clearance (debulking), and potentially R0 resection to improve survival
-It is often part of a multimodality approach including chemotherapy and radiotherapy.
Contraindications: Absolute contraindications include distant metastases, extensive mediastinal lymph node involvement (N2-N3), significant contralateral pleural disease, poor pulmonary function, severe cardiac disease, and unresectable local invasion into the mediastinum or diaphragm.

Preoperative Preparation

Multidisciplinary Team Evaluation:
-Comprehensive evaluation by a multidisciplinary team including thoracic surgeons, medical oncologists, radiation oncologists, pulmonologists, and radiologists is essential
-Discussion of treatment options and patient preferences.
Staging And Imaging:
-Accurate staging with PET-CT, CT chest/abdomen/pelvis, and MRI chest/abdomen is crucial to assess tumor extent and identify metastases
-Endobronchial ultrasound (EBUS) or mediastinoscopy may be required for nodal staging.
Pulmonary Function Tests:
-Detailed pulmonary function tests (PFTs) including spirometry, DLCO, and arterial blood gas analysis to assess respiratory reserve and tolerance to lung resection
-Cardiopulmonary exercise testing may be considered.
Anesthesia Considerations:
-General anesthesia with double-lumen endotracheal intubation for single-lung ventilation is standard
-Careful hemodynamic monitoring and management of potential pneumothorax are critical.

Procedure Steps

Surgical Approach:
-A posterolateral thoracotomy is the traditional approach
-Video-assisted thoracoscopic surgery (VATS) is increasingly used for select patients, offering less invasiveness and faster recovery.
Parietal Pleurectomy:
-The parietal pleura is meticulously dissected from the chest wall, preserving intercostal vessels and nerves
-This removes the pleural plaques and tumor embedded within the parietal pleura.
Decortication Of Visceral Pleura:
-The visceral pleura and underlying lung parenchyma are carefully stripped of tumor
-This involves dissecting the thickened, tumor-infiltrated visceral pleura off the lung surface, aiming for complete macroscopic clearance
-Careful attention is paid to preserve lung parenchyma viability.
Diaphragmatic And Mediastinal Lysis: If tumor involves the diaphragm or mediastinum, careful lysis of tumor from these structures is performed, often requiring resection and reconstruction of the diaphragm, and careful dissection around great vessels and heart.
Chest Drainage And Reconstruction:
-Placement of chest drains (usually two) for pleural space management
-Reconstruction of the chest wall or diaphragm may be necessary if significant resection was performed
-Watertight closure of the pleura or a pleurodesis may be considered.

Postoperative Care

Pain Management:
-Aggressive pain control using epidural analgesia, patient-controlled analgesia (PCA), or nerve blocks is crucial for patient comfort and early mobilization
-Multimodal analgesia is preferred.
Respiratory Support:
-Close respiratory monitoring, incentive spirometry, early ambulation, and physiotherapy are essential to prevent atelectasis, pneumonia, and respiratory compromise
-Supplemental oxygen may be required.
Drain Management:
-Chest drains are monitored for output and air leak
-Early mobilization and physiotherapy help re-expand the lung and facilitate drain removal
-Typically, drains are removed when output is minimal and there is no air leak.
Nutrition And Mobilization:
-Early nutritional support and aggressive mobilization are vital for recovery
-Patients are encouraged to sit up, ambulate, and engage in physiotherapy as tolerated.
Monitoring For Complications: Vigilant monitoring for signs of infection, bleeding, chylothorax, air leak, and cardiovascular complications.

Complications

Early Complications: Pain, bleeding, infection, pneumonia, atelectasis, prolonged air leak, chylothorax, wound dehiscence, cardiac arrhythmias, prolonged air leak, respiratory failure, empyema.
Late Complications: Chronic pain, pleural thickening, restrictive lung disease, recurrence of mesothelioma, infection (empyema), lymphatic obstruction leading to peripheral edema, incisional hernia.
Prevention Strategies: Meticulous surgical technique, careful patient selection, aggressive perioperative pain management, early mobilization, optimal respiratory physiotherapy, judicious use of antibiotics, and careful drain management are key strategies for complication prevention.

Prognosis

Factors Affecting Prognosis:
-Prognosis depends on tumor histology (epithelial generally better than sarcomatous), stage, completeness of surgical resection (R0 vs
-R1/R2), patient performance status, and response to adjuvant therapies
-Age and presence of lymph node involvement are also critical.
Outcomes:
-For select patients undergoing complete macroscopic resection (R0) as part of multimodality therapy, median survival can range from 18-30 months, with some patients achieving long-term survival (5+ years)
-Palliative procedures offer significant symptom relief for a subset of patients not amenable to radical surgery.
Follow Up:
-Regular follow-up with imaging (CT scans) and clinical assessments is essential to monitor for disease recurrence, metastasis, and to manage any late complications
-Frequency of follow-up is typically every 3-6 months for the first 2-3 years, then annually.

Key Points

Exam Focus:
-Understand the indications for radical pleurectomy/decortication vs
-palliative procedures
-Know the critical role of multidisciplinary team assessment and patient selection for radical surgery
-Differentiate between pleurectomy, decortication, and extrapleural pneumonectomy (EPP)
-Recognize common complications and their management.
Clinical Pearls:
-Emphasize achieving R0 resection when performing radical surgery for mesothelioma
-VATS offers benefits for carefully selected patients
-Palliative decortication can significantly improve quality of life for symptomatic patients with unresectable disease.
Common Mistakes:
-Inadequate staging leading to inappropriate surgical candidates
-Failure to achieve complete macroscopic resection
-Underestimation of operative risks and complications
-Insufficient postoperative respiratory physiotherapy
-Not involving a multidisciplinary team in decision-making.