Extrapleural Pneumonectomy (EPP)

Surgical Procedure

Before the procedure begins, the patient is placed under general anesthesia, and an endotracheal tube is inserted in the trachea. This keeps the airway to the healthy lung open and collapses the diseased lung so that it can be removed. The time it takes to complete the procedure varies with each patient, but EPPs have been completed in as few as three hours.

5 Steps of an Extrapleural Pneumonectomy

• 1
  Incision–The surgeon makes an incision along the side of the chest, extending roughly 7-8 inches.
• 2
  Extrapleural dissection–The pleura and pericardium are separated from the diaphragm and the chest wall.
• 3
  Division of pulmonary vessels–Blood vessels and arteries supplying the affected lung are severed and redirected.
• 4
  Removal of the affected areas–The pleura, pericardium, diaphragm, affected lymph nodes, and lung is removed.
• 5
  Reconstruction–The removed linings are reconstructed with Gore-Tex, which is a breathable, waterproof, and pliable material used in the surgical reconstruction.

In cases where intraoperative chemotherapy therapy is used, heated chemotherapy drugs are injected directly into the chest cavity after removal of the lung and before reconstruction.

It creates the ability to apply much higher doses of chemotherapy without causing substantial side effects associated with systemic chemotherapy, which passes through the entire body. The purpose of this procedure is to kill any remaining microscopic mesothelioma cells left behind in the chest cavity that could not be removed surgically.

Who is Eligible for an EPP?

Patients are carefully evaluated and must meet several criteria before they are considered for an EPP. The first and most important factor in determining eligibility is that patients must be healthy enough, to not only undergo surgery but also to withstand the recovery process with a single lung.

According to Brigham and Womenʼs Hospital, overall health and normal body function is a far more important factor than age. If a patient is over 65 but has been maintaining an active lifestyle before their diagnosis, then they may be eligible for surgery.

Having healthy, normal heart function is crucial since the heart and lungs work together to support the breathing process. Normal kidney and liver function are also required.

Patient Eligibility Tests

• Chest X-rays
• CAT (CT) Scans of the chest and abdomen
• Pulmonary function tests (PFT)
• Quantitative ventilation/perfusion scan (V/Q Scan)
• Echocardiogram (ECHO)
• Blood chemistry tests
• Pleural biopsy

Diagnosis is also an important factor in selecting patients for an EPP. This surgery is typically performed on patients in early stages of pleural mesothelioma where the tumor is contained to the pleura and lung.

The purpose of the surgery is to prevent the cancer from spreading. Therefore, if it has already spread, the risks associated with the surgery might outweigh the potential benefits.

Recovering From EPP

Following an EPP surgery, patients are likely to feel sleepy due to the anesthetic, feel nauseated, and have a sore throat caused by the breathing tube used during surgery, which can last for a few days. Hospital recovery time is, on average, about 2 weeks.

During this time, patients are cared for around the clock and work with physiotherapists on deep breathing exercises and shoulder exercises to prevent post-op complications and prepare them for exercises that should be continued at home.

Immediately following the surgery, the patient is placed on a respirator to help the healthy lung adjust to handling the entire respiratory process. An epidural catheter is often placed to help with pain control.

After Surgery Patients Are Monitored For:

• Blood pressure
• Pulse
• Temperature
• Breathing
• Blood-Oxygen level
• Pain

Out-patient Recovery

Recovery at home lasts between 6-8 weeks. During this time, patients are advised to keep up with minor exercises but not to push themselves beyond their limits. As with any surgery, the body needs time to adjust to the changes.

Breathing and walking exercises are resumed at home and the level of activity can be gradually increased over time. Patients may still feel short of breath for a few months after surgery.

Mike Dews was a patient of Dr. Sugarbaker. He underwent the EPP procedure and survived for an amazing 10 years. Regarding his surgery he said:

“My recovery from the surgery was difficult. Learning to breathe with one lung was difficult. But it did move along, and I was able to start walking. I was actually swinging the golf clubs within 100 days after my surgery.”

The recovery process can be difficult for many patients both physically and emotionally. Recovery is more successful when patients are willing to accept support from family, friends, and caregivers.

Key Benefits of EPP

Over the years, the EPP has produced favorable results for improved breathing quality and life expectancy in patients with pleural mesothelioma. Though there now exists another surgical procedure known as a Pleurectomy with Decortication (P/D), which has become favored by some doctors given the more open eligibility criteria, the EPP remains the most extensive surgical treatment for mesothelioma.

Of course, like any radical surgical procedure, it does have its risks. This is why the EPP has strict eligibility that must be met before patients can be considered candidates for surgery.

Risks Associated with Surgery

During the 1970ʼs, when the EPP was introduced, the mortality rate was around 30%. However, the rates have significantly decreased since then, hovering between 5% and 8%.

Typical EPP Risks

• Internal bleeding
• Respiratory failure
• Pneumonia
• Infection
• Blood clots
• Pulmonary edema
• Cardiac Arrhythmias

Cancer centers that employ mesothelioma specialists or ones that have dedicated mesothelioma research centers are more likely to have lower mortality rates than the reported average. As with any major surgery, these risks are mitigated by experienced specialists and hospital staff who have a long history of treating mesothelioma.

Finding Surgical Treatment in VA Healthcare System

For veterans seeking treatment through the VA, it is important to find a specialist in the VA Healthcare System with experience treating mesothelioma. Since most oncologists generally don’t have experience identifying or operating on mesothelioma patients, choosing the right doctor is vital. Oftentimes, veterans are incorrectly told they are ineligible for procedures like the EPP because of their general oncologist’s lack of experience.

Some of the benefits of seeing a specialist through the VA may include:

• Access to specialized treatments, such as the extrapleural pneumonectomy (EPP), that may not be offered by general oncologists.
• Financial assistance for travel and lodging.
• Qualification for cost-free treatment or the option for private health insurance to reduce or eliminate copay.

There are many general oncologists in the VA, but only two mesothelioma specialists. Additionally, only one uses the extrapleural pneumonectomy in his treatment plan: Dr. Avi Lebenthal at the Boston VA.

Dr. Lebenthal is a highly experienced mesothelioma specialist who also serves patients at the nearby Brigham and Women’s Hospital, which collaborates with the Boston VA in treating mesothelioma patients.