Mesothelioma Pleurectomy With Decortication (P/D)
The pleurectomy with decortication is a surgical procedure for patients diagnosed with pleural mesothelioma. The surgery has proven advantageous to many patients.
The Lung-Saving Surgical Option
The pleurectomy with decortication (P/D) is a lung-saving, alternative surgery to the extrapleural pneumonectomy (EPP). The P/D removes the diseased lining of a patient’s lung along with any other tumors in the chest. Many mesothelioma specialists are turning to the P/D because it has become just as effective as the EPP and patients often have a better quality of life with this procedure.
Key Points About the Pleurectomy/Decortication
The life expectancy for patients who had a P/D is comparable to those who had an EPP. The life expectancy is about 9 to 19 months after surgery.
The pleurectomy with decortication was developed by Dr. Robert Cameron of UCLA Medical Center. He developed the procedure as an alternative to the EPP to treat pleural mesothelioma patients in the 1990s.
The ideal candidate for a P/D is a patient with a stage 1 diagnosis who is in good overall health and whose tumor has not spread past the lining of the lung (the pleura).
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History and Philosophy Behind the Pleurectomy
There are only two surgical procedures available to treat pleural mesothelioma: pleurectomy/decortication (P/D) and the extrapleural pneumonectomy (EPP).
P/D is a relatively recent procedure in the treatment of malignant pleural mesothelioma. The extrapleural pneumonectomy was developed in the 1970s and removes the patient’s entire lung along with other cancerous tissue. The P/D has only been developed as a potentially curative procedure for mesothelioma since the mid-90s.
Origin: Before Decortication
The pleurectomy itself has been used to treat mesothelioma patients since roughly the same era as the EPP. A pleurectomy is the part of the procedure involving the removal of the lining surrounding the lung, the pleura. Removing the affected pleura allows for greater breathing comfort, but doesn’t do much to improve survival times. For this reason, the EPP was used more often in patients who were eligible for the surgery.
Decortication is the part of the P/D after the pleura is removed, which focuses on excising the existing tumors surrounding the lung.
A Less Radical Answer to the Extrapleural Pneumonectomy?
The pleurectomy/decortication is increasing in popularity among mesothelioma doctors. The P/D developed out of a desire to implement a procedure as beneficial, but less radical, than the EPP.
What makes P/D a less radical procedure is that it leaves the affected lung intact. In an EPP, portions of the diaphragm and the lining of the heart are also removed if tumors are present. Instead of removing the entire lung, only the lining of the affected lung and the tumor is removed in P/D.
Controversy remains over whether the EPP or the P/D is the optimal procedure for patients. Some medical professionals argue the EPP is unnecessary and can still leave the cancer behind, whereas others argue a P/D doesn’t do enough to remove the cancer.
Many doctors, such as Dr. Raja Flores argue that the type of surgery depends on the individual. Dr. Flores favors the P/D when possible, but sometimes opts for the EPP if the extent of the tumor is too severe.
The most important factor in determining which procedure to use remains the patient’s personal diagnosis. The extent of a patient’s mesothelioma often dictates the type of surgery that is most beneficial for them. Connect with top mesothelioma specialists to get the right treatment for your unique diagnosis.
Who is Eligible for Pleurectomy Surgery?
The steps of a P/D are similar to the steps involved with an EPP, but P/D is a significantly longer procedure. This is due to the intricacies of removing the tumor from the surface and fissures of the lung without causing irreparable damage to the lung itself. Though they are regarded by some as competing procedures, the preoperative assessment and initial surgical steps are nuanced at best.
Preoperative Assessment – Who is Eligible?
Before undergoing any major surgery, patients have to be physically fit enough to handle the stress associated with surgery. For that reason, patients are monitored to assure they are capable of handling the procedure. This is imperative for reducing operative mortality rates.
Preoperative Patient Evaluation
- Age and fitness evaluation
- Blood chemistries
- Pulmonary function evaluation
- CT-scan and MRI of chest
- Echocardiogram (cardiac evaluation)
- Pleural biopsy
This procedure is less invasive than a traditional P/D, but still has potential to remove the tumor and lining of the lung. The main difference involving a VATS P/D is how the surgeon accesses the lung; using small incisions and a camera to see inside the chest cavity rather than completely opening the chest.
Aside from being capable of handling the surgery, the patient’s diagnosis is one of the most important aspects used to determine whether they are eligible for the procedure. Typically, only patients with stage 1or 2 pleural mesothelioma are eligible for a P/D.
“Not resectable” simply means the tumor is deemed too hard for the surgeon to remove without damaging the lung. In these cases, the tumor has spread into the fissures separating the lung where the doctor cannot reach surgically.
Finding Surgical Treatment in VA Healthcare System
Too many veterans in the VA system who have mesothelioma don’t see a specialist. Although a general oncologist may be able to diagnose mesothelioma, they aren’t experienced in treating the disease. This lack of experience could lead to veterans missing out on life-extending treatments like the pleurectomy with decortication.
Dr. Robert Cameron runs the Elmo Zumwalt Comprehensive Mesothelioma Program at the Los Angeles VA. It is one of the best, and most efficient, mesothelioma programs in the country despite the VA’s reputation.
The mesothelioma program at the LA VA is commended as being of equal or better quality than the top cancer centers in the country. Veterans are also likely to learn that they are eligible for a P/D despite what their general oncologist may have said.
Dr. Cameron is able to offer veterans the same type of treatment through the LA VA as patients he sees at the UCLA Medical Center.
Veterans who seek surgical treatment through the LA VA receive:
- Treatment from Dr. Robert Cameron, one of the most renowned specialists in the world
- Access to a P/D performed by doctors who demonstrate high success rates and have patients with longer survival times
- Reduced cost of treatment thanks to VA health benefits
Veterans who aren’t located in Los Angeles need not worry. The VA also offers travel assistance and lodging for veterans who aren’t located in the area.
Pleurectomy Surgical Procedure
Although the first half of the procedure is essentially identical to an EPP, the procedure is considerably less drastic. Before the procedure begins, the patient is, of course, placed under general anesthesia, and an endotracheal tube is inserted into the trachea to keep the lungs inflated. During a P/D, the endotracheal tube is also used as a tool to create a controlled deflation of the lung, which allows the surgeon better access to difficult to reach parts of the tumor.
4 Steps of the Pleurectomy/Decortication
- 1Incision (thoracotomy) – An incision is made from the back to under the pectoral muscle to enter the chest cavity. The sixth rib is removed to allow surgeons appropriate access.
- 2Pleurectomy – The parietal (outer) pleura is removed along with any affected tissues in the chest wall, diaphragm or pericardium.
- 3Decortication – The visceral (inner) pleura is separated from the lung to excise any visible tumors. Sections of the visceral pleura may be removed if deemed necessary. This is the most tedious part of the surgery.
- 4Reconstruction – Sutures are used where necessary to close the chest. Gore-Tex, or a similar material, is used in cases where a considerable amount of the diaphragm has to be removed.
After the patient is stabilized, three chest tubes are inserted to ensure the lung re-expands normally and to allow the pleural space to drain. These tubes are critical for a healthy recovery.
Alternative Method of the P/D
Alternatively, patients whose preoperative assessment didn’t meet the standards may undergo a different procedure using video assisted thoracic surgery.
Traditionally, the lung is accessed by means of a thoracotomy, which is an incision between the ribs of the patient on the side of the affected lung. When patients aren’t fit enough for this procedure, a thoracoscopy can be used as an alternative.
Thoracoscopies involve the employment of VATS to complete the procedure. Rather than making a large incision to gain full access to the lung, three small incisions, or port sites, are made on the side of the affected lung. One of the port sites is the host of an endoscope, which is a flexible tool with a tiny camera on the end.
Once the incisions are made, any pleural effusions (excess liquid in the chest cavity) are drained. The camera is then inserted to see inside the patient’s chest cavity, while the other port sites are used complete the P/D using special tools.
Many patients also take advantage of intraoperative radiation therapy (IORT) as part of their P/D. IORT is introduced before the chest is closed. This allows radiation to kill remaining microscopic cancer cells.
These are cells that could not be removed with surgery without passing radiation through extra tissue.
Recovery after Pleurectomy Surgery
After surgery, patients can expect to spend 5-7 days in the hospital for recovery. They are moved to a recovery room immediately after waking from the anesthesia.
During this time, about 3-4 hours, patients have all their vitals monitored to ensure the surgery was a success. This includes heart rate, blood pressure, breathing rate and oxygen levels. An epidural or morphine pump is used for pain management, along with prescribed pain pills.
The patient is also on a respirator directly after the surgery. A respirator is necessary to guarantee the patient is getting enough oxygen. Breathing is typically labored for a few days following surgery. Patients are also fitted with chest tubes to help the lungs stay inflated and drain any fluid buildup from surgery.
Patients are also started on breathing and coughing exercises with the help of a physiotherapist. These exercises not only help recuperation but prevent infection and pneumonia as well. Infection is possible after any surgery and P/D is no exception.
Coughing helps to rid the lungs of sputum, which tends to build up after major lung surgeries. Ridding the lungs of sputum helps prevent bacteria from forming a haven in the body.
After a week of being monitored in the hospital, patients are allowed to check out of the hospital. The recovery process after the patient goes home takes about three more weeks. During this time patients are continuing their breathing and coughing exercises as well as walking exercises.
On the whole, total recovery from a P/D takes only about one month for most patients. Afterwards, patients can assume a normal life, but still must be careful to avoid overexertion.
Risks Associated with Pleurectomy Surgery
As with any surgical procedure, there are inherent risks involved. A cost/benefit analysis is always taken into consideration to reduce mortality rates and complications.
When treating a pleural mesothelioma patient surgically, the first risk assessed is whether the patient ought to have an EPP or a P/D. When it is determined that a P/D is the better option for the patient, this is typically the result of taking less risk.
Reasons a P/D May Be More Appropriate Than the EPP
- The patient is older
- The patient isn’t fit enough
- The patient has slight cardiac issues
- The tumor hasn’t spread to the lung
In comparison to the EPP, P/D is known for being more risk averse. This is because the lung is saved, fewer complications arise during this procedure than the EPP and mortality rates for this procedure are considerably lower than rates associated with the EPP.
However, this isn’t to say there aren’t risks involved. Risks associated with this procedure are essentially the same as those associated with the EPP; the difference is they occur less frequently.
Risks Associated With the P/D
- Internal bleeding
- Blood clots
- Respiratory failure
- Cardiac failure
- Pneumothorax (air leaking from the lungs)