What Is Pleurectomy/Decortication?
Pleurectomy with decortication (P/D) is one of two surgical procedures used to treat pleural mesothelioma. P/D is a lung-saving procedure that allows the patient to keep their lung. This minimizes future challenges involving strenuous activity. P/D helps increase patient life expectancy and improves quality of life.
The other surgical procedure for pleural mesothelioma is called the extrapleural pneumonectomy (EPP). This procedure involves removing the diseased lung.
P/D has proven to be a safe and highly successful method of treating pleural mesothelioma. It has shown to increase patient life expectancy with a median survival time ranging between 9 and 20 months after surgery.
P/D is used to treat early-stage (stage 1 and 2) pleural mesothelioma by removing as much of the tumor as possible from the pleural lining of the lungs and the surrounding chest cavity. Removing cancerous tissues in these areas reduces the spread of mesothelioma to nearby healthy tissues and organs.
- Patients diagnosed at an early stage of pleural mesothelioma respond better to surgery.
- Pleurectomy/decortication is a two-part surgery used to treat or manage pleural mesothelioma.
- Approximately 2 percent of patients die during or immediately following pleurectomy and decortication surgery.
- The probability of mesothelioma recurrence in the treated area following pleurectomy and decortication surgery is 65%.
The Pleurectomy/Decortication Procedure
Pleurectomy/decortication is split into two parts. The first part is the pleurectomy and the second part is decortication.
Both decortication and pleurectomy are performed under general anesthesia. The entire operation takes roughly five hours and is led by a thoracic surgeon who specializes in pleural mesothelioma treatment.
It is important to remember that this surgery helps reduce disease symptoms and extends the patient’s life, but it will not cure mesothelioma.
The first part of pleurectomy and decortication surgery, the pleurectomy, involves the removal of the tissue lining the lungs, called the pleura. Only the lining of the lungs is removed. The lungs themselves are left intact.
In some cases, surgeons may not be able to determine the exact location or size of the tumor until the operation has begun.
During a pleurectomy procedure:
- The surgeon places the patient on their side and makes a long incision in the chest or thoracic cavity called a thoracotomy.
- The surgeon removes the lining of the lung.
- The lung itself is left intact, but if there are visible tumors elsewhere, then the surgeon may remove sections of the chest wall lining, heart lining, and diaphragm.
When the tumor is larger or more integrated into surrounding tissues, a more extensive pleurectomy may be conducted.
In these circumstances, surgeons may remove the heart lining (pericardium) and part of the diaphragm as well. If tissues in the chest cavity are affected, they may also be removed in the first part of the procedure.
Once the diseased tissues are carefully removed, the second part of the pleurectomy and decortication procedure, called decortication, begins.
The second part of pleurectomy/decortication surgery involves the removal of visible tumors. Surgeons will use a variety of techniques to remove visible and unseen mesothelioma tumors and scrape the lung lining to reduce the chance of remission (when the cancer returns) rates.
During a decortication procedure:
- The surgeon scrapes the lining of the lung with a scalpel to remove visible tumor growth in the cavity.
- Specialists then pack the area with hot gauzes and sponge packs to limit blood loss
- Once the bleeding has slowed, the surgeon closes the incision with stitches.
The surgery takes around 5 hours and often causes a moderate amount of blood loss, so extra blood is always kept on-hand in case the patient needs an emergency transfusion.
Doctors will schedule follow-up appointments after the surgery to make sure the patient does not develop serious complications.
Recovery from a P/D surgical operation is critical and is one of the main reasons a patient must be in relatively good health before proceeding with the surgery.
Because the surgery is less radical than EPP, recovery from pleurectomy/decortication is usually shorter and less demanding. Patients should prepare for a month of recovery between the hospital and resting at home.
Family members, care aids, and others may need to be involved to ensure a patient is comfortable and has an overall successful recovery.
Pleurectomy/Decortication Recovery Process
Most patients remain in the hospital for around a week, which is half the time of patients who undergo the more complex EPP procedure.
Following the surgery, patients must first breathe with the help of a ventilator, which delivers oxygen to the lungs via a tube through the mouth, nose, or neck.
Once the patient can breathe independently, chest tubes will be fitted to help inflate the lungs and drain off any excess fluid, which can build up after surgery. This fluid can cause infection, so it is vital to remove it as quickly as possible.
Once the patient leaves the hospital, they may still need several weeks at home to fully recover.
Pleurectomy/Decortication Recovery Aid
Recovery aids such as complementary treatments and breathing or coughing exercises may be prescribed following pleurectomy and decortication. These recovery aids are intended to reduce the chance of infection and improve a patient’s overall recovery.
Recovery for P/D may involve:
- Postoperative chemotherapy or radiation: Mesothelioma doctors may perform chemotherapy and/or radiation therapy to kill any remaining mesothelioma cells left behind during surgery.
- Physical movement: Following surgery, patients are encouraged to start moving as soon as they are able. It is important for patients to walk and move to keep their strength up and support a speedy recovery.
- Lung exercises: Patients will work with physiotherapists on breathing and coughing exercises. These exercises help to speed the recovery process and work to prevent infection by removing the lungs of a mixture of saliva and mucus called sputum, which often accumulates following lung surgeries.
- Other aid: Additional treatments such as herbal remedies, a specific diet plan, physical therapy, or yoga may be recommended to relieve discomfort following surgery.
Once discharged from the hospital, patients will be advised to continue walking and practicing their breathing and coughing exercises.
Although it is important for mesothelioma patients to remain active during the recovery process, they should also follow their doctor’s instructions to avoid overexerting themselves.
Pleurectomy/Decortication Risks and Side Effects
As with any surgery, there are risks and side effects that patients need to be aware of and P/D is no exception.
Overall, P/D is considered a lower risk surgery in comparison to EPP. Mortality rates during the procedure are higher for EPP at 2-7%, with P/D averaging 1-2%.
Recurrence of mesothelioma in other locations within the chest cavity is a risk within both procedures, although it is lower in EPP as all the infected tissue is removed via total lung resection.
Potential risks and side effects resulting from P/D include:
- Reactions to general anesthesia
- Internal bleeding or blood clots
- Lung or heart failure
- Air leak (air leaking from the lungs)
- Pneumonia and other infections
It is important for patients to discuss all the potential risks, side effects, and potential benefits with their mesothelioma specialist before making a treatment decision.
Who Is a Good Candidate for Pleurectomy with Decortication?
P/D is offered to patients with early-stage pleural mesothelioma. A candidate for the surgery must also be in general good health to ensure that their body can cope with the stress of postoperative care.
Before undergoing P/D, patients may be assessed based on their:
- Age: Younger patients may be better able to survive P/D and recover more quickly.
- Mesothelioma cell type: Epithelioid mesothelioma patients respond better to surgery and other treatment than those with other cell types. Some doctors argue that sarcomatoid mesothelioma patients do not benefit from surgery.
- Mesothelioma stage: P/D is far more likely to be effective if all visible cancer tumors are surgically removed. Late-stage mesothelioma may have progressed too far to be effectively removed through P/D.
- Overall health: Patients who are in poor health may not be able to withstand serious surgery such as P/D.
- Risk of cardiac or lung issues: Patients with health issues related to the lungs or heart may be at higher risk for complications or death from P/D surgery.
- Tumor location: Tumors growing too close to sensitive tissues may be too risky to remove.
Looking at these and other factors helps mesothelioma doctors determine the best candidates for P/D and reduces unnecessary risks and complications.
A healthy immune system is critical for survival after mesothelioma surgery, so a fitness exam is usually required before the operation to ensure good overall health.
The following tests are often carried out before surgery:
- Blood tests to ensure blood can clot (to limit blood loss during surgery)
- A pulmonary function evaluation to ensure the patient can breathe properly
- CT or MRI scan of the chest to locate the tumor
- A pleural biopsy to confirm malignant mesothelioma diagnosis
- General fitness test
- An echocardiogram to ensure the heart can perform properly during surgery
The ideal candidate is a patient in good overall health with a stage 1 mesothelioma diagnosis. Patients are most likely to be treated if the tumors have not spread past the lining of the pleura (lung).
Pleurectomy/Decortication and Quality of Life
Pleurectomy/decortication may lead to both positive and negative changes in a patient’s quality of life. Mesothelioma patients should speak to their doctor to understand how pleurectomy/decortication could improve or impact their lives before deciding to undergo this surgery.
Many mesothelioma specialists and doctors recommend P/D over EPP to treat pleural mesothelioma. P/D is a less radical lung-sparing surgery, so it generally results in a better quality of life and a higher chance of surviving the surgery.
A literature review published in 2018 by Schwartz and other researchers found two studies that compared the two surgeries and their associated impacts on mesothelioma patients’ quality of life.
Patients who underwent EPP had significantly reduced lung function compared to P/D patients. Both procedures resulted in a significant decrease in the quality of life factors the researchers measured following surgery. However, P/D patients returned to baseline levels after 12 months.
Making a decision regarding your treatment plan can be incredibly difficult and stressful for you and your loved ones. However, our support team at Mesothelioma Hope is here for you. Reach out to us today for more information on P/D and other treatment options.