What Is Pleurectomy/Decortication?
Pleurectomy with decortication (P/D) is one of two surgical procedures used to treat malignant pleural mesothelioma (MPM). 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 been shown to increase patient life expectancy with a median survival time of 34 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% 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%.
Step-by-Step Pleurectomy/Decortication (P/D) Procedure Prep Checklist
- Arrival at the Hospital: The patient arrives at the hospital on the day of the surgery and is taken to the preoperative area.
- Arterial Line Placement: Doctors insert an arterial line into one of the patient’s arteries, usually in the wrist. This line allows doctors to continuously monitor the patient’s blood pressure throughout the surgery.
- Urinary Catheter Insertion: A urinary catheter is placed into the patient’s bladder to drain urine during the procedure. This helps to keep the patient comfortable and allows doctors to monitor urine output.
- Nasogastric Tube Placement: A nasogastric tube is inserted through the patient’s nose and down into the stomach. This tube is used to empty the contents of the stomach, reducing the risk of aspiration during surgery.
- Epidural Catheter Placement: Doctors place an epidural catheter into the patient’s back, near the spine. This catheter will be used to deliver pain medication after the surgery to help control discomfort.
- Administering General Anesthesia: The patient is given general anesthesia, which ensures that they are asleep and unable to feel pain during the surgery.
- Double-Lumen Endotracheal Tube Placement: A special breathing tube called a double-lumen endotracheal tube is placed into the patient’s windpipe (trachea). This tube allows doctors to control the patient’s breathing and ventilate only one lung at a time during the surgery. This is important because it allows the surgeons to operate on one lung while the other continues to provide oxygen to the body.
- Bronchoscopy: Before the surgery begins, doctors use a flexible camera called a bronchoscope to carefully examine the patient’s airways. This helps doctors check for any blockages or other issues inside the airways that may need to be addressed before the surgery starts.
- Patient Positioning: Once all of the preoperative preparations are complete, the patient is positioned on the operating table to allow the surgical team to access the area of the chest where the surgery will take place.
- P/D Surgery Begins: The surgical team is ready to begin the pleurectomy/decortication (P/D) procedure with the patient fully prepared and monitored.
The Pleurectomy/Decortication Procedure
Step-by-Step Overview of the Pleurectomy/Decortication (P/D) Procedure
The following explains the general steps that take place during a P/D procedure for malignant pleural mesothelioma.
- Patient Positioning: The patient is positioned on their side on the operating table, allowing the surgeon access to the affected side of the chest.
- Making the Incision: The surgeon makes an S-shaped incision on the patient’s back, along the side of the chest.
- Creating Space: The surgeon carefully creates a space between the tumor and the chest wall, using a combination of cutting and blunt separation to remove all visible tumor while protecting important structures like blood vessels, the esophagus, and the phrenic nerve.
- Diaphragm and Pericardium: In some cases, the surgeon may need to remove part of the diaphragm or the pericardium. If this is necessary, gore-tex mesh is used to reconstruct these areas, with small holes made in the mesh around the heart to prevent fluid buildup.
- Decortication: The surgeon performs decortication, peeling off the cancerous lining from the surface of the lung itself and removing any visible tumor. If needed, bleeding or air leaks are repaired with sutures.
- Lymph Node Removal: The surgeon removes nearby lymph nodes to check for cancer spread.
- Chest Tubes: Three chest tubes are placed in different areas of the chest to help drain fluid and air after surgery.
- Closing Up: The surgical incision is closed, and the patient is gradually awakened from anesthesia.
- Postoperative Care: After the surgery, the patient may be on a ventilator for 24–48 hours to help the lung fully expand and minimize bleeding. Patients are closely monitored for complications and are encouraged to practice deep breathing exercises.
- Chemotherapy: Chemotherapy may be part of the treatment plan before or after surgery. The most common chemotherapy combination is cisplatin and pemetrexed.
- Recovery: Patients are monitored for any air leaks requiring further intervention. The average hospital stay after mesothelioma surgery is about 4 to 5 days.
- Follow-Up: The medical team works with the patient to create a tailored treatment plan, including additional treatments like chemotherapy, with the goal of improving the patient’s outcome and quality of life.
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Pleurectomy with Decortication In-Depth Process
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 operation takes roughly five hours and is led by a thoracic surgeon specializing in pleural mesothelioma treatment.
It is important to remember that this mesothelioma surgery helps reduce disease symptoms and extends patients’ overall survival, but it will not cure mesothelioma.
If you or a loved one has been diagnosed with pleural mesothelioma and are investigating treatment options, our free checklist can help you prepare for your next doctor’s appointment.
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. This is called a thoracotomy.
- The surgeon removes the lining of the lung.
- The lung is left intact, but if there are visible tumors elsewhere, the surgeon may remove parts of the chest wall lining, heart lining (pericardium), diaphragm, or lymph nodes.
A more extensive pleurectomy may be performed when the tumor is larger or more integrated into surrounding tissues.
Once the diseased tissues have been carefully removed, the second part of the pleurectomy and decortication procedure, called decortication, begins.
Many mesothelioma patients have added years — and even decades to their lives — because of life-extending mesothelioma surgery. Learn how 7 mesothelioma survivors found and navigated treatment options that helped them live longer in our Free Mesothelioma Survivors Guide.
The second part of pleurectomy/decortication surgical treatment 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 the cancer returning.
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 sutures.
The surgery takes around 5 hours and often causes moderate blood loss. For that reason, 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 ensure the patient does not develop serious complications.
If you are on a treatment journey for pleural mesothelioma, our Free Doctor Match can connect you with leading mesothelioma specialists near you.
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, health 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 about a week, half the time of patients undergoing the more complex EPP procedure.
Following this thoracic 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 pleural effusions (excess fluid), which can build up after surgery. This fluid can cause infection, so removing it as quickly as possible is vital.
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 help a patient recover.
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 up their strength and make 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 from the lungs of a mixture of saliva and mucus called sputum. Sputum 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.
Patients will be advised to continue walking and practicing breathing and coughing exercises once discharged from the hospital or cancer center.
Although it is important for mesothelioma patients to remain active during recovery, they should also avoid overexerting themselves.
Get our Free Survivors Guide to read about other mesothelioma patients’ recovery process and what helped get them through treatment.
Pleurectomy/Decortication Risks and Side Effects
As with any surgical approach, 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 (number of deaths) 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 in both procedures, although it is lower in EPP. That’s because all of the infected tissue is removed via total lung resection.
Potential risks and side effects resulting from P/D include:
- Air leak (air leaking from the lungs)
- Internal bleeding or blood clots
- Lung or heart failure
- Pneumonia and other infections
- Reactions to general anesthesia
It is important for patients to discuss all the potential risks, side effects, and benefits with their mesothelioma specialist before making a treatment decision.
People who have undergone mesothelioma surgery understand the side effects and what it takes to overcome them. Learn how 7 mesothelioma survivors navigated treatment in our Free Survivors Guide.
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 a different cell type (histology). 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 a higher risk of complications or death from P/D surgery.
- Tumor location: Tumors growing too close to sensitive tissues may be too risky to remove.
Surgical oncologists use a preoperative screen to determine the best candidates for P/D and reduce unnecessary risks and complications.
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).
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Pleurectomy/Decortication and Quality of Life
Pleurectomy/decortication may lead to both positive and negative changes in a patient’s quality of life. Before deciding to undergo this surgery, Mesothelioma patients should speak to their doctor to understand how pleurectomy/decortication could improve or impact their lives.
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 it.
A literature review by R.M. Schwartz and other researchers published in 2018 examined a pair of studies that compared the two surgeries and their impact 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 studies measured following surgery. However, P/D patients returned to baseline levels after 12 months.
A study published in The Annals of Thoracic Surgery in January 2022 found that P/D and EPP both had similar cancer-related results but that patients who underwent P/D had much lower perioperative (around the time of surgery) mortality.
New Research on P/D and Chemotherapy
Researchers continue to study P/D to find ways to maximize its success. For example, several recent studies have looked at P/D in combination with chemotherapy.
A study published in the journal Thoracic Cancer in October 2022 found that patients had better short-term outcomes when they had extended P/D followed by chemotherapy over patients who had chemotherapy before extended P/D.
However, a recent clinical trial conducted by Japanese researchers found that chemotherapy followed by P/D boosted the median overall survival for patients by as much as 3.45 years. The results were published in June 2022 in the Journal of Thoracic and Cardiovascular Surgery.
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Pleurectomy With Decortication FAQs
What is pleurectomy surgery?
Pleurectomy surgery is an operation in which a surgeon removes the pleura, which is the tissue lining the lungs. However, the lungs are left intact. For this reason, it is called the “lung-sparing” surgery.
If there are visible tumors elsewhere, the surgeon may remove parts of the chest wall lining, heart lining, and diaphragm.
Pleurectomy surgery is often performed as part of a two-part procedure known as pleurectomy with decortication, or P/D.
P/D is used to treat early-stage pleural mesothelioma.
What is decortication of the lung?
Decortication of the lung is a surgery that removes fibrous tissue that has formed on the surface of the lung.
Decortication means to remove the outer layer from a structure.
Surgeons use different techniques depending on the patient’s medical condition.
Surgeons who perform mesothelioma decortication scrape the lung lining to remove visible tumors and cancerous cells.
Decortication of the lung is the second part of a procedure known as a pleurectomy with decortication or P/D, which is often used to treat patients with malignant pleural mesothelioma.