Decortication in Modern Thoracic Surgery: Innovations and Best Practices

Decortication is a surgical procedure aimed at removing the thickened fibrous layer of tissue, known as the pleura, from the lung or other organs. This procedure is typically performed when this tissue layer has become scarred or infected, causing impaired function of the lung or other organs. Decortication is most commonly associated with treating chronic empyema (a collection of pus within the pleural cavity) but can also be applied to other conditions where the pleura or surrounding tissues have thickened and hardened, restricting normal movement.

Indications for Decortication

Decortication is indicated in several conditions where the pleura becomes thickened, leading to impaired lung function or chronic pain. The most common indications include:

1. Chronic Empyema: Empyema is the accumulation of pus within the pleural cavity, typically as a result of pneumonia, tuberculosis, or thoracic surgery. When empyema becomes chronic, the pleura thickens and traps the lung, leading to decreased lung function. Decortication is often necessary to remove this fibrous tissue and allow the lung to re-expand.
2. Fibrothorax: This condition occurs when the pleura becomes extensively fibrosed, trapping the lung and preventing its normal expansion. Decortication helps in removing the fibrous tissue, thereby restoring lung function.
3. Pleural Thickening Following Tuberculosis: Tuberculosis can lead to significant pleural thickening, which may not resolve with medical therapy alone. Decortication may be indicated to restore lung function and alleviate symptoms.
4. Hemothorax with Fibrosis: In cases of traumatic or spontaneous hemothorax where blood has organized and led to fibrous thickening of the pleura, decortication may be necessary to remove this thickened tissue.
5. Mesothelioma: In selected cases of pleural mesothelioma, decortication may be performed as part of a multimodal treatment strategy, aimed at relieving symptoms and improving quality of life.
6. Failed Pleurodesis: When pleurodesis (a procedure to adhere the lung to the chest wall) fails, it can result in thickened pleura and trapped lung. Decortication can be performed to address this issue.

Preoperative Evaluation

A thorough preoperative evaluation is crucial for patients undergoing decortication. The evaluation should include:

1. History and Physical Examination: A detailed medical history focusing on respiratory symptoms, prior infections, and previous thoracic procedures is essential. Physical examination should assess respiratory function, with attention to signs of reduced lung expansion.
2. Imaging Studies:
   • Chest X-ray: Initial imaging to identify pleural thickening, trapped lung, or other thoracic pathology.
   • CT Scan: Provides detailed information on the extent of pleural thickening, lung entrapment, and any underlying pathology such as empyema, fibrothorax, or malignancy.
   • MRI: May be used in specific cases to assess the involvement of the chest wall or diaphragm.
   • Ultrasound: Helpful in assessing the presence of pleural effusion and guiding thoracentesis if needed.
3. Pulmonary Function Tests (PFTs): Preoperative PFTs are crucial to assess baseline lung function and predict postoperative outcomes. Patients with severely compromised lung function may be at higher risk for postoperative complications.
4. Laboratory Tests:
   • Complete Blood Count (CBC): To assess for anemia, infection, or other hematologic abnormalities.
   • Coagulation Profile: Ensures that the patient has normal clotting function before surgery.
   • Arterial Blood Gas (ABG): Provides information on the patient’s respiratory status and gas exchange.
5. Cardiopulmonary Assessment: Patients with significant comorbidities may require a cardiology consultation and further testing such as an echocardiogram or stress test.
6. Informed Consent: A thorough discussion with the patient regarding the risks, benefits, and alternatives of the procedure is essential. The potential need for postoperative mechanical ventilation, chest tubes, and intensive care should be discussed.

Contraindications

While decortication can be a life-saving procedure, it is not suitable for all patients. Contraindications include:

1. Severe Pulmonary Dysfunction: Patients with advanced chronic obstructive pulmonary disease (COPD) or other severe lung conditions may not tolerate the procedure.
2. Uncontrolled Coagulopathy: Patients with bleeding disorders or those on anticoagulant therapy may be at high risk for intraoperative and postoperative bleeding.
3. Diffuse Malignant Pleural Disease: In cases where the pleura is extensively involved with malignant disease (e.g., mesothelioma), decortication may not be feasible or beneficial.
4. Extensive Chest Wall Involvement: If the chest wall, diaphragm, or other vital structures are extensively involved, the risks of decortication may outweigh the benefits.
5. Poor Overall Health Status: Patients with poor nutritional status, advanced age, or multiple comorbidities may not be suitable candidates for this major surgical procedure.

Surgical Techniques and Steps

Decortication can be performed using either open thoracotomy or minimally invasive thoracoscopic surgery (VATS). The choice of approach depends on the extent of the disease, the patient’s overall condition, and the surgeon’s expertise.

1. Open Thoracotomy:

• Anesthesia and Positioning: The patient is placed under general anesthesia with single-lung ventilation. The patient is positioned in the lateral decubitus position.
• Incision: A posterolateral thoracotomy incision is made, providing access to the pleural cavity.
• Exploration: The pleural cavity is explored to assess the extent of pleural thickening and underlying lung involvement.
• Decortication: The thickened pleura is carefully dissected away from the lung surface. Care is taken to avoid injury to the lung parenchyma, as this can lead to air leaks. The goal is to completely free the lung so it can fully expand.
• Hemostasis: Bleeding from the chest wall or lung is controlled using electrocautery or sutures.
• Closure: After ensuring that the lung is fully expanded, chest tubes are placed, and the thoracotomy incision is closed in layers.

2. Video-Assisted Thoracoscopic Surgery (VATS):

• Anesthesia and Positioning: Similar to open thoracotomy, with the patient under general anesthesia and single-lung ventilation.
• Port Placement: Several small incisions (ports) are made to introduce the thoracoscope and surgical instruments.
• Thoracoscopic Decortication: The thickened pleura is dissected using thoracoscopic instruments. This technique is less invasive but requires significant expertise.
• Hemostasis: As with open surgery, bleeding is controlled, and the lung is re-expanded.
• Closure: Chest tubes are placed through the ports, and the incisions are closed.

Postoperative Care

Postoperative care is critical to ensure a successful outcome following decortication:

1. Chest Tube Management: Chest tubes are typically left in place to drain fluid and air from the pleural cavity. The tubes are usually connected to a water seal or suction to aid in lung re-expansion. Chest tube output should be monitored closely.
2. Pain Management: Adequate pain control is essential for effective breathing and coughing postoperatively. Epidural analgesia or patient-controlled analgesia (PCA) may be used.
3. Pulmonary Rehabilitation: Early mobilization and respiratory exercises are crucial to prevent atelectasis and promote lung re-expansion. Incentive spirometry, deep breathing exercises, and ambulation should be encouraged.
4. Infection Prevention: Prophylactic antibiotics may be administered to prevent postoperative infections, especially in patients with a history of empyema.
5. Monitoring for Complications: Patients should be closely monitored for complications such as air leaks, bleeding, infection, or respiratory failure.

Possible Complications

Complications following decortication can be significant, and surgeons must be vigilant in their prevention and management:

1. Air Leaks: Persistent air leaks from the lung surface can occur, especially if the lung parenchyma is fragile. Most leaks resolve with time, but some may require additional interventions.
2. Hemorrhage: Intraoperative bleeding from the chest wall, lung, or intercostal vessels can be challenging to manage. Postoperative bleeding may require re-exploration.
3. Infection: Postoperative infections, including pneumonia, wound infections, or empyema recurrence, are possible and require prompt treatment.
4. Respiratory Failure: Patients with compromised lung function may develop respiratory failure, necessitating prolonged mechanical ventilation or tracheostomy.
5. Recurrence of Disease: In cases of malignancy or chronic infection, recurrence of the underlying condition may occur, requiring further treatment.

Prognosis and Outcome

The prognosis following decortication largely depends on the underlying condition being treated:

1. Chronic Empyema: In cases of chronic empyema, successful decortication can result in significant improvement in lung function and symptom relief. Long-term outcomes are generally favorable if the infection is adequately controlled.
2. Fibrothorax: Patients with fibrothorax often experience improved lung expansion and respiratory function following decortication. However, the extent of preexisting lung damage may limit the degree of recovery.
3. Malignant Pleural Disease: In cases of malignant pleural disease, decortication may provide symptom relief and improve quality of life, but it is not curative. The prognosis depends on the stage and aggressiveness of the malignancy.
4. Post-Tuberculosis: Patients with pleural thickening following tuberculosis may benefit from decortication, with improved lung function and reduced pain.

Alternative Options

In some cases, alternative treatments may be considered instead of or in addition to decortication:

1. Thoracentesis: For patients with pleural effusion but without significant pleural thickening, repeated thoracentesis may be an option to manage symptoms.
2. Fibrinolytic Therapy: In early stages of empyema, intrapleural fibrinolytics may be used to break down loculated fluid and avoid the need for decortication.
3. Pleurodesis: For recurrent pleural effusion or pneumothorax, pleurodesis may be an option to prevent fluid accumulation or lung collapse.
4. Bronchoscopic Interventions: For patients with localized airway obstruction, bronchoscopic removal of obstructing material may be considered.

Average Cost

The cost of decortication can vary widely depending on the region, hospital, and complexity of the case. In general, the procedure is expensive due to the need for specialized surgical expertise, prolonged hospitalization, and intensive postoperative care. Costs may include:

1. Surgical Fees: Surgeons, anesthesiologists, and other specialists involved in the procedure.
2. Hospitalization: Costs related to the length of stay, use of the intensive care unit (ICU), and other hospital resources.
3. Postoperative Care: Including chest tubes, medications, and rehabilitation services.
4. Follow-Up: Costs associated with follow-up visits, imaging studies, and potential re-interventions.

Recent Advances

Recent advances in the field of decortication include:

1. Minimally Invasive Techniques: VATS has become increasingly popular for decortication due to its minimally invasive nature, reduced pain, and faster recovery times.
2. Enhanced Recovery Protocols: Implementation of enhanced recovery after surgery (ERAS) protocols has improved outcomes by reducing hospital stay and postoperative complications.
3. Adjunctive Therapies: The use of adjunctive therapies such as intrapleural fibrinolytics, antibiotics, and chest wall reconstruction techniques have improved outcomes in complex cases.