Pleurectomy for Malignant Pleural Mesothelioma: A Surgeon’s Perspective

Introduction to Pleurectomy

Pleurectomy is a surgical procedure that involves the removal of part or all of the pleura, the membrane surrounding the lungs and lining the chest cavity. This procedure is typically employed in the treatment of pleural diseases, such as pleural effusions, pleural mesothelioma, and spontaneous pneumothorax. Pleurectomy can be performed as a standalone procedure or in conjunction with other surgeries, such as decortication or extrapleural pneumonectomy, depending on the underlying condition and the extent of disease.

Pleurectomy is a critical procedure in thoracic surgery, offering potential curative benefits in cases of malignant pleural mesothelioma and providing relief from recurrent pleural effusions. The choice between partial and complete pleurectomy depends on the specific clinical scenario and the surgeon's judgment.

Indications for Pleurectomy

Pleurectomy is indicated in several conditions where the pleura is diseased or compromised. The most common indications include:

1. Malignant Pleural Mesothelioma (MPM): In cases of MPM, pleurectomy is often performed to remove the diseased pleura and alleviate symptoms such as chest pain and breathlessness. This procedure may be part of a larger multimodal treatment plan, including chemotherapy and radiation therapy.
2. Recurrent Pleural Effusion: For patients with recurrent pleural effusions, particularly those with malignancy-related effusions, pleurectomy can help prevent fluid reaccumulation. This is often considered after less invasive options, such as pleurodesis, have failed.
3. Spontaneous Pneumothorax: Pleurectomy is a definitive treatment option for recurrent spontaneous pneumothorax, especially in young, healthy individuals where recurrence rates are high. The procedure aims to eliminate the pleural space, reducing the risk of future pneumothoraces.
4. Empyema: In cases of chronic empyema where the pleural space is infected, pleurectomy may be required to remove the thickened pleura and control the infection.
5. Trapped Lung: In some cases, a trapped lung occurs when the lung cannot fully expand due to a fibrous peel on the pleura. Pleurectomy can relieve this condition by removing the peel, allowing the lung to re-expand.

Preoperative Evaluation

Before performing pleurectomy, a thorough preoperative evaluation is crucial to assess the patient's suitability for surgery and to plan the procedure. The key components of the preoperative evaluation include:

1. Clinical Assessment: A detailed history and physical examination should be conducted to assess the patient's symptoms, underlying condition, and overall fitness for surgery. Particular attention should be paid to respiratory function and any signs of cardiorespiratory compromise.
2. Imaging Studies: High-resolution CT scans of the chest are essential for assessing the extent of pleural disease and planning the surgical approach. MRI may be used in some cases, particularly for better soft tissue contrast in malignant pleural mesothelioma. PET-CT scans can also provide valuable information about the metabolic activity of pleural lesions.
3. Pulmonary Function Tests (PFTs): PFTs are critical in evaluating the patient's respiratory reserve and ability to tolerate lung resection. Patients with poor lung function may require preoperative pulmonary rehabilitation or may not be suitable candidates for pleurectomy.
4. Cardiovascular Assessment: Given the potential for significant intraoperative and postoperative cardiovascular stress, a thorough cardiovascular evaluation is necessary. This may include echocardiography, stress testing, and consultation with a cardiologist in high-risk patients.
5. Laboratory Tests: Routine blood tests, including complete blood count, coagulation profile, renal function, and liver function tests, should be performed to ensure the patient is fit for surgery. Specific tests, such as arterial blood gases (ABG), may be needed to assess baseline respiratory function.
6. Multidisciplinary Discussion: In complex cases, particularly those involving malignancy, a multidisciplinary team (MDT) discussion involving thoracic surgeons, oncologists, pulmonologists, and radiologists is essential for optimal patient management and surgical planning.

Contraindications

While pleurectomy is a valuable procedure, certain contraindications must be considered:

1. Severe Pulmonary Dysfunction: Patients with significantly compromised lung function may not tolerate the procedure and are at high risk for postoperative respiratory failure.
2. Advanced Cardiovascular Disease: Patients with severe cardiac conditions, such as uncontrolled heart failure or significant coronary artery disease, may not be suitable for pleurectomy due to the risk of perioperative cardiac events.
3. Extensive Disease Spread: In cases where the pleural disease has extensively invaded surrounding structures, such as the diaphragm or chest wall, pleurectomy may not be feasible, and other surgical or palliative options should be considered.
4. Poor Performance Status: Patients with a low performance status, as defined by scales such as the Eastern Cooperative Oncology Group (ECOG) performance status, may not be able to tolerate the physiological demands of pleurectomy.
5. Coagulopathy: Uncontrolled bleeding disorders or anticoagulation that cannot be managed perioperatively may preclude pleurectomy due to the risk of excessive bleeding.

Surgical Techniques and Steps

The surgical approach to pleurectomy can vary depending on the indication, extent of disease, and surgeon preference. The procedure can be performed via open thoracotomy or minimally invasive techniques, such as video-assisted thoracoscopic surgery (VATS).

Open Pleurectomy

1. Patient Positioning: The patient is placed in the lateral decubitus position, with the diseased side facing up. Proper padding and securing of the patient are essential to avoid pressure injuries.
2. Incision: A posterolateral thoracotomy incision is made, providing access to the pleural cavity. The length of the incision depends on the extent of pleural disease and the need for exposure.
3. Exploration of the Pleural Cavity: The pleural cavity is carefully explored, and any adhesions between the lung and the chest wall are lysed. This step is crucial in cases of empyema or trapped lung.
4. Pleural Dissection: The pleura is dissected from the underlying lung, diaphragm, and chest wall. In a complete pleurectomy, the entire parietal and visceral pleura are removed. In a partial pleurectomy, only the affected portions of the pleura are excised.
5. Hemostasis: Throughout the procedure, meticulous attention is paid to hemostasis, particularly in areas with significant vascular structures, such as the intercostal arteries.
6. Closure: After the pleurectomy is completed, chest drains are placed to evacuate any residual air or fluid. The thoracotomy incision is then closed in layers, ensuring a secure and airtight closure.

VATS Pleurectomy

1. Patient Positioning: Similar to open pleurectomy, the patient is positioned in the lateral decubitus position.
2. Port Placement: Three to four small incisions (ports) are made in the chest wall for the insertion of the thoracoscope and surgical instruments.
3. Thoracoscopic Exploration: The pleural cavity is visualized using the thoracoscope, and any adhesions are carefully dissected.
4. Pleural Dissection: Using thoracoscopic instruments, the pleura is dissected from the lung, diaphragm, and chest wall. VATS pleurectomy can be as thorough as open pleurectomy, depending on the surgeon's expertise.
5. Hemostasis and Closure: Hemostasis is achieved using electrocautery or other energy devices. Chest drains are placed, and the incisions are closed with sutures or staples.

Postoperative Care

Postoperative care following pleurectomy is focused on monitoring for complications, managing pain, and promoting lung re-expansion. Key aspects of postoperative care include:

1. Pain Management: Effective pain control is essential to facilitate deep breathing and coughing, which are crucial for preventing atelectasis and pneumonia. Epidural analgesia, patient-controlled analgesia (PCA), or intercostal nerve blocks may be used.
2. Chest Drain Management: Chest drains are monitored for output, air leaks, and signs of infection. The drains are typically removed once the output decreases and there are no significant air leaks.
3. Respiratory Care: Incentive spirometry, chest physiotherapy, and early mobilization are encouraged to promote lung expansion and prevent postoperative complications.
4. Monitoring for Complications: Patients are closely monitored for signs of respiratory distress, bleeding, infection, and other potential complications. Regular chest X-rays may be performed to assess lung re-expansion and detect any residual pneumothorax or effusion.
5. Nutritional Support: Adequate nutrition is important for wound healing and recovery. Patients may require dietary modifications or supplementation, particularly if they have undergone extensive surgery.
6. Follow-Up: Regular follow-up with the surgical and medical team is essential to monitor recovery, address any complications, and plan further treatment if needed.

Possible Complications

While pleurectomy can be life-saving, it is associated with several potential complications:

1. Respiratory Failure: Postoperative respiratory failure can occur due to inadequate lung expansion, persistent air leaks, or pre-existing lung disease. Intensive respiratory support may be required in severe cases.
2. Bleeding: Intraoperative or postoperative bleeding can occur, particularly from the intercostal arteries or large pleural vessels. Hemostasis during surgery is critical to minimizing this risk.
3. Infection: Surgical site infections, empyema, or pneumonia can develop postoperatively, requiring antibiotic therapy and, in some cases, surgical intervention.
4. Persistent Air Leak: A prolonged air leak can occur if there is damage to the lung parenchyma during pleurectomy. This may necessitate extended chest drain management or re-intervention.
5. Cardiac Complications: Pleurectomy can lead to arrhythmias, myocardial infarction, or pericarditis, particularly in patients with pre-existing cardiac conditions.
6. Chylothorax: Injury to the thoracic duct during pleurectomy can result in chylothorax, where lymphatic fluid accumulates in the pleural cavity. Management may involve dietary modifications, chest drain placement, or surgical repair.
7. Diaphragmatic Dysfunction: Injury to the phrenic nerve during pleurectomy can cause diaphragmatic paralysis, leading to respiratory compromise.

Different Techniques in Pleurectomy

Several variations of pleurectomy can be performed depending on the clinical scenario:

1. Partial Pleurectomy: In this technique, only the diseased portion of the pleura is removed. This approach is often used in cases of localized pleural disease or when a complete pleurectomy is not feasible due to patient factors.
2. Complete Pleurectomy: The entire parietal and visceral pleura are removed. This approach is more radical and is often used in cases of malignant pleural mesothelioma.
3. Pleurectomy-Decortication (P/D): This involves the removal of the pleura (pleurectomy) along with the peeling of the fibrous layer overlying the lung (decortication). P/D is commonly used in malignant pleural mesothelioma to achieve maximal cytoreduction while preserving lung function.
4. Extrapleural Pneumonectomy (EPP): In this extensive procedure, the pleura, lung, diaphragm, and pericardium are removed en bloc. EPP is usually reserved for advanced malignant pleural mesothelioma with extensive disease.

Prognosis and Outcome

The prognosis following pleurectomy varies depending on the underlying condition, the extent of disease, and the success of the surgery. Key factors influencing prognosis include:

1. Malignant Pleural Mesothelioma: In patients with MPM, pleurectomy can offer symptom relief and, in some cases, prolonged survival, especially when combined with adjuvant therapies. However, the prognosis remains guarded, with a median survival of 12-24 months depending on the stage at diagnosis.
2. Recurrent Pleural Effusion: Pleurectomy can effectively control recurrent pleural effusions, improving the quality of life in patients with malignancy-associated effusions. The outcome is generally favorable, with a low recurrence rate.
3. Spontaneous Pneumothorax: Pleurectomy offers a definitive solution for recurrent pneumothorax, with a high success rate and low recurrence. Long-term outcomes are excellent in most patients.
4. Empyema: In cases of chronic empyema, pleurectomy can help eradicate infection and restore lung function. However, the presence of extensive fibrosis or comorbidities may affect the outcome.
5. Trapped Lung: Pleurectomy can relieve trapped lung, allowing re-expansion and improving respiratory function. The prognosis is generally favorable, provided the lung parenchyma is not severely compromised.

Alternative Options

In cases where pleurectomy is contraindicated or not feasible, alternative treatment options may be considered:

1. Pleurodesis: This involves the instillation of a sclerosing agent into the pleural cavity to induce pleural adhesion, preventing the recurrence of pleural effusions or pneumothorax. Pleurodesis is less invasive than pleurectomy but may be less effective in some cases.
2. Talc Pleurodesis: Talc pleurodesis is a specific type of pleurodesis where sterile talc is used as the sclerosing agent. It is commonly used in patients with malignant pleural effusions.
3. Chest Tube Drainage: For patients with limited life expectancy or significant comorbidities, long-term chest tube drainage may be a palliative option for managing recurrent pleural effusions.
4. Video-Assisted Thoracoscopic Surgery (VATS) Pleurodesis: VATS pleurodesis is a minimally invasive option for patients who are not candidates for open pleurectomy. It can be performed as an outpatient procedure with a relatively low complication rate.

Average Cost of Pleurectomy

The cost of pleurectomy can vary widely depending on the country, healthcare setting, and complexity of the procedure. On average, the cost may range from $20,000 to $60,000 in the United States, including hospital stay, surgeon fees, anesthesia, and postoperative care. Costs may be lower in other countries or in public healthcare systems. It is essential to consider insurance coverage and potential out-of-pocket expenses when planning for surgery.

Recent Advances in Pleurectomy

Recent advances in pleurectomy have focused on improving surgical outcomes, reducing complications, and enhancing patient recovery:

1. Enhanced Recovery After Surgery (ERAS) Protocols: ERAS protocols have been implemented in many centers to improve postoperative recovery following pleurectomy. These protocols include multimodal analgesia, early mobilization, and optimized nutrition.
2. Robotic-Assisted Pleurectomy: Robotic-assisted surgery offers enhanced precision and dexterity, allowing for more meticulous dissection and reduced trauma to surrounding tissues. This approach is being explored in select centers for pleurectomy.
3. Molecular Targeted Therapies: In patients with malignant pleural mesothelioma, the integration of molecular targeted therapies with pleurectomy is being investigated to improve outcomes. Agents targeting specific molecular pathways involved in mesothelioma growth are under clinical evaluation.
4. Minimally Invasive Techniques: Continued advancements in minimally invasive techniques, including VATS and robotic surgery, are making pleurectomy safer and more accessible to a broader range of patients.