Pleurectomy/decortication surgery is an aggressive treatment option for some patients with pleural mesothelioma. It is a major, two-part surgery that first removes the lining surrounding one lung (pleurectomy), then meticulously removes any tumor masses that are growing inside the chest cavity (decortication). The advantage of P/D surgery – often called lung-sparing surgery — is that a patient can keep their lungs.
A P/D is usually performed on patients who are in good overall health and who are still in early stages of pleural mesothelioma. For patients who are eligible for surgery, a pleurectomy/decortication (P/D) can increase their life span, particularly when part of a multimodal approach that includes chemotherapy and radiation. Many mesothelioma specialists believe a P/D is the closest thing to a curative option today in treating the disease.
Although the pleurectomy was once used alone – mainly as a palliative measure to alleviate pain and reduce the buildup of fluid around the lung – it is rarely performed now without the decortication procedure that recent surgical advancements have made possible.
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As the name indicates, pleurectomy/decortication is a two-part procedure that combines pleurectomy and decortication. Experienced thoracic surgeons perform the entire procedure in about 5 hours. Pleurectomy is the first and main part of the surgery. It involves opening up the chest cavity and removing the pleural lining.
Decortication is the second and shorter part of the P/D surgery. It removes any tumor masses that are visible.
The patient is positioned on his or her side to give the surgeon the most direct access to the chest cavity. The surgeon begins by making a long incision along the chest, called a thoracotomy. The cut starts on the back near the sixth or seventh rib from the top and continues down the chest, parallel to the spine, then curves outward to extend parallel to the ribs.
This type of incision is ideal for maximum exposure of the chest cavity. If the tumor extends lower in the chest cavity, a second incision may be made near the eighth or ninth rib.
Once the surgeon has access to the chest cavity, he or she removes the parietal pleura, which is the outside layer of the pleural lining. The lung itself is left intact. This part of the procedure may also include the removal of parts of the chest wall lining, heart sac lining and diaphragm lining.
Once the pleurectomy portion is finished, the surgeon begins decortication. Because the chest cavity already is open, this part of the procedure takes less time. The decortication involves removing any visible tumor growth in the chest area. The surgeon also may scrape the affected lung to remove the maximum possible amount of cancer growth.
While the chest cavity is exposed, doctors pack the area with hot gauze or use other methods to help the blood coagulate and minimize blood loss. Once the pleura and tumors are removed, the surgeon stitches the incision closed.
In the days following P/D surgery, the chest wall can continue to lose small amounts of blood, and air leaks may occur in the area. Patients can expect to be monitored closely after surgery during a hospital stay of about one week. Doctors recommend patients practice deep breathing exercises during their hospital stay to prevent infection.
After patients are discharged from the hospital, total recovery usually takes several more weeks. Patients still struggling with symptoms after recovery may be eligible for complementary treatments, such as pulmonary rehabilitation, to further ease breathing and lessen symptoms.
Success Rate - Pleurectomy/decortication has a high success rate, with about 90 percent of patients experiencing at least a reduction of symptoms.
Mortality Rate - P/D is associated with a low mortality rate of 1 or 2 percent. That means that for every 100 patients who undergo the procedure, one or two patients die during or immediately after P/D.
Complications - Complications are rare. The most common complication is a prolonged air leak, which affects one in 10 patients.
Fast Fact: Studies of P/D report median survivals of up to 20 months, which is about a year longer than median survivals for all mesothelioma patients.
Patients who undergo treatments in addition to surgery tend to have longer survivals. Studies show that the longest life spans are associated with a multimodal approach. When used post-operatively, chemotherapy and radiation can kill many cancer cells that were left behind during surgery and help prevent local recurrence.
A 2009 study found that the longest survival times were in patients who had chemotherapy and radiotherapy after P/D. These patients had a median survival of about 30 months.
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Thoracic surgeon Robert Cameron, M.D., the mesothelioma specialist from the UCLA Medical Center, pioneered the P/D surgery 20 years ago. He is the driving force behind the Pacific Meso Center and has lobbied hard to make the P/D surgery the standard of care for mesothelioma that is found in the early stages. He believes that eventually, mesothelioma can be effectively treated as a chronic illness.
The Pacific Meso Center holds an annual conference to promote the advantages of the procedure for mesothelioma. Some thoracic surgeons in the country have followed his lead and choose P/D over extrapleural pneumonectomy (EPP), a surgical option for pleural mesothelioma in which an entire lung is removed.
An EPP can be more difficult to recover from, and the P/D usually comes with fewer complications. However, a P/D is less likely to remove the entire tumor. Most clinical studies have shown comparable survival times after EPP and P/D, although the P/D usually comes with a higher quality of life.
There is considerable debate among the specialty centers over which procedure is the most beneficial to the patients. There are renowned surgeons on both sides of the debate.
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