Written By: Karen Selby, RN,
Last modified: September 21, 2021

What Is a Pleurectomy/Decortication (P/D)?

Pleurectomy/decortication (P/D) surgery is a two-part procedure. The pleurectomy involves opening the chest cavity and removing the pleural lining around the lung as well as other diseased tissues. The decortication then removes any visible tumor masses from the surface of the lung and the rest of the chest area.

P/D Facts

  • Success Rate: 90% of patients experience reduced symptoms.
  • Mortality Rate: 1 to 2% of patients die during or immediately after P/D.
  • Complications: Mesothelioma specialists say most patients present a prolonged air leak (PAL), a small breach in the lung that allows air to escape but typically resolves on its own.
  • Survival Time: Median survival is about 20 months, depending on other prognostic factors.

In the past, pleurectomy was commonly performed as a palliative measure for pleural mesothelioma patients to reduce the buildup of fluid around a lung and alleviate pain, but ever since surgical advancements made decortication possible, mesothelioma specialists almost always pair the two procedures. This highly detailed two-part procedure takes several hours to complete, and its success depends on the skill of experienced thoracic surgeons.

To qualify for major surgery, mesothelioma patients must usually be in good overall health with an early stage of pleural mesothelioma. Pleurectomy/decortication can extend survival and increase quality of life significantly for eligible patients, especially when part of a multimodal treatment approach including chemotherapy, radiation therapy, immunotherapy or other emerging treatment technologies.

Though thoracic surgeons have increasingly come to prefer P/D over the older and more invasive extrapleural pneumonectomy (EPP) procedure, in many cases surgeons will decide which procedure to perform only after they have already started surgery and evaluated the extent of the cancer growth firsthand.

Surgical Consultation for P/D

A surgical consultation is an important step to ensure the patient is eligible for the procedure and that the patient understands what will happen before, during and after surgery. Patients may meet in person or virtually with the surgeon and the surgical team to discuss how to prepare for surgery and what to expect during recovery.

The surgical team will review all your medical records, including everything related to your mesothelioma diagnosis. Patients can ask questions and bring up concerns, inquire about the surgeon’s success rate and learn all about the procedure.

Pleurectomy

For the pleurectomy (also known as a parietal pleurectomy), the patient is positioned on their side to give the surgeon the most direct access to the chest cavity.

The surgeon begins with a long incision called a thoracotomy. The cut starts on the back, near the sixth or seventh rib from the top, and it continues down the chest, parallel to the spine, then curves outward to extend parallel to the ribs. Some surgeons remove the entire sixth rib to access the entire chest cavity. Others perform a second incision near the eighth or ninth rib if the timor extends lower in the chest.

Once the surgeon has access to the chest cavity, they remove the parietal pleura, which is the outside layer of the pleural lining. The lung itself is left intact, but the surgeon may also remove parts of the chest wall lining, heart sac and diaphragm.

Mesothelioma specialist speaking with a patient and his wife
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Decortication

After finishing the parietal pleurectomy, the surgeon removes any visible tumor growth covering the lung. While the chest cavity is exposed, specialists pack the area with gauze and use other methods to minimize blood loss.

The surgeon may scrape the affected lung to remove the maximum possible amount of cancer tissue. Some specialists have also integrated experimental targeted treatments such as photodynamic therapy, heated intrapleural chemotherapy or chemotherapy gels, which have shown promising results.

Once the decortication (also known as a visceral pleurectomy) is complete, the surgeon stitches the incision closed.

Pleurectomy decortication (P/D) surgery for pleural mesothelioma
Pleurectomy/decortication surgery is a way to treat pleural mesothelioma without removing the affected lung.

Recovery After P/D Surgery

In the days following P/D surgery, the chest wall might continue to lose small amounts of blood, and air leaks may occur in the area. During a hospital stay of about two weeks, doctors monitor the patient’s recovery closely and have them practice deep-breathing exercises.

After the patient is discharged from the hospital, total recovery usually takes several more weeks. Patients still struggling with mesothelioma symptoms after recovery may be eligible for complementary treatments, such as pulmonary rehabilitation, to further ease breathing and lessen symptoms.

Studies show the longest survival times after P/D are associated with a multimodal approach involving other types of treatments. Postoperative chemotherapy, radiation therapy or immunotherapy can kill cancer cells that were left behind during surgery, and many treatment plans include multiple adjuvant therapies to try to prevent cancer reoccurrence as long as possible.

Mesothelioma specialist speaking with a patient and his wife
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Dr. Robert Cameron’s Pioneering Work

Robert Cameron, M.D.
Robert Cameron, M.D.

Thoracic surgeon Dr. Robert Cameron, a mesothelioma specialist from the UCLA Medical Center, pioneered the P/D surgery more than 20 years ago. He is the driving force behind the Pacific Mesothelioma Center and has campaigned to make P/D the standard of care for early-stage pleural mesothelioma.

Since the advent of P/D, specialists have debated whether it is as effective as extrapleural pneumonectomy (EPP), which involves removing the pleural lining and the affected lung.

The advantage of P/D is that it leaves the patient with both their lungs, whereas EPP permanently reduces a patient’s stamina. Proponents of EPP, on the other hand, have argued that because P/D is less invasive, it has a lower chance of successfully eliminating cancer from the body.

However, research studies show EPP and P/D lead to similar survival rates. Because P/D is associated with fewer complications and better quality of life, most mesothelioma specialists today agree P/D is preferable in cases where cancer tissue has not invaded the lung.

Common Questions About Pleurectomy and Decortication (P/D) Surgery

Are pleurectomy and decortication surgeries effective?

Pleurectomy and decortication has a 90% success rate in reducing symptoms and can increase survival time to about 20 months. This surgery is most effective when combined with a multimodal mesothelioma treatment approach.

How can I find a mesothelioma surgeon near me for P/D surgery?

Mesothelioma patients can get access to a specialist for advanced treatments, such as P/D surgery, through The Mesothelioma Center. Pleural mesothelioma doctors include surgeons who have extensive experience in treating this rare cancer with the most effective surgical procedures.

Who developed the pleurectomy and decortication (P/D) surgery?

Dr. Robert B. Cameron pioneered the development of the lung-sparing pleurectomy and decortication surgery. His improvements to surgical techniques led to prolonged survival and a better quality of life for malignant pleural mesothelioma patients.


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