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 cancerous tissues. The decortication then removes any visible tumor masses from the surface of the lung and the rest of the chest area.
This highly detailed procedure takes several hours to complete. Its success depends on the skill of experienced thoracic surgeons. Pleurectomy/decortication can extend survival and increase quality of life significantly for eligible patients, especially when it’s part of a multimodal treatment approach that includes chemotherapy, radiation therapy, immunotherapy or other emerging treatment options.
Studies show the longest survival times after P/D are associated with a multimodal approach. Postoperative chemotherapy, radiation therapy or immunotherapy can kill cancer cells that were left behind during surgery. Many treatment plans include multiple adjuvant therapies to try to prevent cancer reccurrence for as long as possible.
The pleurectomy portion (also known as a parietal pleurectomy) of the P/D involves opening the chest cavity and removing the outside layer of the lining of the lungs. It treats mesothelioma by removing all visible cancerous tissue. 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 sixth rib to access the entire chest cavity. Others perform a second incision near the eighth or ninth rib if the tumor 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. It generally takes between two and four hours to complete the pleurectomy segment of a P/D.
Complications that may occur include infection, bleeding, air leak, pneumonia, cardiac complications, respiratory failure and post-operative pain. A pleurectomy has a risk of failure with a mortality rate around 3.1%.
A decortication is used to remove abnormal cancerous or fibrous tissue that has formed on the surface of the lung, chest wall or diaphragm. After finishing the parietal pleurectomy, the surgeon performs a decortication by removing any visible tumor growth covering the lung. The surgeon may scrape the affected lung to remove the maximum possible amount of cancerous tissue.
While the chest cavity is exposed, specialists pack the area with gauze and use other methods to minimize blood loss. Once the decortication (also known as a visceral pleurectomy) is complete, the surgeon stitches the incision closed. The decortication portion of a P/D takes about two to three hours.
A 2020 study published in The Annals of Thoracic Surgery reported 63.3% of pleural mesothelioma patients who underwent P/D lived longer than three years. Risks of the procedure include infection, bleeding, air leak, cardiac complications and respiratory failure. The risk for respiratory failure with a P/D is around 2.3%.
Some specialists have also integrated experimental targeted treatments such as photodynamic therapy, heated intrapleural chemotherapy or chemotherapy gels, which have shown promising results.
Surgical Consultation and Recovery
A surgical consultation ensures the patient understands what will happen before, during and after surgery. The surgical team will review all your medical records, including everything related to your mesothelioma tests. To qualify for major surgery, mesothelioma patients must usually be in good overall health with an early stage of pleural mesothelioma.
Patients may meet in person or virtually with the surgeon and the surgical team. They can ask detailed questions, bring up concerns and inquire about the surgeon’s success rate.
- 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.
While some surgeons debate the pros and cons of P/D versus the more invasive extrapleural pneumonectomy (EPP) procedure, 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.
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 begin the process by having them practice deep-breathing exercises and other therapies to aid recovery.
Your nurse or surgical team will provide detailed information on how to continue recovery at home. This may include visits from occupational and pulmonary therapists.
After the patient is discharged from the hospital, total recovery usually takes several more weeks. Avoid heavy lifting or vigorous exercise. Patients may be eligible for complementary therapies, such as pulmonary rehabilitation, to further ease breathing and lessen symptoms.
Dr. Robert Cameron’s Pioneering Work
Thoracic surgeon Dr. Robert Cameron, a mesothelioma specialist from 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.
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.
Common Questions About Pleurectomy and Decortication (P/D) Surgery
- Are pleurectomy and decortication surgeries effective?
- 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?