Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma: Extrapleural Pneumonectomy and Pleurectomy/Decortication
Section snippets
Part I: Technique of Right EPP
EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. Fusion of the pleura at the central tendon of the diaphragm and the lateral portion of the pericardium mandates resection and subsequent reconstruction with a prosthetic patch. The right EPP is described first followed by key modifications for a left-sided resection.
The operation is performed through a single extended right posterolateral thoracotomy in the following sequence: (1) incision and exposure; (2)
Preoperative Assessment
Patients undergoing EPP or P/D undergo the same protocol for preoperative assessment. Foremost, this includes pulmonary function tests to assess the patient's respiratory status, chest computed tomography (CT) scan to define abnormalities of the lung parenchyma, and magnetic resonance imaging (MRI) to assess for transdiaphragmatic, mediastinal or diffuse chest wall invasion. [18F] Fluorodeoxyglucose positron emission tomography (FDG-PET) can detect infradiaphragmatic or supraclavicular
Anesthesia
A thoracic epidural catheter is placed for intraoperative and postoperative pain control. Standard lines and probes are placed for continuous intraoperative assessment, including arterial and central venous pressure monitoring, continuous pulse-oximetry, and a Swan-Ganz catheter in most patients. The central line is placed preferably on the operative side to avoid pneumothorax in the nonoperative chest. After general anesthesia is induced, a left-sided double-lumen endotracheal tube is inserted
Operative Technique
Flexible bronchoscopy is performed to survey the right and left tracheobronchial tree to rule out clot, hemorrhage, anatomic variation, active infection, or the presence of unexpected pathology. Patients who have radiologic evidence of intra-abdominal tumor are explored laparoscopically or through a limited subcostal incision along the line of the planned thoracotomy incision before definitive resection. If there is evidence of intra-abdominal disease, histologic diagnosis is confirmed by
Incision and Exposure
The posterolateral thoracotomy begins midway between the scapular tip and the spine and extends along the bed of the sixth rib to the costochondral junction (Fig. 1). To prevent tumor seeding, previous biopsy scars are included in the incision or separately excised leaving a minimum 1-cm margin to the depth of the chest wall fascia. The latissimus dorsi and serratus anterior muscles are divided. The sixth rib is resected and the posterior periosteum in the bed of the sixth rib is incised to
Extrapleural Dissection
The extrapleural dissection is performed with a combination of blunt and sharp dissection to separate tumor from the chest wall. A plane is initiated along the anterior and posterior edges of the incision. Once started, finger fracture can be used to extend the planes between the endothoracic fascia and the parietal pleura. The presence of skeletal muscle on the parietal pleura is indicative of a tumor with invasive characteristics. If extensive invasion of chest wall is encountered such that
Opening the Pericardium
The pericardium is opened anteromedially and the pericardiotomy is extended superiorly from medial to lateral to the azygos recess (Fig. 11). Visualization of the quality of pericardial fluid is important. Clear pericardial fluid indicates lack of tumor invasion. Bloody pericardial fluid may indicate transpericardial and/or myocardial invasion by tumor. At this time, the surgeon also explores the pericardial cavity digitally to identify transpericardial or myocardial invasion.
It is critical to
Control of Pulmonary Vessels
Dissection is continued by extending the pericardiotomy from medial to lateral superficial to the inferior vena cava, which is directly visualized during this dissection. Care is taken to visualize and ligate the phrenic veins as one divides the pericardium superficial to the inferior vena cava. The tumor and diaphragm are then retracted superiorly and the pericardiotomy is continued from inferiorly to superiorly, to the region of the inferior pulmonary vein. The specimen is then retracted
Division of Bronchus
While preparing to divide the right mainstem bronchus, it is critical to ask the anesthesia team to place a pediatric bronchoscope down the right-sided tube. A heavy-gauge wire bronchial stapler (TA-30, Ethicon, Johnson and Johnson, Cincinnati, OH) (Fig. 15) is placed around the right main bronchus after the subcarinal nodal packet has been removed. With direct intraoperative endoscopic visualization of the right main bronchus via video bronchoscopy, the bronchus is divided by firing the
Reconstruction
The defects in the diaphragm and pericardium are reconstructed with a prosthetic patch made of Gore-Tex (W.L. Gore and Associates, Flagstaff, AZ). If there is evidence of pre-existing infection in the chest, we generally use biomaterial for reconstruction, such as bovine pericardial patch for the pericardium and micromesh, such as vicryl, for the diaphragm. For the noninfected chest, the diaphragmatic patch is constructed from two pieces of 2-mm-thick Gore-Tex dual mesh, 20 × 30 cm in dimension
Key Differences in Operative Technique for Left EPP
Patients with tumor involving the left hemithorax are approached through a left posterolateral thoracotomy. The operation is technically similar to right EPP with a few key differences:
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The approach to anesthesia includes placement of a right-sided double-lumen endotracheal tube or left-sided endobronchial blocker.
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When dissecting the pleura off the aorta during the posterior extrapleural dissection, it is vital to begin in the preaortic plane, since it is easy to inadvertently start dissecting
Complications
EPP is a physically rigorous operation that produces significant morbidity for which early and aggressive intervention is requisite to achieving a safe outcome. Recognizing the significance of potential complications and meeting that challenge with appropriate strategies for management has reduced perioperative mortality at our institution to 3.4%. This summary is based on the pneumonectomy literature and detailed morbidity data from 328 patients who underwent EPP for MPM at our institution
Cardiac
The cardiac complications associated with EPP range in severity from reversible atrial fibrillation (AF) to inflammatory epicarditis (leading to constrictive physiology), cardiac tamponade, myocardial infarction, and cardiac arrest. A pericardial patch that is improperly sized or secured can cause constrictive physiology leading to inflammatory epicarditis, tamponade, cardiac herniation, or other catastrophic consequences.
AF was also the most common overall complication in our EPP series,
Pulmonary
In our EPP series, patients experienced the same pulmonary complications one would observe with pneumonectomy or lobectomy: prolonged intubation (7.9%; 26/328), aspiration (2.7%; (9/328), ARDS (3.6%; 12/238); and central airway obstruction necessitating tracheostomy (1.8%; 6/328). To minimize pulmonary morbidity, EPP patients are managed with aggressive diuresis and frequent bronchoscopy as needed to maximize clearance of secretions. Often pulmonary complications after EPP arise in association
Renal, Hematologic, Infectious
In our series, renal failure was associated with ARDS, multiple organ failure, and death (2.7%; 9/328). The most severe hematologic complication was DVT leading to PE, which occurred in 6.4% (21/328) of patients. Aggressive management of DVT is paramount since PE in a patient with a single lung is a life-threatening complication. Our approach is to obtain noninvasive vascular studies on all patients on postoperative day 7. This is another diagnosis that should be pursued aggressively to prevent
Technical
Other potential complications of EPP include diaphragmatic hernia, bleeding, and chylothorax. In addition to the operative techniques described above, careful postoperative monitoring should be performed with daily chest X-rays to identify subtle signs of gastric or intestinal herniation, including unusual gas patterns in the operative hemithorax.
Any sign of herniation warrants immediate chest CT assessment, and if confirmed, reoperation. Excessive bleeding may be detected with intermittent
Part II: Pleurectomy/Decortication
P/D is a lung-sparing operation in which the diseased pleural envelope that encases and constricts the lung is mobilized off the chest wall, mediastinum, diaphragm and pericardium, and then meticulously stripped from the surface of the lung. P/D is generally well tolerated with low morbidity. The mortality rate is approximately 1.8% when the procedure is performed at a high-volume center. Reports of median survival in the literature range from 9 to 20 months. However, the technical challenge of
Anesthesia
A thoracic epidural catheter also is placed for intraoperative and postoperative analgesia. Standard lines are placed in all patients for intraoperative monitoring including arterial and central venous pressure monitoring. Invasive monitoring is vital because blood loss is often significant (approximately 1-2 L). After anesthesia is induced, a double-lumen endotracheal tube is inserted for single-lung ventilation. A nasogastric tube is placed to aid in identification of the esophagus during the
Incision and Exposure
The S-shaped posterolateral thoracotomy incision is smaller than that for EPP. It begins at the level of the posterior border of the scapula, follows the bed of the sixth rib, and terminates in a downward curve at the costal margin. The sixth rib is resected and the underlying periosteum is incised.
Pleurectomy
The technique for extrapleural dissection for P/D is similar to that used for EPP. Briefly, the resection is initiated in the plane between the endothoracic fascia and the parietal pleura. The tumor
Discussion
Cytoreductive surgery is the cornerstone of the multimodality approach to treating patients with diffuse MPM. Maximal cytoreduction is critical to extend long-term survival. EPP can achieve MCR in most cases of tumor confined to the ipsilateral chest. P/D is effective if disease is confined to the parietal pleura without extension into the lung parenchyma or fissures. P/D may also be appropriate as a palliative procedure for patients who cannot tolerate pneumonectomy due to limited cardiac
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