Laser Assisted Extended Pleurectomy Decortication for Malignant Pleural Mesothelioma

Malignant pleural mesothelioma is an aggressive tumor of the pleura. Extended pleurectomy and decortication is a lung sparing cytoreductive procedure used in the management of this disease for curative intent.

In 2011, the International Association of Society of Lung Cancer (IASLC) and International of Mesothelioma Interest Group (IMIG) described the consensus report of the definition of pleurectomy and decortication as parietal and visceral pleurectomy to remove all gross tumor with resection of the diaphragm and/or pericardium (1).

The Patient

This video shows the case of a forty-eight-year-old woman with occupational exposure to asbestos. She had a right VATS pleural biopsy, which confirmed diagnosis of epithelioid malignant pleural mesothelioma. She was also being investigated for a concurrent breast lump. A core biopsy also confirmed invasive ductal carcinoma of the breast. The patient’s other comorbidities included Barret’s esophagus, endometriosis, and a hiatal hernia.

A workup for the procedure showed normal hematological investigations and preserved cardiac function (LVEF 57 percent). A multidisciplinary discussion led to the decision to proceed with mesothelioma surgery prior to any intervention for the breast malignancy.

The Surgery

To begin, an epidural catheter, arterial line, central line, urinary catheter, and nasogastric tube were placed. The patient was administered general anesthetic and intubated with a double lumen endotracheal tube. The patient was positioned in the lateral decubitus position, and the skin was prepared with betadine and chlorhexidine antiseptic solutions.

An extended fifth intercostal space thoracotomy was then made, and a costotome was used to cut the sixth rib posteriorly. At times, there is a need to perform a second thoracotomy two to three rib spaces inferiorly, but that was not needed in this case.

Next, an extrapleural dissection was made to remove the parietal pleura from the chest wall. This was continued anteriorly and posteriorly until the pleural had been fully detached from the chest wall.

At times, localized deposits remain on the chest wall that, if not excised, can be harbingers of disease progression. These were excised using monopolar diathermy and later ablated with use of LASER.

The lung was inflated to facilitate safely making an incision on the visceral pleura and creating a plane. This was performed along the fissure, and the dissection continued anteriorly and posteriorly. Intermittent CPAP was helpful in performing this step.
As the pleurectomy was continued in the mediastinum, a partial pericardiectomy was performed.

Next, a diaphragmatic resection was performed. As the pleura was tightly adherent to the diaphragm muscle, the only reasonable method of preserving integrity of chest wall mechanics without compromising surgical outcomes was by excising the diaphragm enbloc and reconstructing it.
In areas where adherent pulmonary plaques remained, or areas where localized disease on the chest wall was removed, LASER was useful for ablation. The technology was helpful in limiting parenchymal lung damage and helping to control the magnitude of postoperative air leak.

To begin the diaphragm reconstruction, a GORETEX patch was used to create a neodiaphragm. Multiple Prolene sutures were then used to anchor the patch while taking care not to cause intraabdominal visceral injury. Some sutures were placed pericostally in areas where insufficient residual diaphragm was present to provide sturdy anchorage.

After an extended pleurectomy decortication, patients are routinely kept nil by mouth and with a nasogastric tube in situ on free drainage to prevent implant dislocation. Undermining of the soft tissue was needed to facilitate exposure of the appropriate ribs for the pericostal sutures. It is here where a second thoracotomy may be required, although it was not in this case. Upon closure, this was the potential space where the RediVacs would be applied to prevent hematoma or seroma formation.

Next, a Vicryl pericardial patch was used to prevent cardiac herniation. This was also secured in place with interrupted Prolene sutures. Fenestration of the patch was then performed. Blood loss during an EPD ranges from 500–2500 ml, so meticulous hemostasis was performed prior to closure. This employed the use of warm water washout, monopolar diathermy, and Ligaclips.

Repair of the lung parenchyma for pneumostasis and hemostatis was then performed. Control of the parenchymal air leak is a pertinent challenge following radical intent pleurectomy and decortication. Several passes of tissue glue were used on the lung surface to reduce the air leak, together with strategic positioning of the intercostal drains.

Collatamp G was then used for local hemostasis of the capillary, parenchymatous, and seeping hemorrhages in areas with a high risk of infection. This was applied to the chest wall, especially in the recesses and apex.

Three chest drains and one or two subcutaneous RediVacs were placed prior to closure. Two chest drains were placed apically, one apical anterior and one apical posterior, and one was placed basally. These chest drains were then connected to low pressure suction.

Standard principles of chest wall closure were employed after securing the drains and ensuring hemostasis.

References

1. Tod, A. (2017). Nu03.01 supporting patients undergoing radical treatments EPD – Mars Study. Journal of Thoracic Oncology, 12(1). https://doi.org/10.1016/j.jtho.2016.11.178

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