Pleurectomy with Decortication (P/D) Overview
Early-stage pleural mesothelioma patients have important curative surgery options.
If your specialist has recommended a pleurectomy with decortication (P/D), here is what you need to know about this procedure:
- P/D is a procedure developed by world-renowned mesothelioma specialist, Dr. Robert Cameron, in the 1990s. As the driving force behind the Pacific Mesothelioma Centre, he has campaigned to make P/D the standard procedure for early-stage mesothelioma.
- Pleural mesothelioma is a rare form of cancer caused by asbestos exposure. It affects the pleural lining of the lungs. P/D is known as one of the most successful operations to treat pleural mesothelioma and improve the life expectancy of patients who undergo treatment.
- Compared to the more aggressive extrapleural pneumonectomy (EPP) surgery—which involves the removal of the affected lung—P/D is often seen as a safer option.
- To qualify for the surgery, the patient must be in good general health with early-stage pleural mesothelioma.
- 90% of P/D patients experience reduced symptoms, though postoperative mortality is still relatively high. The median survival period is around 20 months.
Pleurectomy with Decortication Procedure
When first developed, the P/D procedure was revolutionary as it meant that the surgeon did not have to remove the lung to remove the tumors—the standard surgical procedure known as extrapleural pneumonectomy (EPP).
The pleurectomy with decortication procedure takes place in two parts and can last for a total of five hours.
During the pleurectomy, the surgeon places the patient on their side and makes a long incision in the chest or thoracic cavity to remove the lining of the lung. The lung itself is left intact, but if there are visible tumors elsewhere, then the surgeon may remove sections of the chest wall lining, heart lining and diaphragm. The operation relieves disease symptoms and extends the patient’s life, but it will not cure mesothelioma.
After finishing the pleurectomy, the surgeon scrapes the lining of the lung with a ten blade scalpel to remove visible tumor growth in the cavity. Specialists then pack the area with hot gauzes and sponge packs to limit blood loss, and once the bleeding has slowed the surgeon closes the incision with stitches. As the surgery takes around 5 hours in total and often incurs a moderate amount of blood loss, extra blood is always kept on-hand before the procedure in the eventuality of an emergency transfusion.
The recovery from the P/D operation is critical and is one of the main reasons a patient must be in relatively good health before proceeding with the surgery. Most patients remain in the hospital for around a week, which is half the time of patients who undergo the more complex EPP procedure.
Following the surgery, patients must first breathe with the help of a ventilator, which delivers oxygen to the lungs via a tube through the mouth, nose or neck. Once the patient can breathe independently, chest tubes will be fitted to help inflate the lungs and drain off any excess fluid, which can build up after surgery. This fluid can cause infection, so it’s vital to remove it as swiftly as possible.
Once the patient leaves the hospital, it can still take several weeks at home to fully recover. Complementary treatments, such as pulmonary rehabilitation, are offered to ease breathing and lessen the risk of fluid build up. Postoperative chemotherapy and radiation are also given to kill any remaining mesothelioma cells left behind during surgery.
Pleurectomy with Decortication Benefits
The advantage of P/D is that it does not involve the removal of a lung. In contrast, EPP involves the full removal of the diseased lung, part of the chest lining, heart lining and diaphragm. While EPP controls tumor growth, it’s also one of the most radical procedures for patients with pleural mesothelioma.
The EPP procedure is complex and intricate, with longer recovery time and an increased chance of complications. However, research from the Annals of Thoracic Surgery in 2014 shows that EPP and P/D lead to similar mortality rates, but as P/D is less invasive it is often regarded as the preferable treatment.
According to research conducted between 1990 and 2014, a total of 1,512 patients were treated with P/D, and 1,391 treated with EPP. While there was a higher proportion of short-term deaths in the EPP group (usually associated with surgery), there was no statistically significant difference in the long-term mortality between these two groups.
Dr. Robert Cameron believes that mesothelioma will one day be treated as a chronic illness, using ongoing treatments to minimize the symptoms and prolong life. Since P/D has become a more popular surgical choice, many specialists wonder whether it is as effective as EPP, or whether the safer procedure outweighs the risks. Other surgeons believe that EPP is an unnecessary procedure because the removal of a lung puts much more pressure on other organs, which can lead to heart or kidney failure during the recovery stage.
To this day, the P/D vs. EPP debate divides opinions among medical professionals, but as research suggests that both procedures are providing almost identical mortality rates, the correct surgical operation is decided on a case-by-case basis.
Who is Eligible for the Pleurectomy with Decortication?
P/D is offered to patients with early-stage pleural mesothelioma. A candidate for the surgery must also be in general good health to ensure that their body can cope with the stress of postoperative care. A healthy immune system is critical for survival after surgery, so a fitness exam is usually required before the operation to ensure good overall health.
The following tests are often carried out before surgery:
- Blood tests to ensure blood can clot (to limit blood loss during surgery)
- A pulmonary function evaluation to ensure the patient can breathe properly
- CT or MRI scan of the chest to locate the tumor
- A pleural biopsy to confirm mesothelioma diagnosis
- General fitness test
- An echocardiogram to ensure the heart can perform properly during surgery
The ideal candidate is a patient in good overall health with a stage 1 mesothelioma diagnosis. Patients are most likely to be treated if the tumors have not spread past the lining of the pleura (lung).
Pleurectomy with Decortication Side Effects and Recovery
Operations to treat pleural mesothelioma have serious side effects and risks, though these are often determined by the health of each patient and the extent of the cancer. The P/D procedure requires the ribs to be spread during surgery, with the lower rib occasionally being removed in extreme cases. This means that the patient will feel significant pain in the area for some time afterward, and activity will be reduced for one or two months.
There are fewer side effects associated with P/D compared to EPP as the lung is kept intact, but chemotherapy is still required after the surgery to kill any remaining cancerous cells. If you have concerns about which surgical option is right for you, contact out Victims Advocates today.