Pleurectomy/decortication (P/D) surgery is one of the two surgical approaches to treat malignant pleural mesothelioma. The surgery’s curative purpose is to remove the primary tumor source and tissues affected by tumor spread. P/D is the more conservative of the two approaches.

P/D: A Two-Step Procedure

There are two steps to P/D. The first step, pleurectomy, removes the parietal pleura, or outer lining of the affected lung, diaphragm, heart, and chest cavity. The second step of P/D is decortication, which removes the visceral pleura, or inner lining of the affected lung. As an alternative, an extended pleurectomy (EPD) can be performed. In addition to removing the same structures as P/D, EPD removes the hemidiaphragm and the outer layer of the heart. 

Effectiveness and Safety of P/D vs. EPD

A 2013 systematic review evaluated the safety and effectiveness of the two techniques. The risk of death for both techniques ranged from 0-11%. However, the risk of non-fatal complications, which ranged from 13-43%, was higher for EPD. EPD had greater risks but also greater benefits of longer overall survival and disease-free survival outcomes. The median overall survival for both techniques ranged from 7.1-31.7 months, with 6-16 of those months being free of disease. The best survival outcomes occur when surgery is combined with other treatments, such as chemotherapy, radiation therapy, and immunotherapy. 

Over the years, the safety of P/D has improved. A 2017 literature review cites a thirty-day mortality rate of 0-6.8%. Concerning non-fatal complications, the most common major complications were bleeding (0-16.7%) and respiratory failure (2.3-7.1%). Minor complications included heart rhythm abnormalities (2.3-21.4%) and prolonged air leaks (7.1-23.5%).¹

Pleurectomy: Step-by-Step

Pleurectomy is conducted by first positioning the patient on their side. This is done to afford the surgeon the most direct access to the patient’s chest cavity. The surgery begins with making a long incision on the patient’s back, normally between the sixth and seventh ribs. This incision, known as a thoracotomy, aligns with the patient’s spine and then tapers out to extend parallel with the ribs. Depending on the number of tumors and their sizes and locations, there may be a need for a second incision, usually beginning between the eighth and ninth ribs.

Having gained access to the chest cavity via thoracotomy, the surgeon can then remove the outer lining of the affected lung, diaphragm, heart, and chest cavity. 

Decortication: Step-by-Step

Once the pleurectomy is completed, the surgeon removes any visible tumors. To minimize blood loss during the procedure, the surgeon fills the area with hot gauze, uses other methods to promote blood clotting, and uses suction tools to prevent fluid buildup.

The surgeon then performs a lung scrape, thereby removing the inner lining of the affected lung. Increasingly, surgeons are incorporating an experimental targeted treatment called photodynamic therapy along with P/D, with favorable results. Once decortication is finished, the surgeon closes the surgical incision site.

Recovery From P/D

Following P/D, patients often lose small quantities of blood and experience minor air leaks through the chest wall. The doctor will monitor these events and have the patient practice deep breathing exercises to assess and support recovery. Upon discharge from the hospital, a patient may require several weeks of pulmonary rehabilitation to fully recover from the surgery.

P/D as a Palliative Treatment 

In addition to having a curative purpose, P/D can have a palliative effect, meaning that it improves symptoms of the disease. In cases of advanced disease, a patient cannot benefit from and often cannot tolerate standard P/D. For these patients, the surgery is adapted to remove only those structures that can be safely extracted. 

Extrapleural Pneumonectomy: The Alternative Surgical Approach

Extrapleural pneumonectomy (EPP) is the other surgical approach to treat malignant pleural mesothelioma. In addition to removing the same structures as EPD, EPP removes the affected lung. Unlike P/D, EPP has been clinically shown to permanently impair an individual’s stamina. Moreover, EPP is considered to have a similar overall survival rate and a greater rate of death and non-fatal complications than P/D. A 2010 systematic review found the survival rate ranged from 9.4-27.5 months, the risk of death ranged from 0-11.8%, and the risk of non-fatal complications ranged from 22-82%. Not surprisingly, P/D is associated with a better quality of life than EPP. As a result, surgical oncologists prefer P/D over EPP unless the cancer has spread to the lung itself.²