Extrapleural Pneumonectomy

Extrapleural Pneumonectomy

Extrapleural pneumonectomy (EPP) is the removal of the entire diseased lung, part of the pericardium, diaphragm, and parietal pleura of the chest wall. In 1949, Dr. Irving Sarot performed the first extrapleural pneumonectomy for tuberculous empyema. Since then, EPP is primarily reserved for malignant pleural mesothelioma.

Patient selection is critical for surgery in order to have the best outcomes. The considered patient should have optimal lung capacity in order to survive with a single lung; this is assessed via pulmonary function tests. The disease has to be of non- sarcomatoid cell subtype, preferably epithelioid cell subtype, which has the best prognosis.

Since the objective of surgery is to eliminate all malignant cells, the patient should have no extension of the disease in the mediastinum. As part of the staging assessment, computed tomography and PETs are obtained, which can provide information concerning the disease outside the chest or lymph nodes. Certain programs carry out additional procedures such as mediastinoscopy or thoracoscopy to identify the lymph nodes enlarged in the mediastinum which are not identified on TEP

Talc pleurodesis can provide symptomatic relief during a thoracoscopic evaluation if malignant pleural effusion is identified while the patient is worked up for EPP. The pleural adhesion can also assist in extrapleural dissection if the patient is selected to undergo EPP.

EPP is performed via posterolateral thoracotomy or a lateral thoracotomy although the technique used can vary. If a previous invasive procedure was per- formed on the same side, the goal is then to incorporate the incision as part of the thoracotomy site. To begin the dissection, a plane is developed between the chest wall and the parietal pleura. 

Care is taken not to enter the pleural cavity to prevent spillage of malignant cells. Blunt and sharp dissection are used to stay in the extra-pleural space inferiorly and superiorly. Medially, the dissection at the hilum is carried in the pericardium, and it is removed as part of the specimen. 

This is later rebuilt with a patch to prevent the heart from moaning in the chest. Lower, the diaphragm is excised in its entirety and rebuilt with a Gore-Tex patch.

The management of these postoperative patients is just as important as the execution of the operation. Adequate pain control is necessary to allow patients to participate in physical therapy and prevent the atelectasis of the contralateral lung caused by a splint. 

During and after surgery, patients receive an intravenous liquid which is managed very carefully in order to prevent the shift in liquid and the development of post-pneumonic pulmonary edema.

Source

Mary Hesdorffer, Gleneara E. Bates-Pappas - Caring for Patients with Mesothelioma_ Principles and Guidelines-Springer International Publishing (2019)

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