Acs0413 Decortication And Pleurectomy

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Acs0413 Decortication And Pleurectomy

  1. 1. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 13 Decortication and Pleurectomy — 1 13 DECORTICATION AND PLEURECTOMY Eric S. Lambright, M.D. In normal circumstances, the pleural space is a potential cavity HISTORY AND PHYSICAL EXAMINATION between the lung and the chest wall—more specifically, between The physiologic consequences of a fibrothorax culminate in pul- the visceral pleura and the parietal pleura. In the average healthy monary restriction, manifested by decreased lung volumes, reduced patient, this space is less than 1 mm thick. There are a number of diffusion capacity, and lower expiratory flow rates. Movement of pathologic processes that can alter the transport of cells and fluid the chest is impaired.4 The initial clinicial presentation of a fibro- within this space and thus give rise to clinically significant sequelae. thorax depends on its cause and severity, as well as on the pres- One such process is fibrothorax, which is defined as the presence ence or absence of underlying parenchymal disease.Typically, dys- of abnormal fibrous tissue within the pleural space, resulting in pnea on exertion is the most common presenting symptom, though entrapment of the underlying pulmonary parenchyma (a state var- cough, fever, pleuritic chest discomfort, malaise, night sweats, weight iously referred to as trapped lung, restrictive pleurisy, or encased loss, or chest pressure may also be present. In obtaining the clinical lung). Decortication is the surgical procedure by which this history, it is important to determine whether the condition is chron- restrictive fibrous layer is peeled away from the lung; the literal ic and whether there are any other underlying disease processes that meaning of the term is the stripping away of a rind (from the Latin may be complicating the pulmonary disease process. Physical ex- word cortex “bark, rind, shell”). The technical goals of the opera- amination yields relatively nonspecific findings; typically, de- tion are to reexpand the lung and resolve the pathologic process creased breath sounds and decreased chest wall excursion are noted. affecting the pleural space so that pulmonary function and chest wall mechanics will improve and the patient’s symptoms will be DIAGNOSTIC IMAGING AND PHYSIOLOGIC TESTING relieved. Radiographic evaluation is the mainstay of diagnosis [see Figures Successful management of a patient with fibrothorax depends 1, 2, and 3]. Computed tomography (CT) of the chest is the imag- on close adherence to basic surgical tenets: appropriate selection of ing modality of choice for delineating abnormalities of the pleural patients for surgical treatment, preoperative optimization of the space and defining the character of the pleural disease process. CT patient’s physiologic status, exacting attention to the technical scanning can assess the extent and thickness of pleural involve- aspects of the procedure, and timely intervention to address peri- ment and characterize associated parenchymal disease. It readily operative complications. If insufficient attention is paid to any of identifies parenchymal abnormalities such as fibrosis, bronchiec- these important tenets, decortication may fail to achieve any signif- tasis, and malignancy. Such factors play a role in surgical decision icant improvement in the patient’s symptoms or physiologic status, making. In particular, malignancy must be included in the differ- potentially leaving him or her in an even more debilitated state. ential diagnosis of fibrothorax and ruled out; the management options for malignant disease are quite different from those for Preoperative Evaluation benign disease. Physiologic testing with spirometry and evaluation of diffusing PATHOPHYSIOLOGY OF FIBROTHORAX capacity helps define the degree of pulmonary dysfunction and facilitates risk stratification. The results of pulmonary function Although any insult to the pleura can result in an inflammato- testing may be quite abnormal preoperatively and are often worse ry response with fibrin deposition,1 hemothorax and infection than would have been expected from the radiographic evaluation. (bacterial and mycobacterial) remain the most common causes of Marked abnormalities in physiologic testing should not be consid- fibrothorax [see Table 1].Typically, empyemas evolve over a 4- to 6- ered absolute contraindications to surgical intervention, because week period as the infection progresses throughout the pleural some degree of improvement may be anticipated. The improve- space.The first (exudative) phase is characterized by a thin, fibrin- ment in dyspnea, pulmonary reexpansion, and parenchymal func- containing fluid exudate. The second (fibropurulent) phase is tion that can realistically be expected after decortication may be characterized by a heavy fibrin deposit over the pleural surface with the development of loculations and fibrous debris in the tho- racic cavity. The third (organizational) phase, which begins at about 3 to 5 weeks, is characterized by the formation of a thick fibrous peel that imprisons the lung and prevents expansion.When Table 1 Common Causes of Fibrothorax fully developed, this peel has three distinct layers: (1) an outer Chronic empyema layer consisting of loosely organized vascular tissue, (2) a middle Retained hemothorax (traumatic or iatrogenic) layer consisting of fibrous connective tissue that is relatively avas- Pleural effusive disease cular and acellular, and (3) an inner layer consisting of necrotic tis- Transudative sue and fibrinoid masses.2 Generally, if a hemothorax is small, it Chylous will be reabsorbed, provided that the lymphatic system is intact. Pancreatic However, if the hemothorax is relatively large, if there is continued Sequelae of Mycobacterium tuberculosis infection bleeding, or if bacteria are present, there is a high likelihood that a Chronic pneumothorax fibrous peel will eventually form.3
  2. 2. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice1 4 THORAX 13 Decortication and Pleurectomy — 2 a b Figure 1 (a) Shown is a chest x-ray from a patient with a 2-month history of dyspnea and cough associated with intermittent fever and night sweats. Treatments included three courses of antibiotics and bronchodilator therapy. (b) A chest CT scan from the same patient shows a large pleural collection containing air and demonstrates pleural thickening (arrow). The findings are consistent with empyema. Thoracentesis was performed, demonstrating white, creamy purulence but failing to achieve reexpansion of the lung. Decortication was performed. estimated on the basis of the preoperative diagnostic imaging and ment of the pleura (usually by adenocarcinoma) is far more com- physiologic testing. Ultimately, the surgeon’s judgment plays the mon than malignant pleural mesothelioma, which is a primary key role in deciding for or against surgical intervention. malignancy of the pleural space. Cytologic evaluation of the pleur- al fluid will establish the diagnosis of metastatic pleural involve- EXCLUSION OF MALIGNANCY ment in most cases; however, it tends to be less effective in estab- In the evaluation of a patient with a fibrothorax, it is essential to lishing the diagnosis of malignant mesothelioma. If the presenta- keep in mind the possibility of a malignant pleural process. If tion of a chronic pleural process is atypical and the etiology is poor- malignancy is a concern, this possibility should be excluded before ly defined, a degree of suspicion for malignancy must be main- a decision is made to proceed with decortication. Decortication of tained. Appropriate initial pleural biopsies can be useful for ruling a malignant fibrous peel is difficult, and the outcome is not partic- out underlying malignancy before decortication. Currently, pleur- ularly satisfying from the standpoint of lung expansion; according- al biopsy is usually performed by means of video thoracoscopy, but ly, for a pleural malignancy, a lesser, palliative intervention is gen- closed pleural biopsy is still done occasionally (though it is fast erally more appropriate than decortication. Metastatic involve- becoming a lost art). If a malignancy is identified, therapeutic alter- a b Figure 2 (a) Shown is a preoperative chest CT scan from a patient with a 6-week history of malaise and weight loss who ultimately presented with hypotension and respiratory insufficiency necessitating mechanical ventilatory support. (b) A chest CT scan obtained from the same patient after decortication shows complete reexpansion of the lung.
  3. 3. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 13 Decortication and Pleurectomy — 3 ease or airway stenosis.9,10 In this setting, decortication is destined to fail: the lung parenchyma will not reexpand to fill the pleural space completely, and any surgical intervention carried out on the diseased lung will only aggravate the underlying disease process. Pleuropneumonectomy may be the only option, though it should be considered a last resort, to be used only if there is significant parenchymal destruction. Decortication may be precluded by invasive uncontrolled pulmonary infection, contralateral pul- monary disease, or a chronically debilitated state that results in a significant or even prohibitive level of operative risk. Medical opti- mization may be required as an initial step. Often, however, the underlying pleural infection process remains unresolved despite optimal medical management, and surgical intervention becomes necessary in a patient who remains medically fragile. Optimally, the patient’s nutritional status should be normalized (with forced feedings, if necessary), and sepsis, if present, should be controlled with appropriate antibiotic therapy. TECHNICAL CONSIDERATIONS Figure 3 Shown is a chest CT scan from a patient with a pul- Essentially, pleural cavity infection and fibrosis are problems of monary abscess (arrow) complicated by pleural space infection. residual intrapleural space.The lung cannot expand sufficiently to The pleural space was drained via a chest tube thoracostomy. The lung did not completely reexpand. Sepsis was controlled with fill the hemithorax, and as a consequence, the residual space antibiotics. Decortication was not considered, because of the becomes or remains infected.These problems often prove difficult extensiveness of the underlying pulmonary parenchymal process. for the thoracic surgeon to address; good surgical judgment is cru- cial for ensuring optimal outcomes. In planning for decortication, there are a number of technical issues that must be considered, natives such as pleurodesis or use of the Pleurx pleural catheter including the timing of intervention (taking into account whether (Denver Biomedical, Golden, Colorado) may be indicated. the disease process is chronic or subacute), the quality of the underlying pulmonary parenchyma, the expected ability of the lung to reexpand, the possible need to address residual space Operative Planning issues, and the physiologic status of the patient. The goal of the procedure is to remove the peel from the visceral pleura so as to INDICATIONS FOR SURGICAL INTERVENTION allow the lung to reexpand and, equally important, to ensure that Fibrothorax is a potentially preventable complication. As noted any potential residual space is obliterated.11 (see above), it is a manifestation of a chronic disease process; thus, There are few absolute contraindications to pulmonary decorti- the earlier a therapeutic intervention is initiated, the better the cation, other than a patient who is unfit to undergo surgery or the chances that fibrothorax can be prevented. In patients with a trau- presence of underlying parenchymal or bronchial disease that matic hemothorax, early and complete drainage often serves to would prevent lung reexpansion. There are, however, some situa- prevent fibrothorax.5 Observational studies have consistently de- tions in which a lesser intervention (e.g., chest tube thoracostomy, monstrated that early evacuation of a clotted hemothorax reduces rib resection, or open window thoracostomy) might yield a better morbidity and mortality and prevents empyema.6,7 When para- outcome than decortication would from the patient’s perspective. pneumonic effusions are thin, simple aspiration or chest tube drain- In general, decortication is not required for a small, well-defined age may suffice. Often, the fibropurulent stage characterized by loc- residual cavity; it is usually reserved for a diffuse pleural process. ulated empyema or clotted hemothorax can be successfully man- Whether the disease process is chronic or subacute will also influ- aged by means of thoracoscopic intervention with debridement of ence the surgeon’s choice of approach. For example, in the earlier the intrathoracic debris and irrigation; this approach allows the stages of pleural space infection, when the peel is less organized, a parenchyma to reexpand before a restrictive peel can be formed.8 thoracoscopic approach that includes cleansing of the pleural The primary indication for decortication in a patient with fibro- space, removal of the pleural debris, and breaking up of loculations thorax is symptomatic pulmonary restriction resulting from the may prove adequate. With a chronic process, however, an attempt development of a fibrinous peel. The timing of the operation is an at thoracoscopic decortication may do more harm than good. important consideration. In many cases, pleuropulmonary process- es are self-limiting, and the symptoms resolve over time. As a rule, Operative Technique decortication should be considered (1) if pleural thickening has been present for a substantial period (> 4 to 6 weeks), (2) if respi- The first step in open decortication (which at times includes ratory symptoms remain disabling, and (3) if there is radiographic parietal pleurectomy in addition to decortication) is bronchoscop- evidence of reversible entrapment of the lung. Decortication is ic evaluation aimed at identifying any endobronchial obstructions often necessary when lesser interventions have not achieved control that might prevent satisfactory lung expansion. Such evaluation of a pleural space infection or have not enabled the lung to reex- sometimes yields unexpected findings, such as malignancy, pand. For tuberculous empyema, drug therapy remains the treat- bronchial stenosis, or a broncholith. ment of choice. Decortication may also be performed to treat The chest is entered at the appropriate predetermined inter- pleural effusions that persist despite long-term medical therapy. space (usually the fifth or sixth) via a standard posterolateral tho- A condition that poses a major challenge to the thoracic sur- racotomy [see Figure 4]; alternatively, a vertical axillary thoracoto- geon is pleural space infection with underlying parenchymal dis- my may be employed. With either approach, the latissimus dorsi
  4. 4. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 13 Decortication and Pleurectomy — 4 Figure 4 Decortication. The chest is entered through a posterolateral thoracotomy at the fifth or sixth interspace. Skin Incision and the serratus anterior should be spared because either or both operated on, coupled with continuous positive airway pressure might subsequently be required for a transposition muscle flap. (CPAP), should provide appropriate countertraction from the Because the chest is often rigid and contracted as a result of the underlying lung parenchyma. underlying inflammatory process, it may be helpful to resect a rib An incision is made in the pleural peel, and the appropriate in a subperiosteal fashion. This measure facilitates exposure and decortication plane is identified [see Figure 6a].The pleural peel is helps define the extrapleural plane for the initiation of parietal then grasped with hemostats, and blunt and sharp dissection is pleurectomy. carried out over a broad area to separate the peel from the viscer- When the disease process is chronic (i.e., has lasted longer than al pleura [see Figure 6b]; a sponge-ball or peanut dissector may be 6 weeks), the parietal pleura and the visceral pleura are often useful for this purpose. Care must be taken to keep from injuring fused. In this situation, one would proceed with pleurectomy. the underlying pulmonary parenchyma, which is fragile; inadver- When adhesions are present between the pleural layers but the vis- tent injury may result in prolonged and unnecessary air leaks. ceral pleura has not fused with the parietal pleura [see Figure 5], Some degree of patience is required, in that this operation often the adhesions may be lysed with a combination of sharp dissection becomes tedious. For an optimal surgical outcome, all portions of and electrocauterization. the lung encased by the peel should be addressed.To this end, it is The key to a technically successful decortication is to define the often necessary to follow the peel into the fissure, down onto the correct plane between the pleural peel and the visceral pleura. If diaphragm, and into the posterior and anterior sulci. At times, a the pleural resection is inadequate, lung expansion will be com- second entry point into the chest through another interspace may promised. If the pleurectomy is too deep, parenchymal injury will be required to achieve an optimal technical result. Should better result, bleeding and air leakage will occur, and postoperative exposure be deemed necessary, one should not hesitate to proceed recovery will be prolonged. Gentle manual ventilation of the lung with this counterincision. Figure 5 Decortication. Any adhesions between the visceral pleura and the parietal pleura are lysed with a combination of sharp dissection and electrocauterization. Adhesions between Visceral and Parietal Pleura
  5. 5. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 13 Decortication and Pleurectomy — 5 a Pleural Peel Incision into Pleural Peel Visceral Pleura Pleural Peel b Figure 6 Decortication. (a) With the lung expanded, the pleural peel is sharply incised, and the appropriate decortication plane is identified. (b) The peel is separat- ed from the visceral pleura with blunt and sharp dissection. Visceral Pleura Once resected, the peel is sent for pathologic and microbiolog- tus. Concerns related to residual space may be managed by means ic evaluation. The lung is tested to confirm that it is capable of of open tube thoracostomy, open window thoracostomy, or place- complete reexpansion. Any large parenchymal air leaks that are ment of a muscle flap. On rare occasions, thoracoplasty with mul- noted may be oversewn, but this step often is not necessary. The tiple rib resection may be considered to obliterate any infection in various pulmonary parenchymal sealants now commercially avail- the residual space by bringing the chest wall down to fill the space. able may reasonably be considered for control of parenchymal air- leaks. Chest tubes are placed—typically, one along the diaphragm, a second anteriorly, and a third posteriorly, toward the apex. Outcome Evaluation Provided that the lung is satisfactorily reexpanded, air leaks will The morbidity and mortality to be expected after decortication seal promptly. Hemostasis must be ensured: a residual hemotho- depend on the severity of the underlying illness and on the occur- rax in a patient with a pleural space infection will serve as a nidus rence of perioperative complications. In a review from 1985, mor- for ongoing infection. tality was less than 8%.13 Complications tend to be either infec- The role of parietal pleurectomy in this setting remains unclear. tion related (e.g., perioperative sepsis syndrome) or technique Opinions differ, but objective data are sparse. Parietal pleurectomy related (e.g., bronchopleural fistula, hemorrhage, and persistent does result in some improvement of the mechanics of the thoracic air leakage); some of them may necessitate additional surgical cage12; however, it also increases the risk of bleeding, prolongs the intervention. As with all operations in the chest, close attention to procedure, and places vital intrathoracic structures (e.g., the detail and meticulous surgical technique are critical for minimiz- phrenic and vagus nerves, the esophagus, the brachial plexus, and ing the incidence of postoperative complications. certain blood vessels) at risk for injury. In addition, it is often pos- The degree of functional improvement attained after decortica- sible that the pleural process will resolve without parietal pleurec- tion depends primarily on the presence and extent of disease in tomy once the underlying issues are addressed. The technically the underlying lung parenchyma.14-16 If the parenchyma of the optimal strategy may be to adopt a compromise approach—that is, lung is normal, complete reexpansion of the lung and obliteration to perform a partial parietal pleurectomy and to take extra care of the pleural space should be achievable. Lung volumes usually when dissecting near the vital mediastinal structures. improve measurably after decortication, but they generally do not Postoperative management of the chest tube is dictated by cul- return to normal.14,17 Changes within the chest (i.e., mediastinal ture results, intraoperative findings, and the patient’s clinical sta- shift and elevation of the diaphragm, with a resultant decrease in
  6. 6. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 13 Decortication and Pleurectomy — 6 Table 2 Causes of Failed Decortication Inability to define the plane of dissection between the peel and the visceral pleura is an especially troublesome technical chal- Active tuberculosis or invasive pulmonary infection lenge that can adversely affect results. If visceral pleurectomy is Underlying parenchymal disease Bronchial stenosis performed, air leakage and postoperative hemorrhage may com- Chronic lung collapse promise pulmonary function. Care must be taken throughout Residual space the operation to protect the phrenic nerve from injury; fortu- Inadequate lung expansion nately, this usually is not an issue, because the mediastinal pleu- Technical considerations Air leakage ra is rarely involved in the inflammatory process. Incomplete Postoperative hemothorax parietal pleurectomy or inability to free the diaphragm may also compromise results. If patients are appropriately selected, complete reexpansion of the lung after decortication can usually be achieved. Occasionally, the size of the thorax) may account for this finding. It is unclear to however, an issue related to residual pleural space may arise after what extent the expected functional improvement is influenced by an otherwise technically satisfactory decortication. If this space is whether the pleural process is acute or chronic. Some authors have not obliterated, failure is inevitable. Options for addressing the observed an association between shorter durations of pleural dis- residual space problem include thoracoplasty and tissue transpo- ease before treatment and improved outcomes18,19; others have not sition. Either the latissimus dorsi or the abdominal omentum will observed such an association.14 Failure to achieve improvement provide sufficient bulk for obliteration of the residual space.20,21 after decortication appears to be most strongly related to errors of The omentum is preferable when the space is in the inferior surgical judgment (in particular, poor patient selection) and to hemithorax, whereas the latissimus dorsi is preferable when the insufficiently meticulous surgical technique (leading to periopera- space is in the superior hemithorax. At the time of the initial inci- tive complications). sion, the surgeon should keep in mind the possibility that tissue Although to date, no studies have dealt specifically with fail- transposition may eventually prove necessary and should therefore ure after decortication, it is likely that technical difficulties are opt for a muscle-sparing thoracotomy if possible. the most common cause of such failure, with the main problem At present, the use of thoracoscopy to address fibrothorax being inadequate obliteration of the pleural space [see Table 2]. definitively cannot be recommended. References 1. Samson PC, Merrill DL, Dugan DJ, et al:Technical 9. Savage T, Flemin JA: Decortication of the lung in improvement following decortication in pulmonary considerations in decortication for the pleural com- tuberculous disease. Thorax 10:293, 1955 tuberculosis. Ann Thor Surg 1:532, 1965 plications of pulmonary tuberculosis. J Thorac Surg 10. Magdeleinat P, Icard P, Pouzet B, et al: Indications 17. LeMense GF, Strange CH, Sahn S: Empyema tho- Cardiovasc 36:431, 1958 actuelles et resultats des decortications pulmonaries racis: therapeutic management and outcome. Chest 2. Wachsmuth W, Schautz R: Untersuchungen uber die pour pleurisies purulentes non tuberculeuses. Ann 107:1532, 1994 Lungen-Pleura-Grenzschicht beider extrapleuralen Chir 53:41, 1999 18. Carroll D, McClement J, Himmelstein A, et al: Dekortikation. Chirurg 22:237, 1961 11. Kaiser LR: Pleurectomy and decortication. Atlas of Pulmonary function following decortication of the 3. Drummond DS, Craig RH:Traumatic hemothorax: General Thoracic Surgery. Philadelphia, Mosby- lung. Am Rev Tuberc 63:231, 1951 complications and management. Am Surg 33:404, Year Book, 1997 19. Morton JR, Boushy SF, Guinn GA: Physiological 1967 12. Waterman DH, Domm SE, Roger WK: A clinical evaluation of results of pulmonary decortication. Ann evaluation of decortication. J Thorac Cardiovasc Surg Thorac Surg 4:321, 1970 4. Bollinger CT, de Kock MA: Influence of a fibrotho- 33:1, 1957 rax on the flow volume curve. Respiration 54:197, 20. Marshall MD, Kaiser LR, Kucharczuk JC: Simple 1988 13. Mayo P: Early thoracotomy and decortication for technique for maximal thoracic muscle harvest. Ann nontuberculous empyema in adults with and with- Thorac Surg 4:1465, 2004 5. Wilson JM, et al: Traumatic hemothorax: is decorti- out underlying disease: a twenty-five year review. Am cation necessary? J Thorac Cardiovasc Surg 77:494, Surg 51:230, 1985 21. Shrager JB, Wain JC, Wright CD, et al: Omentum is 1979 highly effective in the management of complex car- 14. Patton WE, Watson TR, Gaensler EA: Pulmonary 6. Milfield DJ, Mattox KL, Beall AC: Early evacuation diothoracic surgical problems. J Thorac Cardiovasc function before and at intervals after surgical decor- of clotted hemothorax. Am J Surg 136:686, 1978 Surg 125:526, 2003 tication of the lung. Surg Gynecol Obstet 95:477, 7. Beall AC, Crawford HW, DeBakey ME: Consider- 1952 ations in the management of acute traumatic hemo- 15. Siebens AA, Storey CF, Newman MM, et al: The thorax. J Thorac Cardiovasc Surg 52:353, 1966 physiological effects of fibrothorax and the function- 8. Deslauriers J, Mehran RJ: Role of thoracoscopy in al results of surgical treatment. J Thorac Surg 32:53, Acknowledgment the diagnosis and management of pleural disease. 1956 Semin Thorac Cardiovasc Surg 5:284, 1993 16. Barker WL, Neuhaus H, Langston HT: Ventilatory Figures 4 through 6 Alice Y. Chen.

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