Surgery for pleural mesothelioma - Revision history

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:46:19Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:46, 21 February 2022
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	\|Hypercoagulability due to underlying malignancy		\|Hypercoagulability due to underlying malignancy
	\|-		\|-
	\|~~Respiratory~~		\|Pulmonary
	\|Pulmonary function testing; CT scan to evaluate extent of lung compression on the operative side, extent of pleural effusion		\|Pulmonary function testing; CT scan to evaluate extent of lung compression on the operative side, extent of pleural effusion
	\|-		\|-

Karen.Sibert at 17:43, 13 November 2021

2021-11-13T17:43:30Z

← Older revision		Revision as of 10:43, 13 November 2021
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	# Video laryngoscope		# Video laryngoscope
	# Arterial line setup and transducer		# Arterial line setup and transducer
	# Consider flow parameter monitoring (e.g. FloTrac system, Edwards Lifesciences)		# Consider flow parameter monitoring (e.g. [https://www.edwards.com/devices/hemodynamic-monitoring/FloTrac FloTrac system, Edwards Lifesciences])
	# IV fluid warming device		# IV fluid warming device
	# Infusion pumps for vasoactive infusion		# Infusion pumps for vasoactive infusion

Karen.Sibert: Added photo

2021-11-13T16:56:29Z

Added photo

← Older revision		Revision as of 09:56, 13 November 2021
Line 9:		Line 9:
	}}Malignant pleural mesothelioma (MPM) is an aggressive disease, is often diagnosed at an advanced stage, and has a 5-year survival rate of only 5 to 10%.<ref>{{Cite journal\|last=Janes\|first=Sam M.\|last2=Alrifai\|first2=Doraid\|last3=Fennell\|first3=Dean A.\|date=2021-09-23\|editor-last=Longo\|editor-first=Dan L.\|title=Perspectives on the Treatment of Malignant Pleural Mesothelioma\|url=http://www.nejm.org/doi/10.1056/NEJMra1912719\|journal=New England Journal of Medicine\|language=en\|volume=385\|issue=13\|pages=1207–1218\|doi=10.1056/NEJMra1912719\|issn=0028-4793}}</ref> The most important risk factor for its development is exposure to asbestos; the transformation of work practices worldwide has led to a modest decline in incidence. The three primary histologic types are epithelioid, sarcomatoid, and biphasic or mixed histology, with epithelioid resulting in more favorable outcomes than sarcomatoid or mixed histology.<ref>{{Cite journal\|last=Neragi-Miandoab\|first=Siyamek\|last2=Richards\|first2=William G.\|last3=Sugarbaker\|first3=David J.\|date=2008-08-01\|title=Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma\|url=https://www.sciencedirect.com/science/article/pii/S1743919108000605\|journal=International Journal of Surgery\|language=en\|volume=6\|issue=4\|pages=293–297\|doi=10.1016/j.ijsu.2008.04.004\|issn=1743-9191}}</ref><ref>{{Cite journal\|last=Vigneswaran\|first=Wickii T.\|last2=Kircheva\|first2=Diana Y.\|last3=Ananthanarayanan\|first3=Vijayalakshimi\|last4=Watson\|first4=Sydeaka\|last5=Arif\|first5=Qudsia\|last6=Celauro\|first6=Amy Durkin\|last7=Kindler\|first7=Hedy L.\|last8=Husain\|first8=Aliya N.\|date=March 1, 2017\|title=Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497516311316\|journal=The Annals of Thoracic Surgery\|language=en\|volume=103\|issue=3\|pages=962–966\|doi=10.1016/j.athoracsur.2016.08.063\|via=}}</ref>		}}Malignant pleural mesothelioma (MPM) is an aggressive disease, is often diagnosed at an advanced stage, and has a 5-year survival rate of only 5 to 10%.<ref>{{Cite journal\|last=Janes\|first=Sam M.\|last2=Alrifai\|first2=Doraid\|last3=Fennell\|first3=Dean A.\|date=2021-09-23\|editor-last=Longo\|editor-first=Dan L.\|title=Perspectives on the Treatment of Malignant Pleural Mesothelioma\|url=http://www.nejm.org/doi/10.1056/NEJMra1912719\|journal=New England Journal of Medicine\|language=en\|volume=385\|issue=13\|pages=1207–1218\|doi=10.1056/NEJMra1912719\|issn=0028-4793}}</ref> The most important risk factor for its development is exposure to asbestos; the transformation of work practices worldwide has led to a modest decline in incidence. The three primary histologic types are epithelioid, sarcomatoid, and biphasic or mixed histology, with epithelioid resulting in more favorable outcomes than sarcomatoid or mixed histology.<ref>{{Cite journal\|last=Neragi-Miandoab\|first=Siyamek\|last2=Richards\|first2=William G.\|last3=Sugarbaker\|first3=David J.\|date=2008-08-01\|title=Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma\|url=https://www.sciencedirect.com/science/article/pii/S1743919108000605\|journal=International Journal of Surgery\|language=en\|volume=6\|issue=4\|pages=293–297\|doi=10.1016/j.ijsu.2008.04.004\|issn=1743-9191}}</ref><ref>{{Cite journal\|last=Vigneswaran\|first=Wickii T.\|last2=Kircheva\|first2=Diana Y.\|last3=Ananthanarayanan\|first3=Vijayalakshimi\|last4=Watson\|first4=Sydeaka\|last5=Arif\|first5=Qudsia\|last6=Celauro\|first6=Amy Durkin\|last7=Kindler\|first7=Hedy L.\|last8=Husain\|first8=Aliya N.\|date=March 1, 2017\|title=Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497516311316\|journal=The Annals of Thoracic Surgery\|language=en\|volume=103\|issue=3\|pages=962–966\|doi=10.1016/j.athoracsur.2016.08.063\|via=}}</ref>

	One of two operations is performed: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. P/D is a lung-sparing but still radical procedure in which the diseased pleural envelope that encases and constricts the lung is dissected from the chest wall, mediastinum, ~~diaphram~~, and pericardium, and then is stripped from the surface of the lung.<ref>{{Cite journal\|last=Wolf\|first=Andrea S.\|last2=Daniel\|first2=Jonathan\|last3=Sugarbaker\|first3=David J.\|date=2009-06-01\|title=Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma: Extrapleural Pneumonectomy and Pleurectomy/Decortication\|url=https://www.semthorcardiovascsurg.com/article/S1043-0679(09)00084-7/abstract\|journal=Seminars in Thoracic and Cardiovascular Surgery\|language=English\|volume=21\|issue=2\|pages=132–148\|doi=10.1053/j.semtcvs.2009.07.007\|issn=1043-0679\|pmid=19822285}}</ref><ref>{{Cite journal\|last=Ng\|first=Ju-Mei\|last2=Hartigan\|first2=Philip M.\|date=February 1, 2008\|title=Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma\|url=https://journals.lww.com/co-anesthesiology/Abstract/2008/02000/Anesthetic_management_of_patients_undergoing.6.aspx\|journal=Current Opinion in Anesthesiology\|language=en-US\|volume=21\|issue=1\|pages=21–27\|doi=10.1097/ACO.0b013e3282f2a9c3\|issn=0952-7907\|via=}}</ref><ref>{{Cite journal\|last=Vlahu\|first=Tedi\|last2=Vigneswaran\|first2=Wicki T.\|date=June 1, 2017\|title=Pleurectomy and decortication\|url=http://atm.amegroups.com/article/view/14825/15364\|journal=Annals of Translational Medicine\|volume=5\|issue=11\|pages=246–246\|doi=10.21037/atm.2017.04.03\|pmc=PMC5497109\|pmid=28706914\|via=}}</ref>P/D is the more frequently used approach as of this writing as EPP has shown no survival advantage and patients experience improved quality of life when the lung remains intact.<ref>{{Cite journal\|last=Infante\|first=Maurizio\|last2=Morenghi\|first2=Emanuela\|last3=Bottoni\|first3=Edoardo\|last4=Zucali\|first4=Paolo\|last5=Rahal\|first5=Daoud\|last6=Morlacchi\|first6=Andrea\|last7=Ascolese\|first7=Anna Maria\|last8=De Rose\|first8=Fiorenza\|last9=Navarria\|first9=Pierina\|last10=Crepaldi\|first10=Alessandro\|last11=Testori\|first11=Alberto\|date=December 1, 2016\|title=Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma\|url=https://academic.oup.com/ejcts/article-lookup/doi/10.1093/ejcts/ezw215\|journal=European Journal of Cardio-Thoracic Surgery\|language=en\|volume=50\|issue=6\|pages=1077–1082\|doi=10.1093/ejcts/ezw215\|issn=1010-7940\|via=}}</ref><ref>{{Cite journal\|last=Sugarbaker\|first=David J\|last2=Wolf\|first2=Andrea S\|date=June 1, 2010\|title=Surgery for malignant pleural mesothelioma\|url=http://www.tandfonline.com/doi/full/10.1586/ers.10.35\|journal=Expert Review of Respiratory Medicine\|language=en\|volume=4\|issue=3\|pages=363–372\|doi=10.1586/ers.10.35\|issn=1747-6348\|via=}}</ref><ref>{{Cite journal\|last=Neragi-Miandoab\|first=S.\|last2=Weiner\|first2=S.\|last3=Sugarbaker\|first3=D. J.\|date=2008-12-01\|title=Incidence of atrial fibrillation after extrapleural pneumonectomy vs. pleurectomy in patients with malignant pleural mesothelioma\|url=https://academic.oup.com/icvts/article-lookup/doi/10.1510/icvts.2008.181099\|journal=Interactive CardioVascular and Thoracic Surgery\|language=en\|volume=7\|issue=6\|pages=1039–1042\|doi=10.1510/icvts.2008.181099\|issn=1569-9293}}</ref>		One of two operations is performed: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. P/D is a lung-sparing but still radical procedure in which the diseased pleural envelope that encases and constricts the lung is dissected from the chest wall, mediastinum, diaphragm, and pericardium, and then is stripped from the surface of the lung.<ref>{{Cite journal\|last=Wolf\|first=Andrea S.\|last2=Daniel\|first2=Jonathan\|last3=Sugarbaker\|first3=David J.\|date=2009-06-01\|title=Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma: Extrapleural Pneumonectomy and Pleurectomy/Decortication\|url=https://www.semthorcardiovascsurg.com/article/S1043-0679(09)00084-7/abstract\|journal=Seminars in Thoracic and Cardiovascular Surgery\|language=English\|volume=21\|issue=2\|pages=132–148\|doi=10.1053/j.semtcvs.2009.07.007\|issn=1043-0679\|pmid=19822285}}</ref><ref>{{Cite journal\|last=Ng\|first=Ju-Mei\|last2=Hartigan\|first2=Philip M.\|date=February 1, 2008\|title=Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma\|url=https://journals.lww.com/co-anesthesiology/Abstract/2008/02000/Anesthetic_management_of_patients_undergoing.6.aspx\|journal=Current Opinion in Anesthesiology\|language=en-US\|volume=21\|issue=1\|pages=21–27\|doi=10.1097/ACO.0b013e3282f2a9c3\|issn=0952-7907\|via=}}</ref><ref>{{Cite journal\|last=Vlahu\|first=Tedi\|last2=Vigneswaran\|first2=Wicki T.\|date=June 1, 2017\|title=Pleurectomy and decortication\|url=http://atm.amegroups.com/article/view/14825/15364\|journal=Annals of Translational Medicine\|volume=5\|issue=11\|pages=246–246\|doi=10.21037/atm.2017.04.03\|pmc=PMC5497109\|pmid=28706914\|via=}}</ref> P/D is the more frequently used approach as of this writing as EPP has shown no survival advantage and patients experience improved quality of life when the lung remains intact.<ref>{{Cite journal\|last=Infante\|first=Maurizio\|last2=Morenghi\|first2=Emanuela\|last3=Bottoni\|first3=Edoardo\|last4=Zucali\|first4=Paolo\|last5=Rahal\|first5=Daoud\|last6=Morlacchi\|first6=Andrea\|last7=Ascolese\|first7=Anna Maria\|last8=De Rose\|first8=Fiorenza\|last9=Navarria\|first9=Pierina\|last10=Crepaldi\|first10=Alessandro\|last11=Testori\|first11=Alberto\|date=December 1, 2016\|title=Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma\|url=https://academic.oup.com/ejcts/article-lookup/doi/10.1093/ejcts/ezw215\|journal=European Journal of Cardio-Thoracic Surgery\|language=en\|volume=50\|issue=6\|pages=1077–1082\|doi=10.1093/ejcts/ezw215\|issn=1010-7940\|via=}}</ref><ref>{{Cite journal\|last=Sugarbaker\|first=David J\|last2=Wolf\|first2=Andrea S\|date=June 1, 2010\|title=Surgery for malignant pleural mesothelioma\|url=http://www.tandfonline.com/doi/full/10.1586/ers.10.35\|journal=Expert Review of Respiratory Medicine\|language=en\|volume=4\|issue=3\|pages=363–372\|doi=10.1586/ers.10.35\|issn=1747-6348\|via=}}</ref><ref>{{Cite journal\|last=Neragi-Miandoab\|first=S.\|last2=Weiner\|first2=S.\|last3=Sugarbaker\|first3=D. J.\|date=2008-12-01\|title=Incidence of atrial fibrillation after extrapleural pneumonectomy vs. pleurectomy in patients with malignant pleural mesothelioma\|url=https://academic.oup.com/icvts/article-lookup/doi/10.1510/icvts.2008.181099\|journal=Interactive CardioVascular and Thoracic Surgery\|language=en\|volume=7\|issue=6\|pages=1039–1042\|doi=10.1510/icvts.2008.181099\|issn=1569-9293}}</ref>

	Currently a multi-center trial, MARS 2, is ongoing in the UK to test the hypothesis that P/D and chemotherapy is superior to chemotherapy alone with respect to overall survival for patients with pleural mesothelioma. The trial will also examine a range of secondary outcomes including adverse health events and cost-effectiveness. If the results of this trial are negative, there will be reason to question if radical surgery, as opposed to palliative procedures such as PleurX catheter insertion, should continue to have a role in the treatment of mesothelioma.<ref>{{Cite journal\|last=Lim\|first=Eric\|last2=Darlison\|first2=Liz\|last3=Edwards\|first3=John\|last4=Elliott\|first4=Daisy\|last5=Fennell\|first5=D A\|last6=Popat\|first6=Sanjay\|last7=Rintoul\|first7=Robert C\|last8=Waller\|first8=David\|last9=Ali\|first9=Clinton\|last10=Bille\|first10=Andrea\|last11=Fuller\|first11=Liz\|date=September 1, 2020\|title=Mesothelioma and Radical Surgery 2 (MARS 2): protocol for a multicentre randomised trial comparing (extended) pleurectomy decortication versus no (extended) pleurectomy decortication for patients with malignant pleural mesothelioma\|url=https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2020-038892\|journal=BMJ Open\|language=en\|volume=10\|issue=9\|pages=e038892\|doi=10.1136/bmjopen-2020-038892\|issn=2044-6055\|pmc=PMC7467531\|pmid=32873681\|via=}}</ref>		Currently a multi-center trial, MARS 2, is ongoing in the UK to test the hypothesis that P/D and chemotherapy is superior to chemotherapy alone with respect to overall survival for patients with pleural mesothelioma. The trial will also examine a range of secondary outcomes including adverse health events and cost-effectiveness. If the results of this trial are negative, there will be reason to question if radical surgery, as opposed to palliative procedures such as [[PleurX catheter insertion]], should continue to have a role in the treatment of mesothelioma.<ref>{{Cite journal\|last=Lim\|first=Eric\|last2=Darlison\|first2=Liz\|last3=Edwards\|first3=John\|last4=Elliott\|first4=Daisy\|last5=Fennell\|first5=D A\|last6=Popat\|first6=Sanjay\|last7=Rintoul\|first7=Robert C\|last8=Waller\|first8=David\|last9=Ali\|first9=Clinton\|last10=Bille\|first10=Andrea\|last11=Fuller\|first11=Liz\|date=September 1, 2020\|title=Mesothelioma and Radical Surgery 2 (MARS 2): protocol for a multicentre randomised trial comparing (extended) pleurectomy decortication versus no (extended) pleurectomy decortication for patients with malignant pleural mesothelioma\|url=https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2020-038892\|journal=BMJ Open\|language=en\|volume=10\|issue=9\|pages=e038892\|doi=10.1136/bmjopen-2020-038892\|issn=2044-6055\|pmc=PMC7467531\|pmid=32873681\|via=}}</ref>
			[[File:Mesothelioma tumors.png\|thumb\|Mesothelioma tumors studding the pleura]]
	This article will focus on the anesthetic management of radical pleurectomy/decortication, which is done via open thoracotomy with one-lung ventilation by double-lumen endotracheal tube. These procedures may last for eight hours or more, and typically involve substantial blood and fluid loss. Most centers send patients directly to ICU whether or not extubation is possible at the conclusion of surgery.		This article will focus on the anesthetic management of radical pleurectomy/decortication, which is done via open thoracotomy with one-lung ventilation by double-lumen endotracheal tube (DLT). These procedures may last for eight hours or more, and typically involve substantial blood and fluid loss. Most centers send patients directly to ICU whether or not extubation is possible at the conclusion of surgery.

	== Preoperative management ==		== Preoperative management ==

Karen.Sibert: Correcting some punctuation and capitalization

2021-11-11T18:16:02Z

Correcting some punctuation and capitalization

← Older revision		Revision as of 11:16, 11 November 2021
Line 2:		Line 2:
	\| anesthesia_type = General		\| anesthesia_type = General
	\| airway = Double-lumen tube; CPAP and PEEP control equipment		\| airway = Double-lumen tube; CPAP and PEEP control equipment
	\| lines_access = Arterial line +/- flow monitoring equipment (i.e. ~~Flotrac~~); ~~Large~~ bore peripheral access		\| lines_access = Arterial line +/- flow monitoring equipment (e.g. FloTrac); large-bore peripheral access
	\| monitors = Standard; blood gas monitoring		\| monitors = Standard; blood gas monitoring
	\| considerations_preoperative = Cardiac testing and prehabilitation		\| considerations_preoperative = Cardiac testing and prehabilitation
	\| considerations_intraoperative = ~~vasoplegia~~; colloid infusion requirements		\| considerations_intraoperative = Vasoplegia; colloid infusion requirements
	\| considerations_postoperative = Extended post-op hypotension and fluid shifts; large ~~post-operative~~ air leaks from chest tubes		\| considerations_postoperative = Extended post-op hypotension and fluid shifts; large air leaks from chest tubes
	}}Malignant pleural mesothelioma (MPM) is an aggressive disease, is often diagnosed at an advanced stage, and has a 5-year survival rate of only 5 to 10%.<ref>{{Cite journal\|last=Janes\|first=Sam M.\|last2=Alrifai\|first2=Doraid\|last3=Fennell\|first3=Dean A.\|date=2021-09-23\|editor-last=Longo\|editor-first=Dan L.\|title=Perspectives on the Treatment of Malignant Pleural Mesothelioma\|url=http://www.nejm.org/doi/10.1056/NEJMra1912719\|journal=New England Journal of Medicine\|language=en\|volume=385\|issue=13\|pages=1207–1218\|doi=10.1056/NEJMra1912719\|issn=0028-4793}}</ref> The most important risk factor for its development is exposure to asbestos; the transformation of work practices worldwide has led to a modest decline in incidence. The three primary histologic types are epithelioid, sarcomatoid, and biphasic or mixed histology, with epithelioid resulting in more favorable outcomes than sarcomatoid or mixed histology.<ref>{{Cite journal\|last=Neragi-Miandoab\|first=Siyamek\|last2=Richards\|first2=William G.\|last3=Sugarbaker\|first3=David J.\|date=2008-08-01\|title=Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma\|url=https://www.sciencedirect.com/science/article/pii/S1743919108000605\|journal=International Journal of Surgery\|language=en\|volume=6\|issue=4\|pages=293–297\|doi=10.1016/j.ijsu.2008.04.004\|issn=1743-9191}}</ref><ref>{{Cite journal\|last=Vigneswaran\|first=Wickii T.\|last2=Kircheva\|first2=Diana Y.\|last3=Ananthanarayanan\|first3=Vijayalakshimi\|last4=Watson\|first4=Sydeaka\|last5=Arif\|first5=Qudsia\|last6=Celauro\|first6=Amy Durkin\|last7=Kindler\|first7=Hedy L.\|last8=Husain\|first8=Aliya N.\|date=March 1, 2017\|title=Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497516311316\|journal=The Annals of Thoracic Surgery\|language=en\|volume=103\|issue=3\|pages=962–966\|doi=10.1016/j.athoracsur.2016.08.063\|via=}}</ref>		}}Malignant pleural mesothelioma (MPM) is an aggressive disease, is often diagnosed at an advanced stage, and has a 5-year survival rate of only 5 to 10%.<ref>{{Cite journal\|last=Janes\|first=Sam M.\|last2=Alrifai\|first2=Doraid\|last3=Fennell\|first3=Dean A.\|date=2021-09-23\|editor-last=Longo\|editor-first=Dan L.\|title=Perspectives on the Treatment of Malignant Pleural Mesothelioma\|url=http://www.nejm.org/doi/10.1056/NEJMra1912719\|journal=New England Journal of Medicine\|language=en\|volume=385\|issue=13\|pages=1207–1218\|doi=10.1056/NEJMra1912719\|issn=0028-4793}}</ref> The most important risk factor for its development is exposure to asbestos; the transformation of work practices worldwide has led to a modest decline in incidence. The three primary histologic types are epithelioid, sarcomatoid, and biphasic or mixed histology, with epithelioid resulting in more favorable outcomes than sarcomatoid or mixed histology.<ref>{{Cite journal\|last=Neragi-Miandoab\|first=Siyamek\|last2=Richards\|first2=William G.\|last3=Sugarbaker\|first3=David J.\|date=2008-08-01\|title=Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma\|url=https://www.sciencedirect.com/science/article/pii/S1743919108000605\|journal=International Journal of Surgery\|language=en\|volume=6\|issue=4\|pages=293–297\|doi=10.1016/j.ijsu.2008.04.004\|issn=1743-9191}}</ref><ref>{{Cite journal\|last=Vigneswaran\|first=Wickii T.\|last2=Kircheva\|first2=Diana Y.\|last3=Ananthanarayanan\|first3=Vijayalakshimi\|last4=Watson\|first4=Sydeaka\|last5=Arif\|first5=Qudsia\|last6=Celauro\|first6=Amy Durkin\|last7=Kindler\|first7=Hedy L.\|last8=Husain\|first8=Aliya N.\|date=March 1, 2017\|title=Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497516311316\|journal=The Annals of Thoracic Surgery\|language=en\|volume=103\|issue=3\|pages=962–966\|doi=10.1016/j.athoracsur.2016.08.063\|via=}}</ref>

Nkamdar at 01:52, 8 November 2021

2021-11-08T01:52:09Z

← Older revision		Revision as of 18:52, 7 November 2021
Line 1:		Line 1:

	Malignant pleural mesothelioma (MPM) is an aggressive disease, is often diagnosed at an advanced stage, and has a 5-year survival rate of only 5 to 10%.<ref>{{Cite journal\|last=Janes\|first=Sam M.\|last2=Alrifai\|first2=Doraid\|last3=Fennell\|first3=Dean A.\|date=2021-09-23\|editor-last=Longo\|editor-first=Dan L.\|title=Perspectives on the Treatment of Malignant Pleural Mesothelioma\|url=http://www.nejm.org/doi/10.1056/NEJMra1912719\|journal=New England Journal of Medicine\|language=en\|volume=385\|issue=13\|pages=1207–1218\|doi=10.1056/NEJMra1912719\|issn=0028-4793}}</ref> The most important risk factor for its development

	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type = General		\| anesthesia_type = General
Line 10:		Line 7:
	\| considerations_intraoperative = vasoplegia; colloid infusion requirements		\| considerations_intraoperative = vasoplegia; colloid infusion requirements
	\| considerations_postoperative = Extended post-op hypotension and fluid shifts; large post-operative air leaks from chest tubes		\| considerations_postoperative = Extended post-op hypotension and fluid shifts; large post-operative air leaks from chest tubes
	}}		}}Malignant pleural mesothelioma (MPM) is an aggressive disease, is often diagnosed at an advanced stage, and has a 5-year survival rate of only 5 to 10%.<ref>{{Cite journal\|last=Janes\|first=Sam M.\|last2=Alrifai\|first2=Doraid\|last3=Fennell\|first3=Dean A.\|date=2021-09-23\|editor-last=Longo\|editor-first=Dan L.\|title=Perspectives on the Treatment of Malignant Pleural Mesothelioma\|url=http://www.nejm.org/doi/10.1056/NEJMra1912719\|journal=New England Journal of Medicine\|language=en\|volume=385\|issue=13\|pages=1207–1218\|doi=10.1056/NEJMra1912719\|issn=0028-4793}}</ref> The most important risk factor for its development is exposure to asbestos; the transformation of work practices worldwide has led to a modest decline in incidence. The three primary histologic types are epithelioid, sarcomatoid, and biphasic or mixed histology, with epithelioid resulting in more favorable outcomes than sarcomatoid or mixed histology.<ref>{{Cite journal\|last=Neragi-Miandoab\|first=Siyamek\|last2=Richards\|first2=William G.\|last3=Sugarbaker\|first3=David J.\|date=2008-08-01\|title=Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma\|url=https://www.sciencedirect.com/science/article/pii/S1743919108000605\|journal=International Journal of Surgery\|language=en\|volume=6\|issue=4\|pages=293–297\|doi=10.1016/j.ijsu.2008.04.004\|issn=1743-9191}}</ref><ref>{{Cite journal\|last=Vigneswaran\|first=Wickii T.\|last2=Kircheva\|first2=Diana Y.\|last3=Ananthanarayanan\|first3=Vijayalakshimi\|last4=Watson\|first4=Sydeaka\|last5=Arif\|first5=Qudsia\|last6=Celauro\|first6=Amy Durkin\|last7=Kindler\|first7=Hedy L.\|last8=Husain\|first8=Aliya N.\|date=March 1, 2017\|title=Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497516311316\|journal=The Annals of Thoracic Surgery\|language=en\|volume=103\|issue=3\|pages=962–966\|doi=10.1016/j.athoracsur.2016.08.063\|via=}}</ref>

	is exposure to asbestos; the transformation of work practices worldwide has led to a modest decline in incidence. The three primary histologic types are epithelioid, sarcomatoid, and biphasic or mixed histology, with epithelioid resulting in more favorable outcomes than sarcomatoid or mixed histology.<ref>{{Cite journal\|last=Neragi-Miandoab\|first=Siyamek\|last2=Richards\|first2=William G.\|last3=Sugarbaker\|first3=David J.\|date=2008-08-01\|title=Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma\|url=https://www.sciencedirect.com/science/article/pii/S1743919108000605\|journal=International Journal of Surgery\|language=en\|volume=6\|issue=4\|pages=293–297\|doi=10.1016/j.ijsu.2008.04.004\|issn=1743-9191}}</ref><ref>{{Cite journal\|last=Vigneswaran\|first=Wickii T.\|last2=Kircheva\|first2=Diana Y.\|last3=Ananthanarayanan\|first3=Vijayalakshimi\|last4=Watson\|first4=Sydeaka\|last5=Arif\|first5=Qudsia\|last6=Celauro\|first6=Amy Durkin\|last7=Kindler\|first7=Hedy L.\|last8=Husain\|first8=Aliya N.\|date=March 1, 2017\|title=Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497516311316\|journal=The Annals of Thoracic Surgery\|language=en\|volume=103\|issue=3\|pages=962–966\|doi=10.1016/j.athoracsur.2016.08.063\|via=}}</ref>

	One of two operations is performed: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. P/D is a lung-sparing but still radical procedure in which the diseased pleural envelope that encases and constricts the lung is dissected from the chest wall, mediastinum, diaphram, and pericardium, and then is stripped from the surface of the lung.<ref>{{Cite journal\|last=Wolf\|first=Andrea S.\|last2=Daniel\|first2=Jonathan\|last3=Sugarbaker\|first3=David J.\|date=2009-06-01\|title=Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma: Extrapleural Pneumonectomy and Pleurectomy/Decortication\|url=https://www.semthorcardiovascsurg.com/article/S1043-0679(09)00084-7/abstract\|journal=Seminars in Thoracic and Cardiovascular Surgery\|language=English\|volume=21\|issue=2\|pages=132–148\|doi=10.1053/j.semtcvs.2009.07.007\|issn=1043-0679\|pmid=19822285}}</ref><ref>{{Cite journal\|last=Ng\|first=Ju-Mei\|last2=Hartigan\|first2=Philip M.\|date=February 1, 2008\|title=Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma\|url=https://journals.lww.com/co-anesthesiology/Abstract/2008/02000/Anesthetic_management_of_patients_undergoing.6.aspx\|journal=Current Opinion in Anesthesiology\|language=en-US\|volume=21\|issue=1\|pages=21–27\|doi=10.1097/ACO.0b013e3282f2a9c3\|issn=0952-7907\|via=}}</ref><ref>{{Cite journal\|last=Vlahu\|first=Tedi\|last2=Vigneswaran\|first2=Wicki T.\|date=June 1, 2017\|title=Pleurectomy and decortication\|url=http://atm.amegroups.com/article/view/14825/15364\|journal=Annals of Translational Medicine\|volume=5\|issue=11\|pages=246–246\|doi=10.21037/atm.2017.04.03\|pmc=PMC5497109\|pmid=28706914\|via=}}</ref>P/D is the more frequently used approach as of this writing as EPP has shown no survival advantage and patients experience improved quality of life when the lung remains intact.<ref>{{Cite journal\|last=Infante\|first=Maurizio\|last2=Morenghi\|first2=Emanuela\|last3=Bottoni\|first3=Edoardo\|last4=Zucali\|first4=Paolo\|last5=Rahal\|first5=Daoud\|last6=Morlacchi\|first6=Andrea\|last7=Ascolese\|first7=Anna Maria\|last8=De Rose\|first8=Fiorenza\|last9=Navarria\|first9=Pierina\|last10=Crepaldi\|first10=Alessandro\|last11=Testori\|first11=Alberto\|date=December 1, 2016\|title=Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma\|url=https://academic.oup.com/ejcts/article-lookup/doi/10.1093/ejcts/ezw215\|journal=European Journal of Cardio-Thoracic Surgery\|language=en\|volume=50\|issue=6\|pages=1077–1082\|doi=10.1093/ejcts/ezw215\|issn=1010-7940\|via=}}</ref><ref>{{Cite journal\|last=Sugarbaker\|first=David J\|last2=Wolf\|first2=Andrea S\|date=June 1, 2010\|title=Surgery for malignant pleural mesothelioma\|url=http://www.tandfonline.com/doi/full/10.1586/ers.10.35\|journal=Expert Review of Respiratory Medicine\|language=en\|volume=4\|issue=3\|pages=363–372\|doi=10.1586/ers.10.35\|issn=1747-6348\|via=}}</ref><ref>{{Cite journal\|last=Neragi-Miandoab\|first=S.\|last2=Weiner\|first2=S.\|last3=Sugarbaker\|first3=D. J.\|date=2008-12-01\|title=Incidence of atrial fibrillation after extrapleural pneumonectomy vs. pleurectomy in patients with malignant pleural mesothelioma\|url=https://academic.oup.com/icvts/article-lookup/doi/10.1510/icvts.2008.181099\|journal=Interactive CardioVascular and Thoracic Surgery\|language=en\|volume=7\|issue=6\|pages=1039–1042\|doi=10.1510/icvts.2008.181099\|issn=1569-9293}}</ref>		One of two operations is performed: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. P/D is a lung-sparing but still radical procedure in which the diseased pleural envelope that encases and constricts the lung is dissected from the chest wall, mediastinum, diaphram, and pericardium, and then is stripped from the surface of the lung.<ref>{{Cite journal\|last=Wolf\|first=Andrea S.\|last2=Daniel\|first2=Jonathan\|last3=Sugarbaker\|first3=David J.\|date=2009-06-01\|title=Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma: Extrapleural Pneumonectomy and Pleurectomy/Decortication\|url=https://www.semthorcardiovascsurg.com/article/S1043-0679(09)00084-7/abstract\|journal=Seminars in Thoracic and Cardiovascular Surgery\|language=English\|volume=21\|issue=2\|pages=132–148\|doi=10.1053/j.semtcvs.2009.07.007\|issn=1043-0679\|pmid=19822285}}</ref><ref>{{Cite journal\|last=Ng\|first=Ju-Mei\|last2=Hartigan\|first2=Philip M.\|date=February 1, 2008\|title=Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma\|url=https://journals.lww.com/co-anesthesiology/Abstract/2008/02000/Anesthetic_management_of_patients_undergoing.6.aspx\|journal=Current Opinion in Anesthesiology\|language=en-US\|volume=21\|issue=1\|pages=21–27\|doi=10.1097/ACO.0b013e3282f2a9c3\|issn=0952-7907\|via=}}</ref><ref>{{Cite journal\|last=Vlahu\|first=Tedi\|last2=Vigneswaran\|first2=Wicki T.\|date=June 1, 2017\|title=Pleurectomy and decortication\|url=http://atm.amegroups.com/article/view/14825/15364\|journal=Annals of Translational Medicine\|volume=5\|issue=11\|pages=246–246\|doi=10.21037/atm.2017.04.03\|pmc=PMC5497109\|pmid=28706914\|via=}}</ref>P/D is the more frequently used approach as of this writing as EPP has shown no survival advantage and patients experience improved quality of life when the lung remains intact.<ref>{{Cite journal\|last=Infante\|first=Maurizio\|last2=Morenghi\|first2=Emanuela\|last3=Bottoni\|first3=Edoardo\|last4=Zucali\|first4=Paolo\|last5=Rahal\|first5=Daoud\|last6=Morlacchi\|first6=Andrea\|last7=Ascolese\|first7=Anna Maria\|last8=De Rose\|first8=Fiorenza\|last9=Navarria\|first9=Pierina\|last10=Crepaldi\|first10=Alessandro\|last11=Testori\|first11=Alberto\|date=December 1, 2016\|title=Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma\|url=https://academic.oup.com/ejcts/article-lookup/doi/10.1093/ejcts/ezw215\|journal=European Journal of Cardio-Thoracic Surgery\|language=en\|volume=50\|issue=6\|pages=1077–1082\|doi=10.1093/ejcts/ezw215\|issn=1010-7940\|via=}}</ref><ref>{{Cite journal\|last=Sugarbaker\|first=David J\|last2=Wolf\|first2=Andrea S\|date=June 1, 2010\|title=Surgery for malignant pleural mesothelioma\|url=http://www.tandfonline.com/doi/full/10.1586/ers.10.35\|journal=Expert Review of Respiratory Medicine\|language=en\|volume=4\|issue=3\|pages=363–372\|doi=10.1586/ers.10.35\|issn=1747-6348\|via=}}</ref><ref>{{Cite journal\|last=Neragi-Miandoab\|first=S.\|last2=Weiner\|first2=S.\|last3=Sugarbaker\|first3=D. J.\|date=2008-12-01\|title=Incidence of atrial fibrillation after extrapleural pneumonectomy vs. pleurectomy in patients with malignant pleural mesothelioma\|url=https://academic.oup.com/icvts/article-lookup/doi/10.1510/icvts.2008.181099\|journal=Interactive CardioVascular and Thoracic Surgery\|language=en\|volume=7\|issue=6\|pages=1039–1042\|doi=10.1510/icvts.2008.181099\|issn=1569-9293}}</ref>

Nkamdar at 21:20, 5 November 2021

2021-11-05T21:20:35Z

← Older revision		Revision as of 14:20, 5 November 2021
Line 22:		Line 22:
	== Preoperative management ==		== Preoperative management ==
	Patients may present for P/D with substantial disease burden including decreased lung function on the affected side, pleural or pericardial effusion, anemia, poor nutritional status, and effects of neoadjuvant chemotherapy. Whenever possible, prehabilitation in preparation for surgery should be considered to correct anemia, improve nutritional status, and improve functional capacity.		Patients may present for P/D with substantial disease burden including decreased lung function on the affected side, pleural or pericardial effusion, anemia, poor nutritional status, and effects of neoadjuvant chemotherapy. Whenever possible, prehabilitation in preparation for surgery should be considered to correct anemia, improve nutritional status, and improve functional capacity.
	* Patient evaluation

			=== Patient evaluation ===
	{\| class="wikitable"		{\| class="wikitable"
	\|+		\|+

Nkamdar at 15:45, 5 November 2021

2021-11-05T15:45:54Z

← Older revision		Revision as of 08:45, 5 November 2021
Line 6:		Line 6:
	\| airway = Double-lumen tube; CPAP and PEEP control equipment		\| airway = Double-lumen tube; CPAP and PEEP control equipment
	\| lines_access = Arterial line +/- flow monitoring equipment (i.e. Flotrac); Large bore peripheral access		\| lines_access = Arterial line +/- flow monitoring equipment (i.e. Flotrac); Large bore peripheral access
	\| monitors = Standard; ~~Point of Care Blood Gas~~ monitoring		\| monitors = Standard; blood gas monitoring
	\| considerations_preoperative = Cardiac testing and prehabilitation		\| considerations_preoperative = Cardiac testing and prehabilitation
	\| considerations_intraoperative = vasoplegia; colloid infusion requirements		\| considerations_intraoperative = vasoplegia; colloid infusion requirements

Nkamdar: Added the summary box.

2021-11-05T15:42:39Z

Added the summary box.

← Older revision		Revision as of 08:42, 5 November 2021
Line 1:		Line 1:

	Malignant pleural mesothelioma (MPM) is an aggressive disease, is often diagnosed at an advanced stage, and has a 5-year survival rate of only 5 to 10%.<ref>{{Cite journal\|last=Janes\|first=Sam M.\|last2=Alrifai\|first2=Doraid\|last3=Fennell\|first3=Dean A.\|date=2021-09-23\|editor-last=Longo\|editor-first=Dan L.\|title=Perspectives on the Treatment of Malignant Pleural Mesothelioma\|url=http://www.nejm.org/doi/10.1056/NEJMra1912719\|journal=New England Journal of Medicine\|language=en\|volume=385\|issue=13\|pages=1207–1218\|doi=10.1056/NEJMra1912719\|issn=0028-4793}}</ref> The most important risk factor for its development is exposure to asbestos; the transformation of work practices worldwide has led to a modest decline in incidence. The three primary histologic types are epithelioid, sarcomatoid, and biphasic or mixed histology, with epithelioid resulting in more favorable outcomes than sarcomatoid or mixed histology.<ref>{{Cite journal\|last=Neragi-Miandoab\|first=Siyamek\|last2=Richards\|first2=William G.\|last3=Sugarbaker\|first3=David J.\|date=2008-08-01\|title=Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma\|url=https://www.sciencedirect.com/science/article/pii/S1743919108000605\|journal=International Journal of Surgery\|language=en\|volume=6\|issue=4\|pages=293–297\|doi=10.1016/j.ijsu.2008.04.004\|issn=1743-9191}}</ref><ref>{{Cite journal\|last=Vigneswaran\|first=Wickii T.\|last2=Kircheva\|first2=Diana Y.\|last3=Ananthanarayanan\|first3=Vijayalakshimi\|last4=Watson\|first4=Sydeaka\|last5=Arif\|first5=Qudsia\|last6=Celauro\|first6=Amy Durkin\|last7=Kindler\|first7=Hedy L.\|last8=Husain\|first8=Aliya N.\|date=March 1, 2017\|title=Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497516311316\|journal=The Annals of Thoracic Surgery\|language=en\|volume=103\|issue=3\|pages=962–966\|doi=10.1016/j.athoracsur.2016.08.063\|via=}}</ref>		Malignant pleural mesothelioma (MPM) is an aggressive disease, is often diagnosed at an advanced stage, and has a 5-year survival rate of only 5 to 10%.<ref>{{Cite journal\|last=Janes\|first=Sam M.\|last2=Alrifai\|first2=Doraid\|last3=Fennell\|first3=Dean A.\|date=2021-09-23\|editor-last=Longo\|editor-first=Dan L.\|title=Perspectives on the Treatment of Malignant Pleural Mesothelioma\|url=http://www.nejm.org/doi/10.1056/NEJMra1912719\|journal=New England Journal of Medicine\|language=en\|volume=385\|issue=13\|pages=1207–1218\|doi=10.1056/NEJMra1912719\|issn=0028-4793}}</ref> The most important risk factor for its development

			{{Infobox surgical procedure
			\| anesthesia_type = General
			\| airway = Double-lumen tube; CPAP and PEEP control equipment
			\| lines_access = Arterial line +/- flow monitoring equipment (i.e. Flotrac); Large bore peripheral access
			\| monitors = Standard; Point of Care Blood Gas monitoring
			\| considerations_preoperative = Cardiac testing and prehabilitation
			\| considerations_intraoperative = vasoplegia; colloid infusion requirements
			\| considerations_postoperative = Extended post-op hypotension and fluid shifts; large post-operative air leaks from chest tubes
			}}

			is exposure to asbestos; the transformation of work practices worldwide has led to a modest decline in incidence. The three primary histologic types are epithelioid, sarcomatoid, and biphasic or mixed histology, with epithelioid resulting in more favorable outcomes than sarcomatoid or mixed histology.<ref>{{Cite journal\|last=Neragi-Miandoab\|first=Siyamek\|last2=Richards\|first2=William G.\|last3=Sugarbaker\|first3=David J.\|date=2008-08-01\|title=Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma\|url=https://www.sciencedirect.com/science/article/pii/S1743919108000605\|journal=International Journal of Surgery\|language=en\|volume=6\|issue=4\|pages=293–297\|doi=10.1016/j.ijsu.2008.04.004\|issn=1743-9191}}</ref><ref>{{Cite journal\|last=Vigneswaran\|first=Wickii T.\|last2=Kircheva\|first2=Diana Y.\|last3=Ananthanarayanan\|first3=Vijayalakshimi\|last4=Watson\|first4=Sydeaka\|last5=Arif\|first5=Qudsia\|last6=Celauro\|first6=Amy Durkin\|last7=Kindler\|first7=Hedy L.\|last8=Husain\|first8=Aliya N.\|date=March 1, 2017\|title=Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma\|url=https://linkinghub.elsevier.com/retrieve/pii/S0003497516311316\|journal=The Annals of Thoracic Surgery\|language=en\|volume=103\|issue=3\|pages=962–966\|doi=10.1016/j.athoracsur.2016.08.063\|via=}}</ref>

	One of two operations is performed: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. P/D is a lung-sparing but still radical procedure in which the diseased pleural envelope that encases and constricts the lung is dissected from the chest wall, mediastinum, diaphram, and pericardium, and then is stripped from the surface of the lung.<ref>{{Cite journal\|last=Wolf\|first=Andrea S.\|last2=Daniel\|first2=Jonathan\|last3=Sugarbaker\|first3=David J.\|date=2009-06-01\|title=Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma: Extrapleural Pneumonectomy and Pleurectomy/Decortication\|url=https://www.semthorcardiovascsurg.com/article/S1043-0679(09)00084-7/abstract\|journal=Seminars in Thoracic and Cardiovascular Surgery\|language=English\|volume=21\|issue=2\|pages=132–148\|doi=10.1053/j.semtcvs.2009.07.007\|issn=1043-0679\|pmid=19822285}}</ref><ref>{{Cite journal\|last=Ng\|first=Ju-Mei\|last2=Hartigan\|first2=Philip M.\|date=February 1, 2008\|title=Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma\|url=https://journals.lww.com/co-anesthesiology/Abstract/2008/02000/Anesthetic_management_of_patients_undergoing.6.aspx\|journal=Current Opinion in Anesthesiology\|language=en-US\|volume=21\|issue=1\|pages=21–27\|doi=10.1097/ACO.0b013e3282f2a9c3\|issn=0952-7907\|via=}}</ref><ref>{{Cite journal\|last=Vlahu\|first=Tedi\|last2=Vigneswaran\|first2=Wicki T.\|date=June 1, 2017\|title=Pleurectomy and decortication\|url=http://atm.amegroups.com/article/view/14825/15364\|journal=Annals of Translational Medicine\|volume=5\|issue=11\|pages=246–246\|doi=10.21037/atm.2017.04.03\|pmc=PMC5497109\|pmid=28706914\|via=}}</ref>P/D is the more frequently used approach as of this writing as EPP has shown no survival advantage and patients experience improved quality of life when the lung remains intact.<ref>{{Cite journal\|last=Infante\|first=Maurizio\|last2=Morenghi\|first2=Emanuela\|last3=Bottoni\|first3=Edoardo\|last4=Zucali\|first4=Paolo\|last5=Rahal\|first5=Daoud\|last6=Morlacchi\|first6=Andrea\|last7=Ascolese\|first7=Anna Maria\|last8=De Rose\|first8=Fiorenza\|last9=Navarria\|first9=Pierina\|last10=Crepaldi\|first10=Alessandro\|last11=Testori\|first11=Alberto\|date=December 1, 2016\|title=Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma\|url=https://academic.oup.com/ejcts/article-lookup/doi/10.1093/ejcts/ezw215\|journal=European Journal of Cardio-Thoracic Surgery\|language=en\|volume=50\|issue=6\|pages=1077–1082\|doi=10.1093/ejcts/ezw215\|issn=1010-7940\|via=}}</ref><ref>{{Cite journal\|last=Sugarbaker\|first=David J\|last2=Wolf\|first2=Andrea S\|date=June 1, 2010\|title=Surgery for malignant pleural mesothelioma\|url=http://www.tandfonline.com/doi/full/10.1586/ers.10.35\|journal=Expert Review of Respiratory Medicine\|language=en\|volume=4\|issue=3\|pages=363–372\|doi=10.1586/ers.10.35\|issn=1747-6348\|via=}}</ref><ref>{{Cite journal\|last=Neragi-Miandoab\|first=S.\|last2=Weiner\|first2=S.\|last3=Sugarbaker\|first3=D. J.\|date=2008-12-01\|title=Incidence of atrial fibrillation after extrapleural pneumonectomy vs. pleurectomy in patients with malignant pleural mesothelioma\|url=https://academic.oup.com/icvts/article-lookup/doi/10.1510/icvts.2008.181099\|journal=Interactive CardioVascular and Thoracic Surgery\|language=en\|volume=7\|issue=6\|pages=1039–1042\|doi=10.1510/icvts.2008.181099\|issn=1569-9293}}</ref>		One of two operations is performed: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. P/D is a lung-sparing but still radical procedure in which the diseased pleural envelope that encases and constricts the lung is dissected from the chest wall, mediastinum, diaphram, and pericardium, and then is stripped from the surface of the lung.<ref>{{Cite journal\|last=Wolf\|first=Andrea S.\|last2=Daniel\|first2=Jonathan\|last3=Sugarbaker\|first3=David J.\|date=2009-06-01\|title=Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma: Extrapleural Pneumonectomy and Pleurectomy/Decortication\|url=https://www.semthorcardiovascsurg.com/article/S1043-0679(09)00084-7/abstract\|journal=Seminars in Thoracic and Cardiovascular Surgery\|language=English\|volume=21\|issue=2\|pages=132–148\|doi=10.1053/j.semtcvs.2009.07.007\|issn=1043-0679\|pmid=19822285}}</ref><ref>{{Cite journal\|last=Ng\|first=Ju-Mei\|last2=Hartigan\|first2=Philip M.\|date=February 1, 2008\|title=Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma\|url=https://journals.lww.com/co-anesthesiology/Abstract/2008/02000/Anesthetic_management_of_patients_undergoing.6.aspx\|journal=Current Opinion in Anesthesiology\|language=en-US\|volume=21\|issue=1\|pages=21–27\|doi=10.1097/ACO.0b013e3282f2a9c3\|issn=0952-7907\|via=}}</ref><ref>{{Cite journal\|last=Vlahu\|first=Tedi\|last2=Vigneswaran\|first2=Wicki T.\|date=June 1, 2017\|title=Pleurectomy and decortication\|url=http://atm.amegroups.com/article/view/14825/15364\|journal=Annals of Translational Medicine\|volume=5\|issue=11\|pages=246–246\|doi=10.21037/atm.2017.04.03\|pmc=PMC5497109\|pmid=28706914\|via=}}</ref>P/D is the more frequently used approach as of this writing as EPP has shown no survival advantage and patients experience improved quality of life when the lung remains intact.<ref>{{Cite journal\|last=Infante\|first=Maurizio\|last2=Morenghi\|first2=Emanuela\|last3=Bottoni\|first3=Edoardo\|last4=Zucali\|first4=Paolo\|last5=Rahal\|first5=Daoud\|last6=Morlacchi\|first6=Andrea\|last7=Ascolese\|first7=Anna Maria\|last8=De Rose\|first8=Fiorenza\|last9=Navarria\|first9=Pierina\|last10=Crepaldi\|first10=Alessandro\|last11=Testori\|first11=Alberto\|date=December 1, 2016\|title=Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma\|url=https://academic.oup.com/ejcts/article-lookup/doi/10.1093/ejcts/ezw215\|journal=European Journal of Cardio-Thoracic Surgery\|language=en\|volume=50\|issue=6\|pages=1077–1082\|doi=10.1093/ejcts/ezw215\|issn=1010-7940\|via=}}</ref><ref>{{Cite journal\|last=Sugarbaker\|first=David J\|last2=Wolf\|first2=Andrea S\|date=June 1, 2010\|title=Surgery for malignant pleural mesothelioma\|url=http://www.tandfonline.com/doi/full/10.1586/ers.10.35\|journal=Expert Review of Respiratory Medicine\|language=en\|volume=4\|issue=3\|pages=363–372\|doi=10.1586/ers.10.35\|issn=1747-6348\|via=}}</ref><ref>{{Cite journal\|last=Neragi-Miandoab\|first=S.\|last2=Weiner\|first2=S.\|last3=Sugarbaker\|first3=D. J.\|date=2008-12-01\|title=Incidence of atrial fibrillation after extrapleural pneumonectomy vs. pleurectomy in patients with malignant pleural mesothelioma\|url=https://academic.oup.com/icvts/article-lookup/doi/10.1510/icvts.2008.181099\|journal=Interactive CardioVascular and Thoracic Surgery\|language=en\|volume=7\|issue=6\|pages=1039–1042\|doi=10.1510/icvts.2008.181099\|issn=1569-9293}}</ref>

Karen.Sibert: Completed postoperative section

2021-11-04T20:57:05Z

Completed postoperative section

← Older revision		Revision as of 13:57, 4 November 2021
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	The choice of maintenance anesthetic is per anesthesiologist preference; inhaled agents offer the advantage of bronchodilation. Muscle relaxation is continued throughout the procedure.		The choice of maintenance anesthetic is per anesthesiologist preference; inhaled agents offer the advantage of bronchodilation. Muscle relaxation is continued throughout the procedure.

	Lung protective ventilation strategies are recommended:		Lung protective ventilation strategies are recommended:

	* Tidal volume 4-6 ml/kg on one-lung ventilation		* Tidal volume 4-6 ml/kg on one-lung ventilation
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	* Permissive hypercapnia if necessary		* Permissive hypercapnia if necessary
	* PEEP to the nonoperative lung		* PEEP to the nonoperative lung

	Regular blood gas measurement helps in the assessment of blood loss, volume status, and electrolyte balance. The development of metabolic acidosis may be a valuable indicator of volume deficit. For diabetic patients, insulin infusion may be helpful. The surgeon may use intermittent irrigation of the plane of dissection with sterile water to aid in lysis of adhesions, so careful attention must be paid to distinguish irrigation fluid from accumulated blood loss.		Regular blood gas measurement helps in the assessment of blood loss, volume status, and electrolyte balance. The development of metabolic acidosis may be a valuable indicator of volume deficit. For diabetic patients, insulin infusion may be helpful. The surgeon may use intermittent irrigation of the plane of dissection with sterile water to aid in lysis of adhesions, so careful attention must be paid to distinguish irrigation fluid from accumulated blood loss.

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	=== Emergence ===		=== Emergence ===
	If the operative lung has a large air leak, it may be necessary to maintain positive pressure ventilation on the dependent lung until the patient begins to breathe spontaneously.		If the operative lung has a large air leak, it may be necessary to maintain positive pressure ventilation on the dependent lung until the patient begins to breathe spontaneously.

			Bronchoscopy and bronchial lavage may be helpful near the end of surgery to clear blood or secretions from the upper airways.

	As air leaks are common, it is preferable to extubate at the conclusion of surgery in order to avoid worsening the air leaks in the operative lung.		As air leaks are common, it is preferable to extubate at the conclusion of surgery in order to avoid worsening the air leaks in the operative lung.
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	== Postoperative management ==		== Postoperative management ==
	=== Disposition ~~<!-- List and/or describe the postoperative disposition and any special considerations for transport of~~ patients for ~~this case~~. --> ===		=== Disposition ===
			At most centers, patients are transferred to intensive care after surgery for mesothelioma resection unless the procedure was a minimal palliative intervention. A step-down unit may be appropriate in some cases. Many patients continue to require vasopressor support in the initial period of post-extubation recovery.

			=== Pain management ===
			Continuous epidural thoracic analgesia is the most common method used, with a combination of low-dose local anesthetic (e.g. bupivacaine, ropivacaine) and narcotic (e.g. fentanyl, hydromorphone). A low-dose ketamine infusion may be helpful in the management of opioid-tolerant patients. If hypotension is problematic, local anesthetic can be eliminated from the epidural infusion.

	=== ~~Pain management <!-- Describe the expected level~~ of ~~postoperative pain~~ and ~~approaches to pain management for this case~~. --> ~~===~~		=== Potential complications ===
			The most frequent major complications of pleurectomy/decortication are respiratory failure (2.3–7.1%), bleeding (0.0–16.7%), and prolonged air leak (7.1–23.5%). However, as with other thoracic surgeries, atrial fibrillation (2.3–21.4%, higher risk in age > 65), myocardial infarction, DVT/PE, pneumonia, acute renal failure, empyema, pleural sepsis, prolonged intubation, UTI, and wound infections may also be seen.

	~~=== Potential complications <!-- List~~ and~~/or describe any potential postoperative complications for this case~~. ~~--> ===~~		Immediate postoperative bleeding may occur due to extensive raw surface oozing. It is best managed by correcting any coagulopathy and with increased PEEP on the ventilator if the patient is intubated.

	~~== Procedure variants <!~~-~~- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table~~ to ~~very briefly compare~~ and ~~contrast various aspects between approaches~~. ~~Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g~~. ~~+, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool~~ in the ~~editor)~~. ~~--> ==~~		Delayed hemorrhage 8-10 hours postoperatively is often due to unopposed regional hyperfibrinolysis and consumptive coagulopathy after removal of the hypercoagulable tumor. Treatment with aminocaproic acid has been utilized in this setting. ROTEM monitoring can aid in the diagnosis of fibrinolysis.

	~~{\| class="wikitable wikitable~~-~~horizontal-scroll"~~		The pleural space is monitored with serial chest X-rays. Prolonged air leak is common and is managed by maintaining chest tubes on mild suction, then weaning to water seal, and finally using pneumostats for portability if needed.
	\|+
	!
	~~!Variant 1~~
	~~!Variant 2~~
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	~~\|Unique considerations~~
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	~~\|Position~~
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	~~\|Surgical time~~
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	~~\|EBL~~
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	~~\|Postoperative disposition~~
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	~~\|Pain management~~
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	~~\|Potential complications~~
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	\|}

	== References ==		== References ==

Karen.Sibert: Continued description of intraop and emergence care.

2021-11-04T20:20:18Z

Continued description of intraop and emergence care.

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