Surgery for pleural mesothelioma

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%. 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.

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.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.

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.

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.

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. If possible, prehabilitation in preparation for surgery should be considered to correct anemia, improve nutritional status, and improve functional capacity.

• Patient evaluation

System	Considerations
Cardiovascular	Consider stress testing, echocardiography; look for evidence of ventricular dysfunction, pulmonary hypertension, right heart strain from tumor involvement of pericardium
Hematologic	Hypercoagulability due to underlying malignancy
Respiratory	Pulmonary function testing; CT scan to evaluate extent of lung compression on the operative side, extent of pleural effusion
Neurologic	Peripheral neuropathy due to chemotherapy; assess appropriateness for epidural analgesia
Renal	Preexisting renal disease may worsen under stress of fluid shifts, blood loss, potential hypotension

Operating room setup

The operating room setup will be for open thoracotomy with an operating room table that can be flexed.p- A checklist for equipment and supplies typically will include:

1. Double-lumen endotracheal tube
2. Fiberoptic bronchoscope
3. Video laryngoscope
4. Arterial line setup and transducer
5. Consider flow parameter monitoring (e.g. FloTrac system, Edwards Lifesciences)
6. IV fluid warming device
7. Infusion pumps for vasoactive infusion
8. Availability of cross-matched blood, albumin
9. CPAP equipment with airflow and PEEP control

Patient preparation and premedication

Patients should fast per institutional guidelines. Premedication is at the choice of the anesthesiologist depending on the patient's age and other relevant factors.

Regional and neuraxial techniques

Thoracic epidural analgesia is highly recommended as it will benefit the patient's ability to breathe comfortably and resume mobility after the extensive thoracotomy required for radical mesothelioma resection.

The epidural catheter should be inserted at a high enough level that the patient will not have any lumbar motor block and can safely ambulate. Insertion prior to surgery offers the advantage of beginning epidural infusion before the patient emerges from anesthesia.

As there will be continuous blood and fluid loss throughout surgery, it may be preferred not to give any bolus dose or epidural infusion until near the end of surgery to avoid the effects of sympathectomy. This decision must be weighed against the potential analgesic value of preemptive dosing.

If the patient has a contraindication to epidural catheter placement, other regional techniques may be considered: lumbar spinal opioid analgesia, erector spinae plane block , intercostal or paravertebral blocks.

Intraoperative management

Monitoring and access

1. Arterial monitoring is highly recommended for continuous blood pressure monitoring and blood gas measurement. Consider use of a flow parameter monitoring transducer (e.g. FloTrac, Edwards Lifesciences).
2. Large-bore IV access is indicated; central venous access is not mandatory unless peripheral veins are inadequate.

Induction and airway management

1. Induction medications and muscle relaxant choice per anesthesiologist preference
2. A double-lumen endotracheal tube (typically 37-39 Fr) is inserted and position confirmed with fiberoptic bronchoscopy

Positioning

The patient is placed in the lateral decubitus position with the table flexed. No position changes are usually necessary during the operation.

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

1. Janes S, Alrefai D, Fennell D. Perspectives on the Treatment of Malignant Pleural Mesothelioma. N Engl J Med 2021; 385:1207-18. DOI: 10.1056/NEJMra1912719.
2. Neragi-Miandoab, Siyamek, William G. Richards, and David J. Sugarbaker. “Morbidity, Mortality, Mean Survival, and the Impact of Histology on Survival after Pleurectomy in 64 Patients with Malignant Pleural Mesothelioma.” International Journal of Surgery (London, England) 6, no. 4 (August 2008): 293–97. https://doi.org/10.1016/j.ijsu.2008.04.004.
3. Vigneswaran, Wickii T., Diana Y. Kircheva, Vijayalakshimi Ananthanarayanan, Sydeaka Watson, Qudsia Arif, Amy Durkin Celauro, Hedy L. Kindler, and Aliya N. Husain. “Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma.” The Annals of Thoracic Surgery 103, no. 3 (March 1, 2017): 962–66. https://doi.org/10.1016/j.athoracsur.2016.08.063.
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5. Ng, Ju-Mei, and Philip M. Hartigan. “Anesthetic Management of Patients Undergoing Extrapleural Pneumonectomy for Mesothelioma.” Current Opinion in Anesthesiology 21, no. 1 (February 2008): 21. https://doi.org/10.1097/ACO.0b013e3282f2a9c3.
6. Vlahu, Tedi, and Wicki T. Vigneswaran. “Pleurectomy and Decortication.” Annals of Translational Medicine 5, no. 11 (June 2017). https://doi.org/10.21037/atm.2017.04.03.
7. Infante, Maurizio, Emanuela Morenghi, Edoardo Bottoni, Paolo Zucali, Daoud Rahal, Andrea Morlacchi, Anna Maria Ascolese, et al. “Comorbidity, Postoperative Morbidity and Survival in Patients Undergoing Radical Surgery for Malignant Pleural Mesothelioma.” European Journal of Cardio-Thoracic Surgery 50, no. 6 (December 2016): 1077–82. https://doi.org/10.1093/ejcts/ezw215.
8. Sugarbaker, David J, and Andrea S Wolf. “Surgery for Malignant Pleural Mesothelioma.” Expert Review of Respiratory Medicine 4, no. 3 (June 2010): 363–72. https://doi.org/10.1586/ers.10.35.
9. Neragi-Miandoab, Siyamek, Shoshana Weiner, and David J. Sugarbaker. “Incidence of Atrial Fibrillation after Extrapleural Pneumonectomy vs. Pleurectomy in Patients with Malignant Pleural Mesothelioma.” Interactive Cardiovascular and Thoracic Surgery 7, no. 6 (December 2008): 1039–42. https://doi.org/10.1510/icvts.2008.181099.
10. Lim E, Darlison L, Edwards J On behalf of MARS 2 Trialists, et al. 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. BMJ Open 2020;10:e038892. doi: 10.1136/bmjopen-2020-038892.
11. Adhikary, SanjibDas; Pruett, Ashlee; Forero, Mauricio; Thiruvenkatarajan, Venkatesan (2018). "Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane". Indian Journal of Anaesthesia. 62 (1): 75. doi:10.4103/ija.IJA_693_17. ISSN 0019-5049. PMC 5787896. PMID 29416155.