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 bophasic 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

Patient evaluation

System	Considerations
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Procedure variants

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