INDICATIONS

The most common indication for extrapleural pneumonectomy (EPP) is the resection of malignant pleural mesothelioma (MPM). Although there has been a recent shift away from EPP in favor of pleurectomy/decortication (P/D), EPP may still be the optimal operation for a select group of MPM patients with early stage disease. EPP can also be a useful approach for the resection of other malignancies such as large intrathoracic sarcomas, or recurrent fibrous tumors of the pleura. In addition, EPP has occasionally been used to resect nonsmall cell lung carcinomas (NSCLC) metastatic to the pleura without associated extrathoracic disease.

PREOPERATIVE PLANNING

Preoperative evaluation should determine whether the patient has potentially resectable tumor and assess cardiopulmonary reserve and overall surgical risk.

Computed tomography (CT) scan of the chest and upper abdomen is the primary means of assessing the extent of the primary tumor and identifying metastatic disease in the peritoneum or the contralateral lung and pleura. In MPM, some institutions also use magnetic resonance imaging (MRI) to determine whether the primary tumor invades the chest wall or diaphragm but in general MRI does not add significantly to CT in preoperative staging. MRI may also be useful in other diseases where there is a need to assess involvement of cardiac or neurologic (e.g., spine, spinal foramina, brachial plexus) structures.

Positron emission tomography (PET) adds to CT in staging MPM. It identifies metastatic disease not detected by CT in approximately 10% of patients. The standardized uptake value (SUV) on PET is also an independent prognostic factor for overall survival and is useful in selecting patients for treatment. We use PET-CT routinely in the initial evaluation of patients with MPM. It is also important in the extent of disease evaluation of other malignancies being considered for EPP.

Mediastinoscopy has been advocated as a routine staging procedure before EPP because the presence of mediastinal nodal metastases (N2 disease) is an adverse prognostic factor in MPM, and CT and PET are known to be inaccurate in detecting nodal disease. However, mediastinoscopy fails to identify N2 disease in some patients because the pattern of nodal metastases from MPM differs from that of lung cancer. In addition, N2 disease is only one of several important prognostic factors in MPM and does not uniformly identify patients who have a poor prognosis. At the current time, we do not routinely perform mediastinoscopy as part of the initial staging evaluation for MPM.

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) has largely replaced mediastinoscopy for the detection of hilar and mediastinal nodal metastases. It may be useful in the preresection evaluation of some malignancies such as NSCLC, which would not be considered for EPP if nodal disease was present.

Laparoscopy has also been advocated as a staging maneuver before resection of MPM because it identifies transdiaphragmatic tumor extension or intra-abdominal metastases. However, routine laparoscopy is not required in patients whose imaging studies show earlier stage tumors and no intra-abdominal abnormalities.

The assessment of cardiopulmonary reserve is a pivotal part of the preoperative evaluation for EPP. Complete pulmonary function testing (PFT) should be performed, including a diffusion capacity (DLCO), especially in MPM patients who have had asbestos exposure and often, underlying interstitial lung disease. A quantitative ventilation/perfusion (V/Q) lung scan should also be done to help calculate the patient’s postoperative pulmonary function following an EPP.

Most patients being considered for EPP are older and have medical comorbidities, especially underlying cardiovascular disease. An EPP places patients at high risk for myocardial ischemia because of intraoperative blood loss and postoperative fluid shifts. Therefore, some form of stress testing should be considered preoperatively.

In summary, routine preoperative evaluation of patients being considered for EPP includes a CT scan of the chest and upper abdomen, a PET-CT scan, complete PFTs, a quantitative V/Q scan, and usually, some form of stress testing. Additional evaluation may include MRI, laparoscopy, mediastinoscopy, or EBUS is performed selectively.

SURGERY

Preparation, Positioning, and Incision

An epidural catheter is placed for postoperative analgesia. After induction of general anesthesia, a double-lumen endotracheal tube is inserted. In addition to standard intraoperative monitoring (arterial line, pulse oximetry), a central venous catheter is inserted to help manage perioperative fluid shifts.

The patient is placed in the standard lateral decubitus position. An extended S-shaped posterolateral thoracotomy incision is made (Fig. 32.1). Extension of the incision down toward the costal margin provides exposure for diaphragmatic resection and reconstruction. Some surgeons add a second small posterior thoracotomy incision at the level of the eleventh rib to provide exposure to the costophrenic sulcus but this causes chest wall edema and pain and does not significantly improve exposure. If postoperative hemithoracic radiation is planned there is no need to excise previous chest wall incisions because the radiation treats potential tumor implants. Both the latissimus dorsi and the serratus anterior muscles are divided.

Some authors recommend using a median sternotomy rather than a thoracotomy, especially for right-sided resection. However, this approach does not provide as much exposure for resection and reconstruction of the posterior aspect of the diaphragm.

Resection Technique

The sixth rib is excised to expose the extrapleural plane. This approach is lower than for a standard pulmonary resection to facilitate exposure of the diaphragm. The intercostal muscles are carefully preserved for reclosure at the end of the operation. Blunt dissection is performed in the extrapleural plane freeing the parietal pleura from the endothoracic fascia using a sweeping motion of the hand up to apex of the chest, then down to the diaphragm, anteriorly to the pericardium, and posteriorly to the spine (Fig. 32.2

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