Types of Pleural Mesothelioma Surgery
A thoracentesis is used to drain fluid from a pleural effusion, the accumulation of fluid that often occurs in a mesothelioma patient’s chest in the lung’s protective membrane, the pleura. The pleura consists of layers of tissue that cover the outside of the lung and line the chest cavity. During the procedure, a tube is inserted into the pleura to drain off the excess fluid. The purpose of thoracentesis is to relieve the patient’s discomfort from the pressure to the lungs and chest caused by of the build-up of fluid. The fluid prevents the lung from expanding fully when a person tries to breathe. Eventually, the fluid will build up to the point that the pressure on the lung causes shortness of breath. Because thoracentesis is done to relieve pain, it is referred to as palliative treatment.
Pleurodesis is a surgical procedure that offers a more long lasting solution to the problem of pleural effusion than can be achieved through thoracentesis. Pleurodesis works by sealing the space between the tissues of the pleura to prevent fluid from accumulating there. The procedure is most effective when performed early on, before fluid has been drawn multiple times or the pleural effusion traps the underlying lung
Pleurodesis may be performed on an outpatient basis, depending on a person’s health. Some patients with a very large amount of fluid accumulation are required to spend the night in the hospital due to the added time necessary for the procedure and the need to be kept under observation during the process. Like thoracentesis, pleurodesis does not treat the cancer, but it does relieve painful symptoms associated with a pleural effusion, such as breathlessness.
Two types of pleurodesis may be performed: thoracoscopic talc pleurodesis or bedside talc slurry pleurodesis:
Thoracoscopic (VATS) talc pleurodesis
Talc pleurodesis uses video-assisted thoracoscopy (sometimes called keyhole surgery). Two small incisions are made between the ribs. A camera is inserted through one incision to allow the surgeon to get a better look at the pleura. Surgical instruments are placed through the other incision. The procedure is performed while the patient is under general anesthesia.
During the surgery, all fluid is drained from the pleural cavity. A form of talc powder is then inserted into the cavity to coat the lung’s surface and the inside of the ribs. The talc causes an inflammatory reaction that makes the lung stick to the ribcage. Over time, scar tissue develops that forms permanent adhesions, leaving no space for fluid to accumulate in the future.
At the time of the pleurodesis, the surgeon may also break up any existing adhesions that are preventing the lung from re-expanding. In addition, a biopsy is often taken from the lung or the pleura.
Bedside talc slurry pleurodesis
At times, it is preferred to perform pleurodesis at the bedside with local, rather than general, anesthesia. This may be the case when the patient has no adhesions that need to be broken apart or when no biopsy is necessary.
Prior to the bedside pleurodesis, a local anesthetic is given to numb the ribcage area. An incision is made, through which a chest drain tube is inserted, stitched to the skin and attached at the other end to a drainage bottle. The fluid is then drained away from the pleura. Sometimes, this preliminary step is performed a few days before the pleurodesis itself.
During the pleurodesis, talc is combined with saline solution to make a “slurry.” Using a large syringe, the physician injects the slurry into the chest tube so that it enters the area of the lung and ribcage. The patient is then moved into a series of different positions, tilting up, down, and side-to-side, for about ten minutes in each position. The movement helps to make sure that the talc slurry is distributed over the entire surface of the lung and the ribs. After the talc slurry has coated the necessary surfaces, suction is applied to the chest drain tube. The suction pulls together the two pleural surfaces, causing them to fuse to one another. As with the thoracoscopic pleurodesis, this fusing process prevents fluid from collecting in the area..
A pleurectomy / decortication is a surgical procedure that removes the pleura where the tumor is located and allows the underlying lung to expand and fill the pleural cavity. Mesothelioma frequently causes a process known as fibrothorax, which means that abnormal fibrous tissue has grown in the pleural space, between the visceral pleura and the parietal pleura. This abnormal tissue causes an “entrapment” of the lung underneath, a condition sometimes called trapped lung, encased lung, or restrictive pleurisy. In a pleurectomy/decortication, the abnormal fibrous tissue is actually stripped away from the lung.
The operation may prevent future pleural effusions and also aid in reducing the pain caused by the tumor. Pleurectomy / decortication is a palliative treatment; its goal is to reduce the pain and discomfort that accompany mesothelioma.
A pneumonectomy is an operation to take out all or part of the diseased lung. In the procedure, the surgeon makes an incision in the side of the chest so the lung is visible. After examining the size and location of the tumor, the surgeon is able to determine how much of the lung should be removed.
Extrapleural pneumonectomy is a surgery that is more extensive than a pneumonectomy alone. Extra-pleural pneumonectomy involves the surgical removal not just of the lung, but also its lining and the associated linings of the diaphragm and pericardium, and possibly other tissues as well.
Types of surgery for peritoneal mesothelioma include:
Paracentesis is an operation associated with peritoneal mesothelioma. With this type of mesothelioma, fluid may build up in the abdomen to cause a peritoneal effusion, just as pleural mesothelioma can cause an accumulation of fluid in the chest cavity. With paracentesis, the excess abdominal fluid is drained through a needle and tube placed in the abdomen. The procedure is sometimes referred to as an “ascitic tap.”
The procedure is a palliative treatment; paracentesis takes the pressure off the internal organs that is caused by the build-up of fluid. Removing this pressure helps to reduce the pain and discomfort associated with a peritoneal effusion.
In a peritonectomy, the surgeon removes the lining of the abdomen, called the peritoneum, which is the place where peritoneal mesothelioma begins. This procedure is used most when the tumor is found at an early stage. A peritonectomy is sometimes performed in conjunction with a type of heated chemotherapy called “intraperitoneal hypothermic perfusion,” in which the chemotherapy is actually inserted directly into the abdomen as part of the operation. Research has shown that chemotherapy may work better when it is first heated to a few degrees above body temperature.
Cytoreductive surgery is also known as “debulking” surgery because it requires the surgeon to remove as much of the tumor as possible. The surgeon opens the abdominal cavity (called a “laparotomy”) and basically searches for cancer and removes it wherever it is found. The procedure may last quite a long time, because it involves the surgeon performing as many as six different peritonectomy procedures, to take out as much of the cancer as possible. Like a peritonectomy, cytoreductive surgery may also be done together with “intraperitoneal hypothermic perfusion,” the insertion of heated chemotherapy drugs directly into the abdominal cavity.
Cytoreductive surgery has been beneficial for some people. Some studies report that about half of the patients who received this treatment were still living five years later. The treatment is very intensive, however, and is only possible for people in excellent physical condition with earlier stage mesothelioma.
Types of surgery for pericardial mesothelioma include:
In pericardial mesothelioma cases, pericardiocentesis is a procedure to remove an accumulation of fluid from the area of the heart. The surgeon inserts a needle into the pericardium, the sac around the heart, to draw off the excess fluid. The procedure is a palliative treatment, meaning that its goal is to relieve the discomfort and circulatory problems caused by the build-up of fluid.