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Extrapleural pneumonectomy

JOHN C. KUCHARCZUK, MD

Assistant Professor of Surgery, Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA

LARRY R. KAISER, MD

The John Rhea Barton Professor and Chairman, Department of Surgery, University of Pennsylvania; Surgeon-in-Chief, University of Pennsylvania Health System, Philadelphia, PA, USA

HISTORY

The extrapleural pneumonectomy operation was described in 1949 for application in patients with pleural-pulmonary tuberculosis. Today, the procedure is used almost exclusively in carefully selected patients with malignant pleural mesothelioma. The intent of the procedure, although elusive, is cure and as such the procedure is performed as part of a multimodality treatment regimen. Adequate palliation of symptoms can often be obtained in patients who are not candidates for cure by less invasive/aggressive procedures with lower morbidity and mortality rates.

PRINCIPLES AND JUSTIFICATION

The relationship between malignant pleural mesothelioma and asbestos exposure was observed over 45 years ago in South African miners. Unfortunately, asbestos use was widespread in construction and heavy industry worldwide, exposing large numbers of workers. In the 1970s, American government agencies including the Occupational Safety and Health Administration and the Environmental Protection Agency set forth strict regulations for asbestos exposures in the workplace and nonoccupational setting. Because of these regulations, the incidence of malignant pleural mesothelioma, which presents 30–40 years after exposure, has peaked in the United States. Worldwide, however, the incidence of malignant pleural mesothelioma is expected to increase for the next 20–30 years.

Traditionally, malignant pleural mesothelioma has been viewed as a locally aggressive disease; it was thought that metastatic disease occurred late. Largely because of this point of view, the radical operations proposed for the eradication of advanced pleural pulmonary tuberculosis were modiﬁed and

applied to patients with malignant pleural mesothelioma. Initial results from series published in the 1970s and 1980s revealed only a few long-term survivors with relatively high morbidity and mortality rates. Recently, with improved patient selection and reﬁned surgical techniques, 2-year survival rates have been reported in the 30% range with acceptable morbidity and mortality. Combined multimodality treatments hold out the prospect of even better future outcomes.

PREOPERATIVE EVALUATION AND PATIENT SELECTION

The clinical difﬁculty in managing patients with malignant pleural mesothelioma begins with diagnosis. Patients usually present with shortness of breath, chest pain, and imaging studies showing a pleural effusion and pleural nodularity. Many will have had thoracentesis and/or closed pleural biopsy which may still be cytologically inconclusive. Needle aspiration of a pleural lesion usually provides inadequate material for a deﬁnitive diagnosis. Usually, a video-assisted biopsy with specialized immunohistochemical staining and electron microscopy is required to ﬁnalize the diagnosis. Securing an accurate diagnosis is critical. Patients with pleural carcinomatosis will not beneﬁt from extrapleural pneumonectomy; they would be better served by other palliative or experimental treatments. We use a single pulmonary pathologist with special interest and expertise to review and conﬁrm all malignant mesothelioma cases. In institutions without such expertise, outside pathological consultation should be obtained.

In symptomatic patients with large pleural effusions talc pleurodesis is performed at the time of diagnostic thoracoscopy if the lung fully expands. Despite popular notion,

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effective pleurodesis does not complicate later extrapleural pneumonectomy; it actually makes establishment of the extrapleural plane easier and provides symptomatic relief while evaluation is underway.

An interesting and early observation in malignant pleural mesothelioma was that patients with epithelioid histology had the best outcomes following aggressive surgery. By contrast, patients with mixed or sarcomatoid features had poor outcomes regardless of the treatment selected. In our current practice we consider only patients with pure epithelioid histology for extrapleural pneumonectomy. Patients with mixed or sarcomatoid pathology are encouraged to consider enrolling in experimental treatment trials. This histological selection criterion is particularly important if patients are to be subjected to the potential morbidity and mortality of extrapleural pneumonectomy. The procedure should be conﬁned to those patients with the best chance of long-term survival where the potential beneﬁt justiﬁes the risk.

Once the diagnosis of pure epithelioid mesothelioma is conﬁrmed, the preoperative evaluation focuses on determining the patients’ extent of disease and ﬁtness to undergo aggressive surgical resection. Unfortunately, no staging system or preoperative evaluation is universally agreed upon for patients with malignant pleural mesothelioma. Presently, the staging systems used include: the Union International Contre le Cancer Staging System, The New International Staging System proposed by the International Mesothelioma Interest Group, The Brigham and Women’s Hospital/Dana Farber Cancer Institute Staging System, and the original Butchart Staging System proposed in the late 1970s. Regardless of the staging system used, patients considered for extrapleural pneumonectomy must have disease conﬁned to a single hemithorax. As previously mentioned, the traditional view of malignant pleural mesothelioma as strictly a local disease is erroneous. We have come to understand that a substantial number of patients have metastatic disease to the mediastinal lymph nodes and/or through the diaphragm into the peritoneal cavity, or into the other pleural space. Our current pre-

operative assessment includes cervical mediastinoscopy and diagnostic laparoscopy with biopsy. Often, we perform these procedures separately to allow for complete assessment of the pathological specimens. Patients determined to have mediastinal nodal metastasis and/or peritoneal involvement are not offered extrapleural pneumonectomy.

Physiological evaluation also requires experience and mature surgical judgment. The performance of an extrapleural pneumonectomy puts a signiﬁcant physiological stress on the patient above and beyond that imposed by a standard pneumonectomy. The intrapericardial procedure and the excision of the hemidiaphragm add to the morbidity of the procedure. All patients undergo preoperative cardiac evaluation and pulmonary function testing. Eligible patients should have a postoperative predicted FEV1of greater than 1 liter. Although we do not have strict age criteria, we offer the procedure only rarely in those over age 60. Perhaps this approach is being somewhat conservative, but older patients tend to show their age following this procedure, and the mortality in those over age 60 is considerable.

OPERATION

Right extrapleural pneumonectomy

The patient is brought to the operating room, and a thoracic epidural catheter is placed for intra- and postoperative pain management. Preoperative antibiotics are administered, and pneumatic compression boots are applied to avoid venous stasis in the lower extremities. General anesthesia is induced, and the patient is intubated with a left-sided double-lumen endotracheal tube. A ﬂexible pediatric bronchoscope is used to examine the airway and position the tube for isolated lung ventilation. The tube is secured. A nasogastric tube is placed and used later as a guide when the extrapleural dissection approaches the esophagus. The patient is repositioned in the left lateral decubitus manner.

A long skin incision is made along the sixth rib.

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Electrocautery is used to achieve hemostasis in the subcutaneous tissues. The latissimus dorsi muscle is divided with electrocautery. When possible, we like to mobilize and spare the serratus anterior muscle as this can be used as a pedicled muscle ﬂap later in the procedure if needed.

The sixth rib is identiﬁed, and its periosteum is scored. A periosteal elevator is used to completely strip the periosteum from the rib, and then the entire rib is removed with a bone cutter. Removing the sixth rib facilitates the initiation of the extrapleural dissection. We like to begin the dissection sharply by establishing the extrapleural plane under the ﬁfth rib. Once the plane is established the entire lateral dissection is done quickly and bluntly with a dissecting hand. Chest wall bleeding is temporarily controlled with packing sponges. After the lateral extrapleural dissection is done both superiorly and inferiorly, a chest retractor can be placed. The packing sponges are removed, and any ongoing chest wall bleeding is controlled with electrocautery or the argon beam coagulator.

Operation 317

Dissection proceeds around the apex of the lung in a

more controlled manner with sharp scissor dissection. Care must be taken to avoid injury to the subclavian artery and vein. As the dissection moves medially, the internal mammary vessels are identiﬁed and allowed to remain on the chest wall. Likewise the pleural envelope is carefully dissected away from the superior vena cava and azygous vein.

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Attention is directed posteriorly for dissection of the

specimen from the esophagus. The nasogastric tube is palpated in the esophagus and used as a guide. The attachments between the extrapleural plane and the esophagus are divided sharply as far inferiorly as possible. Up to this point, no irreversible moves have been made. If the disease is found to be more extensive than anticipated and to involve nonresectable thoracic structures or to have invaded through the chest wall, the procedure can be aborted. If the mass is still deemed resectable, we move onto the diaphragmatic portion of the procedure.

Several different techniques have been described for

facilitating the diaphragmatic dissection, resection, and reconstruction. We have found the most effective technique to be simply making a second intercostal muscle incision two interspaces lower without making any additional skin incisions. A small child chest retractor is used and exposure to the diaphragm is excellent. The diaphragmatic division is begun at the lateral attachment of the diaphragm to the chest wall.

A small incision is made, and the underlying peritoneum

is swept away with a sponge stick.

Once the peritoneum is pushed away with a sponge

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stick, the lateral diaphragmatic resection is completed

with electrocautery.

Moving medially, we switch to sharp dissection with tissue scissors. The pleural envelope is carefully dissected away from the inferior vena cava and distal esophagus. At this juncture we mass ligate all tissue on the spine between the esophagus and the aorta with a 2-0 silk suture as a prophylactic maneuver to decrease the incidence of thoracic duct leak. Dissection continues in a cephalad direction toward the pericardium. The chest retractor is removed and repositioned into the sixth intercostal space incision. The pericardium is opened and removed with the specimen.

Operation 319

The right main pulmonary artery is isolated within the

pericardium and taken with a single ﬁring of an Endo GIA vascular stapling device. Likewise the pulmonary veins are isolated within the pericardium and divided with a vascular stapling device. Finally, the bronchus is circumferentially dissected, small bronchial vessels are controlled with electrocautery, and the right mainstem bronchus is taken ﬂush with the carina using a TA stapling device. The specimen is removed from the ﬁeld, oriented, and forwarded to pathology for evaluation.

Meticulous hemostasis is required. Residual chest wall bleeding from the endothoracic fascia is controlled with electrocautery or the argon beam coagulator. When available, the pericardial fat pad is mobilized to cover the bronchial stump. Otherwise, the uncut serratus anterior muscle is mobilized and transposed into the chest to provide a buttress for the bronchial stump. When it is required, the serratus anterior muscle is brought into the chest through the third intercostal space. We reoutinely buttress a right pneumonectomy stump.

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Next, attention is turned towards diaphragmatic and

pericardial reconstruction. The retractor is moved to the lower intercostal incision. The diaphragm is reconstructed with a 2-mm polytetraﬂuoroethylene (PTFE) soft tissue patch. The patch is secured to the chest wall laterally by placement of interrupted #1 Prolene sutures. The sutures are placed at close intervals around the ribs to provide secure purchase. Medially, an unsecured open area remains for passage of the esophagus and inferior vena cava. On the right side the pericardium must be reconstructed in order to prevent herniation of the heart with compromise of venous return, a potentially lethal situation.

The pericardium is reconstructed with a 0.1-mm PTFE

pericardial patch. The patch is fenestrated to allow drainage and avoid tamponade. It is secured to the cut edges of the pericardium with 4-0 Prolene suture placed in a running fashion. Inferiorly, the patch is secured to the diaphragmatic patch with several interrupted Prolene sutures.

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Operation 321

The completed repair is shown. The entire chest is irrigated with several liters of sterile saline.

A 28 Fr. chest tube is brought through a separate stab incision and directed toward the apex. The chest tube is connected to a balanced drainage system with a safety mechanism that precludes any attachment to suction.

Number 1 braided absorbable sutures are placed in a pericostal position. The ribs are brought together with the aid of a Bailey rib approximator. The pericostal sutures are secured. The incision is irrigated, and the latissimus dorsi muscle is reapproximated with a running number absorbable suture. The subcutaneous tissues are approximated with running absorbable suture, and the skin is closed with a subcuticular suture. The patient is returned to the supine position and allowed to emerge from anesthesia.

Left extrapleural pneumonectomy

Performance of the left extrapleural pneumonectomy is technically easier than the right. Following induction of general anesthesia, a right-sided double-lumen endotracheal tube is placed. The tube is positioned for isolated lung ventilation with a pediatric bronchoscope. The Murphy’s eye of the right-sided double-lumen endobronchial tube is aligned with the right upper lobe oriﬁce. Improper placement can result in right upper lobe consolidation with hypoxia during single lung ventilation. The tube also can migrate during patient positioning or extrapleural dissection. The pediatric bronchoscope remains with the anesthesia team during the procedure, and conﬁrmation of tube position should be performed if the patient becomes hypoxic during single lung ventilation.

The patient is repositioned in the right lateral decubitus position. A long posterolateral incision is made along the left sixth rib. The latissimus dorsi muscle is divided with electrocautery. The serratus anterior muscle is mobilized and spared when possible. The periosteum of the sixth rib is stripped, and the entire sixth rib is removed. The dissection is begun by sharply establishing an extrapleural plane under the ﬁfth rib, as was described above for the right-sided pneumonectomy. Once the plane is developed, the entire lateral dissection is performed with a dissecting hand. The space is packed with surgical sponges to control chest wall bleeding, and the chest retractor is placed. The sponges are removed, and chest wall hemostasis is obtained with electrocautery or the argon beam coagulator. As on the right side, careful sharp dissection is used at the apex to avoid injury to the subclavain artery and vein. Likewise medially, the internal mammary vessels are left on the chest wall. As dissection continues along the mediastinum, care is taken to avoid injury to the left vagus and left recurrent laryngeal nerve. Damage to the recurrent laryngeal nerve will lead to postoperative left vocal cord paralysis with susceptibility to aspiration. This complication can be life threatening following pneumonectomy.

Attention now is directed posteriorly. The extrapleural dissection is continued along the aorta with careful scissor dissection. As with right extrapleural pneumonectomy, we make an accessory intercostal incision through the eighth intercostal space and move the rib spreader to this interspace. This maneuver provides excellent exposure to the diaphragm. The extrapleural dissection is continued bluntly well into the costophrenic sulcus. The diaphragmatic dissection is started

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by incision of the lateral attachments of the diaphragm to the chest wall. The peritoneal membrane is swept away, and the diaphragmatic resection is continued with electrocautery. Occasionally, the peritoneal cavity is entered inadvertently. This situation is not a particular problem since the diaphragm is to be reconstructed. Care is taken medially along the diaphragmatic hiatus to avoid injury to the esophagus and left vagus nerve. Once the inferior dissection is complete, the retractor is moved back to the ﬁfth intercostal space. The pericardium is opened and widely incised to complete the dissection. The left main pulmonary artery is isolated in an intrapericardial location and ligated and divided with an endoscopic linear stapling device. As the intrapericardial portion of the left pulmonary artery is short, care must be taken to avoid injury or encroachment on the main or right pulmonary artery. The upper and lower pulmonary veins are encircled within the pericardium and individually divided with a vascular stapling device. Finally, the left main bronchus is circumferentially dissected back to the carina and taken with a stapling device. The bronchus is divided ﬂush with the carina to avoid an excessively long stump which is susceptible to breakdown. The left-sided stump retracts back into the mediastinum and usually does not require buttressing as is required on the right. Hemostasis is conﬁrmed, and attention is directed toward diaphragmatic reconstruction.

The retractors are moved to the lower intercostal incision. The diaphragm is reconstructed with a 2-mm thick PTFE soft tissue patch. The patch is secured to the chest wall laterally by placement of interrupted #1 sutures in the same fashion as used on the right. Unlike on the right side, pericardial reconstruction is not required on the left since torsion with compromise of venous return is not an issue in the left chest.

The entire chest is irrigated with several liters of sterile saline. A 28Fr. chest tube is brought through a separate stab incision and directed toward the apex. The chest tube is connected to a balanced pneumonectomy drainage device. #1 absorbable sutures are placed in a pericostal position. The rest of the closure proceeds as usual as described above.

The patient is returned to the supine position and allowed to emerge from anesthesia.

POSTOPERATIVE CARE

Our intent is to extubate all patients in the operating room following extrapleural pneumonectomy. After a short stay in the postanesthesia recovery area, they are transferred to the thoracic surgical unit for their postoperative care. The pneumonectomy tube is removed the following morning after a chest X-ray conﬁrms the midline position of the mediastinum. The epidural catheter remains connected to a patient-controlled epidural administration device for 5 days. During this time, patients receive intensive pulmonary physiotherapy. Starting on postoperative day 2, they are ambulated three times per day in the hall with assistance. A chest radiograph is obtained every other day to follow appropriate

ﬁlling of the pneumonectomy space. Rapid ﬁlling may indicate unrecognized bleeding and the need for re-exploration. The hemoglobin is checked every other day as patients have a tendency to become progressively anemic as the pneumonectomy space ﬁlls. Symptomatic patients with a hemoglobin level below 8 mg/dL are transfused. Occasionally, the space ﬁlls rapidly with a shift of the mediastinum. This situation requires drainage of the space to prevent hemodynamic embarrassment. Patients with an uncomplicated course are usually discharged on postoperative day 7.

Pitfalls, complications

The most common intraoperative complication is bleeding. Chest wall bleeding should be controlled as the operation progresses to avoid excessive blood loss. This goal is facilitated by use of the argon beam coagulator. Catastrophic bleeding can occur due to injury of major vascular structures during dissection around the apex of the chest or when dissecting around the inferior vena cava. The complication is avoided by careful attention to detail and absolute familiarity with the anatomy.

Transient hypotension in the immediate postoperative period is often related to sympathectomy with vasodilation due to the thoracic epidural administration of narcotic or local anesthesia. The blood pressure is supported with intravenous vasoactive drugs such as neosynephrine. Large ﬂuid boluses are avoided. Profound hypotension with tamponade physiology may be due to acute mediastinal shift. Because of our use of a balanced pneumonectomy drainage system, we have avoided this complication. It must, however, be considered in those units which use only a single catheter with a stopcock to add or remove air to move the mediastinum to a midline position. An overly tight pericardial patch can cause constriction, with tamponade physiology. Finally, if the fenestrations in the pericardial patch are too small to allow free drainage, even a small amount of clot within the reconstructed pericardium can result in tamponade. Early recognition of these potential problems is mandatory if the patient is to be salvaged.

From a pulmonary perspective, the most dangerous complication is development of postpneumonectomy pulmonary edema. Unfortunately, the etiological factors causing this phenomenon remain obscure. When it occurs, the treatment is supportive. In any event, we limit perioperative ﬂuid administration in an attempt to minimize this complication. The complication occurs much more commonly following right extrapleural pneumonectomy than left. This complication usually manifests within the ﬁrst 96 hours following the resection.

Postoperative space infections are particularly difﬁcult to manage because of the presence of prosthetic material used to reconstruct the diaphragm and the pericardium. In patients without pneumonectomy stump breakdown, early space infection occasionally can be managed with complete