SURGICAL TECHNIQUE
European Journal of Cardio-Thoracic Surgery 44 (2013) 563–564 doi:10.1093/ejcts/ezt082 Advance Access publication 13 March 2013
Thoracic shaping technique to avoid residual space after extended pleurectomy/decortication† Servet Bölükbasa,*, Michael Eberleinb and Joachim Schirrena a b
Department of Thoracic Surgery, Dr.-Horst-Schmidt-Klinik (Teaching Hospital of Johannes Gutenberg University, Mainz), Wiesbaden, Germany Division of Pulmonary, Critical Care and Occupational Medicine, Carver College of Medicine, University of Iowa, Iowa, IA, USA
* Corresponding author. Department of Thoracic Surgery, Dr.-Horst-Schmidt-Klinik, Ludwig-Erhard-Strasse 100, 65199 Wiesbaden, Germany. Tel: +49-611433132; fax: +49-611433135; e-mail:
[email protected] (S. Bölükbas). Received 22 October 2012; received in revised form 16 January 2013; accepted 27 January 2013
Abstract Extended pleurectomy/decortication or radical pleurectomy is defined as a lung-sparing surgical procedure for malignant pleural mesothelioma. A significant size mismatch between the thoracic cavity and the reduced size of the remaining lung might occur as a result of multiple resections at different sites and lead to residual thoracic space. Residual thoracic space and significant air leakage might result in postoperative complications. A simple technique of diaphragm reconstruction to avoid the residual thoracic space and to reduce the incidence of postoperative complications is described. Keywords: Mesothelioma • Diaphragm • Surgery • Complication • Technique
DISCUSSION
A 71-year old man with previous occupational asbestos exposure presented with unilateral left-sided pleural effusion. An initial CT-scan showed a pleural effusion and thickened pleura within the left chest, including fissures. Video-thoracoscopic pleural biopsy confirmed the diagnosis of epitheloid malignant pleural mesothelioma. The patient underwent radical pleurectomy (RP) as described in detail elsewhere [1]. Because of infiltration detected during surgery, complete diaphragmatic resection was carried out. Due to deep infiltration of the lung parenchyma, multiple wedge resections of the lung were necessary. Macroscopic complete resection (MCR) could be determined during surgery. However, a significant size mismatch between the thoracic cavity and the reduced size of the remaining lung was recognized. Diaphragmatic reconstruction was completed not on the previous, but three intercostal spaces, above (Fig. 2). The diaphragm was reconstructed with a Goretex patch (2 mm). We prefer non-absorbable 0 Mersilene (Ethicon, Germany) placed around the ribs and non-absorbable 0 Prolene (Ethicon, Germany) sutured at both the pericardium and mediastinum. The patient could be extubated immediately after surgery and was transferred to the intensive care unit in a stable condition. The postoperative X-ray of the chest after surgery showed full expansion of the left lung (Fig. 1). The final examination of the resected specimens confirmed the pathological International Mesothelioma Interest Group (IMIG) Stage III [ pT2 pN2 (2 of 27)].
Extended pleurectomy/decortication (P/D) or RP is defined as a surgical procedure to remove the entire macroscopic tumour, which can include resection of the diaphragm or the pericardium [2]. The goal of RP or extended P/D is MCR of the tumour burden while preserving the lung [3–5]. Additional resections are carried out in the event of deep infiltration of the lung parenchyma, mediastinal and pericardial fat as well as thymus. Generally, sealing of the denuded lung is accelerated once the lung is fully expanded, and there is a contact between the SURGICAL TECHNIQUE
CASE DESCRIPTION/TECHNIQUE
Figure 1: Postoperative X-ray of the chest after RP and thoracic shaping. †
Presented in part at the 11th International Conference of the International Mesothelioma Interest Group (iMig 2012), Boston, USA, 11–14 September 2012.
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Figure 2: Illustration showing normal anatomy (A) and the resized thoracic space (B) by suturing the diaphragm prosthesis one or more intercostal spaces above the previous anatomic level of the diaphragm depending on the emerged residual space.
denuded lung and the chest wall. However, a significant size mismatch between the thoracic cavity and the fistulating remaining lung might occur as a result of multiple resections at different sites (lung parenchyma, mediastinal and pericardial fat) and lead to residual ‘pleural’ space. The term residual thoracic space should be used instead of pleural space since there is no pleural tissue left behind. The management of the residual thoracic space is important and different after RP or extended P/D. Residual thoracic space and significant air leakage might result in postoperative complications, such as persistent pneumothorax, persistent ‘pleural’ effusion and chronic empyema. Thus, prevention and control of the residual thoracic space have significant importance. Decreasing the thoracic cavity is easy if the diaphragm can be preserved. Either temporary or permanent paralysis of the phrenic nerve is the most commonly applied manoeuvre. The diaphragm lifts within a few days even without these manoeuvres. However, decreasing the size of the hemithorax might be difficult if the diaphragm was resected. Usually, the diaphragmatic reconstruction is carried out at the same level to facilitate the radiation of the hemithorax after extrapleural pneumonectomy. However, this does not need to be considered after RP since hemithoracic radiation after RP is not indicated. Thus, an option to decrease the residual space is to ‘re-shape’ the hemithorax by changing the level of the diaphragmatic reconstruction (Fig. 2). The thoracic space should be inspected after inflation of the denuded lung at the end of surgery. The prosthetic material for the diaphragmatic reconstruction can be sutured one and more intercostal spaces above the previous anatomical level of the diaphragm, depending on the emerged residual space. This simple manoeuvre might facilitate the complete expansion of the remaining denuded lung. We have performed this technique with good success in 7 patients to date. It is an effective technique on the right side as well. In this case on the right side, the space between the Goretex patch and the remaining diaphragm or peritoneum was prematurely liquid-filled. The liquid was reabsorbed during the late course after remodelling the thoracic cavity and abdomen. All patients had an uneventful
postoperative course. There seemed to be shorter air leakage, chest tube duration and length of hospital stay.
CONCLUSION This simple and safe technique of diaphragm reconstruction might avoid the residual thoracic space and reduce the incidence of postoperative complications.
ACKNOWLEDGEMENT We thank Teresa Ruggle (Design Center, Department of Internal Medicine, University of Iowa Hospitals and Clinics) for the assistance with the illustration of Fig. 2. Conflict of interest: none declared.
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© The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
