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Yip SWS, Weinberg L, Gooi J, Sivenayagam S, Coulson TG, Barnett SA, Knight SR, Ludski J, Lee DK. Anaesthetic and perioperative considerations for extrapleural pneumonectomy and extended pleurectomy/decortication: a scoping review protocol. BMJ Open 2024; 14:e078125. [PMID: 38760041 PMCID: PMC11103232 DOI: 10.1136/bmjopen-2023-078125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 05/05/2024] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION Extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (ePD) are surgical cytoreductive techniques aimed at achieving macroscopic resection in malignant pleural tumours such as pleural mesothelioma, non-mesothelioma pleural malignancies such as thymoma and sarcoma, and rarely for pleural tuberculosis, in a more limited fashion. Despite extensive studies on both surgical techniques and consequences, a significant knowledge gap remains regarding how best to approach the perioperative anaesthesia challenges for EPP and ePD.It is unknown if the risk stratification processes for such surgeries are standardised or what types of functional and dynamic cardiac and pulmonary tests are employed preoperatively to assist in the perioperative risk stratification. Further, it is unknown whether the types of anaesthesia and analgesia techniques employed, and the types of haemodynamic monitoring tools used, impact on outcomes. It is also unknown whether individualised haemodynamic protocols are used to guide the rational use of fluids, vasoactive drugs and inotropes.Finally, there is a dearth of evidence regarding how best to monitor these patients postoperatively or what the most effective enhanced recovery protocols are to best mitigate postoperative complications and accelerate hospital discharge. To increase our knowledge of the perioperative and anaesthetic treatment for patients undergoing EPP/ePD, this scoping review attempts to synthesise the literature and identify these knowledge gaps. METHODS AND ANALYSIS This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review Protocols methodology. Electronic databases, OVID Medline, EMBASE and the Cochrane Library, will be systematically searched for relevant literature corresponding to EPP or ePD and perioperative or anaesthetic management. Data will be analysed and summarised descriptively and organised according to the three perioperative stages: preoperative, intraoperative and postoperative factors in clinical care. ETHICS AND DISSEMINATION Ethics approval was not required. The findings will be disseminated through professional networks, conference presentations and publications in scientific journals.
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Affiliation(s)
- Sui Wah Sean Yip
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - Julian Gooi
- Department of Cardiothoracic Surgery, The Alfred, Melbourne, Victoria, Australia
| | - Siven Sivenayagam
- Department of Cardiothoracic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Tim G Coulson
- Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, Victoria, Australia
- Department of Anaesthesiology and Perioperative Medicine, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Stephen A Barnett
- Department of Thoracic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Simon R Knight
- Department of Thoracic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Jarryd Ludski
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea (the Republic of)
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Nakamura A, Kuribayashi K. Do we still need to debate the merits of pleurectomy/decortication vs. extrapleural pneumonectomy for malignant pleural mesothelioma? Transl Lung Cancer Res 2023; 12:193-196. [PMID: 36895923 PMCID: PMC9989799 DOI: 10.21037/tlcr-23-24] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/26/2023] [Indexed: 02/09/2023]
Affiliation(s)
- Akifumi Nakamura
- Division of Thoracic Surgery, Department of Surgery, Hyogo Medical University, Hyogo, Japan
| | - Kozo Kuribayashi
- Department of Respiratory Medicine and Hematology, Hyogo Medical University, Hyogo, Japan
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Mangiameli G, Bottoni E, Cariboni U, Ferraroli GM, Morenghi E, Giudici VM, Voulaz E, Alloisio M, Testori A. Single-Center 20-Year Experience in Surgical Treatment of Malignant Pleural Mesothelioma. J Clin Med 2022; 11:jcm11154537. [PMID: 35956152 PMCID: PMC9369992 DOI: 10.3390/jcm11154537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 12/10/2022] Open
Abstract
Objectives: We examined a series of malignant pleural mesothelioma (MPM) patients who consecutively underwent surgery in our institution during the last 20 years. Across this period, we changed our surgical approach to MPM, adopting extended pleurectomy and decortication (eP/D) instead of extrapleural pneumonectomy (EPP). In this study, we compare the perioperative outcomes and long-term survival of patients who underwent EPP vs. eP/D. Methods: A retrospective analysis was carried out of all the MPM patients identified from our departmental database who underwent EPP or P/D from 2000 to 2021. Clavien−Dindo criteria was adopted to score postoperative complications, while Kaplan−Meier methods and a Cox multivariable analysis were used to perform the survival analysis. Results: Of 163 patients, 78 (48%) underwent EPP and 85 (52%) eP/D. Induction chemotherapy was significantly administrated more often in the eP/D group (88% vs. 51%). Complete trimodality treatment including induction chemotherapy, radical surgery, and adjuvant radiotherapy was administered in 74% of the eP/D group versus 32% of the EPP group (p < 0.001). The postoperative morbidity rate was higher in the eP/D group (54%) compared to the EPP group (36%) (p = 0.02); no statistically significant differences were identified concerning major complications (EPP 43% vs. eP/D 24%, p = 0.08). No statistical differences were identified in 30-day mortality, 90-day mortality, median disease-free, and overall survival statistics between the two groups. The Cox multivariable analysis confirmed no induction chemotherapy (HR, 0.5; p = 0.002), RDW (HR, 1.08; p = 0.02), and the presence of pathological nodal disease (HR, 1.99; p = 0.001) as factors associated with worse survival in the entire series. Conclusions: Our data support that eP/D is a well-tolerated procedure allowing the implementation of a trimodality strategy (induction chemotherapy, surgery, and radiotherapy) in most MPM patients. When eP/D is offered in this setting, the oncological results are comparable to EPP. To obtain the best oncological results, the goal of surgical resection should be macroscopic complete resection (R0) in carefully selected patients (clinical N0).
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Affiliation(s)
- Giuseppe Mangiameli
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (E.B.); (U.C.); (G.M.F.); (V.M.G.); (E.V.); (M.A.); (A.T.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Italy
- Correspondence: ; Tel.: +39-339-128-5344; Fax: +39-028-224-7585
| | - Edoardo Bottoni
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (E.B.); (U.C.); (G.M.F.); (V.M.G.); (E.V.); (M.A.); (A.T.)
| | - Umberto Cariboni
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (E.B.); (U.C.); (G.M.F.); (V.M.G.); (E.V.); (M.A.); (A.T.)
| | - Giorgio Maria Ferraroli
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (E.B.); (U.C.); (G.M.F.); (V.M.G.); (E.V.); (M.A.); (A.T.)
| | - Emanuela Morenghi
- Biostatistic Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy;
| | - Veronica Maria Giudici
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (E.B.); (U.C.); (G.M.F.); (V.M.G.); (E.V.); (M.A.); (A.T.)
| | - Emanuele Voulaz
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (E.B.); (U.C.); (G.M.F.); (V.M.G.); (E.V.); (M.A.); (A.T.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Italy
| | - Marco Alloisio
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (E.B.); (U.C.); (G.M.F.); (V.M.G.); (E.V.); (M.A.); (A.T.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Italy
| | - Alberto Testori
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy; (E.B.); (U.C.); (G.M.F.); (V.M.G.); (E.V.); (M.A.); (A.T.)
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Nasser A, Baird A, Saint-Pierre MD, Amjadi K, Laurie S, Wheatley-Price P. Three Decades of Malignant Pleural Mesothelioma: An Academic Center Experience. Clin Lung Cancer 2021; 22:441-448. [PMID: 33893043 DOI: 10.1016/j.cllc.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/08/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Malignant pleural mesothelioma (MPM) remains a challenging disease to manage. In the past few decades, extrapleural pneumonectomy (EPP), pemetrexed-based chemotherapy, and indwelling pleural catheters were introduced to MPM care with variable levels of efficacy and evidence. PATIENTS AND METHODS This was a retrospective review of patients diagnosed with MPM between January 1991 and March 2019. The primary outcome was overall survival (OS). Data were examined by decade to assess trends in MPM demographics, management, and OS. A subgroup analysis was then conducted to examine the impact of EPP, pemetrexed, and indwelling pleural catheters on OS. RESULTS The study included 337 patients; 309 patients had died at last follow-up (91.7%). Median age at diagnosis and the proportion of female patients increased from 65.8 years (interquartile range [IQR], 57.1-73.7) and 11.6% female from 1991 to 1999 to 75 years (IQR, 68.1-80.6) and 20.5% female from 2010 to 2019. Median OS was largely unchanged in the three study periods: 9.0 months (95% confidence interval [CI], 6.9-12.7) in the 1991-1999 cohort, 9.3 months (95% CI, 7.6-13.2) in the 2000-2009 cohort, and 10.1 months (95% CI, 7.9-13.6) in the 2010-2019 cohort. Controlling for a number of demographic and prognostic factors, EPP (hazard ratio [HR] = 0.50; 95% CI, 0.3-0.9; P = .02), pemetrexed-based chemotherapy (HR = 0.59; 95% CI, 0.40-0.87; P = .007), and indwelling pleural catheters (HR = 0.3; 95% CI, 0.13-0.71; P = .006) were each associated with improvements in OS. CONCLUSION Despite the small incremental improvements in survival shown by the three interventions we examined, prognosis remains guarded for MPM patients. Better modalities of management are needed.
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Affiliation(s)
- Abdullah Nasser
- Department of Medical Oncology, Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Andrew Baird
- Division of Respirology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Kayvan Amjadi
- Division of Respirology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Scott Laurie
- Department of Medical Oncology, Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Paul Wheatley-Price
- Department of Medical Oncology, Ottawa Hospital Cancer Centre, Ottawa, ON, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
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Nakamura A, Hashimoto M, Matsumoto S, Kondo N, Kijima T, Hasegawa S. Outcomes of Conversion to Extrapleural Pneumonectomy From Pleurectomy/Decortication for Malignant Pleural Mesothelioma. Semin Thorac Cardiovasc Surg 2021; 33:873-881. [PMID: 33609685 DOI: 10.1053/j.semtcvs.2021.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Abstract
In recent years, there has been a shift from extrapleural pneumonectomy (EPP) toward pleurectomy/decortication (P/D) as the preferred surgical technique. However, we occasionally encounter difficult cases wherein visceral pleurectomy requires conversion to EPP from P/D. We sought to clarify the preoperative risk factors and clinical outcomes associated with conversion to EPP. We compared and analyzed conversion to EPP and P/D between September 2012 and December 2019. Conversion to EPP was decided in case of diffuse tumor invasion to the pulmonary parenchyma or due to failure of decortication. Univariable regression analysis was performed to determine the association of preoperative variables with conversion to EPP. Survival was analyzed by the Kaplan-Meier method and log-rank test. Of the 181 patients who underwent intended P/D, 145 (80.1%) patients underwent P/D and 18 (9.9%) patients underwent conversion to EPP. The sum of 3-level pleural thickness (P < 0.001), maximum of 3-level pleural thickness (P = 0.006), and clinical T stage (P < 0.001) demonstrated association with conversion to EPP. Overall survival and progression-free survival were significantly worse in the conversion to EPP group (median overall survival, 29.2 months vs 57.0 months [P = 0.008]; median progression-free survival, 15.3 months vs 23.2 months [P = 0.005]. Our data show that approximately 1 of every 10 patients with P/D intention converted to EPP. Preoperative pleural thickness and clinical T stage may be risk factors associated with conversion to EPP. The survival rate of conversion to EPP was worse than that of P/D.
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Affiliation(s)
- Akifumi Nakamura
- Divisions of Thoracic Surgery and Respiratory Medicine, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan.
| | - Masaki Hashimoto
- Divisions of Thoracic Surgery and Respiratory Medicine, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Seiji Matsumoto
- Divisions of Thoracic Surgery and Respiratory Medicine, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Nobuyuki Kondo
- Divisions of Thoracic Surgery and Respiratory Medicine, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Takashi Kijima
- Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Seiki Hasegawa
- Divisions of Thoracic Surgery and Respiratory Medicine, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
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Donahoe LL, de Perrot M. The Role of Extrapleural Pneumonectomy in Malignant Pleural Mesothelioma. Thorac Surg Clin 2020; 30:461-471. [DOI: 10.1016/j.thorsurg.2020.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Nakamura A, Kondo N, Nakamichi T, Hashimoto M, Takuwa T, Matsumoto S, Kuribayashi K, Kijima T, Hasegawa S. Complications and Predictive Factors for Air Leak > 10 Days with Neoadjuvant Chemotherapy Followed by Pleurectomy/Decortication for Malignant Pleural Mesothelioma. Ann Surg Oncol 2020; 28:3057-3065. [PMID: 33123856 DOI: 10.1245/s10434-020-09275-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/22/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND A few studies have reported the incidence and clinical implications of complications after pleurectomy/decortication (P/D). OBJECTIVE The aim of this study was to assess the details of complications and predictive factors of particularly durable air leak with P/D. METHODS Data on 163 consecutive patients who underwent neoadjuvant chemotherapy (NAC) followed by P/D for malignant pleural mesothelioma between September 2012 and May 2020 at our institution were retrospectively analyzed. Postoperative complications and the significance of various preoperative risk factors for air leak > 10 days (AL10) to identify the group having a higher risk for particularly durable air leak were investigated. Risk factors for AL10 were sought using univariate and multivariate analyses. RESULTS Of 163 patients, 30- and 90-day mortality was 0.6% and 2.5%, respectively. Eighty-four (51.4%) patients experienced grade III or worse postoperative complications according to the Clavien-Dindo classification. The median duration of air leak was 7 postoperative days. AL10 occurred in 53 (32.5%) patients. Fifty-eight patients (35.6%) underwent pleurodesis and five patients (3.1%) underwent reoperation to control the air leak. On univariate analysis, performance status (PS; p = 0.003), prognostic nutritional index (p = 0.01), and pleural effusion (p = 0.04) were statistically significant risk factors for AL10, while on multivariate analysis, PS (odds ratio 4.0, 95% confidence interval 1.3-12.7; p = 0.02) remained the only variable predicted for AL10. CONCLUSIONS Recent postoperative mortality rates in NAC followed by P/D are quite acceptable. Approximately one in every three patients experienced AL10, and PS may be a risk factor associated with AL10.
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Affiliation(s)
- Akifumi Nakamura
- Division of Thoracic Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | - Nobuyuki Kondo
- Division of Thoracic Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Toru Nakamichi
- Division of Thoracic Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Masaki Hashimoto
- Division of Thoracic Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Teruhisa Takuwa
- Department of Thoracic Surgery, Saiseikai Noe Hospital, Osaka, Japan
| | - Seiji Matsumoto
- Division of Thoracic Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kozo Kuribayashi
- Division of Respiratory Medicine, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Takashi Kijima
- Division of Respiratory Medicine, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Seiki Hasegawa
- Division of Thoracic Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Abstract
Malignant pleural mesothelioma (MPM) is a rare disease of the pleura and is largely related to asbestos exposure. Despite recent advancements in technologies and a greater understanding of the disease, the prognosis of MPM remains poor; the median overall survival rate is about 6 to 9 months in untreated patients. The main therapeutic strategies for MPM are surgery, chemotherapy, and radiation therapy (RT). The two main surgical approaches for MPM are extrapleural pneumonectomy (EPP), in which the lung is removed en bloc, and pleurectomy/decortication, in which the lung stays in situ. Chemotherapy usually consists of a platinum-based chemotherapy, such as cisplatin, often combined with a folate antimetabolite, such as pemetrexed. More recently, immunotherapy has emerged as a possible therapeutic strategy for MPM. Evidence suggests that single-modality treatments are not an effective therapeutic approach for MPM. Therefore, researchers have started to explore different multimodality treatment approaches, in which often combinations of surgery, chemotherapy, immunotherapy, and RT are investigated. There is still no definitive answer to the question of which multimodality treatment combinations are most effective in improving the poor prognosis of MPM. Research into the effects of trimodality treatment approaches have found that radical approaches such as EPP and hemithoracic RT post-EPP are less effective than was previously assumed. In general, there are still a great number of unanswered questions and unknown factors regarding the ideal treatment approach for MPM. Hopefully, more research into multimodality therapy will provide insight into which combination of treatment modalities is most effective.
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Affiliation(s)
- Lawek Berzenji
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium
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