In an extrapleural pneumonectomy the lung is removed en bloc, together with parietal and visceral pleura, ipsilateral hemidiaphragm and pericardium, as well as mediastinal lymph nodes.
The operation is now reserved almost exclusively for the treatment of mesothelioma. A recent randomized control trial showed no improved survival in patients treated with surgery in the context of trimodal therapy.
2-10% of individuals with prolonged asbestos exposure will develop mesothelioma, but more than 80% of mesothelioma patients have a history of exposure to asbestos.
The major anesthetic issues are significant blood loss, hemodynamic instability, difficult fluid therapy, risk of cardiac herniation and high probability of dysrhythmias.
The patient is a 57-year-old ex-shipyard worker who presents for an extrapleural pneumonectomy after a work-up for dyspnea revealed a malignant pleural effusion positive for mesothelioma. He has no evidence of extrathoracic disease. He has a history of 40 pack-years of smoking but has not smoked in 10 years.
He has no other medical problems and medications include only a multivitamin. Vital signs: BP 135/70, HR 70, room air SpO2 93%. Routine laboratory examination is unremarkable. Pulmonary function tests are notable for a FEV1/FVC ratio of 80%, an FEV1 of 70% predicted, a FVC of 75% predicted, and a DLCO of 50% predicted.
Extrapleural pneumonectomy (EPP) was introduced in the 1940s for the treatment of tuberculous empyema and other pleural space infections.1 It is a radical surgery that differs from conventional pneumonectomy in that the lung is removed en bloc, together with parietal and visceral pleura, ipsilateral hemidiaphragm and pericardium, as well as mediastinal lymph nodes. In modern times the operation is reserved almost exclusively for the treatment of malignant pleural mesothelioma (MPM). Rarely, it can also be performed for locally advanced lung cancer, or other malignancies and infections confined to a single pleural space.
EPP is a technically difficult operation accompanied by a significant mortality rate, recently estimated at between 3% and 7%.2-4 This has dramatically improved since the 1970s when mortality was over 30%,5 with the trend now toward improved operative survival, especially if used as part of a multimodal approach (Table 14–1). Nevertheless, morbidity remains high even in large volume centers with aggressive intervention, exceeding that for pneumonectomy.4 Accordingly its use remains controversial, and patient selection is imperative. Anesthesia management is challenging and may contribute to safe patient outcomes.
Table 14–1. Mortality of Extrapleural Pneumonectomy |Favorite Table|Download (.pdf)
Table 14–1. Mortality of Extrapleural Pneumonectomy
No. of Patients
Operative Mortality (%)
Bamler and Maassenn
Butchart et al
Lung Cancer Study Group
Rusch and Venkatramen
Sugarbaker et al
Malignant pleural mesothelioma (MPM) is a rare, locally aggressive tumor of the mesothelial ...