Strategies to reduce morbidity following pleurectomy and decortication for malignant pleural mesothelioma

Our plain-English summary of Strategies to reduce morbidity following pleurectomy and decortication for malignant pleural mesothelioma, by P. Bou-Samra, A. Chang, K. Zhang, et al (Thoracic Cancer, 2023).

The study

• Authors: P. Bou-Samra, A. Chang, K. Zhang, F. Azari, G. Kennedy, E. Guo, W.T. Hwang, S. Singhal
• Journal: Thoracic Cancer
• Published: 2023;14(27):2770-2776
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT), and foreign catheter sepsis. We instituted four strategies to reduce these complications and report our experience.

Methods: This was a retrospective review of patients who underwent PD at the University of Pennsylvania between 2015 and 2022. Our patients underwent standard of care PD in addition to tracheostomy and gastrostomy/jejunostomy tube with therapeutic anticoagulation (AC) leading up to surgery. Measured outcomes were postoperative PNA, DVT, and sepsis. The predicted risk of those same outcomes had patients not undergone the interventions was calculated based on the American College of Surgeons (ACS) surgical risk calculator (SRC). A McNemar's test was used to determine whether the risk of having PNA, DVT and sepsis differed between the two subgroups.

Results: Fifty-five patients were included in the study. The mean age was 70 years (SD 6.2) with a mean of 21 (SD 19) pack-years of smoking. PNA, DVT, and catheter-related sepsis occurred in 12, four, and seven patients, respectively. Upon using the ACS SRC prediction model of the nonintervention group, PNA, DVT and catheter related sepsis was predicted to occur in 24 (paired data OR 5, 95% CI: 1.4-17.2; McNemar's test p = 0.008), 14 (paired data OR 3.5, 95% CI: 1.15-10.6; McNemar's test p = 0.03), and 17 (paired OR 3, 95% CI: 1.09-8.3; McNemar's test p = 0.04) patients, respectively.

Discussion: Patients undergoing tracheostomy creation, therapeutic AC at the time of diagnosis, and gastrostomy tube placement had a reduced risk of aspiration PNA, DVT, and catheter sepsis.

© 2023 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.

In plain English

This retrospective review studied 55 patients with malignant pleural mesothelioma who had pleurectomy and decortication at the University of Pennsylvania hospital, 2015 to 2022. This operation removes the lining of the chest wall and lesions on the lung's lining. In all, 76.4% had a history of asbestos exposure. All patients received preventive measures: a mini-tracheostomy at the end of surgery, gastrostomy and jejunostomy tubes 2 weeks before, and a blood thinner (therapeutic low molecular weight heparin) before surgery. No real patients went without these measures. Instead, the authors used the American College of Surgeons surgical risk calculator to estimate each patient's risk without them. They counted patients above the calculator's average risk as predicted to have the complication. Pneumonia occurred in 12/55 patients against 24/55 predicted, and deep vein thrombosis in 4/55 against 14/55. Line sepsis occurred in 7/55, against 17/55 predicted cases of any sepsis. The calculator also did not single out aspiration pneumonia. All three differences were statistically significant. The authors concluded that the measures were associated with reduced risk of these complications, and called for larger multi-institutional studies.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective review of a single-center surgical cohort. Observed outcomes were compared with outcomes predicted by the ACS NSQIP surgical risk calculator, using the calculator's average risk per complication as a cutoff. There was no actual untreated control group.
• Who was studied: 55 patients with malignant pleural mesothelioma who underwent pleurectomy and decortication at the Hospital of the University of Pennsylvania, 2015 to 2022. Mean age was 70.2; there were 43 males and 12 females. 42 (76.4%) had asbestos exposure.
• Exposure: Perioperative interventions: a mini-tracheostomy at the end of surgery, gastrostomy and jejunostomy tubes placed 2 weeks before surgery, and preoperative therapeutic low molecular weight heparin. Asbestos exposure was recorded only as a baseline characteristic (76.4% yes), with no fiber types given.
• Main results:
  • Pneumonia: 12/55 (21.8%) observed in the intervention patients versus 24/55 (43.6%) predicted without tracheostomy (matched-pair OR 5.0, 95% CI 1.4 to 17.2; McNemar's test p = 0.008). The calculator's prediction covered pneumonia in general, not specifically aspiration pneumonia.
  • Deep vein thrombosis: 4/55 (7.3%) observed versus 14/55 (25.5%) predicted without therapeutic LMWH (matched-pair OR 3.5, 95% CI 1.15 to 10.6; McNemar's test p = 0.03).
  • Sepsis: 7/55 (12.7%) observed, which the authors describe as line sepsis, versus 17/55 (30.9%) predicted sepsis of any kind without a gastrostomy tube (matched-pair OR 3, 95% CI 1.09 to 8.3; McNemar's test p = 0.04).
• The authors' conclusion: The authors concluded that tracheostomy, therapeutic anticoagulation at diagnosis, and gastrostomy and jejunostomy tubes were associated with reduced risk of aspiration pneumonia, DVT and line sepsis in MPM patients undergoing PD. They added that larger multi-institutional studies are needed.
• Limitations the authors state:
  • Small sample size and a single-center study
  • No control patients from the same hospital before the interventions were introduced
  • The calculator predicts pneumonia in general, not specifically aspiration pneumonia
  • The calculator predicts sepsis in general, not specifically line sepsis
  • Tumor stage (stage I to IIB) was not included as a variable

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma.

Related studies

• Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma — R.M. Schwartz, W. Lieberman-Cribbin, et al. (2018)
• Lymphangitic carcinomatosis: A common radiographic manifestation of local failure following extended pleurectomy/decortication in patients with malignant pleural mesothelioma — I. Berger, K.A. Cengel, et al. (2019)
• Pharmacokinetics of Hyperthermic Intrathoracic Chemotherapy following Pleurectomy and Decortication — P.H. Sugarbaker, O.A. Stuart, et al. (2012)
• Salvage pleurectomy/decortication following immunotherapy for malignant pleural mesothelioma — M. Takenaka, K. Kuroda, et al. (2024)
• Quantitation and predictors of short-term mortality following extrapleural pneumonectomy, pleurectomy/decortication, and nonoperative management for malignant pleural mesothelioma — C. Wright, V. Verma, et al. (2020)
• Abdominal Wall Morbidity Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy — F. Struller, I. Koenigsrainer, et al. (2017)

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