Surgical Management and Reconstruction of Diaphragm, Pericardium and Chest Wall in Mesothelioma Surgery: A Review

Our plain-English summary of Surgical Management and Reconstruction of Diaphragm, Pericardium and Chest Wall in Mesothelioma Surgery: A Review, by P. Bertoglio, E. Garelli, J. Brandolini, et al (Journal of Clinical Medicine, 2021).

The study

• Authors: P. Bertoglio, E. Garelli, J. Brandolini, K. Kawamukai, F. Antonacci, S. Ricciardi, A. Cipolli, B. Bonfanti, S.N. Forti Parri, N. Daddi, G. Dolci, P. Solli
• Journal: Journal of Clinical Medicine
• Published: 2021;10(11)
• Type of article: Review
• Cited by: 9 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Mesothelioma is an aggressive disease arising from parietal pleura. Surgery is a valuable option in the frame of a multimodality treatment. Several surgical approaches have been standardized with the aim of a macroscopic complete resection; these often require homolateral diaphragm and pericardial resection and reconstruction. Extrapleural pneumonectomy (EPP) and extended pleurectomy decortication (EPD) have been recognized as radical surgical procedures. Nevertheless, both operations are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. Moreover, in the case of localized chest wall recurrence, surgery might be considered a valuable therapeutical option for highly selected and fit patients. All the technical aspects of the resection and reconstruction of the diaphragm, pericardium, and chest wall are described as well as the possible use of new minimally invasive techniques. In addition, the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

In plain English

This article was a review of how surgeons remove and rebuild the diaphragm, the pericardium (the sac around the heart) and the chest wall during surgery for malignant pleural mesothelioma. It presented no new patient data. The authors described two operations: extrapleural pneumonectomy, which removes the lung, and extended pleurectomy decortication, which keeps it. Both remove the diaphragm and pericardium on the affected side. They wrote that no clear evidence or guidelines show which diaphragm repair material is best. Citing earlier studies, they reported a 2.4% infection risk and a 3.8% to 12% herniation risk with synthetic diaphragm materials. They also reported removal of rigid methyl methacrylate chest wall implants in up to 5% of patients. Asbestos was mentioned only as a recognized risk factor. The authors concluded that diaphragm and pericardial reconstruction are well-defined steps of both operations, and that minimally invasive surgery still plays a marginal role in radical surgery for this disease.

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: Review of surgical techniques and prosthetic materials (no original patient data)
• Who was studied: No study population of its own; the review covered published reports on patients with malignant pleural mesothelioma undergoing extrapleural pneumonectomy (EPP), extended pleurectomy and decortication (EPD), or chest wall resection
• Exposure: Not studied. The review concerns surgical techniques, and asbestos exposure is mentioned only as a recognized risk factor for malignant pleural mesothelioma
• Main results:
  • Both EPP and EPD remove the parietal pleura, diaphragm and pericardium on the affected side. EPP also removes the whole lung, while EPD preserves it
  • No clear evidence or guidelines identify the best diaphragm reconstruction material. 2 mm-thick expanded polytetrafluoroethylene (e-PTFE) was described as probably the most popular
  • Citing an earlier study (reference 17), synthetic diaphragm materials were associated with a 2.4% infection risk and a herniation risk of 3.8% to 12%
  • Citing earlier studies, mesh dehiscence (separation) was most frequent in the left posterior mediastinum, at up to 7%
  • Citing Sugarbaker and colleagues, leaving a small rim of the patient's own diaphragm significantly reduced gastric herniation. Those authors noted there were no data on any effect on cancer outcomes
  • For pericardial meshes, permeability was described as important because of the risk of cardiac tamponade
  • Citing an earlier study (reference 28), methyl methacrylate chest wall prostheses were associated with higher wound complication rates, requiring removal in up to 5% of patients
  • Only a few cases of video-assisted (VATS) extrapleural pneumonectomy have been reported
• The authors' conclusion: The authors concluded that diaphragm and pericardial resection and reconstruction are well-defined steps of both EPP and EPD, that chest wall resection might be needed in highly selected patients, and that minimally invasive surgery still has a marginal role in radical resection of malignant pleural mesothelioma
• Limitations the authors state:
  • The authors stated that no clear evidence or guidelines exist for choosing diaphragm reconstruction materials or techniques, so the choice rests on surgeon preference
  • The authors stated there are no clear data on the strength and absorption time of absorbable pericardial meshes

Topics

Medical terms in this study, explained in our Lexicon: Diaphragm, Pericardium, Mesothelioma, Parietal Pleura, Pericardial, Extrapleural Pneumonectomy (EPP).

Related studies

• Initial experience with the use of biological implants for soft tissue and chest wall reconstruction in thoracic surgery — A. Barua, J.A. Catton, et al. (2012)
• Experience of biological implants in thoracic surgery for soft tissue and chest wall reconstruction in clean and contaminated environments — H. Jesani, V. Surendrakumar, et al. (2026)
• Chest wall resection for mesothelioma recurrence after surgery — P. Bertoglio, O. Fanucchi, et al. (2016)
• Effect of asbestos-related pleural fibrosis on excursion of the lower chest wall and diaphragm — B. Singh, P.R. Eastwood, et al. (1999)
• Massive chest wall resection and reconstruction for malignant disease — C.N. Foroulis, A.D. Kleontas, et al. (2016)
• Long-term results of chest wall reconstruction with DualMesh — T. Nagayasu, N. Yamasaki, et al. (2010)

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