Decortication of Lung- A Surgical Intervention

What Is Decortication of the Lung?

Decortication is a surgical intervention employed to remove anomalous fibrous tissue that has developed on the lung, chest wall, or diaphragm. The pleural cavity exists between the lungs and the chest wall, with a lining of fluid that serves as a lubricant. The moisture in this region facilitates the smooth expansion and contraction of the lungs during respiration.

However, specific diseases or medical situations have the potential to result in an excessive accumulation of fluid that can occupy this space. The accumulation of excessive fluid is referred to as pleural effusion. Without intervention, fluid accumulation might undergo solidification, leading to the development of fibrous tissues that constrict and enclose the lung, leading to compromised respiratory function.

Decortication can be conducted via two primary methods: minimally-invasive procedures involving small incisions measuring approximately two to three inches in length, performed under general anesthesia, or open-surgery techniques involving larger incisions measuring around eight to ten inches in length, also performed under general anesthesia. Selecting a certain methodology is contingent upon the individual's medical condition.

What Are the Indications?

The primary indication for decortication is in situations of pleural empyema.

• Chronic empyema (accumulations of pus within a bodily cavity) necessitating decortication can manifest symptoms.

• Pyogenic empyema (an accumulation of pus in the pleural cavity resulting from germs, mostly bacteria) can arise from various bacterial pathogens, including Streptococcus pneumoniae, Staphylococcus aureus, and Klebsiella pneumoniae, among others.

• Additional indications for lung decortication encompass hemothorax and pleural thickening resulting from inflammatory disorders such as rheumatoid arthritis, tumors such as malignant mesothelioma, and other related factors.

• Nevertheless, the measurement of vital capacity could serve as a reliable indicator for determining the necessity of decortication.

What Are the Contraindications?

There are several contraindications associated with the performance of a decortication procedure, which include the following:

• The presence of a severely damaged lung can complicate the outcome of decortication. During this, re-expansion of the lung may not be achieved despite the intervention, which encompasses a lung with significant impairment or pathology. These individuals do not exhibit any improvement throughout the postoperative period regarding symptom relief.

• Following an assessment, it is possible that these individuals could be presented with the option of undergoing a pneumonectomy either immediately or at a subsequent point during the postoperative period.

• Patients with bronchial stenosis require a bronchial anastomosis to be constructed and the stenosed segment removed since the condition prevents improperly produced fibrous tissue removal.

• Patients with unstable blood flow, problems with clotting, failure of multiple organs, and a generally poor health state probably will not be able to handle the risks of major surgery. Due to this, surgical decortication is usually not recommended.

What Are the Treatment Methods?

1. Posterolateral Thoracoscopic Lobectomy

• The skin incision begins at a level midway between the spinous process and the apex of the scapula and curves downwards. This incision extends approximately two inches below the scapula's point; with electrocautery, a deeper incision is made.

• The fifth or sixth interspace is the entry point into the thoracic cavity. The electrocautery must separate the intercostal muscles at the upper border of the lower rib to preserve the neurovascular bundle. A rib resection may be necessary if there is excessive rib congestion.

• After dividing the intercostal muscles, it enters the extrapleural compartment. It is necessary to take precautions to avoid harming the mediastinal structures. Similarly, the lung's apex must be cautiously released.

• During the apical dissection, damage to the subclavian vessels is possible and can result in hemorrhage. Care must also be taken to avoid injury to the esophagus, vena cava, and diaphragm during the medial and inferior dissections. Lung parenchyma, including fissures, must be removed from the pleural epidermis or rind.

• Following the removal of the thick peel, the lung is instructed to be inflated to locate air breaches. All significant air leaks must be closed off formally with sutures. Appropriate coagulation must be maintained.

• Insertion of the intercostal duct into the thoracic interspace. Some surgeons install two drains at the base (posterior) and the other at the apex (anterior). These tubes are left in position until clinical and radiographic signs of lung expansion appear. Finally, a layered thoracic wall closure is performed.

2. Thoracoscopic Video-Assisted Surgery (VATS)

• An anterior route is typically used to accomplish VATS-decortication, according to the surgeon's preference; three ports can be inserted. Some surgeons also like the uniportal approach. During the operation, a 30-degree camera is employed for visualization. The unaffected region of the thoracic cavity is entered using the preoperative computed tomogram as a guide.

• Suction cannulas and cautery hooks are efficient dissection tools.

• The dissection's boundaries match those of open surgery.

• Adhesiolysis (removal of scar tissue adhesions) can be done at several locations within the pleural cavity by switching the camera port.

• The port sites can accommodate the chest tube.

• VATS has already been shown to be effective for pleural toileting in the early stages of empyema. Thoracotomy had greater mortality, significant morbidity, prolonged duration of stay, and discharge to a location other than home than video-assisted thoracoscopic surgery.

Following Surgery Care

Adequate analgesia, antimicrobial medication, hydration, and nutritional assistance are all included in postoperative care. Mechanical ventilation is frequently needed for sick individuals. Therefore, prolonged surveillance must be ensured in these patients' initial postoperative time. The airway tubes must also be properly cared for. In addition to serial chest radiography, periodic analysis of arterial blood gases may also be necessary in these patients.

What Are the Complications of the Condition?

The following is a list of the most common issues that might result from lung decortication:

• Hemorrhage: The loss of blood that can occur due to the rough lung surfaces can cause a large amount of bleeding. A postoperative blood profile should be performed to determine whether or not the patient requires a blood transfusion after surgery.

• Persistent Air-Leak as Well as Bronchopleural Fistula: While decortication is taking place, minor air leaks may occur. However, when a few days have passed, these leaks will fix themselves. To prevent the formation of a bronchopleural fistula, it is necessary to use formal suturing techniques to repair large leaks.

• Persistent Lung Collapse: Collapse and non-expansion of the lung parenchyma are frequently noted in the postoperative phase after decortication. This condition is known as persistent lung collapse. Chest physiotherapy and incentive spirometry play a significant part in re-expanding the parenchyma that lies under the surface. On the other hand, a minority of patients might not display enough lung expansion because their lungs are damaged or diseased. To avoid damaging essential structures, highly skilled surgeons must carry out the decortication procedure with extreme caution. If the limitations of peel removal are not adhered to, there is a high risk of injuring critical structures such as the subclavian arteries, diaphragm, esophagus, and pericardium.

• Pus: If there is a retained infective focus or sepsis, it is imperative that the pus be completely removed and that pleural toileting be conducted before beginning the decortication process. Pus that are left behind after surgery can act as breeding grounds for infection, which increases the risk of developing sepsis in the postoperative period.

• Severe Postoperative Pain: It is possible for any thoracotomy, particularly ones that involve rib excision, to result in a large amount of discomfort in the postoperative period. A sufficient amount of postoperative analgesia is required, and in some cases, this may call for a combination of intravenous and epidural analgesia.

• Deformities: Scoliosis and deformities of the chest wall are both commonly seen in patients.

Conclusion

The surgical procedure involves the removal of the thickened pleura from both the lung and chest wall. This procedure is typically performed in chronic pyogenic empyema, tuberculous empyema, and a hemothorax with clot formation. The operation above confers multiple benefits, including a reduction in the patient's recovery period and enhancements in pulmonary function and chest-wall movement. Decortication's efficacy is contingent upon managing the underlying infection and the timely and thorough closure of the pleural gap, facilitating the swift re-expansion of the lung. In certain instances, the lung may fail to adequately occupy the remaining space within the chest cavity, necessitating a thoracoplasty procedure to achieve comprehensive treatment.