Your lungs are covered by a protective membrane called the pleura, which allows your lungs to expand while breathing. Sometimes, this covering may become hardened because of disease such as chronic infection or cancer, which can affect your breathing. This may require a treatment called decortication to improve the ability of your lungs to expand when you breathe.

What Is Decortication?

Inside the chest cavity is a pair of lungs that is surrounded with membranes (pleura). Between the pleura and the lung tissue is a potential space that is lubricated with a thin layer of fluid. This keeps the pleura and the lung tissue sliding against each other and allows for lung expansion. Sometimes, conditions such as infection (pneumonia), traumatic bleeding or cancer can fill this space with inflammatory fluid, which can solidify and make the pleura adhere to the lungs. It forms a capsule that can entrap the lungs and make breathing difficult.

A surgical procedure that involves removal of diseased pleura is called decortication. When the pleura form fibrous tissues due to an inflammatory process that restricts lung expansion, surgeons perform decortication, which aims to peel off the hardened tissue. This results in the return of lung compliance, which leads to improvement of symptoms.

Newer techniques include video-assisted thoracoscopic surgery or VATS decortication, which is a less invasive method that uses a small camera to guide thin instruments through small skin incisions.

When Is Decortication Needed?

Decortication is necessary to improve a patient’s breathing that may be compromised due to conditions such as empyema, pleurisy, fibrothorax and malignant mesothelioma.

Empyema

Pus that forms within a body cavity is called empyema. The pleural space around the lungs is commonly affected. Empyema typically develops over 4 to 6 weeks as infection (pyothorax) progresses inside the pleural space. This is usually caused by pneumonia caused by bacterial infection of the lungs.

Pleurisy

Various infectious and non-infectious conditions can cause inflammation in the lining of the lungs (pleurisy), which can lead to painful respiration and many other symptoms.

Fibrothorax

Another form of pleurisy, fibrothorax occurs when abnormal fibrous tissue develops within the pleural space and results in entrapment of the lung tissue. Any injury to the pleura can result in inflammation with fibrous deposition and fibrothorax. However, blood accumulation and bacterial infection in the pleural cavity are the most common reasons for fibrothorax.

Malignant Mesothelioma

This is a type of cancer that is associated with chronic exposure to asbestos. Malignant mesothelioma causes tumors to develop in the protective membranes that cover most internal organs, especially the lungs.

How Is Decortication Done?

Decortication consists of two parts - pleurectomy and decortication. The whole procedure can last for about 5 hours. The procedure is done under general anesthesia.

Pleurectomy

A pleurectomy involves making an incision or laceration at the back of the torso, beginning at the sixth rib, extending downward along the spine. Then the cut is extended outward, going parallel with the ribs. This incision allows access to the cavity of the thorax that contains the lungs. Another small incision may be made if a large tumor extends lower into the thoracic cavity.

Upon exposure to the tumor, the surgeon removes the outside lining (parietal pleura) of the lungs as well as the affected parts of the chest wall, diaphragm and pericardium (lining of the heart). If the tumor is widespread and cannot be entirely removed entirely, a pleurectomy without decortication may be done.

Decortication

After pleurectomy, the surgeon performs decortication, where he scrapes the lining of the lung to remove as much of the pleura and cancer or infection as possible. The lung is left undamaged. The open chest cavity is packed with gauze to minimize loss of blood. Then, the surgeon closes the cavity incision with stitches.

After the Decortication

Recovering from Decortication

After decortication, lung recovery takes place within several days while the patient is in the hospital. This will ensure that serious complications which can occur after the surgery are monitored. Your chest wall may continue to shed some blood and air leaks through the lungs may occur within the first few days.

When everything goes well after about a week, you can go home safely and rest for another three to four weeks until fully healed. Your doctor will recommend deep breathing exercises to help expand your lungs and strengthen your muscles as well. You will be advised to avoid strenuous physical activities for the first two months of recovery to avoid surgical wound from being reopened or infected.

Success Rate and Possible Complications of Decortication

Most cases of pleurectomy/decortication are done successfully. Up to 90% of patients who undergo this surgery achieve significant improvement with increased life expectancy. Median survival rates are about 20 months, which is about a year longer than some mesothelioma patients.

Mortality rate for decortication is 1%. Complications are uncommon. These include prolonged air leaks, which occur in one out of ten patients. Some patients have a recurrence of their cancer.