Hasegawa S
Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Japan.
Kyobu Geka. 2010 Jul;63(8 Suppl):692-6.
Because extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) suffers from unsatisfiable risk/benefit ratio, very careful consideration on its indication should be required. EPP is a complicated, multi-step surgery that includes pleural dissection, division of hilum, resection of a block of pleura, lung, diaphragm and pericardium, and reconstruction of diaphragm and pericardium. Therefore establishment of surgical images of whole procedures before starting surgery is essential. Dissection of parietal pleura is a particularly important procedure of EPP, because it determinates operating time, surgical blood loss, surgical morbidity/mortality and curability. Technical difficulty of pleural dissection strikingly differs according to the degree of pleural thickening, pleural adhesion and the severity of pleural invasion of the tumor. Although good surgical view is essential for safety, excessive thoracotomy may lead to postoperative pain and respiratory disorder. Underestimation of clinical stage is rather common in MPM even after vigorous preoperative assessment. Surgeons sometimes encounter T4 (i.e., unresectable) MPM such as diffuse chest wall invasion, vascular invasion, peritoneal invasion, and positive pericardial effusion that have not been detected preoperatively. Therefore, potentially-T4 site should be 1st processed for possible discontinuance of operation.
由于恶性胸膜间皮瘤（MPM）的胸膜外肺切除术（EPP）存在风险/收益比不理想的问题，因此在其适应症方面需要非常谨慎地考虑。EPP是一种复杂的多步骤手术，包括胸膜剥离、肺门分离、切除一大块胸膜、肺、膈肌和心包，以及膈肌和心包重建。因此，在开始手术前建立整个手术过程的手术影像至关重要。壁层胸膜剥离是EPP特别重要的一个步骤，因为它决定了手术时间、手术失血量、手术并发症/死亡率以及治愈率。胸膜剥离的技术难度根据胸膜增厚程度、胸膜粘连以及肿瘤胸膜侵犯的严重程度而有显著差异。虽然良好的手术视野对安全至关重要，但过度开胸可能导致术后疼痛和呼吸紊乱。即使经过严格的术前评估，MPM中临床分期低估也相当常见。外科医生有时会遇到术前未检测到的T4期（即不可切除）MPM，如弥漫性胸壁侵犯、血管侵犯、腹膜侵犯和心包积液阳性。因此，对于可能无法继续手术的潜在T4部位应首先进行处理。
