Decortication of Lung

Decortication

Decortication is a medical procedure involving the surgical removal of the surface layer, membrane, or fibrous cover of anorgan. The procedure is usually performed when the lung is covered by a thick, inelastic pleural peel restricting lung expansion. In a non-medical aspect, decortication is the removal of the bark, husk, or outer layer, or peel of an object.  It may also be done in the treatment of chronic laryngitis.

Decortication is performed under general anaesthesia. It is a major thoracic operation requiring a full thoracotomy. Nowadays this procedure can be performed using thoracoscopy. All fibrous tissue is removed from the visceral pleural peel and pus is subsequently drained from the pleural space.

Decortication is frequently necessary when other minor interventions (eg, chest tube) have not resulted in clearance of the infection or hemothorax.

The primary indication for decortication in a patient with fibrothorax is presence of symptoms due to lung restriction resulting from development of a thick fibrinous peel.

In some patients who also have underlying lung disease, removal of the peel may not help the lung expand and thus surgery would be futile.

Decortication may not be possible in presence of uncontrolled lung infection or contralateral lung disease, or for a chronically debilitated patient.

Decortication gives the best results in patients who seek early treatment. Among patients with chest trauma who suffer a hemothorax, placement of a chest tube and complete drainage usually prevents development of fibrothorax. If visceral pleurectomy is performed, air leakage and postoperative hemorrhage may compromise pulmonary function. If patients are appropriately selected, complete reexpansion of the lung after decortication can usually be achieved.

Outcomes

The results after decortication are often fruitful. The morbidity and mortality after a decortication is dependent on the patient age, underlying comorbidities, and development of complications from the surgery. Decortication in general has an excellent outcome in young people.

If the decortication is done adequately, lung function improvement is remarkable. However, the ultimate return of lung function depends on preoperative lung disease.

If the lung parenchyma was normal prior to surgery, then complete reexpansion of the lung and obliteration of the pleural space is certainly possible. In most cases, lung volumes improve after decortication, but it is rare to see return to preoperative values.

The boundaries of the pleural space are the visceral pleura, which envelops the lungs, and the parietal pleura, which is the inner lining of the thoracic cavity. If the peel is very thick and adherent, injury to the lung parenchyma can occur with moderate air leak. Moreover, once inside the chest cavity, no lung may initially be visible because of the thick fibrous peel. For safe decortication, the chest cavity is best entered at the 5th/6th intercostal space and dissection should be started where the peel is the thinnest and easily removed. Blind digital peeling should be avoided, especially near the apex of the lung.