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| 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.
