Paracentesis Procedure Mesothelioma, used to remove excess fluid from the abdominal cavity

Paracentesis is a minimally-invasive procedure used to remove excess fluid from the abdominal cavity, a condition also called ascites. This procedure may also be an abdominal or ascites tap, and may be used for either diagnostic or therapeutic reasons. This excess fluid tends to collect in patients with peritoneal mesothelioma, which affects the membrane that lines the abdominal cavity.

A small amount of fluid is normal to prevent friction between the organs and other structures in the abdomen, but when too much collects, it can cause pressure and discomfort. It can also negatively affect a patient’s ability to breathe, interfering with the normal function of the intestines or stomach. Paracentesis removes the excess fluid to help reduce or eliminate pressure buildup and relieve symptoms so mesothelioma patients experience an improved quality of life. The procedure is also used to help relieve fluid buildup that occurs for other conditions, including other types of cancer, infections or liver disease.

The Paracentesis Procedure

Paracentesis uses a long, hollow needle or tube to access the excess fluid in the abdominal cavity so it can be removed. Before the procedure, the needle insertion site will be carefully cleaned and numbed with a local anesthetic. The needle will be carefully placed into the abdominal cavity at the site of fluid buildup. The needle may be guided by a CT scan or ultrasound to ensure it’s in the proper location. After the needle reaches the treatment site, the fluid will be gently extracted.

Patients may feel a slight pulling sensation as the needle is inserted and the fluid is removed. Patients may also experience lightheadedness, and should let the doctor know they start to feel sick or unwell during the procedure. Once the fluid is extracted, the needle will be removed and a bandage will be placed over the injection site. The procedure can be performed right in the doctor’s office, in a medical center or imaging center, or in a hospital.

Patients may have some drainage from the site for a day or two, especially if a lot of fluid is removed during the procedure. They may also need to take part in multiple sessions, since fluid buildup may return.

Palliative Benefits

Once the fluid is removed, patients generally experience a relief from symptoms, including:

• Being able to breath more comfortably
• Reduced sensation of fullness or pressure in stomach

Risks and Complications

Paracentesis is generally considered to be a safe procedure, but as with any type of medical procedure, there are risks that should be considered prior to undergoing treatment, including:

• Perforation (puncturing) of the bowel, bladder or a blood vessel
• Transfer of cancer cells from one area of the abdomen to another
• Shock, especially if a very large amount of fluid is removed causing your blood pressure to rapidly drop
• Kidney malfunction, especially in those with kidney disease or risk factors for kidney disease
• Bleeding and infection

If you have questions about paracentesis or other procedures used in the management of mesothelioma, speak with your doctor.

Sources:
1. Paracentesis: Procedure, Preparation, Risks, and Results.” WebMD. WebMD, n.d. Web. 29 Jan. 2016.
2. “Advanced Cancer.” American Cancer Society. (n.d.): 91. Web
3. Bfahey. “Interventional Radiology: Paracentesis (“belly tap”) or Thoracentesis (“chest tap”)”. NIH Clinical Center Patient Education Materials.
4. https://www.maacenter.org/treatment/surgery/paracentesis/

Pleurodesis Sugery, a Procedure that helps to relieve a patient’s Mesothelioma

Mesothelioma is a rare type of cancer that develops in the mesothelium, the lining that surrounds and protects the body’s internal organs. When the cancer develops in the lining that surrounds the lungs, the pleura, it can cause fluid to build up between the layers of the pleura. Symptoms include: shortness of breath, difficulty breathing, and a racing heart. This is where pleurodesis can help. Pleurodesis is a procedure that helps prevent this fluid buildup, easing the patient’s ability to breathe. Choosing the correct mesothelioma treatment option is critical.

Pleurodesis Surgery

Pleurodesis is used specifically to treat the symptoms of pleural mesothelioma, which is the type of mesothelioma that forms in the lining surrounding the lungs. Pleural mesothelioma and other cancers that affect the lungs often cause pleural effusion, or a buildup of fluid between the layers of the pleural lining. This fluid places pressure on the lungs so they cannot fully expand. Pleural effusion is usually diagnosed with a chest X-ray.

Pleurodesis is what is known as a “palliative” procedure, that is, a procedure that helps to relieve a patient’s symptoms but doesn’t deal with the underlying disease. When the fluid buildup causes the patient significant trouble breathing, the doctor may recommend chemical pleurodesis to relieve breathing problems.

Although pleurodesis does not treat or cure mesothelioma, it can be very helpful dealing with patients’ symptoms. Not every mesothelioma patient is a candidate for pleurodesis. Talk to your doctor to determine whether or not this procedure will be helpful for you.

Chemical Pleurodesis

The concept of pleurodesis is simple: the physician drains the fluid from between the pleural layers and inserts a chemical irritant into the space. This irritant causes inflammation and scarring, which causes the two layers to stick together. No space remains in which fluid can collect.

The first step in the procedure it to drain the fluid from around the lungs. The doctor administers an anesthetic, then inserts a wide needle into the chest. A drainage tube connects the needle to a collection bag. Fluid drains slowly through this tube.

Once the fluid has completely drained, the treatment agent is inserted between the pleural layers. This is usually sterile talc powder; other chemicals used include Bleomycin, Tetracycline, and Doxycycline. Sometimes the doctor has the patient change positions while the irritant is in place, to help to distribute it evenly between the pleural layers. The chest tube remains in place until fluid drainage decreases, indicating that the pleurodesis procedure was successful. This is usually confirmed with an x-ray.

Pleurodesis can be performed either in or out of the operating room. In the operating room, the patient receives general anesthesia and the surgeon examines the inside of the chest with a thin, lighted tube called a thoracoscope. The thoracoscope can also take tissue samples, if needed, and is used to insert the chemical agent. When pleurodesis is performed as a “bedside” procedure, it is carried out in the hospital using a local anesthetic and a sedative. The physician does not use a thoracoscope in the bedside procedure.

After the Procedure

After the procedure, you are likely to feel sore at the site of the chest tube or when taking a deep breath. Some patients develop a fever. The doctor may prescribe pain medication. You should avoid taking anti-inflammatory medications such as Ibuprofen, which will interfere with the adhesion of the pleural layers. Check with your health team for specific post-procedure instructions.

Sources:
Boston Medical Center. Pleurodesis or Pleural Effusion.
https://www.bmc.org/thoraciconcology/treatments/Pleurodesis.htm
https://www.maacenter.org/treatment/surgery/pleurodesis/

Cytoreductive Surgery, Remove visible peritoneal tumors from within the abdominal cavity

Cytoreductive Surgery (Debulking)

Cytoreductive surgery, also known as debulking, is a surgical option for peritoneal mesothelioma patients. The procedure aims to remove visible peritoneal tumors from within the abdominal cavity. Cytoreduction is a long procedure, averaging anywhere from 10-12 hours. The duration and complexity of cytoreduction performed correlates with the amount of peritoneal mesothelioma encountered in the abdominal cavity. Depending on the amount of visible tumors, cytoreduction may include the removal of: the omentum in front of the stomach, the greater omentum and spleen, tumors on the liver, part of the large intestine and uterus or ovaries in female patients, and part of the gall bladder and peritoneum between the stomach and liver.

Cytoreductive Surgery Procedure

After the initiation of general anesthesia, the patient is positioned lying on their back. The surgeon makes a large midline incision from the bottom of the sternum to the top of the pubic bone. The surgeon then examines the abdominal cavity and organs for visible tumors.  

Cytoreduction is performed with a ball-tip electrosurgical hand piece which separates cancerous tissue from healthy peritoneal tissue.  Electricity creates heat at the tip of the hand piece cauterizing as it cuts, minimizing blood loss. Heat also kills cancer cells as cancerous tissue is separated from healthy tissue. The goal of cytoreduction is to remove as much visible tumor as possible.

Cytoreduction with HIPEC

The surgery is often combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC), which helps kill any remaining cancer cells in the abdomen. HIPEC is when a heated chemotherapeutic agent is circulated throughout the abdominal cavity with occasional abdominal massage ensuring thorough distribution of chemotherapy throughout the abdominal cavity.

After cytoreduction is performed, the surgeon inserts two catheters, or tubes, into the abdominal cavity, closes the midline incision, and initiates HIPEC. The infused agent is heated to approximately 104-107 degrees and circulated throughout the abdominal cavity for 60-100 minutes. Accessing all areas in the abdomen during cytoreduction is difficult, thus, HIPEC it utilized to kill missed cells preventing them from growing into new tumors.

HIPEC is beneficial because it allows for a larger, more focused dose of chemotherapy to be administered. Heated chemotherapy enhances peritoneal tissue penetration and increases the efficacy of the chemotherapeutic agent. HIPEC does not have the systemic effects commonly associated with chemotherapy such as nausea, vomiting, and hair loss. The goal of HIPEC is to kill all intraperitoneal cancer cells, but successfully doing so cannot be guaranteed. After HIPEC is completed, the surgeon removes the catheters and closes the abdominal incision.

Recovery

Patients spend up to two days in the ICU or Stepdown unit followed by eight to ten more days in the surgical unit. Surgical pain is controlled with a PCA (patient controlled analgesia) pump or IV pain medications. Patients also receive any food and fluids through an IV. They are connected to a nasogastric tube which drains stomach contents until normal bowel and digestive function resumes. Recovery focuses heavily on digestive function, where most of the complications occur.

Patients are usually encouraged to mobilize often by sitting in a chair and/or walking. Patients are also routinely use an incentive spirometer to maintain proper lung ventilation and function. Once discharged from the hospital, normal activity generally resumes within four to six weeks with lifting restrictions.

Risks and Benefits

As with all surgical procedures, there are inherent risks. These risks include reactions to anesthesia, damage to internal organs, blood loss, formation of blood clots, infection, and chemotherapeutic side effects. A majority of complications following cytoreduction deal with the digestive system.

Patients undergoing cytoreduction with HIPEC have experienced median survival rates up to 5 years. However, survival rates are dependent on several factors including the extent of intraperitoneal tumors encountered and success of the procedure itself. The Completeness of Cytoreduction Score, which ranges from 0 to 4, evaluates the amount of cancerous tissue that may remain. Patients with a score of 0 or 1 generally survive for 35 months.

Cytoreductive surgery can also be used to treat other more common cancers, including ovarian and stomach cancer. In other words, while mesothelioma is a rare cancer, the procedure has been used often and perfected over time, leading to high survival rates after surgery.

In general, combining cytoreductive surgery with chemotherapy has been reported to improve prognosis, with patients living between 3 to 7 years.
To find out which treatment option is best for you, talk with your doctor.

Extrapleural Pneumonectomy Surgery, Removal of the Entire Diseased Lung

Mesothelioma is a rare type of cancer that develops in the mesothelium, the lining that surrounds and protects the body’s internal organs. Presently, only two types of potentially “curative” surgeries exist to treat pleural mesothelioma– pleurectomy and extrapleural pneumonectomy. These two surgeries do not always cure mesothelioma, but can remove the bulk of the cancer cells, which in turn helps to control the disease and increase a patient’s life expectancy. Extrapleural pneumonectomy is a more risky, invasive, and severe surgery than pleurectomy, but it also provides great potential for the outcome of the patient.

About Extrapleural Pneumonectomy

Extrapleural pneumonectomy involves the removal of the entire diseased lung, the pleural lining of the chest wall, the diaphragm, and the pleural lining of the heart. Extra pleural pneumonectomy is considered a serious operation, it is often determined as a surgery of last resort. It is only performed on patients who are in the early stages of cancer; that is, before the cancer spreads to the lymph nodes and before it invades surrounding tissues and organs. This allows the bulk of the cancer cells to be surgically removed.

Surgery candidates need to be in relatively good health, with good lung and heart function, because removal of an entire lung will increase the load on both the heart and the remaining lung. Surgery candidates also need to be strong and healthy enough to withstand the demands of major surgery and the healing it will require.

Benefits and Risks

Those considering extrapleural pneumonectomy need to be aware of the surgery’s potential risks and benefits. For those who are viable candidates, this operation is considered the best method of controlling malignant mesothelioma for the longest period of time. It can slow the progression of the disease, increase the patient’s quality of life, and improve the patient’s breathing. Combined with a regimen of radiation treatment and chemotherapy, extrapleural pneumonectomy can increase a patient’s life expectancy by months or years.

These possible benefits, however, need to be weighed against the major risks posed by this surgery. Possible complications include internal bleeding, respiratory failure, pneumonia, infection, blood clotting, and even death. About 6 or 7 out of every one hundred patients who receive extrapleural pneumonectomy die during or immediately following the operation. In some cases, mesothelioma reoccurs even after the surgery is complete.

What is Involved in Surgery?

Due to extrapleural pneumonectomy being such a technically complicated surgery, it is usually performed only in large medical centers by surgeons who are experienced with mesothelioma. Qualified surgeons are found across the country. This means that many patients need to travel to receive this mesothelioma treatment.

Extrapleural pneumonectomy requires general anesthesia. In order to access the patient’s chest cavity, the surgeon opens the chest either at the front, called a sternotomy, or at the side, called a thoracotomy. This creates a wound about 9 inches long. The surgeon then visually inspects the chest cavity for diseased tissue. Any visible cancer is removed, including the entire diseased lung, the pleural lining of the chest and heart, and the diaphragm.

Recovery from the surgery usually requires a two week stay in the hospital, during which a health care team monitors the patient’s recovery and watches for possible complications. Full recovery takes an additional 6 to 8 weeks.

Is a Extrapleural Pneumonectomy for You?

Patients need to remember that this operation does not always cure mesothelioma. The operation must be a part of an overall treatment plan that includes radiation and chemotherapy. Talk to your doctor to determine whether or not this procedure will be helpful for you. A major surgery such as extrapleural pneumonectomy is not the right choice for everyone, but for those patients who are candidates, it can substantially increase both life expectancy and quality of life.

Sources:
1. The Encyclopedia of Surgery. “Pneumonectomy” Advameg, Inc. http://www.surgeryencyclopedia.com/Pa-St/Pneumonectomy.html
2. USCF Medical Center. Extrapleural Pneumonectomy.
http://www.thoracic.surgery.ucsf.edu/conditions–procedures/extrapleural-pneumonectomy-.aspx
3. https://www.maacenter.org/treatment/surgery/extrapleural-pneumonectomy/

Surgery Option for Mesothelioma Cancer

In its early stages, some mesothelioma cases may be treated through surgery.

For mesothelioma patients, treatment options can be limited and aggressive. When discussing treatment options with your oncologist, surgery may be recommended. Surgery is often part of a larger treatment plan that can include chemotherapy and/or radiation. Known as a multimodal treatment strategy, surgery is used to remove as much of the cancer as possible, and other treatment options are used before or after surgery to rid the body of as many cancer cells as possible.

Surgery options available to you will depend on the stage of your disease at diagnosis and the state of your general health. For mesothelioma treatment, some surgeries are intended as a curative measure, while others may be palliative and recommended to relieve symptoms of the disease and improve the quality of life of a patient.

If you are a candidate for surgery, the type of surgeon you will be referred to will depend on your type of mesothelioma cancer. If you are suffering from pleural or pericardial mesothelioma, you will be referred to a thoracic surgeon. Thoracic surgeons specialize in surgery involving the heart, lungs and other areas of the chest. If you are suffering from peritoneal mesothelioma, you will be referred to a gastrointestinal surgeon. Gastrointestinal surgeons specialize in surgery involving the abdomen.

Potentially Curative Surgery Options

There are a few curative surgery options available to mesothelioma patients that can potentially improve your prognosis:

• Pleurectomy/decortication (P/D) – P/D surgery involves removing the affected pleura – the lining of the lung – and then removing any visible tumor masses on the lung. This combination surgery is known as a lung-sparing surgery because it doesn’t involve removing an entire lung.
• Pneumonectomy – A pneumonectomy surgery involves the removal of the entire affected lung. Because of the severity of the operation and due to the fact that up to 50 percent of patients experience complications, recovery time can be lengthy following this procedure.
• Extrapleural Pneumonectomy (EPP) – EPP surgery involves the removal of the entire diseased lung, the pleural lining of the chest wall, the affected part of the diaphragm, and the pleural lining of the heart. EPP is considered a radical operation and it is only performed on patients who are in the early stages of cancer. The recovery time following an EPP surgery is lengthy.
• Cytoreduction – For peritoneal mesothelioma patients, cytoreduction surgery is used to remove the peritoneum – the lining of the abdomen. Cytoreduction surgery is usually followed by a heated chemotherapy treatment to the abdomen to continue fighting remaining cancer cells.

Palliative Surgery Options

Palliative surgeries are meant to help relieve painful side effects of mesothelioma.

• Pleurodesis – This procedure involves the injection of talc or other chemicals into the chest cavity, which causes scarring and prevents fluid from returning. The American Cancer Society reports that this procedure has about a 90% success rate and that it will eliminate or significantly reduce the build-up of fluid at least temporarily in a majority of patients. Because this is a surgical procedure that requires anesthesia, a short hospital stay is in order.
• Paracentesis – Similar to the pleurocentesis procedure, a paracentesis procedure is performed to remove fluid build up from the abdominal cavity to relieve symptoms associated with peritoneal mesothelioma.
• Thoracentesis – This procedure is often used to determine why a pleural effusion is present in a patient. The procedure involves removing a small amount of the excess fluid to send to a pathology lab for analysis. Thoracentesis can also serve as a palliative procedure by removing the pleural effusion and relieving a patient of the symptoms and discomfort it causes.
  
  Source:
  1 American Cancer Society. Detailed Guide: Surgery for malignant mesothelioma
  2 National Cancer Institute, Malignant Mesothelioma Treatment (PDQ®), Treatment Option Overview.
  3 Treasure, T. et al. Radical Surgery for Mesothelioma. British Medical Journal. 2004;328:237-238. 31 January 2007. http://www.bmj.com/content/328/7434/237.
  4 https://www.maacenter.org/treatment/surgery