Pleurectomy decortication is a lung-sparing surgery that strips away the diseased lining of the chest cavity and the surface of the lung while leaving the lung itself intact. It is most closely associated with the treatment of malignant pleural mesothelioma, where it has largely replaced the older, more radical approach of removing the entire lung. But the procedure also has a long track record in treating chronic infections like empyema, where a thick rind of scar tissue traps the lung and prevents it from expanding. Whether for cancer or infection, the core idea is the same: peel away the pathologic tissue, preserve as much functioning lung as possible, and combine surgery with other treatments when the disease demands it.
What the Procedure Involves and How Surgeons Classify It
In a pleurectomy decortication, the surgeon removes the parietal pleura (the membrane lining the inside of the chest wall) and the visceral pleura (the membrane coating the lung surface). In mesothelioma cases, the goal is to strip away all visible tumor. The International Mesothelioma Interest Group and the International Association for the Study of Lung Cancer break the operation into three categories based on how extensive it is. An extended pleurectomy decortication removes all gross tumor and also resects the diaphragm, the pericardium, or both. A standard pleurectomy decortication removes all gross tumor but leaves the diaphragm and pericardium in place. A partial pleurectomy removes only some of the pleura, typically for diagnosis or symptom relief, and knowingly leaves tumor behind.1European Journal of Cardio-Thoracic Surgery. Pleurectomy–decortication in malignant pleural mesothelioma: are different surgical techniques associated with different outcomes? Results from a multicentre study
In non-cancer settings, the terminology is simpler. Decortication refers to peeling the fibrous peel off a trapped lung, and the approach can be open (via thoracotomy) or minimally invasive (video-assisted thoracoscopic surgery, or VATS). The distinction that matters most to patients and their surgical teams is whether the operation is intended to remove all visible disease or simply to free a trapped lung and drain infection.
Why P/D Has Replaced Extrapleural Pneumonectomy at Most Centers
For decades, the default surgical option for mesothelioma was extrapleural pneumonectomy, or EPP, which removes the entire affected lung along with the pleura, diaphragm, and pericardium. EPP was considered the more “complete” cancer operation, but it carried a punishing complication profile. A meta-analysis pooling data from numerous comparative studies found that perioperative mortality was roughly two and a half times higher after EPP than after P/D, with rates of about 4.5% versus 1.7%.2PubMed. Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma A later propensity-matched comparison was even starker, reporting perioperative mortality of 11% for EPP versus 0% for P/D.3Annals of Thoracic Surgery. Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma – Section: Results
The survival question is more complicated. Neither the meta-analysis nor the propensity-matched data showed a clear long-term survival advantage for either operation. After adjusting for perioperative deaths, median overall survival was around 22 months for P/D and 15 months for EPP in one study, though the difference did not reach statistical significance.4Annals of Thoracic Surgery. Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma – Section: Results Multi-institution analyses have confirmed that P/D, along with epithelioid histology and completeness of resection, independently predict better survival.5PubMed. Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma The upshot is that P/D achieves comparable or better oncologic outcomes while killing far fewer patients on the operating table. That calculus has driven a worldwide institutional shift away from EPP and toward extended pleurectomy decortication as the standard cytoreductive approach.6The Journal of Thoracic and Cardiovascular Surgery. Cytoreductive surgery of both chest and abdomen for bicavitary mesothelioma
One nuance worth understanding: whether removing every visible speck of tumor actually translates to longer life remains genuinely uncertain. A study that matched patients who achieved macroscopic complete resection against those who did not found no significant difference in median survival, roughly 21 months versus 16 months unmatched, and virtually identical after propensity matching.7The Journal of Thoracic and Cardiovascular Surgery. Macroscopic complete resection is not associated with improved survival in patients with malignant pleural mesothelioma – Section: Results That finding does not mean surgery is pointless; it means the biology of mesothelioma is aggressive enough that microscopic disease almost always remains, and the survival benefit of surgery likely depends on the multimodal treatments layered on top of it.
Combining P/D With Chemotherapy, Radiation, and Newer Therapies
Pleurectomy decortication is almost never used as a standalone treatment for mesothelioma. The current standard pairs it with platinum-based chemotherapy, and trials continue to explore what else can be added. The MARS 2 trial, a phase 3 randomized controlled trial, tested extended pleurectomy decortication plus chemotherapy against chemotherapy alone. Patients received two initial cycles of chemotherapy, then were randomized either to surgery followed by further chemotherapy or to chemotherapy alone.8The Lancet Respiratory Medicine. Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial This trial drew significant attention because it provided high-level evidence on whether adding surgery actually extends life, and its cost analysis showed that surgery approximately doubled the total cost of care, with a mean difference of roughly £14,600 (about $20,000) driven almost entirely by the surgical admission.9The Lancet. Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial – Section: Results
Other centers have investigated heating chemotherapy drugs and washing them directly through the chest cavity during surgery, a technique called hyperthermic intrathoracic chemotherapy, or HITOC. A comparative study reported that adding HITOC after P/D was safe, with zero 30-day mortality in the HITOC group and only transient complications like brief heart-rhythm changes or mild kidney stress in about 16% of patients. Overall survival trended longer in the HITOC group (about 28 months versus 22 months for surgery alone), though the difference was not statistically significant in this small cohort.10PubMed Central. Effect of intraoperative hyperthermic intrathoracic chemotherapy after pleurectomy decortication for treatment of malignant pleural mesothelioma: a comparative study The approach is considered safe for selected patients with localized epithelial-type mesothelioma.11PubMed Central. Pleurectomy/decortication and hyperthermic intrathoracic chemoperfusion using cisplatin and doxorubicin for malignant pleural mesothelioma
Immunotherapy is the newest entrant. A case report described a patient with sarcomatoid mesothelioma, an aggressive subtype, who received immunotherapy first and then underwent salvage P/D. Pathology of the resected specimen showed less than 1% of tumor cells were still viable, suggesting the immunotherapy had produced a dramatic response. The authors argued that P/D may be particularly well suited as a follow-on to immunotherapy because the lung-sparing approach avoids the respiratory devastation that can occur when immunotherapy-related lung inflammation meets a pneumonectomy.12PubMed Central. Salvage Pleurectomy/Decortication After Immunotherapy for Sarcomatoid Malignant Pleural Mesothelioma This is still early-stage evidence, but it points toward a future where immunotherapy and lung-sparing surgery are combined as standard neoadjuvant therapy for resectable mesothelioma.
Radiation After Lung-Sparing Surgery
Delivering radiation to the hemithorax after P/D is trickier than after EPP, for an obvious reason: the lung is still there. After EPP, radiation oncologists can treat the empty chest cavity aggressively. After P/D, every beam of radiation passes through functioning lung tissue, raising the risk of radiation pneumonitis, an inflammatory reaction that can seriously impair breathing.
A systematic review of intensity-modulated radiation therapy after P/D found that severe (grade 3) pneumonitis rates ranged from 0% to 16% across studies, with most reporting rates below 9%. Life-threatening (grade 4 or 5) pneumonitis was rare, occurring in under 1.5% of cases, except in one series that used unusually high radiation doses.13PubMed. Disease-Related Outcomes and Toxicities of Intensity Modulated Radiation Therapy After Lung-Sparing Pleurectomy for Malignant Pleural Mesothelioma: A Systematic Review The mean dose the lung received was the strongest predictor of trouble: patients who developed pneumonitis had a mean total lung dose of about 20 Gy compared to about 13 Gy in those who did not.14International Journal of Radiation Oncology, Biology, Physics. Pleurectomy and Decortication Followed by Adjuvant Intensity Modulated Radiation Therapy for Malignant Pleural Mesothelioma – Section: Results
Pulmonary function does decline in a stepwise fashion: first from the surgery itself, then again from radiation. One series documented that forced vital capacity dropped by about 21% after surgery and then an additional 10 percentage points after radiation. The lung’s ability to transfer gases (measured by diffusion capacity) followed a similar pattern.15PubMed. Hemithoracic intensity modulated radiation therapy after pleurectomy/decortication for malignant pleural mesothelioma: toxicity, patterns of failure, and a matched survival analysis These declines are real, but they are generally tolerable when radiation is delivered at conventional doses and with careful planning to minimize the dose to healthy lung tissue.
Complications and the Air Leak Problem
The most common headache after pleurectomy decortication is prolonged air leak. Stripping the visceral pleura off the lung surface inevitably damages the delicate tissue underneath, and small air leaks from the lung into the chest cavity are expected. In most patients these seal within a few days, but a substantial minority deal with leaks lasting a week or longer. One series reported that 44% of patients had air leaks persisting beyond seven days.16PubMed. Control of air leakage during pleurectomy/decortication by the ventilation and anchoring method A larger study found a median air leak duration of seven days, with about a third of patients experiencing leaks lasting more than ten days; roughly 36% of their cohort needed chemical pleurodesis to seal the leak, and about 3% needed reoperation.17PubMed. Complications and Predictive Factors for Air Leak > 10 Days with Neoadjuvant Chemotherapy Followed by Pleurectomy/Decortication for Malignant Pleural Mesothelioma
Other complications include atrial fibrillation (especially in older patients or after extended resections), wound infections, and, less commonly, bronchopleural fistula. The hospital stay after P/D for mesothelioma is not trivial: the MARS 2 trial reported a median stay of 13 days.18The Lancet. Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial – Section: Results Still, this compares favorably with EPP, which historically carries higher complication and mortality rates.
Quality of Life and Lung Function Recovery
One of the selling points of lung-sparing surgery is that patients retain more lung function and recover quality of life faster than after pneumonectomy. The data broadly support this, but the picture is not immediately rosy. In the first month after P/D, quality of life dips. Patients with good baseline fitness experienced significant increases in pain and insomnia scores. By five to six months, though, patients who started with poorer performance status actually reported meaningful improvements in overall quality of life and reductions in fatigue, breathlessness, and appetite loss.19The Annals of Thoracic Surgery. Quality of Life After Radical Pleurectomy Decortication for Malignant Pleural Mesothelioma – Section: Results A systematic review comparing P/D and EPP found that P/D patients had better physical function, social function, and global health scores at follow-up, while pain and cough were similar between the two groups.20PubMed Central. Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma
Lung function tests tell a consistent story. Forced vital capacity dropped from about 98% of predicted to 61% after P/D in one mesothelioma cohort, and forced expiratory volume fell from 93% to 67%. These reductions did not recover over the follow-up period.21PubMed Central. Quality of life and lung function after pleurectomy/decortication for malignant pleural mesothelioma That represents a real and permanent reduction in breathing capacity, even though patients subjectively feel better than they would after losing an entire lung. Tumor histology and nodal status remain the strongest predictors of long-term outcomes. Epithelioid histology, absence of lymph node involvement, and receipt of trimodality treatment (surgery, chemotherapy, and radiation) have all been independently linked to better survival.22PubMed. Adoption of pleurectomy and decortication for malignant mesothelioma leads to similar survival as extrapleural pneumonectomy
Recurrence After P/D for Mesothelioma
Even when the surgeon removes all visible tumor, mesothelioma has a strong tendency to come back. A large analysis of recurrence patterns after P/D found that local recurrence in the same hemithorax was overwhelmingly the most common pattern, occurring in 85% of patients who relapsed. In about 29% of cases, local recurrence was the only site of disease.23PubMed Central. Recurrence Patterns and Management after Pleurectomy Decortication for Pleural Mesothelioma – Section: Results Sarcomatoid tumors relapsed earlier and spread to distant sites more often than other subtypes. When recurrence did happen, re-operation and chemotherapy were both independently associated with longer survival after recurrence, suggesting that an aggressive approach to relapse can still buy meaningful time for some patients.24PubMed Central. Recurrence Patterns and Management after Pleurectomy Decortication for Pleural Mesothelioma – Section: Results
Decortication for Empyema and Trapped Lung
Outside of cancer, decortication is a mainstay in the management of chronic empyema, a condition where pus or infected fluid fills the pleural space and, over time, forms a thick fibrous peel that encases and collapses the underlying lung. The trapped lung cannot inflate, leaving the patient breathless and prone to recurrent infections. Decortication strips off that peel and allows the lung to re-expand.
Timing matters enormously. A study of chronic empyema patients found that when VATS decortication was performed within roughly the first week of hospitalization, 90-day mortality was about 14%. Waiting longer than that was associated with a threefold increase in mortality, to about 45%.25PubMed Central. Optimal timing for video assisted thoracic surgery decortication for improved survival in chronic empyema – Section: Results Older age, end-stage kidney disease, and very acidic pleural fluid were also negative prognostic factors.
The choice between VATS and open thoracotomy for empyema decortication has been studied in meta-analyses. VATS decortication was associated with shorter operative times, shorter hospital stays, fewer prolonged air leaks, and lower overall complication and mortality rates compared to open surgery.26PubMed Central. A meta-analysis of video-assisted thoracoscopic decortication versus open thoracotomy decortication for patients with empyema Recurrence rates were similar between the two approaches. Not every case can be completed thoracoscopically, however. In tuberculous empyema, preoperative steroid use and certain lung lesions increased the odds of intraoperative conversion from VATS to open surgery.27Heliyon. Factors involved in the conversion from video-assisted thoracoscopic surgery decortication to open thoracotomy in non-complicated, non-MDR/XDR stage III tuberculous empyema patients
Unlike in mesothelioma, lung function after empyema decortication generally improves. One study found that forced expiratory volume increased from about 71% of predicted before surgery to about 83% afterward, and forced vital capacity rose from about 70% to 85%.28PubMed Central. Change in Pulmonary Function Following Decortication for Chronic Pleural Empyema The improvement was consistent regardless of which side was affected, whether the patient smoked, or whether they had diabetes. This is the inverse of the mesothelioma scenario: in empyema, the lung is fundamentally healthy but mechanically imprisoned, and freeing it restores function. In mesothelioma, the operation itself sacrifices some functional tissue to remove cancer.
Anesthesia During P/D
The anesthetic management for pleurectomy decortication has its own quirks. The surgeon needs the affected lung to be still while they peel away the pleura, which means the anesthesiologist must ventilate the patient with one lung at a time. This is achieved by placing a double-lumen endotracheal tube, which allows each lung to be inflated or deflated independently.29The Open Anesthesiology Journal. Clinical Pearls in Anaesthesia for Pleurectomy/Decortication for Malignant Mesothelioma During the critical phase when the visceral pleura is being stripped, some centers use differential lung ventilation, connecting each lung to a separate ventilator so that the operated lung can be gently inflated to test for air leaks and assist in the dissection without interrupting oxygenation through the healthy side.30PubMed. Anesthetic Management of Pleurectomy/Decortication Under Differential Lung Ventilation
From the patient’s perspective, this means P/D is a major operation requiring general anesthesia, typically lasting several hours. Blood loss can be significant because the pleura is highly vascular, and the surgical field in mesothelioma cases is large. Postoperatively, patients generally spend at least a night in intensive care and remain in the hospital for nearly two weeks in the mesothelioma setting.
Decortication in Children
Empyema is not limited to adults. Children, particularly in lower-resource settings, can develop advanced empyema requiring surgical intervention when antibiotics and chest drainage fail. Open decortication through thoracotomy remains the standard approach for advanced pediatric empyema. A series of 125 children who underwent open decortication reported zero mortality and successful lung re-expansion in all patients, with a mean chest drain duration of about seven days.31PubMed Central. Surgical management and outcome analysis of stage III pediatric empyema thoracis
As in adults, lung function improves after the peel is removed. Pediatric patients in one study showed significant gains in both forced expiratory volume and forced vital capacity after decortication. Common complications included bleeding (about 10%), infection (about 12%), and prolonged air leaks (about 15%). Malnourished children recovered more slowly and had more complications, underscoring the importance of nutritional support alongside surgical management.32Journal of Neonatal Surgery. Decortication in Chronic Pleural Empyema and Its Effect on Lung Function in Pediatric patients – Section: Results Tuberculous empyema is a particularly common indication for pediatric decortication in endemic regions, where delayed referral and incomplete antibiotic courses often allow the disease to progress to the point where the lung becomes trapped.33PubMed Central. Breaking Free: Managing Trapped Lung in Tubercular Empyema