Blood Loss in Extended Pleurectomy/Decortication (EPD) for Pleural Mesothelioma
Yes, significant blood loss is a recognized risk in Extended Pleurectomy/Decortication (EPD) for pleural mesothelioma, though it is generally less than with extrapleural pneumonectomy (EPP).
Magnitude of Blood Loss Risk
The evidence clearly demonstrates that EPD, while less morbid than EPP, still carries substantial bleeding risk:
Perioperative bleeding requiring reoperation occurs in approximately 1% of standard lung resections but increases to 5% in pneumonectomy or extended resections 1. This establishes that more extensive thoracic procedures inherently carry higher bleeding risk.
EPP procedures result in major morbidity rates of 24.2% compared to 3.8% for pleurectomy/decortication procedures 1. While this encompasses all major complications, bleeding is a significant component.
Blood transfusion requirements are substantial: In EPP series (which are more extensive than EPD but provide relevant context), 88% of patients required red blood cell transfusions with a median of 4 units 2. Patients receiving more than 4 units of RBC transfusion had significantly increased risk of major complications 2.
Comparative Risk: EPD vs EPP
EPD demonstrates significantly lower perioperative mortality and morbidity compared to EPP 1:
- Perioperative mortality: 2.9% for extended P/D versus 6.8% for EPP (p = 0.02) 1
- Perioperative morbidity: 27.9% for extended P/D versus 62.0% for EPP (p < 0.001) 1
- Major morbidity including bleeding: 3.8% for P/D versus 24.2% for EPP 1
Specific Bleeding-Related Factors
Several factors increase bleeding risk during EPD:
Right-sided procedures carry significantly higher bleeding risk than left-sided operations 2, 3. Right-sided EPP showed 54% major complication rates versus 21% for left-sided procedures (p = 0.007) 2.
Longer operative duration correlates with increased bleeding complications 4. Major morbidity occurred more frequently after longer operations (p < 0.0005) 4.
Induction chemotherapy lowers preoperative hemoglobin levels (122 ± 16 g/L versus 134 ± 15 g/L, p = 0.02) and increases transfusion requirements (5.1 ± 3.5 units versus 2.1 ± 2.3 units, p = 0.007) 2, though it does not directly increase complication rates.
Clinical Implications
EPD should only be performed at high-volume centers with thoracic surgery expertise 1. The British Thoracic Society guidelines note that perioperative morbidity for pleurectomy procedures ranges from 13% to 43% across studies 1.
Patients must meet specific preoperative criteria including adequate cardiopulmonary function and absence of significant comorbidities 1. Those at high risk for bleeding complications—including elderly patients, those with poor performance status, or significant comorbidities—should be carefully counseled about these risks 1.
Common Pitfalls
Underestimating blood loss in extended procedures: While EPD is "lung-sparing," the resection of diaphragm and/or pericardium significantly increases bleeding risk beyond simple pleurectomy 1.
Inadequate preoperative optimization: Patients receiving induction chemotherapy require careful monitoring of hemoglobin levels and may need preoperative transfusion or erythropoietin support 2.
Proceeding with surgery despite inability to achieve macroscopic complete resection: If complete gross cytoreduction is not achievable, surgery should be aborted to minimize morbidity without oncologic benefit 1.