Anyone who has had cancer can tell you that cancer treatment is a full-time job. Even the tests to diagnose cancer are not painless. In order to get rid of the entire tumor and any possible cancer cells that may have spread, oncologists often prescribe a course of treatment that includes surgery plus chemotherapy or radiation. Since pleural mesothelioma affects the linings of the lungs and the chest wall, and sometimes also the lungs themselves, surgery to remove the tumors is invasive and requires several weeks of recovery. All surgeries, even minor ones, carry a risk of complications, and your doctors will explain the risks of your surgery to you before you consent to undergo the procedure. Your doctor should follow up closely with you to make sure that complications do not develop, and to address them promptly if they do.
Common Surgical Treatments for Mesothelioma
Depending on where the cancer is located and how far it has spread, your doctors might perform a pleurectomy decortication (PD) or an extrapleural pneumonectomy (EPP). PD involves removing the pleurae, which are the lining covering the outside of the lungs and the one on the inner surface of the chest wall. EPP involves removal of an entire lung and sometimes part of the diaphragm, which is the muscle that separates the chest cavity from the abdominal cavity and moves down when you inhale to allow the lungs to expand. It could also involve the removal of part of the pericardium, which is the membrane on the outside of the heart. If your surgeons remove part of the diaphragm or pericardium, they will need to rebuild them out of artificial materials. All of this means that your chest cavity will be in a very different shape after surgery, compared to how it was before. Therefore, you can expect to be sore in the beginning, and it will take some work to get used to breathing with your respiratory organs in their current shape.
Pain Relief During and Immediately After Surgery
All surgical procedures require pain relief during or after surgery. During the surgery, your surgical team will insert an epidural catheter, which is a tube inserted into the spinal canal; it does not touch the spinal cord. Epidural catheters are the usual way of administering pain medication to women during childbirth with or without a Caesarean section. In the case of mesothelioma surgery, the epidural catheter will reduce the sensation in your chest, and the doctors will leave the catheter in place for a while even after you wake up. The goal is for you to have enough feeling in your chest area so that you can be aware of your breathing but not so much that it is painful to breathe.
The pain relief drugs used during surgery are opioids, and you will continue to receive these medications through your epidural catheter for the first few days after surgery. After you get the catheter removed, you will continue to take pain medication by mouth before or after your discharge from the hospital. In the beginning, you will get opioid painkillers such as codeine, oxycodone, or hydrocodone, but because of the risks associated with long-term use of these kinds of painkillers, doctors will switch you to other kinds of pain relief drugs, such as acetaminophen, when you have recovered to the point that your pain can be managed without prescription opioids.
Practice Taking Deep Breaths After Surgery
After you have your pleurae removed in a PD or an entire lung removed during an EPP, it will take some practice to breathe deeply enough to get enough oxygen. The best way to prepare for this is to spend several minutes each day before your surgery doing breathing exercises where you inhale as deeply as you can and then exhale completely. Starting to do this as soon as you find out that you are going to have surgery, or even as soon as you get a diagnosis of mesothelioma before your doctors even decide which treatments to perform.
Of course, taking deep breaths when you have a cancerous tumor in your chest cavity is one thing, but taking deep breaths when you have just undergone major surgery and have only one lung is quite another. Your doctors might refer you for one or more sessions with a pulmonary therapist, who is a physical therapist who specializes in lungs and breathing. Even if your doctor does not mention it first, you should request to see a pulmonary therapist, even if your insurance does not pay for this treatment. Preserving your ability to take deep breaths in the first days after your PD or EPP is not just about short-term relief. If you do not breathe deeply enough right after your surgery, parts of your lung could collapse, which would lead to a permanently reduced breathing capacity and increase your risk of pneumonia, which is a dangerous infection of the lungs.
Therefore, the goal of pain management after surgery is to optimize your ability to take deep breaths. It is not easy to take deep breaths when your chest is sore from major surgery. This is why you will keep the epidural catheter, which will reduce the amount of sensation in your chest, for a few days after the surgery; you will be able to feel your chest muscles to be aware of your breathing but not enough to make it painful to breathe. Both before and after the removal of the epidural catheter, doctors will want to give you just the right dose of pain medication, but just the right dose may not mean the complete absence of discomfort. If they give you too much medication, you might be too drowsy to concentrate on taking deep breaths. Therefore, you might still feel sore as you practice breathing deeply after the surgery, especially after your epidural catheter is removed, but it is important to keep breathing as deeply as you can. Your doctors and nurses will follow up with you about pain management.
Preventing the Buildup of Fluid and Air in the Chest Cavity
It is almost inevitable that, during surgery, some air and fluid will build up in the chest cavity. In order to minimize the discomfort related to this buildup of air and fluid, doctors insert a chest tube during surgery and leave it in place until several days later. You will not feel the chest tube, because it is thin and made of flexible plastic. Over the first few days of your recovery, you will notice less and less fluid draining out, which is an indication that you are healing; the amount of fluid may temporarily increase after you eat. The fluid should be clear. If it is gray or some other color, this could be a sign of a complication, so you should alert your medical team.
Possible Complications of Mesothelioma Surgery
These are some post-surgical complications that patients may experience after PD or EPP:
- Empyema – This is an accumulation of pus in the chest cavity. It is treated by leaving the chest tube in place, or reinserting it if it has been removed. Antibiotics are also part of the treatment.
- Hemorrhage – Hemorrhage just means bleeding, but in this context, it refers to bleeding inside the chest cavity. Your surgeon might need to do another surgery to stop the bleeding.
- Cardiac arrhythmia – Irregular heartbeat is a possible complication of chest surgery, especially if part of the pericardium is removed. It is treated with medication, which you will continue to take until your doctors are confident that you can continue to have a normal heart rhythm without it.
- Broncho-pleural fistula – This complication occurs when a hole forms in the bronchus (the tube leading to the lungs) of the lung that was removed during EPP. When it happens, air builds up in the chest cavity, causing a persistent cough. If inserting a drainage tube does not resolve the problem, your doctors may need to do another surgery to repair it. If untreated, broncho-pleural fistula can lead to life-threatening pneumonia.
- Pulmonary embolism – This is a potentially life-threatening complication in which a blood clot from the leg travels to the lung. Anyone who has been bedridden for several days, such as people who have recently undergone surgery, is at risk of developing this complication.
The best way to avoid developing serious complications after a mesothelioma surgery such as PD or EPP is to follow the instructions of your medical team before and after surgery. Your doctors will help you manage postoperative pain and discomfort, as well as any other complications that might arise. You might find that physical therapy and other interventions that relieve your discomfort are not covered under your health insurance policy. You should pursue the treatments you need even if the doctors bill out of pocket for them. Your mesothelioma lawyer can help you seek compensation for the cost of all your treatments, both the ones that your insurance covers and the ones it does not.