Reconstruction of the thoracic wall-long-term follow-up including pulmonary function tests

Efficiency of an algorithm for the prevention of sternal infection after cardiac surgery in children under 1 year of age: A single-center retrospective study

Background

Sternal infection is one of the most challenging complications to manage after heart surgery. The aim of our study is to evaluate the effectiveness of a developed algorithm for preventing sternal infection in pediatric patients after surgery for congenital heart disease (CHD).

Methods

We conducted a single-center study examining the treatment of 478 children with CHD. Patients were divided into 2 groups, taking into account the application of a developed management algorithm. A multivariate logistic regression analysis was used to identify the factors influencing the development of sternal infection following heart surgery using median sternotomy.

Results

A developed algorithm was applied in 308 children. In total, there were 16 cases of sternal infection (3.34 %) across both groups. Deep wound infection developed in 6 patients (1.26 %). Sternal infection developed in 2 children (0.65 %) in the first group (in which the algorithm was applied) and 14 children (8.2 %) in the second group. Deep sternal infection developed in 1 patient in the first group (0.33 %) and in 5 patients in the second group (2.94 %). As a result, perioperative risk factors as postoperative resternotomy (OR 23.315; p < 0.001), delayed sternal closure (OR 9.087; p = 0.003), development of acute renal failure (OR 5.322; p = 0.018) were associated with increased risk of infection and application of the developed algorithm resulted in a significant reduction in risk (OR 0.032; p < 0.001).

Conclusion

The suggested method for the prevention of sternal infection has significantly reduced the incidence of sternal infection after cardiac surgery in children less than 1 year of age. In patients with moderate to high risk for surgical site infection, surgeons can enhance wound healing and prevent wound infections with simple, inexpensive, and readily available tools and techniques. Surgical aspects, topical use of antibiotics, prevention of peripheral vasoconstriction, maintenance of normal oxygen delivery rates, and an individual approach to intensive care are essential.

The application of three-dimensional custom-made prostheses in chest wall reconstruction after oncologic sternal resection

BACKGROUND AND OBJECTIVES

As one of the cutting-edge advances in the field of reconstruction, three-dimensional (3D) printing technology has been constantly being attempted to assist in the reconstruction of complicated large chest wall defects. However, there is little literature assessing the treatment outcomes of 3D printed prostheses for chest wall reconstruction. This study aimed to analyze the surgical outcomes of 3D custom-made prostheses for the reconstruction of oncologic sternal defects and to share our experience in the surgical management of these rare and complex cases.

METHODS

We summarized the clinical features of the sternal tumor in our center, described the surgical techniques of the application of 3D customized prosthesis for chest wall reconstruction, and analyzed the perioperative characteristics, complications, overall survival (OS), and recurrence-free survival of patients.

RESULTS

Thirty-two patients with the sternal tumor who underwent chest wall resection were identified, among which 13 patients used 3D custom-made titanium implants and 13 patients used titanium mesh for sternal reconstruction. 22 cases were malignant, and chondrosarcoma is the most common type. The mean age was 46.9 years, and 53% (17/32) of the patients were male. The average size of tumor was 6.4 cm, and the mean defect area was 76.4 cm2. 97% (31/32) patients received R0 resection. Complications were observed in 29% (9/32) of patients, of which wound infection (22%, 7/32) was the most common. The OS of the patients was 72% at 5 years.

CONCLUSION

We demonstrated that with careful preoperative assessment, 3D customized prostheses could be a viable alternative for complex sternal reconstruction.

Should wide chest wall resections and reconstruction intimidate thoracic surgeons?

Background

This study aimed to compare patients in whom wide chest wall resection and reconstruction or primary closure was performed.

Methods

A total of 63 patients who underwent chest wall resection and reconstruction between January 2018 and December 2022 were included in the retrospective study. The patients were divided into two groups: the first group, which included 31 patients (14 males, 17 females; mean age: 44.6±16.4 years; range, 16 to 71 years) who were closed primarily, and the second group, constituting 32 patients (25 males, 7 females; mean age: 54.6±17.2 years; range, 9 to 80 years) who underwent reconstruction with plates and meshes.

Results

There was no significant difference between the two groups in terms of smoking and diabetes. Primary chest wall or metastatic tumor was determined in 33 patients; benign tumor and trauma were determined in 30 patients. The difference between the two groups in mean defect diameter (p=0.009), mean number of plates used (p<0.001), and mean hospital stay (p<0.001) was statistically significant. However, there was no significant difference in terms of complications (p=0.426).

Conclusion

Wide chest wall resection and reconstruction is a safe and feasible surgical procedure when compared with primary closure.

Long-Term Outcome of Chest Wall and Diaphragm Repair with Biological Materials

INTRODUCTION

 Chest wall and/or diaphragm reconstruction aims to preserve, restore, or improve respiratory function; conserve anatomical cavities; and upkeep postural and upper extremity support. This can be achieved by utilizing a wide range of different grafts made of synthetic, biological, autologous, or bioartificial materials. We aim to review our experience with decellularized bovine pericardium as graft in the past decade.

PATIENTS AND METHODS

 We conducted a retrospective analysis of patients who underwent surgical chest wall and/or diaphragm repair with decellularized bovine pericardium between January 1, 2012 and January 13, 2022 at our institution. All records were screened for patient characteristics, intra-/postoperative complications, chest tube and analgesic therapy duration, length of hospital stay, presence or absence of redo procedures, as well as morbidity and 30-day mortality. We then looked for correlations between implanted graft size and postoperative complications and gathered further follow-up information at least 2 months after surgery.

RESULTS

 A total of 71 patients either underwent isolated chest wall (n = 51), diaphragm (n = 12), or pericardial (n = 4) resection and reconstruction or a combination thereof. No mortality was recorded within the first 30 days. Major morbidity occurred in 12 patients, comprising secondary respiratory failure requiring bronchoscopy and invasive ventilation in 8 patients and secondary infections and delayed wound healing requiring patch removal in 4 patients. There was no correlation between the extensiveness of the procedure and extubation timing (chi-squared test, p = 0.44) or onset of respiratory failure (p = 0.27).

CONCLUSION

 A previously demonstrated general viability of biological materials for various reconstructive procedures appears to be supported by our long-term results.

The contribution of microvascular free flaps and pedicled flaps to successful chest wall surgery

OBJECTIVE

Pedicled flaps (PFs) have historically served as the preferred option for reconstruction of large chest wall defects. More recently, the indications for microvascular-free flaps (MVFFs) have increased, particularly for defects in which PFs are inadequate or unavailable. We sought to compare oncologic and surgical outcomes between MVFFs and PFs in reconstructions of full-thickness chest wall defects.

METHODS

We retrospectively identified all patients who underwent chest wall resection at our institution from 2000 to 2022. Patients were stratified by flap reconstruction. End points were defect size, rate of complete resection, rate of local recurrence, and postoperative outcomes. Multivariable analysis was performed to identify factors associated with complications at 30 days.

RESULTS

In total, 536 patients underwent chest wall resection, of whom 133 had flap reconstruction (MVFF, n = 28; PF, n = 105). The median (interquartile range) covered defect size was 172 cm2 (100-216 cm2) for patients receiving MVFF versus 109 cm2 (75-148 cm2) for patients receiving PF (P = .004). The rate of R0 resection was high in both groups (MVFF, 93% [n = 26]; PF, 86% [n = 90]; P = .5). The rate of local recurrence was 4% in MVFF patients (n = 1) versus 12% in PF patients (n = 13, P = .3). Postoperative complications were not statistically different between groups (odds ratio for PF, 1.37; 95% confidence interval, 0.39-5.14]; P = .6). Operative time >400 minutes was associated with 30-day complications (odds ratio, 3.22; 95% confidence interval, 1.10-9.93; P = .033).

CONCLUSIONS

Patients with MVFFs had larger defects, a high rate of complete resection, and a low rate of local recurrence. MVFFs are a valid option for chest wall reconstructions.

New perspectives in prosthetic reconstruction in chest wall resection

The extension of chest wall resection for the treatment of primary and secondary tumours is still widely debated. The reconstructive strategy after extensive surgery is challenging as well as chest wall demolition itself. Reconstructive surgery aims to avoid respiratory failure and to guarantee intra-thoracic organs protection. The purpose of this review is to analyse the literature on this issue focusing on the planning strategy for chest wall reconstruction. This is a narrative review, reporting data from the most interesting studies on chest wall demolition and reconstruction. Representative surgical series on chest wall thoracic surgery were selected and described. We focused to identify the best reconstructive strategies analyzing employed materials, techniques of reconstruction, morbidity and mortality. Nowadays the new "bio-mimetic" materials in "rigid" and "non-rigid" chest wall systems reconstructive represent new horizons for the treatment of challenging thoracic diseases. Further prospective studies are warranted to identify new materials enhancing thoracic function after major thoracic excisions.

Full-thickness chest wall resection for malignant chest wall tumors and postoperative problems

Background

Chest wall malignant tumor (including primary and metastatic lesions) is rare, representing less than 5% of all thoracic malignancies. Local control of chest wall malignancies requires wide resection with tumor-free margins. These requirements increase the risk of thoracic cavity failure and subsequent pulmonary failure. The restoration strategy for chest wall defects comprises chest wall reconstruction and soft-tissue coverage. Various reconstruction methods have been used, but both evidence and guidelines for chest wall reconstruction remain lacking. The purposes of this study were to collate our institutional experience, evaluate the outcomes of full-thickness chest wall resection and reconstruction for patients with chest wall malignant tumor, and identify problems in current practice for chest wall reconstruction with a focus on local control, complications, pulmonary function and scoliosis.

Methods

Participants comprised 30 patients with full-thickness chest wall malignant tumor who underwent chest wall resection and reconstruction between 1997 and 2021 in Mie University Hospital. All patients underwent chest wall resection of primary, recurrent or metastatic malignant tumors. A retrospective review was conducted for 32 operations.

Results

Recurrence was observed after 5 operations. Total 5-year recurrence-free survival (RFS) rate was 79.3%. Diameter ≥5 cm was significantly associated with poor RFS. The postoperative complication rate was 18.8%. Flail chest was observed with resection of ≥3 ribs in anterior and lateral resections or with sternum resection without polyethylene methylmethacrylate reconstruction. Postoperative EFV1.0% did not show any significant decrease. Postoperative %VC decreased significantly with resection of ≥4 ribs or an area of >70 cm2. Postoperative scoliosis was observed in 8 of 28 patients. Posterior resection was associated with a high prevalence of scoliosis (88.9%).

Conclusion

With chest wall reconstruction, risks of pulmonary impairment, flail chest and scoliosis were significantly increased. New strategies including indications for rigid reconstruction are needed to improve the outcomes of chest wall reconstruction.

Chest wall reconstruction in benign and malignant tumors with non-rigid materials: An overview

Several materials and techniques have been described for the procedure of chest wall reconstruction: the choice of using a technique or a material over another relies mainly on the surgeon's experience as well as thoracic defect localization and dimension, local availability of materials, and costs. From a technical point of view, autologous and alloplastic reconstruction are available, and, in both cases, rigid and non-rigid prostheses are found. Each material has its peculiarities, with advantages and disadvantages; thus, it is mandatory to be confident when planning the intervention to foresee possible complications and minimize them. We have reviewed the literature on chest wall reconstruction in chest wall tumors (both malignant and non malignant) with non-rigid prosthetic materials, focusing on safety outcomes.

Resection and reconstruction of huge tumors in the chest wall

OBJECTIVE

To evaluate the experience and effects of resection and reconstruction of 4 cases of huge tumors in the chest wall.

METHODS

The clinical data of 4 patients with huge tumors in the chest wall from July 2015 to January 2020 were collected and analyzed. There were 2 males and 2 females.Chondrosarcoma was diagnosed in 2 cases, giant cell tumor was diagnosed in 1 case,and metastasis from breast cancer was diagnosed in 1 case.All patients underwent extensive tumor resection and had thoracic exposure after tumor resection.Two patients underwent reconstruction with mesh and titanium mesh, and the incision was closed directly.The third patient underwent reconstruction with mesh and latissimus dorsi flap,and the fourth patient underwent reconstruction with mesh,titanium mesh and latissimus dorsi flap.

RESULT

One patient had incision infection after operation,which resolved after debridement.All patients were followed up for 2-6 years, no tumor recurrence or metastasis was noted during follow-up.None of patients had abnormal breathing, dyspnea or other physical discomfort.

CONCLUSION

It is difficult to resect the huge tumors in the chest wall,and it is more reasonable and safer to choose a reconstruction method using mesh and titanium mesh.The latissimus dorsi flap can achieve good results in repairing soft tissue defects.Close perioperative management and multidisciplinary team discussions can help to achieve better curative effects.

Chest Wall Reconstruction With 3D Printing: Anatomical and Functional Considerations

Large chest wall defects, as a result of wide local excision of chest wall pathology, require skeletal and soft-tissue reconstruction to restore the anatomical shape, structure, and respiratory function of the thorax. Reconstruction is challenging and requires the surgical reconstructive team to understand the anatomic and physiologic morbidity related to the defect and the choice of reconstructive techniques available to restore form and function. Rapidly emerging 3-dimensional (3D) printing technology allows the reconstructive surgical team to customize the therapeutic process of skeletal reconstruction by accurately mimicking the shape and structure of the chest wall being replaced. An integrated knowledge of the anatomy, physiology, mechanics of breathing, and respiratory tests is important to restore form and function. The focus of this article is to review the anatomy, physiology, and assessment of respiratory function from the classical textbooks and integrate this knowledge with the precise anatomy of the chest wall created by 3D printing technology. By doing so, this article will demonstrate how 3D printing may help the reconstructive team to understand the anatomic and physiologic morbidity related to the chest wall defect and the importance of taking each of these aspects into consideration when undertaking chest wall reconstruction of the thorax.

The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Appraise and evaluate risk factors for respiratory compromise following oncologic resection. 2. Outline and apply an algorithmic approach to reconstruction of the chest wall based on defect composition, size, and characteristics of surrounding tissue. 3. Recognize and evaluate indications for and types of skeletal stabilization of the chest wall. 4. Critically consider, compare, and select pedicled and free flaps for chest wall reconstruction that do not impair residual respiratory function or skeletal stability.

SUMMARY

Chest wall reconstruction restores respiratory function, provides protection for underlying viscera, and supports the shoulder girdle. Common indications for chest wall reconstruction include neoplasms, trauma, infectious processes, and congenital defects. Loss of chest wall integrity can result in respiratory and cardiac compromise and upper extremity instability. Advances in reconstructive techniques have expanded the resectability of large complex oncologic tumors by safely and reliably restoring chest wall integrity in an immediate fashion with minimal or no secondary deficits. The purpose of this article is to provide the reader with current evidenced-based knowledge to optimize care of patients requiring chest wall reconstruction. This article discusses the evaluation and management of oncologic chest wall defects, reviews controversial considerations in chest wall reconstruction, and provides an algorithm for the reconstruction of complex chest wall defects. Respiratory preservation, semirigid stabilization, and longevity are key when reconstructing chest wall defects.

Health-Related Quality of Life Issues Experienced by Thoracic and Breast Sarcoma Patients: A Rare and Understudied Group

Thoracic and breast sarcomas constitute a rare subgroup within the sarcoma population. There is limited knowledge about their health-related quality of life (HRQoL) and a valid disease-specific HRQoL instrument is lacking. This qualitative study aimed to investigate the HRQoL issues experienced by a small group of thoracic and breast sarcoma patients. Semi-structured interviews with 19 thoracic and four breast sarcoma patients were conducted and thematically analysed. Physical issues mentioned by both groups were fatigue, sleep disturbances, pain, wound infections, and symptoms related to chemotherapy and radiotherapy. Tightness in the back and restrictions in performing tasks above arm height were specific physical issues for breast sarcoma patients, whereas respiratory problems were only mentioned by thoracic sarcoma patients. Body image issues, changes in mood, fear of recurrence, and living with uncertainty were important mental health issues for both subgroups. Social issues in both groups included challenges in work and relationships, financial difficulties, loss of independence, and limitations in social activities. The identified physical, mental, and social health challenges can significantly impact thoracic and breast sarcoma patients’ HRQoL. Results of this qualitative study will guide personalised supportive care for breast and thoracic sarcoma patients and help in determining the best possible HRQoL measurement strategy for sarcoma patients with different primary sarcoma locations.

A South American Experience With Postoperative Complications Following Chest Wall Reconstruction for Neoplasms

BACKGROUND

This study aims to report postoperative complications of chest wall reconstructions due to resections of primary or secondary neoplasms in a South American cancer institution and their association with prosthesis reconstruction.

MATERIALS AND METHODS

We retrospectively reviewed clinical records of patients with primary or secondary chest wall neoplasms who underwent resection and reconstruction between November 2008 and October 2018 at the Instituto Nacional de Cancerología, Bogota, Colombia.

RESULTS

A total of 77 patients were analyzed, 50 were women (64.9%), and the median age was 45.8 years. There were 22(28.6%) sternal resections and 55(71.4%) costal resections. Prosthetic material was used in 14(18.2%) sternal and 37(48.1%) costal reconstructions. There were 26(33.7%) early postoperative complications and 16(20.8%) reinterventions. Infections were observed in 12(15.6%) patients and 4(5.2%) patients developed respiratory complications. 33.3% of all the early infections were presented in patients with methyl methacrylate (MMA) reconstructions and the same percentage in those with titanium plates. There were six (7.8%) late complications and five were related to prosthetic material extrusion, all required prosthetic material removal. The mean overall survival was 77,3 months (SD = 8 months), and 1-year and 5-year overall survival was 85% and 61%, respectively.

CONCLUSIONS

Infections were the more frequent postoperative complications in chest wall reconstructions. The use of either MMA or titanium plates was not related to early postoperative complications, although MMA reconstructions developed higher late complications and required prosthetic material removal.

Three-dimensional (3D)-printed titanium sternum replacement: A case report

After sternal tumor resection, reconstruction of chest wall defects is still a challenging part of thoracic surgery. Three-dimensional (3D)-printed titanium alloy prosthesis implants provide an effective solution. The bionic bone trabecular micropore structure, which is beneficial to the human body, increases stability and robustness of the prosthesis. Here, we report a successful case of a customized prosthesis using a 3D-printed titanium alloy to repair and reconstruct bone defects in a patient with sternal osteosarcoma who underwent radical resection of the whole sternum.

Complete sternal cleft treatment in a low birth weight patient

A complete sternal cleft is a very rare congenital anomaly causing severe respiratory compromise. Surgical reconstruction options are limited, particularly in low birth weight newborns. Herein, we report a case of low birth weight premature newborn with a complete sternal cleft and its surgical treatment.

Reconstruction of massive chest wall defects: A 20-year experience

BACKGROUND

Large chest wall resections can result in paradoxical chest wall movement leading to prolonged ventilator dependence and major respiratory impairment. The purpose of this study was to determine as to which factors are predictive or protective of complications in massive oncologic chest wall defect reconstructions.

METHODS

A retrospective review of a prospectively maintained database of consecutive patients who underwent immediate reconstruction of massive thoracic oncologic defects (≥5 ribs) was performed. Univariate and multivariate logistic regression analyses identified risk factors.

RESULTS

We identified 59 patients (median age, 53 years) with a mean follow-up of 36 months. Rib resections ranged from 5 to 10 ribs (defect area, 80-690 cm²). Sixty-two percent of the patients developed at least one postoperative complication. Superior/middle resections were associated with increased risk of general and pulmonary complications (71.4% vs. 35.3%; OR 4.54; p = 0.013). The 90-day mortality rate following massive chest wall resection and reconstruction was 8.5%. Two factors that were significantly associated with shorter overall survival time were preoperative XRT and preoperative chemotherapy (p = 0.021 and p < 0.001, respectively).

CONCLUSIONS

Patients with massive oncological thoracic defects have a high rate of reconstructive complications, particularly pulmonary, leading to prolonged ventilator dependence. Superior resections were more likely to be associated with increased pulmonary and overall complications. The length of postoperative recovery was significantly associated with the size of the defect, and larger defects had prolonged hospital stays. Because of the large dimensions of chest wall defects, almost half of the cases required flap coverage to allow for appropriate defect closure. Understanding the unique demands of these rare but challenging cases is critically important in predicting patient outcomes.

Anterior chest wall resection and sternal body wedge for primary chest wall tumour: reconstruction technique with biological meshes and titanium plates

Chest wall tumours are heterogeneous neoplasms, either primary or metastatic, with a malignancy rate of 50%. Surgical resection is one of the mainstays of the treatment, however, chest wall resections can be particularly challenging depending onto the resection size, site and patient habitus. The surgical strategy should be carefully analysed preoperatively, keeping in mind the need of an oncological radical resection (R0) in accordance to the reconstruction principles elicited by le Roux and Sherma since 1983, which include restoring the chest wall rigidity, preserving pulmonary mechanics, protect the intrathoracic organs, avoiding paradox movements of the chest cavity and, possibly, to reduce the thoracic deformity. In this context, we herewith report our surgical reconstruction technique following an anterior chest wall resection and sternal body wedge for a primary chest wall tumour (chondrosarcoma).

Health-related quality of life after oncological resection and reconstruction of the chest wall

OBJECTIVES

There is limited information of the health-related quality of life (HRQoL) after surgical treatment of chest wall tumors. This cross-sectional study aimed to assess long-term HRQoL after chest wall reconstruction following oncological resection.

METHODS

Seventy-eight patients having undergone chest wall tumor resection and reconstruction during 1997-2015 were invited to complete the 15D and QLQ-C30 HRQoL instruments.

RESULTS

Altogether, 55 patients (17 men and 38 women), with a mean (SD) age of 68 (14) years, completed the questionnaires (response rate 71%). Patients had been operated due to soft tissue sarcoma (n = 16), advanced breast cancer (n = 15), osteo- or chondrosarcoma (n = 14), or other tumor (n = 10). Median time after primary surgery was 66 (IQR 38, 141) months. The resection was full thickness in 29/55 cases and partial thickness in 26/55 cases. Chest wall reconstruction was required for 47/55 cases (85%). Reconstruction was performed using soft-tissue flap in eight cases, skeletal stabilizations with mesh or mesh-cement-mesh (sandwich method) in 15 cases, and skeletal stabilizations and soft-tissue flap in 24 cases. Patients' mean 15D score (0.878, SD 0.111) was comparable to that of the age- and gender-standardized general population (0.891, SD 0.041). Limitations in breathing and usual activities were noted. The QLQ-C30 cancer-specific HRQoL was 72 points (maximum 100). Scores in the QLQ-C30 Functional scales ranged from 78 (Physical) to 91 (Social).

CONCLUSIONS

Long-term HRQoL in patients after chest wall reconstruction following oncological resection is fair and comparable to that of the general population. Limitations in breathing and usual activities can occur.

Materials and techniques in chest wall reconstruction: a review

Extensive chest wall resection and reconstruction are a challenging procedure that requires a multidisciplinary approach, including input from thoracic surgeon, plastic surgeon and oncologist. In particular chest wall neoplastic pathology is associated with high surgical morbidity and can result in full thickness defects hard to reconstruct. The goals of a successful chest wall reconstruction are to restore the chest wall rigidity, preserve pulmonary mechanic and protect the intrathoracic organs minimizing the thoracic deformity. In case of large full thickness defects synthetic, biologic or composite meshes can be used, with or without titanium plate to restore thoracic cage rigidity as like as more recently the use of allograft to reconstruct the sternum. After skeletal stability is established full tissue coverage can be achieved using direct suture, skin graft or local advancement flaps, pedicled myocutaneous flaps or free flaps. The aim of this article is to illustrate the indications, various materials and techniques for chest wall reconstruction with the goal to obtain the best chest wall rigidity and soft tissue coverage.

Chest wall reconstruction after extended resection

Extensive chest wall resection and reconstruction is a challenging procedure that requires a multidisciplinary approach, including input from thoracic surgeons, plastic surgeons, neurosurgeons, and radiation oncologists. The primary goals of any chest wall reconstruction is to obliterate dead space, restore chest wall rigidity, preserve pulmonary mechanics, protect intrathoracic organs, provide soft tissue coverage, minimize deformity, and allow patients to receive adjuvant radiotherapy. Successful chest wall reconstruction requires the re-establishment of skeletal stability to prevent chest wall hernias, avoids thoracoplasty-like contraction of the operated side, protects underlying viscera, and maintain a cosmetically-acceptable appearance. After skeletal stability is established, full tissue coverage can be achieved using direct closure, skin grafts, local advancement flaps, pedicled myocutaneous flaps, or free flaps. This review examines the indications for chest wall reconstruction and describes techniques for establishment of chest wall rigidity and soft tissue coverage.

Dynamic 3D printed titanium copy prosthesis: a novel design for large chest wall resection and reconstruction

Due to high rates of complications, chest wall resection and reconstruction is a high risk procedure when large size of resection is required. Many different prosthetic materials have been used with similar results. Recently, thanks to the new advances in technology, personalized reconstruction have been possible with specific custom-made prosthesis. Nevertheless, they all generate certain amount of stiffness in thoracic motion because of his rigidity. In this report, we present a forward step in prosthesis design based on tridimensional titanium-printed technology. An exact copy of the resected chest wall was made, even endowing simulated sternochondral articulations, to achieve the most exact adaptation and best functional results, with a view to minimize postoperative complications. This novel design, may constitute an important step towards the improvement of the functional postoperative outcomes compared to the other prosthesis, on the hope, to reduce postoperative complications.

Thoracic Wall Reconstruction after Tumor Resection

Introduction

Surgical treatment of malignant thoracic wall tumors represents a formidable challenge. In particular, locally advanced tumors that have already infiltrated critical anatomic structures are associated with a high surgical morbidity and can result in full-thickness defects of the thoracic wall. Plastic surgery can reduce this surgical morbidity by reconstructing the thoracic wall through various tissue transfer techniques. Sufficient soft-tissue reconstruction of the thoracic wall improves quality of life and mitigates functional impairment after extensive resection. The aim of this article is to illustrate the various plastic surgery treatment options in the multimodal therapy of patients with malignant thoracic wall tumors.

Materials and methods

This article is based on a review of the current literature and the evaluation of a patient database.

Results

Several plastic surgical treatment options can be implemented in the curative and palliative therapy of patients with malignant solid tumors of the chest wall. Large soft-tissue defects after tumor resection can be covered by local, pedicled, or free flaps. In cases of large full-thickness defects, flaps can be combined with polypropylene mesh to improve chest wall stability and to maintain pulmonary function. The success of modern medicine has resulted in an increasing number of patients with prolonged survival suffering from locally advanced tumors that can be painful, malodorous, or prone to bleeding. Resection of these tumors followed by thoracic wall reconstruction with viable tissue can substantially enhance the quality of life of these patients.

Discussion

In curative treatment regimens, chest wall reconstruction enables complete resection of locally advanced tumors and subsequent adjuvant radiotherapy. In palliative disease treatment, plastic surgical techniques of thoracic wall reconstruction provide palliation of tumor-associated morbidity and can therefore improve patients’ quality of life.

Chest wall tumors and prosthetic reconstruction: A comparative analysis on functional outcome

Background

To address the question of how much chest-wall (CW) resections and prosthetic reconstructions influence functional outcome.

Methods

We retrospectively reviewed 175 patients who underwent surgery for CW tumors. The clinical, histological, surgical, oncological, and functional factors were analyzed.

Results

We performed: 75 rib resections; 20 sternal resections; 15 combined resections; and 27 lung resections. In 39 cases (22.2%) CW was stabilized with non-rigid prosthesis (Vicryl-mesh: 8 patients; Goretex-mesh: 31 patients). Postoperative complications occurred in 22 cases (12.6%): a correlation with lung resection was evidenced by multivariate analysis (P = 0.025). Five-year survival for primary and secondary tumors was 50% and 36%, respectively: multivariate analysis (P = 0.048) showed a worse survival in men only. In the prosthesis subset, pulmonary function tested as percentage of forced expiratory volume in one second (%FEV1) (pre: 87.1 ± 18.9%; post: 82.3 ± 23.0%, P = ns), percentage of forced vital capacity (pre: 94.1 ± 19.3%; post: 82.0 ± 21.6%, P = ns), diffusing capacity of the lungs for carbon monoxide (pre: 15.7 ± 7.4; post: 12.1 ± 4.1, P = ns) and paO2 (pre: 82.6 ± 10.9 mmHg; post: 83.9 ± 7.3 mmHg, P = ns) was slightly modified from pre to postoperative. Interestingly, the decline of FEV1% was lower in the prosthesis-subset (4.1 ± 15.9%) compared with the subgroup who did not undergo prosthetic stabilization (17.5 ± 16.2%), but this difference was not statistically significant (P = ns).

Conclusion

Because of the low decrease of lung parameters, CW prosthetic reconstruction could be helpful for avoiding postoperative worsening of functional outcome, mostly in patients with pre-existing pulmonary diseases.

Prognostic risk factors for the development of scoliosis after chest wall resection for malignant tumors in children

BACKGROUND

Surgical resection of a malignant tumor of the chest wall in children may result in the development of progressive scoliosis. The aim of this study was to identify the risk factors associated with scoliosis following resection of a tumor of the chest wall and to evaluate the prevalence and characteristics of the scoliosis.

METHODS

Forty children who underwent resection of a malignant tumor of the chest wall from 1984 to 2005 were included in a multicenter, retrospective cohort study. The mean age of the patients at the time of surgery was 9.8 years (range, 0.2 to nineteen years). Resections were classified with the use of the following scheme: the number of resected ribs was noted in Roman numerals, and the level of the resection was identified by dividing the thorax into three sectors (A [anterior], B [lateral], and C [posterior]) in the horizontal plane. One to five ribs (mean, 2.3 ribs) were resected. Patients with scoliosis were compared with patients who did not have scoliosis through the use of univariate and multivariate analyses. The mean duration of follow-up was 8.5 years (range, three to twenty-three years).

RESULTS

Patients who had a tumor resection during a rapid-growth period (patient age of less than six years or between twelve and fifteen years) had a 5.8 times higher risk of scoliosis. The resection of three or more ribs in the posterior sector (C) was the primary risk factor for scoliosis, with an odds ratio of 18.9. Seventeen (43%) of the children developed scoliosis, which was convex toward the resection side without vertebral rotation in all of them.

CONCLUSIONS

The risk of scoliosis following the resection of a primary malignant tumor of the chest wall in children was shown to be higher when resection was performed during a rapid-growth period and when the resection involved three or more ribs in the posterior sector.

Reconstruction of chest wall using a two-layer prolene mesh and bone cement sandwich

Wide surgical resection is the most effective treatment for the vast majority of chest wall tumors. This study evaluated the clinical success of chest wall reconstruction using a Prolene mesh and bone cement prosthetic sandwich. The records of all patients undergoing chest wall resection and reconstruction were reviewed. Surgical indications, the location and size of the chest wall defect, diaphragm resection, pulmonary performance, postoperative complications, and survival of each patient were recorded. From 1998 to 2008, 43 patients (27 male, 16 female; mean age of 48 years) underwent surgery in our department to treat malignant chest wall tumors: chondrosarcoma (23), osteosarcoma (8), spindle cell sarcoma (6), Ewing's sarcoma (2), and others (4). Nine sternectomies and 34 antero-lateral and postero-lateral chest wall resections were performed. Postoperatively, nine patients experienced respiratory complications, and one patient died because of respiratory failure. The overall 4-year survival rate was 60 %. Chest wall reconstruction using a Prolene mesh and bone cement prosthetic sandwich is a safe and effective surgical procedure for major chest wall defects.

Microsurgical chest wall reconstruction after oncologic resections

Defect reconstruction after radical oncologic resection of malignant chest wall tumors requires adequate soft tissue reconstruction with function, stability, integrity, and an aesthetically acceptable result of the chest wall. The purpose of this article is to describe possible reconstructive microsurgical pathways after full-thickness oncologic resections of the chest wall. Several reliable free flaps are described, and morbidity and mortality rates of patients are discussed.

Prosthetic reconstruction of the chest wall

Chest wall reconstructions can be complex and challenging procedures, especially when huge thoracic defects have been generated by radical excisions. Nonrigid reconstructions with meshes or patches have the goal of avoiding a lung hernia caused by the chest wall defect, or preventing the impaction of the scapula in case of posterior chest wall resections, especially when the resection is extended down to the 5th and 6th ribs. Large anterior and lateral resections result in thoracic instability and alteration of pulmonary physiology, and render intrathoracic structures vulnerable to external impact. They necessitate rigid reconstructions according to several techniques using alloplastic materials (eg, methyl methacrylate-based customized plates or neo-ribs, osteosynthesis systems, or dedicated prosthesis). Nowadays, the availability of these multiple, possibly combined, more adapted, and better tolerated materials have pushed past the limits of resection to those involving soft tissue coverage.