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

Surgical Outcomes after Full Thickness Chest Wall Resection Followed by Immediate Reconstruction: A 7-Year Observational Study of 42 Cases

Introduction

Reconstruction of full thickness chest wall defects is challenging and is associated with a considerable risk of complications. Therefore, the aim of this study was to investigate the surgical outcomes and their associations with patient and treatment characteristics following full thickness chest wall reconstruction.

Patients and methods

A retrospective observational study was performed by including patients who underwent reconstruction of full thickness chest wall defect at the Erasmus MC between January 2014 and December 2020. The type of reconstruction was categorized into skeletal and soft tissue reconstructions. For skeletal reconstruction, only non-rigid prosthetic materials were used. Patient and surgical characteristics were retrieved and analyzed for associations with postoperative complications.

Results

Thirty-two women and 10 men with a mean age of 60 years were included. In 26 patients (61.9%), the reconstruction was performed using prosthetic material and a soft tissue flap, in nine cases (21.4%) only a soft tissue flap was used, and in seven other patients (16.7%) only the prosthetic material was used. Pedicled musculocutaneous latissimus dorsi flaps were used most often (n=17), followed by pectoralis major flaps (n=8) and free flaps (n=8). Twenty-two patients (52.4%) developed at least one postoperative complication. Wounds (21.4%) and pulmonary (19.0%) complications occurred most frequently. Five (11.9%) patients required reoperation. There were no associations between patient and treatment characteristics and the occurrence of major complications. There was no mortality.

Conclusions

Reconstruction of full thickness chest wall defects using only non-rigid prosthetic material for skeletal reconstruction appears safe with an acceptable reoperation rate and low mortality, questioning the need for rigid fixation techniques.

Postoperative Complications of Flap Procedures in Chest Wall Defect Reconstruction: A Two-Center Experience

Background and Objectives: Chest wall defect reconstruction is a complex procedure aimed at restoring thoracic structural integrity after trauma, tumor removal, or congenital issues. In this study, postoperative complications were investigated to improve the care of patients with these critical conditions. Materials and Methods: A retrospective study of chest wall reconstructions from 2004 to 2023 was conducted at Klinikum Nürnberg and Evangelisches Waldkrankenhaus Spandau-Berlin. Data included patient demographics, comorbidities, defect etiology, surgery details, and complications using the Clavien-Dindo classification. Results: Among the 30 patients included in the study, a total of 35 complications occurred in 35 thoracic wall defect reconstructions. These complications were classified into 22 major and 13 minor cases. Major complications were more common in patients with cancer-related defects, and considerable variations were observed between free flap and pedicled flap surgeries. Notably, the use of the anterolateral thigh (ALT) flap with vastus lateralis muscle demonstrated promise, exhibiting fewer complications in select cases. The reconstruction of chest wall defects is associated with substantial complications regardless of the etiology of the defect and the particular surgical procedure used. Interestingly, there was a lower complication rate with free flap surgery than with pedicled flaps. Conclusions: The ALT flap with vastus lateralis muscle deserves further research in this field of reconstruction. Multidisciplinary approaches and informed patient discussions are crucial in this complex surgical field, emphasizing the need for ongoing research and technique refinement.

Practical Strategies in Reconstruction of Soft-Tissue Sarcoma

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Discuss the natural history and pathophysiology of sarcoma. 2. Summarize the most up-to-date multidisciplinary management of soft-tissue sarcoma. 3. Provide a synopsis of reconstructive modalities based on anatomical location. 4. Highlight some novel strategies for treatment of lymphedema and phantom limb pain that are common sequelae following treatment and resection of soft-tissue sarcomas.

SUMMARY

The management of soft-tissue sarcoma presents unique challenges to the reconstructive surgeon. The optimal management mandates a multidisciplinary approach; however, reconstruction must take into account the extent of the resection and exposed vital structures, but often occurs in the setting of adjuvant treatments including chemotherapy and radiation therapy. Reconstruction is based on the extent of the defect and the location of the primary tumor. As such, an evidence-based, algorithmic approach following the reconstructive ladder is warranted to minimize the risks of complications and maximize success, which varies from head and neck to torso to breast to extremity sarcomas. Aside from reconstruction of the defect, advances in the surgical treatment of lymphedema and neuropathic pain resulting from treatment and extirpation of soft-tissue sarcoma are critical to maintain function and patients' quality of life.

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.

Hybrid nanocomposite as a chest wall graft with improved vascularization by copper oxide nanoparticles

Chest wall repair can be necessary after tumor resection or chest injury. In order to cover or replace chest wall defects, autologous tissue or different synthetic materials are commonly used, among them the semi-rigid gold standard Gore-Tex® and prolene meshes. Synthetic tissues include composite materials with an organic and an inorganic component. On the basis of previously reported hybrid nanocomposite poly-lactic-co-glycolic acid amorphous calcium phosphate nanocomposite (PLGA/aCaP), a CuO component was incorporated to yield (60%/35%/5%). This graft was tested in vitro by seeding with murine adipose-derived stem cells (ASCs) for cell attachment and migration. The graft was compared to PLGA/CaCO3 and PLGA/hydroxyapatite, each providing the inorganic phase as nanoparticles. Further characterization of the graft was performed using scanning electron microscopy. Furthermore, PLGA/aCaP/CuO was implanted as a chest wall graft in mice. After 4 weeks, total cell density, graft integration, extracellular matrix components such as fibronectin and collagen I, the cellular inflammatory response (macrophages, F4/80 and lymphocytes, CD3) as well as vascularization (CD31) were quantitatively assessed. The nanocomposite PLGA/aCaP/CuO showed a good cell attachment and cells migrated well into the pores of the electrospun meshes. Cell densities did not differ between PLGA/aCaP/CuO and PLGA/CaCO3 or PLGA/hydroxyapatite, respectively. When applied as a chest wall graft, adequate stability for suturing into the thoracic wall could be achieved. Four weeks post-implantation, there was an excellent tissue integration without relevant fibrotic changes and a predominating collagen I matrix deposition within the graft. Slightly increased inflammation, reflected by increased infiltration of macrophages could be observed. Vascularization of the graft was significantly enhanced when compared with PLGA/aCaP (no CuO). We conclude that the hybrid nanocomposite PLGA/aCaP/CuO is a viable option to be used as a chest wall graft. Surgical implantation of the material is feasible and provides stability and enough flexibility. Proper tissue integration and an excellent vascularization are characteristics of this biodegradable material.

Custom 3D-printed Titanium Implant for Reconstruction of a Composite Chest and Abdominal Wall Defect

Background

Three-dimensional (3D) printing of implantable materials is a recent technological advance that is available for clinical application. The most common medical application of 3D printing in plastic surgery is in the field of craniomaxillofacial surgery. There have been few applications of this technology in other areas.

Methods

Here, we discuss a case of a large, symptomatic composite thoracic and abdominal defect resulting from the resection of a chondrosarcoma of the costal marginand sections of the abdominal wall, diaphragm, and sternum. The initial and second attempts at reconstruction failed, resulting in a massive hernia. Given the size of the defect, the contiguity with a large abdominal wall defect, and the high risk of recurrence, a rigid thoracic reconstruction was essential to durably repair the thoracic hernia and serve as a scaffold to which both the diaphragm and the abdominal mesh could be secured. A custom-made plate offered the most durable and anatomically accurate reconstruction in this particular clinical scenario. This technology was used in concert with a single section of coated mesh for reconstruction of the diaphragm, chest wall, and abdominal wall.

Results

There were no post-operative complications. The patient has improvement of his symptoms and increased functional capacity. There is no evidence of hernia recurrence 1.5 years after repair.

Conclusions

3D printing technology proved to be a useful and effective application for reconstruction of this large thoracic defect involving the costal margin. It is an available technology that should be considered for reconstruction of rigid structures with defect-specific precision.

Ventilatory failure in a cat following radical chest wall resection for feline injection site sarcoma

Case summary

A 12-year-old spayed female domestic shorthair cat presented for chest wall resection and radiation therapy following incomplete surgical excision of a feline injection site sarcoma. A CT scan for surgical planning was performed under general anesthesia and showed extensive tumor infiltration of the soft tissues of the right thorax. The cat recovered uneventfully from this anesthetic event. Nineteen days later, the patient was reanesthetized for forequarter amputation plus radical chest wall resection, including ribs 3–8 and all associated soft tissues plus adjacent spinous processes. Postoperatively, the patient developed acute respiratory failure secondary to hypoventilation. The cat was mechanically ventilated for 12 h prior to being successfully weaned from the ventilator. However, the improvement was transient and mechanical ventilation was reinitiated 6 h later owing to respiratory fatigue. On the second day, the cat developed unexplained central nervous system signs and was euthanized.

Relevance and novel information

To our knowledge, this is the first case report to describe ventilatory failure secondary to radical chest wall resection in a cat. Hypoventilation with subsequent need for mechanical ventilation is a potential complication that should be considered during preoperative planning in patients requiring extensive chest wall resections.