An innovative method of pediatric chest wall reconstruction using Surgisis and swinging rib technique

Reconstructive Strategies in Pediatric Patients after Oncological Chest Wall Resection: A Systematic Review

An appropriate reconstruction strategy after surgical resection of chest wall tumors in children is important to optimize outcomes, but there is no consensus on the ideal approach. The aim of this study was to provide an up-to-date systematic review of the literature for different reconstruction strategies for chest wall defects in patients less than 18 years old. A systematic literature search of the complete available literature was performed and results were analyzed. A total of 22 articles were included in the analysis, which described a total of 130 chest wall reconstructions. All were retrospective analyses, including eight case reports. Reconstructive options were divided into primary closure (n = 21 [16.2%]), use of nonautologous materials (n = 83 [63.8%]), autologous tissue repair (n = 2 [1.5%]), or a combination of the latter two (n = 24 [18.5%]). Quality of evidence was poor, and the results mostly heterogeneous. Reconstruction of chest wall defects can be divided into four major categories, with each category including its own advantages and disadvantages. There is a need for higher quality evidence and guidelines, to be able to report uniformly on treatment outcomes and assess the appropriate reconstruction strategy.

Chest wall osteochondroma resection with biologic acellular bovine dermal mesh reconstruction in pediatric hereditary multiple exostoses: A case report and review of literature

BACKGROUND

Hereditary multiple exostoses is a rare genetic disorder characterized by the growth of multiple osteochondromas affecting primarily long bones. Chest wall lesions may represent a challenge, particularly in pediatric patients. Pain is a common manifestation. However, life-threatening complications can result from direct involvement of adjacent structures. Surgical resection with appropriate reconstruction is often required.

CASE SUMMARY

A 5-year-old male who was diagnosed with hereditary multiple exostoses presented with significant pain from a large growing chest wall exostosis lesion. After appropriate preoperative investigations, he underwent surgical resection with reconstruction of his chest wall using a biologic bovine dermal matrix mesh.

CONCLUSION

Resection of chest wall lesions in children represents a challenge. Preoperative planning to determine the appropriate reconstruction strategy is essential.

Expert consensus on resection of chest wall tumors and chest wall reconstruction

Chest wall tumors are a relatively uncommon disease in clinical practice. Most of the published studies about chest wall tumors are usually single-center retrospective studies, involving few patients. Therefore, evidences regarding clinical conclusions about chest wall tumors are lacking, and some controversial issues have still to be agreed upon. In January 2019, 73 experts in thoracic surgery, plastic surgery, science, and engineering jointly released the Chinese Expert Consensus on Chest Wall Tumor Resection and Chest Wall Reconstruction (2018 edition). After that, numerous experts put forward new perspectives on some academic issues in this version of the consensus, pointing out the necessity to further discuss the points of contention. Thus, we conducted a survey through the administration of a questionnaire among 85 experts in the world. Consensus has been reached on some major points as follows. (I) Wide excision should be performed for desmoid tumor (DT) of chest wall. After excluding the distant metastasis by multi-disciplinary team, solitary sternal plasmacytoma can be treated with extensive resection and adjuvant radiotherapy. (II) Wide excision with above 2 cm margin distance should be attempted to obtain R0 resection margin for chest wall tumor unless the tumor involves vital organs or structures, including the great vessels, heart, trachea, joints, and spine. (III) For patients with chest wall tumors undergoing unplanned excision (UE) for the first time, it is necessary to carry out wide excision as soon as possible within 1–3 months following the previous surgery. (IV) Current Tumor Node Metastasis staging criteria (American Joint Committee on Cancer) of bone tumor and soft tissue sarcoma are not suitable for chest wall sarcomas. (V) It is necessary to use rigid implants for chest wall reconstruction once the maximum diameter of the chest wall defect exceeds 5 cm in adults and adolescents. (VI) For non-small cell lung cancer (NSCLC) invading the chest wall, wide excision with neoadjuvant and/or adjuvant therapy are recommended for patients with stage T_3-4N_0-1M₀. As clear guidelines are lacking, these consensus statements on controversial issues on chest wall tumors and resection could possibly serve as further guidance in clinical practice during the upcoming years.

A Novel Approach to Extensive Chest Wall Reconstruction in a Child

Reconstruction of extensive chest wall defects is challenging in young children. Rigid prosthetic plates, designed to prevent paradoxic respiration, do not grow with the child and may result in progressive chest and spinal deformity. Also because of the greater proportionate size of the thorax relative to the limbs in young children, extrathoracic soft tissue flaps may be too small for an adequate reconstruction. Here we report reconstruction of a large chest wall defect after resection of a Ewing's sarcoma in a 2-year-old boy using Permacol membrane (Medtronic, Minneapolis, MN) supported by a diagonally translocated seventh rib and covered by a latissimus dorsi flap.

Reconstruction of an anterior chest wall defect in a child using a latissimus dorsi muscle-thoraco-lumbar fascia composite flap - A case report

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Reconstruction of chest wall defects in children poses a challenge because the use of hard implants will impair chest wall growth.

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We demonstrate the reconstruction of a chest wall defect in a pediatric patient with an innovative technique.

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At final follow-up 11 years later, there was no bulging of the lung through the defect.

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The case demonstrates that the composite flap is rigid enough to prevent bulging of the lung though the defect.

Introduction

Reconstruction of chest wall defects in children poses a challenge because the use of hard implants will impair chest wall growth. In this report, we demonstrate the reconstruction of a chest wall defect in a pediatric patient with an innovative technique using the latissimus dorsi muscle-thoraco-lumbar fascia composite flap.

Case Report

A 5-year old boy presented to the clinic with a congenital anterior right chest wall defect. Reconstruction was done using this composite flap. Drill holes were made in the sternum and remaining ribs at the edges of the chest wall defect. The muscle-fascia composite flap was then sutured over the defect using polypropylene sutures anchored to these drill holes. There were no post-operative complications. At final follow-up 11 years later, the chest wall depression was still present but to a lesser degree when compared to the pre-operative depression. There was no bulging of the lung through the defect.

Discussion

The composite flap technique was compared to other options of chest wall reconstruction in children.

Conclusions

Congenital anterior chest wall defects that are not associated with breathing problems may be reconstructed in early childhood with a pedicled latissimus dorsi muscle-thoraco-lumbar fascia composite flap. The flap is rigid enough to prevent bulging of the lung though the defect and hence, it provides an adequate reconstruction. However, the remaining chest wall depression and further chest wall rigidity requires a second operation after puberty.

Primary paediatric chest wall tumours necessitating surgical management

INTRODUCTION

Limited literature exists on oncological chest wall reconstruction in the paediatric population, with the field still largely undecided on the best surgical reconstructive techniques to employ. The use of biological grafts/meshes is gaining popularity in certain adult surgical procedures but their use in paediatric procedures is rarely reported in the literature. We present the outcomes of our institution's multidisciplinary approach to managing paediatric chest wall tumours as well as our experience with the use of biological grafts for chest wall reconstruction following oncological resections.

METHODS

Data were analysed retrospectively from eight paediatric patients who were treated for primary chest wall tumours between 2010 and 2018.

RESULTS

The tumours comprised two lipoblastomas, three Ewing's sarcomas, an undifferentiated sarcoma with osteosarcomatous differentiation, a high grade undifferentiated sarcoma and a myofibroma. Seven of the eight patients underwent chest wall reconstruction with a biological graft. There were no postoperative mortalities and no evidence of recurrence in any of the patients in the series. No further chest wall operations were required and there were no postoperative infection related complications.

CONCLUSIONS

We support the use of biological grafts for chest wall reconstruction after oncological resections and maintain that a multidisciplinary approach is essential for the management of paediatric chest wall tumours.

LDT classification and therapeutic strategy of congenital body wall defects

BACKGROUND

Repairing body wall defects is a critical step in the treatment of some congenital deformities, and this procedure may need the help from plastic surgeons. Although there are many articles about congenital deformities, body wall defects of these malformations are rarely studied as independent targets.

METHODS

In this article, the authors present an LDT classification for congenital body wall defects according to the position of the defects, the tissue layers involved, and the surgical urgency, each of which is represented by letters L, D, and T, respectively. That is, the defects in different areas (L), full-thickness (D₁), or partial (D_0A, D_0B) defects, defects needing instant repair (T₂), semi-elective repair (T₁), or elective repair (T₀). Based on this classification system, the authors have performed body wall reconstruction on two pairs of thoraco-omphalopagus twins, one pair of ischiopagus tetrapus twins, and an infant and an adult, both of whom were diagnosed with pentalogy of Cantrell associated with ectopia cordis.

RESULTS

Except for one pair of thoraco-omphalopagus twins who died after emergency separation, all the other patients survived. Another pair of thoraco-omphalopagus twins suffered from wound dehiscence and partial flap necrosis, respectively, after surgery. An expanded polytetrafluoroethylene mesh in one sister of the ischiopagus twins was removed because of infection.

CONCLUSIONS

LDT classification not only can help doctors categorise different congenital body wall defects rapidly and easily, but can also guide the reconstruction of these defects. It may have clinical value to plastic surgeons to some extent.

Thoracic wall reconstruction with bioabsorbable plates in pediatric malignant thoracic wall tumors

AIM

Childhood malignant chest wall tumors may require extensive surgical resection and reconstruction with musculoskeletal flaps or non-resorbable prosthetic materials. Implant-related complications and scoliosis often occur. This study analyzes the outcomes of chest wall reconstruction using resorbable plates as an alternative approach.

METHODS

Retrospective review (2007-2015) of patients who underwent resection of malignant primary chest wall tumors in 2 tertiary pediatric centers. Reconstruction was performed using copolymer (l-lactic and glycolic acid) plates, fixed to the ribs and surrounding structures with copolymer screws and/or polyglactin sutures.

RESULTS

Eight patients aged 10.6+2.6years were treated. There were no operative complications, and implant removal was not required in any case. Six patients received postoperative radiotherapy. Over follow-up (39.6months, range 9.4-78), chest wall shape was maintained in all, and there were no radiological artifacts. Three patients developed scoliosis (Cobb 17°-33°), but treatment was needed only in one, who had undergone hemivertebrectomy. There were no cases of local tumor relapse. One patient died because of metastatic spread.

CONCLUSIONS

Implantation of bioabsorbable l-lactic and glycolic acid copolymer plates with a relatively simple technique provided a rigid, stable reconstruction with only mild mid-/long-term complications. Resorbable plates may be a good alternative for pediatric chest wall reconstruction.

LEVEL OF EVIDENCE

IV.

A technique for pediatric chest wall reconstruction using custom-designed titanium implants: description of technique and report of two cases

PURPOSE

We present a surgical technique for chest wall reconstruction using custom-designed titanium implants developed for two female patients to provide both chest wall symmetry and adequate stability for staged breast reconstruction.

METHODS

A retrospective review was performed for two adolescent female patients with large chest wall defects who underwent the described technique. The etiology of the chest wall deficiency was secondary to Poland's syndrome in one patient, and secondary to surgical resection of osteosarcoma in the other patient. For each patient, a fine-cut computed tomography scan was obtained to assist with implant design. After fabrication of the prosthesis, reconstruction was performed though a curvilinear thoracotomy approach with attachment of the implant to the adjacent ribs and sternum. Wound closure was obtained with use of synthetic graft material, local soft tissue procedures, and flap procedures as necessary.

RESULTS

The two patients were followed post-operatively for 35 and 38 months, respectively. No intra-operative or post-operative complications were identified. Mild scoliosis that had developed in the patient following chest wall resection for osteosarcoma did not demonstrate any further progression following reconstruction.

CONCLUSIONS

We conclude that this technique was successful at providing a stable chest wall reconstruction with satisfactory cosmetic results in our patients.