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Sparreboom CL, Hop MJ, Mazaheri M, Rothbarth J, Maat AP, Corten EM, Mureau MA. Surgical Outcomes after Full Thickness Chest Wall Resection Followed by Immediate Reconstruction: A 7-Year Observational Study of 42 Cases. JPRAS Open 2024; 41:14-24. [PMID: 38845680 PMCID: PMC11153933 DOI: 10.1016/j.jpra.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/15/2024] [Indexed: 06/09/2024] Open
Abstract
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.
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Affiliation(s)
- Cloë L. Sparreboom
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M. Jenda Hop
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Masood Mazaheri
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joost Rothbarth
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Alexander P.W.M. Maat
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eveline M.L. Corten
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marc A.M. Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Merhej H, Ali M, Nakagiri T, Zinne N, Selman A, Golpon H, Goecke T, Zardo P. Long-Term Outcome of Chest Wall and Diaphragm Repair with Biological Materials. Thorac Cardiovasc Surg 2023. [PMID: 37914155 DOI: 10.1055/a-2202-4154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
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.
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Affiliation(s)
- Hayan Merhej
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Mohammed Ali
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Tomoyuki Nakagiri
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Norman Zinne
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Medizinische Hochschule Hannover Zentrum Chirurgie, Hannover, Germany
| | - Alaa Selman
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Heiko Golpon
- Department of Pneumology and Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Goecke
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Patrick Zardo
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
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Duranti L, Tavecchio L. New perspectives in prosthetic reconstruction in chest wall resection. Updates Surg 2023:10.1007/s13304-023-01562-z. [PMID: 37402065 DOI: 10.1007/s13304-023-01562-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/03/2023] [Indexed: 07/05/2023]
Abstract
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.
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Affiliation(s)
- Leonardo Duranti
- Thoracic Surgey Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via G Venezian 1, 20133, Milano, Italy.
| | - Luca Tavecchio
- Thoracic Surgey Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via G Venezian 1, 20133, Milano, Italy
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Kong TH, Kim IK. Treatment of chest wall osteoradionecrosis with a contralateral breast Y-V flap: a case report. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2022. [DOI: 10.14730/aaps.2021.00416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Chest wall osteoradionecrosis, one of the most serious complications of radiation therapy for breast cancer treatment, is usually treated by wide debridement followed by coverage with a well-vascularized flap. However, the extent of radiation-induced injury and limits in performing wide resection of the injured bones often present challenges in treatment. Herein, we present our experience treating chest wall osteoradionecrosis with a contralateral breast Y-V flap in an 81-year-old woman. She was diagnosed with chest wall osteoradionecrosis and had grade 3 ptotic breasts. Redundant contralateral breast tissue was used for reconstruction to cover the wound. The flap was elevated in the subfascial plane after an inverted-T incision was made in the lower pole and inframammary fold of the contralateral breast, while preserving the perforators of the left lateral thoracic artery. The flap was spread using the Y-V advancement fashion to cover the wound. The patient was discharged 2 weeks after surgery. At 19 months postoperation, there were no complications or recurrence. The patient was satisfied with the short recovery time and surgical results. The contralateral breast Y-V flap allows simple and quick reconstruction, potentially expanding the available treatment options and therefore increasing flexibility in choosing a treatment plan for patients.
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Complications of Chest Wall Resection in Conjunction with Pulmonary Resection. Thorac Surg Clin 2021; 31:393-398. [PMID: 34696851 DOI: 10.1016/j.thorsurg.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Techniques for chest wall resection and reconstruction have evolved over the years. Chest wall resection in conjunction with pulmonary resection has several complications, including pulmonary and infectious. Risk factors for complications are related to the size of the defect, number of ribs resected, and the addition of a pulmonary resection. Material used for reconstruction does not impact the overall complication rate.
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Carvajal C, Ramirez AM, Guerrero-Macías S, Beltrán R, Buitrago R, Carreño J. A South American Experience With Postoperative Complications Following Chest Wall Reconstruction for Neoplasms. World J Surg 2021; 45:2982-2992. [PMID: 34180010 DOI: 10.1007/s00268-021-06215-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Carlos Carvajal
- Thoracic Surgery Department, Instituto Nacional de Cancerología, Calle 1 No. 9-85, Bogotá, 111511, Colombia.
| | - Ana María Ramirez
- Thoracic Surgery Department, Instituto Nacional de Cancerología, Calle 1 No. 9-85, Bogotá, 111511, Colombia
| | - Silvia Guerrero-Macías
- Surgical Oncology Department, Instituto Nacional de Cancerología, Calle 1 No. 9-85, Bogotá, 111511, Colombia
| | - Rafael Beltrán
- Thoracic Surgery Department, Instituto Nacional de Cancerología, Calle 1 No. 9-85, Bogotá, 111511, Colombia
| | - Ricardo Buitrago
- Thoracic Surgery Department, Instituto Nacional de Cancerología, Calle 1 No. 9-85, Bogotá, 111511, Colombia
| | - José Carreño
- Research Department, Instituto Nacional de Cancerología, Calle 1 No. 9-85, Bogotá, 111511, Colombia
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Dharmaraj B, Diong NC, Shamugam N, Sathiamurthy N, Mohd Zainal H, Chai SC, Koh KL, Mat Zain MA, Haji Basiron N. Chest wall resection and reconstruction: a case series of 20 patients in Hospital Kuala Lumpur, Malaysia. Indian J Thorac Cardiovasc Surg 2020; 37:82-88. [PMID: 33442211 DOI: 10.1007/s12055-020-00972-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 05/11/2020] [Accepted: 05/20/2020] [Indexed: 11/27/2022] Open
Abstract
Chest wall resection is defined as partial or full-thickness removal of the chest wall. Significant morbidity has been recorded, with documented respiratory failure as high as 27%. Medical records of all patients who had undergone chest wall resection and reconstruction were reviewed. Patients' demographics, length of surgery, reconstruction method, size of tumor and chest wall defect, histopathological result, complications, duration of post-operative antibiotics, and hospital stay were assessed. From 1 April 2017 to 30 April 2019, a total of 20 patients underwent chest wall reconstructive surgery. The median age was 57 years, with 12 females and 8 males. Fourteen patients (70%) had malignant disease and 6 patients (30%) had benign disease. Nine patients underwent rigid reconstruction (titanium mesh for sternum and titanium plates for ribs), 6 patients had non-rigid reconstruction (with polypropylene or composite mesh), and 5 patients had primary closure. Nine patients (45%) required closure with myocutaneous flap. Complications were noted in 70% of patients. Patients who underwent primary closure had minor complications. In total, 66.7% of patients who had closure with either fasciocutaneous or myocutaneous flaps had threatened flap necrosis. Two patients developed pneumonia and 3 patients (15%) had respiratory failure requiring tracheostomy and prolonged ventilation. There was 1 mortality (5%) in this series. In conclusion, chest wall resections involving large defects require prudent clinical judgment and multidisciplinary assessments in determining the choice of chest wall reconstruction to improve outcomes.
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Affiliation(s)
- Benedict Dharmaraj
- Thoracic Surgery Unit, Department of General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Nguk Chai Diong
- Thoracic Surgery Unit, Department of General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Navindra Shamugam
- Thoracic Surgery Unit, Department of General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Narasimman Sathiamurthy
- Thoracic Surgery Unit, Department of General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Hamidah Mohd Zainal
- Department of Plastic and Reconstructive Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Siew Cheng Chai
- Department of Plastic and Reconstructive Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Khai Luen Koh
- Department of Plastic and Reconstructive Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Mohammad Ali Mat Zain
- Department of Plastic and Reconstructive Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Normala Haji Basiron
- Department of Plastic and Reconstructive Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
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Corkum JP, Garvey PB, Baumann DP, Abraham J, Liu J, Hofstetter W, Butler CE, Clemens MW. Reconstruction of massive chest wall defects: A 20-year experience. J Plast Reconstr Aesthet Surg 2020; 73:1091-1098. [PMID: 32269009 DOI: 10.1016/j.bjps.2020.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 10/22/2019] [Accepted: 02/12/2020] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Joseph P Corkum
- The Division of Plastic Surgery, Dalhousie University, Nova Scotia, Canada
| | - Patrick B Garvey
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Donald P Baumann
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Jasson Abraham
- The University of Texas Medical School at Houston, Houston, Texas, USA
| | - Jun Liu
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Wayne Hofstetter
- Department of Thoracic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Charles E Butler
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Mark W Clemens
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA.
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Malathi L, Das S, Nair JTK, Rajappan A. Chest wall reconstruction: success of a team approach-a 12-year experience from a tertiary care institution. Indian J Thorac Cardiovasc Surg 2019; 36:44-51. [PMID: 33061093 DOI: 10.1007/s12055-019-00841-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/16/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022] Open
Abstract
Background The thoracic cavity was considered as a forbidden area in the past and anyone attempting to meddle with it was expected to be doomed. But the past several decades have seen a marked improvement in the management and reconstruction of complex chest wall defects. This study was undertaken to review our experience in chest wall reconstruction during the past 12 years and to stress upon the importance of a multidisciplinary team approach to this complex problem. Methods After obtaining the necessary clearance from institutional ethics committee, we did a retrospective review of all case records of chest wall reconstructions (CWR) performed in our institution during a 12-year period from May 2005 to September 2016. Patient characteristics, co-morbidities, operative data and post-operative complications and outcomes were reviewed. Results During the study period, a total of 32 patients underwent CWR. All patients were assessed, planned, operated and managed by a team consisting of thoracic surgeons, plastic surgeons, intensivists and pulmonologists. Patients were in the age group of 14-72 with a male:female ratio of 15:17. Indications for CWR were neoplasms (n = 13-40.62%), post-sternotomy wound dehiscence (n = 12-37.5%), osteoradionecrosis (n = 4-12.5%), tuberculosis (n = 2-6.25%) and osteomyelitis rib (1/32-3.125%). Inflammatory defects were mostly closed with soft tissue alone whereas skeletal stabilisation with soft tissue cover was required in tumour resections. All were pedicled flaps, the most common being pectoralis major (PM) muscle flap (n = 12). Others include latissimus dorsi (LD) muscle (n = 9); rectus abdominis (RA) muscle (n = 2); transverse rectus abdominis musculocutaneous flap (TRAM) (n = 2), deltopectoral (DP) (n = 1), omentum (n = 3) and breast flap (n = 3). Post-operative complications include wound dehiscence (12%), wound infection (21%) and recurrent sinus formation (7%). One partial flap failure was recorded. Post-operative mortality was 3%. Conclusion Chest wall reconstruction is a complex procedure and each defect needs an individualised approach for optimum outcome. Extensive chest wall resections can be safely undertaken with the support of the reconstructive surgeon and with good critical care back up.
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Affiliation(s)
- Lekshmi Malathi
- Department of Plastic Surgery, Government Medical College Kottayam, Kottayam, Kerala India
| | - Sankar Das
- Department of Plastic Surgery, Government Medical College Kottayam, Kottayam, Kerala India
| | | | - Aniraj Rajappan
- Department of Plastic Surgery, Government Medical College Kottayam, Kottayam, Kerala India
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Khalil HH, Kalkat M, Malahias MN, Rhobaye S, Ashour T, Djearaman MG, Naidu B. Chest Wall Reconstruction with Porcine Acellular Dermal Matrix (Strattice) and Autologous Tissue Transfer for High Risk Patients with Chest Wall Tumors. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1703. [PMID: 29922541 PMCID: PMC5999444 DOI: 10.1097/gox.0000000000001703] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 01/10/2018] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Tenets of chest wall reconstruction for malignancy are well known; however, the insertion of synthetic prosthetic material to achieve rigid and nonrigid skeletal reconstruction could be associated with more complications including infection and extrusion especially in high risk patients. This includes fungating, infected tumors, previous radiotherapy, scars, smoking, diabetes, and morbid obesity. Bioprosthesis Acelluar Dermal Matrix Strattice would be a substitute to resist infection and provide stable coverage. Methods: A retrospective data analysis study on 8 high-risk patients who underwent chest wall resection and reconstruction with bioprosthesis (Strattice) with/without titanium plates in the period between 2012 and 2017 was performed. Patient’s demographics, risk factors, clinico-pathological, radiological, operative details, adjuvant therapy, postoperative morbidity, and follow-up data were recorded. Results: Sarcoma was the pathology in 7 and recurrent breast cancer in 1 with age range from 21 to 71 years (mean, 50) and preponderance of female patients (n = 5). Defects were located anterior/anterolateral with size ranging from 270 to 1,050 cm2 (mean, 511). Reconstruction was performed using Strattice only in 4 patients, whereas in 4 it was combined with titanium plates. All patients required flap reconstruction (3 pedicled and 5 free). The follow-up ranged from 9 to 52 months (mean, 24.8). Minor complications occurred in 2 patients; however, good functional outcome was achieved in all. Conclusion: Strattice would act as a safe alternative modality for chest wall reconstruction to resist infection in high-risk patients with extensive defects. It should be considered as a valuable tool in the armamentarium of chest wall reconstruction.
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Affiliation(s)
- Haitham H Khalil
- Department of Oncoplasty and Reconstructive Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, West Midlands, United Kingdom
| | - Maninder Kalkat
- Department of Thoracic Surgery, Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, West Midlands, United Kingdom
| | - Marco N Malahias
- Department of Oncoplasty and Reconstructive Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, West Midlands, United Kingdom
| | - Saif Rhobaye
- Department of Oncoplasty and Reconstructive Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, West Midlands, United Kingdom
| | - Tarek Ashour
- Department of Oncoplasty and Reconstructive Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, West Midlands, United Kingdom
| | - Madava G Djearaman
- Department of Radiology, Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, West Midlands, United Kingdom
| | - Babu Naidu
- Department of Thoracic Surgery, Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, West Midlands, United Kingdom
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Betancourt Cuellar SL, Heller L, Palacio DP, Hofstetter WL, Marom EM. Intra- and Extra-Thoracic Muscle Flaps and Chest Wall Reconstruction Following Resection of Thoracic Tumors. Semin Ultrasound CT MR 2017; 38:604-615. [PMID: 29179900 DOI: 10.1053/j.sult.2017.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Improvements in surgical technique over the last decade enable surgeons to perform extensive resection and reconstruction in patients presenting with tumors involving the soft tissue or bony structures of the chest wall. The type of surgical resection and its size, depend on the type of tumor resected and its location. In addition to providing a better esthetic result, the reconstruction restores support and functionality of the thoracic cage. The approach to chest wall repair includes primary closure or reconstruction by using transposition flaps, free flaps, prosthetic material, or a mixture of a flap and prosthetic material.
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Affiliation(s)
- Sonia L Betancourt Cuellar
- Department of Diagnostic Radiology, The University of Texas, MD Anderson Cancer Center, Houston, TX; Address reprint requests to Sonia L. Betancourt Cuellar, MD, Diagnostic Radiology Department, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030.
| | - Lior Heller
- Department of Plastic Surgery, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Diana P Palacio
- Department of Diagnostic Radiology, University of Arizona, Medical Center, Tucson, AZ
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Edith M Marom
- Department of Diagnostic Radiology, The University of Texas, MD Anderson Cancer Center, Houston, TX; Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Ramat-Gan, Israel, affiliated with the Tel Aviv University, Israel
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12
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Multidisciplinary Oncoplastic Approach Reduces Infection in Chest Wall Resection and Reconstruction for Malignant Chest Wall Tumors. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e809. [PMID: 27536488 PMCID: PMC4977137 DOI: 10.1097/gox.0000000000000751] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 04/12/2016] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Management of complex thoracic defects post tumor extipiration is challenging because of the nature of pathology, the radical approach, and the insertion of prosthetic material required for biomechanical stability. Wound complications pose a significant problem that can have detrimental effect on patient outcome. The authors outline an institutional experience of a multidisciplinary thoracic oncoplastic approach to improve outcomes. Methods: Prospectively collected data from 71 consecutive patients treated with chest wall resection and reconstruction were analyzed (2009–2015). The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection were recorded. All patients were managed in a multidisciplinary approach to optimize perioperative surgical planning. Results: Pathology included sarcoma (78%), locally advanced breast cancer (15%), and desmoids (6%), with age ranging from 17 to 82 years (median, 42 years) and preponderance of female patients (n = 44). Chest wall defects were located anterior and anterolateral (77.5%), posterior (8.4%), and apical axillary (10%) with skeletal defect size ranging from 56 to 600 cm2 (mean, 154 cm2). Bony reconstruction was performed using polyprolene mesh, methyl methacrylate prosthesis, and titanium plates. Soft tissue reconstructions depended on size, location, and flap availability and were achieved using regional, distant, and free tissue flaps. The postoperative follow-up ranged from 5 to 70 months (median, 32 months). All flaps survived with good functional and aesthetic outcome, whereas 2 patients experienced surgical site infection (2.8%). Conclusions: Multidisciplinary thoracic oncoplastic maximizes outcome for patients with large resection of chest wall tumors with reduction in surgical site infection and wound complications particularly in association with rigid skeletal chest wall reconstruction.
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Abstract
The main indications for chest wall resection continue to be tumors, infection, and radiation injury. Complications surrounding chest wall resection procedures include respiratory failure, wound complications, and prosthetic complications. The main risk factors for complications are size of defect, age, and concomitant lung resection. Most complications related to either the wound or the prosthesis are late postoperative events. The identification of complications related to chest wall reconstruction requires clinical examination and the use of detailed imaging studies. The management of both prosthetic and wound complications often requires reoperation and removal of the prosthesis combined with soft tissue wound management.
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Affiliation(s)
- Kweku Hazel
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver School of Medicine, 12631 East 17th Avenue, MS C310, Aurora, CO 80045, USA
| | - Michael J Weyant
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver School of Medicine, 12631 East 17th Avenue, MS C310, Aurora, CO 80045, USA.
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Aragón J, Pérez Méndez I. Dynamic 3D printed titanium copy prosthesis: a novel design for large chest wall resection and reconstruction. J Thorac Dis 2016; 8:E385-9. [PMID: 27293863 DOI: 10.21037/jtd.2016.03.94] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Javier Aragón
- Department of Thoracic Surgery, Asturias University Central Hospital, Asturias, Spain
| | - Itzell Pérez Méndez
- Department of Thoracic Surgery, Asturias University Central Hospital, Asturias, Spain
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Wee HE, Akbar FA, Rajapaksha K, Aneez DBA. Anterior chest wall resection and reconstruction for locally advanced breast cancer. Multimed Man Cardiothorac Surg 2015; 2015:mmv025. [PMID: 26362545 DOI: 10.1093/mmcts/mmv025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 08/05/2015] [Indexed: 11/12/2022]
Abstract
With breast cancer awareness, the incidence of large invasive tumours is rare. We present a video of locally advanced breast cancer invading the anterior chest wall requiring en bloc resection that resulted in a large chest wall defect with exposed pleural and pericardial surface. Skeletal reconstruction and provision of adequate soft tissue coverage in order to avoid respiratory failure was challenging. A 58-year-old female presented with a 3-year history of locally invasive breast carcinoma with contiguous spread to sternum, clavicles, sternoclavicular joints and bilateral second to fifth ribs. She underwent total sternectomy, bilateral second to fifth ribs and chest wall resection resulting in a 21 × 18 cm chest wall defect. Reconstruction of her sternum was with methyl-methacrylate cement prosthesis. Ribs were reconstructed with titanium plates. Soft tissue coverage was achieved with left vertical rectus abdominis pedicle flap, right external oblique transposition flap and a right latissimus dorsi free flap. Flap failure necessitated a right vastus lateralis free flap. She was discharged ambulant without respiratory compromise. Resection and reconstruction of large chest wall defects is possible due to new bioprosthetic materials and is possible with acceptable morbidity and mortality.
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Affiliation(s)
- Hide Elfrida Wee
- Department of Thoracic Surgery, Tan Tock Seng Hospital, Singapore
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Kużdżał J, Warmus J, Grochowski Z, Gądek A. Reconstruction of the sternal manubrium. J Thorac Cardiovasc Surg 2014; 147:1986-8. [PMID: 24642560 DOI: 10.1016/j.jtcvs.2014.01.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 01/27/2014] [Accepted: 01/31/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Jarosław Kużdżał
- Department of Thoracic Surgery, Jagiellonian University Collegium Medicum, John Paul II Hospital, Cracow, Poland.
| | - Janusz Warmus
- Department of Thoracic Surgery, Jagiellonian University Collegium Medicum, John Paul II Hospital, Cracow, Poland
| | - Zbigniew Grochowski
- Department of Thoracic Surgery, Jagiellonian University Collegium Medicum, John Paul II Hospital, Cracow, Poland
| | - Artur Gądek
- Department of Orthopaedics, Jagiellonian University Collegium Medicum, Cracow, Poland
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18
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Huang K, Ding X, Lv B, Wei L, Sun J, Xu Z, Qin X, Tang H. Reconstruction of large-size abdominal wall defect using biodegradable poly-p-dioxanone mesh: an experimental canine study. World J Surg Oncol 2014; 12:57. [PMID: 24625138 PMCID: PMC3995574 DOI: 10.1186/1477-7819-12-57] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 02/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reconstruction of large-size abdominal wall defect (AWDs) is a huge challenge faced in current surgical practice. In this study, we aimed to evaluate the effectiveness and safety of biodegradable poly-p-dioxanone (PDO) mesh for reconstructing large-size AWDs in an experimental canine model. METHODS Eighteen experimental canines were randomly and equally divided into three groups, namely, a PDO group, a Marlex group and a control group (n = 6 each). Following the creation of a 6 cm × 5.5 cm AWD, PDO mesh and Marlex mesh were used to reconstruct the defect in the PDO and Marlex groups, respectively. The defect was closed using relaxation sutures alone in the control group. Animals were killed 24 weeks after surgery, and reconstruction outcomes were evaluated using radiography, histology and biomechanical testing. RESULTS All animals except those in the control group survived the experiment. The PDO group showed no wound dehiscence, herniation or infection, whereas the animals in the Marlex group exhibited marked foreign body reactions. The PDO group had less intraabdominal adhesion than the Marlex group. As shown by radiography, histology and biomechanical testing, PDO mesh exhibited complete degradation and favorable biochemical strength at 24 weeks postsurgery. CONCLUSIONS PDO mesh implantation is an effective, safe treatment modality for reconstructing large-size AWDs.
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Affiliation(s)
| | | | | | | | | | | | - Xiong Qin
- Department of Thoracic and Cardiovascular Surgery, Changzheng Hospital, the Second Military Medical University, 415 Fengyang Road, Shanghai 200003, China.
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Xuan Y, Tang H, Wu B, Ding X, Lu Z, Li W, Xu Z. A specific groove design for individualized healing in a canine partial sternal defect model by a polycaprolactone/hydroxyapatite scaffold coated with bone marrow stromal cells. J Biomed Mater Res A 2013; 102:3401-8. [PMID: 24142768 DOI: 10.1002/jbm.a.35012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 10/15/2013] [Accepted: 10/15/2013] [Indexed: 11/08/2022]
Abstract
The reconstruction of sternal defects remains clinically challenging for thoracic surgeons. Here we aimed to explore the individualized reconstruction of partial sternal defects with new biodegradable material in a large animal model. We used the fused deposition modeling (FDM) technique to manufacture polycaprolactone/hydroxyapatite (PCL/HA) tissue scaffolds with individualized grooves to repair the sternal defect. The defects were surgically created in a sternocostal joint of eighteen Beagle dogs. The animals were separated into three groups (n = 6): Blank group, PCL/HA group, and PCL/HA/BMSCs group. Radiographic examination, histological, and histomorphometric analyses were performed to evaluate the result. In the blank group, the defect site couldn't maintain its original integrity due to no bone union. In the PCL/HA group and PCL/HA/BMSCs group, it was observed that the scaffolds retained their shapes without significant degradation at 12 weeks. Both groups could observe new bone-union by radiographic and histological examination. And PCL/HA/BMSCs would be more mineralized tissue area at implant sites (p < 0.05). These results reveal that using the FDM technique to manufacture the PCL/HA scaffolds with specific grooves could repair the sternal defect satisfactorily. Furthermore the scaffolds with BMSCs-seeded could enhance the amount of bone ingrowth and seemed to be more promising.
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Affiliation(s)
- Yiwen Xuan
- Department of Thoracic Surgery, Shanghai Changzheng Hospital Affliated to Second Military Medical University, Shanghai, 200001, China
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Berthet JP, Solovei L, Tiffet O, Gomez-Caro A, Bommart S, Canaud L, Alric P, Marty-Ané CH. Chest-wall reconstruction in case of infection of the operative site: is there any interest in titanium rib osteosynthesis?†. Eur J Cardiothorac Surg 2013; 44:866-74. [DOI: 10.1093/ejcts/ezt084] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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The use of Permacol for the reconstruction of a complex thoraco-abdominal wall defect from a recurrent leiomyosarcoma. EUROPEAN JOURNAL OF PLASTIC SURGERY 2013. [DOI: 10.1007/s00238-013-0814-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Aghajanzadeh M, Alavi A, Aghajanzadeh G, Ebrahimi H, Jahromi SK, Massahnia S. Reconstruction of chest wall using a two-layer prolene mesh and bone cement sandwich. Indian J Surg 2013; 77:39-43. [PMID: 25829710 DOI: 10.1007/s12262-013-0811-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 01/07/2013] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Manouchehr Aghajanzadeh
- Respiratory Diseases and TB Research Center, Guilan University Medical Sciences (GUMS), Rasht, Iran
| | - Ali Alavi
- Respiratory Diseases and TB Research Center, Guilan University Medical Sciences (GUMS), Rasht, Iran
| | - Gilda Aghajanzadeh
- Respiratory Diseases and TB Research Center, Guilan University Medical Sciences (GUMS), Rasht, Iran
| | - Hannan Ebrahimi
- Student Research Center, Guilan University of Medical Sciences (GUMS), Rasht, Iran ; Student Research Committee Office, Guilan University of Medical Sciences, Research Deputy Building, Namjoo Street, Rasht, Iran
| | - Sina Khajeh Jahromi
- Student Research Center, Guilan University of Medical Sciences (GUMS), Rasht, Iran
| | - Sara Massahnia
- Respiratory Diseases and TB Research Center, Guilan University Medical Sciences (GUMS), Rasht, Iran
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23
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Effectiveness of muscle coverage to manage osteomyelitis of very late onset in the irradiated chest wall. Surg Today 2011; 42:306-11. [PMID: 22143358 DOI: 10.1007/s00595-011-0078-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Accepted: 03/23/2011] [Indexed: 10/15/2022]
Abstract
Radiation therapy for breast cancer has improved survival rates; however, a consequence of this is treatment-induced complications in longer-living patients. Decades after chest wall irradiation, very late onset radiation-induced osteomyelitis can develop, caused by osteoradionecrosis. This may lead to the development of small, but very refractory, skin ulcers. Many reports recommend well-vascularized tissue coverage after appropriate debridement for irradiation ulcers; however, when the ulcers are of very late onset, this sometimes causes recurrence of ulceration in non-muscle-covered areas after flap transfer. Thus, for very late onset cases, we propose treatment with an absolute muscle flap to cover both the obviously infected focus and the surrounding irradiated area. A muscle flap consisting of the entire latissimus dorsi, the shape of which is very large in the horizontal direction, satisfies this requirement. Latissimus dorsi muscle coverage for the treatment of very late onset osteomyelitis should be reappraised.
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Eguchi T, Kondo R, Shiina T, Yoshida K. An intrathoracic scapular prolapse with hemorrhagic shock after a thoracotomy. Interact Cardiovasc Thorac Surg 2010; 12:326-7. [PMID: 21051382 DOI: 10.1510/icvts.2010.248690] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein present a case in which an emergency operation was performed for an intrathoracic hemorrhage resulting from a scapular prolapse after a thoracotomy, a rare complication of this procedure. A 59-year-old man had undergone a right upper lobectomy with an extended resection of the posterior chest wall including the second to fourth ribs due to a direct invasion by a lung cancer. On postoperative day 80, we performed an emergency operation as the patient had gone into shock due to an intrathoracic hemorrhage with a right scapular prolapse. The scapula protruded through the enlarged fourth intercostal space. The prolapsed scapula was reduced and the defect in the chest wall was covered with Marlex mesh.
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Affiliation(s)
- Takashi Eguchi
- Department of Thoracic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan.
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Nagayasu T, Yamasaki N, Tagawa T, Tsuchiya T, Miyazaki T, Nanashima A, Obatake M, Yano H. Long-term results of chest wall reconstruction with DualMesh. Interact Cardiovasc Thorac Surg 2010; 11:581-4. [PMID: 20724421 DOI: 10.1510/icvts.2010.242040] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The aim of this study was to evaluate the clinical outcomes of chest wall reconstruction using a new, expanded polytetrafluoroethylene prosthesis, 'DualMesh'. Between December 2005 and March 2010, chest wall reconstruction using 2-mm DualMesh was performed in 11 patients. The indication for resection was primary lung cancer in six patients, malignant mesothelioma in one patient, recurrent lung cancer in one patient, recurrent invasive thymoma in one patient, postirradiated osteomyelitis in one patient, and chondro-hamartoma in one patient. The mean observation period was 23 months, and four cases were observed for more than three years. There were no operative deaths and no wound infections. There were two postoperative complications: prolonged air leakage occurred in a patient with pulmonary emphysema who underwent right lower lobectomy, and slight paradoxical respiration occurred in the patient who underwent resection of the entire sternal body for osteomyelitis. Follow-up chest computed tomography was performed routinely. No dehiscence occurred in any cases. Chest wall reconstruction using DualMesh demonstrated acceptable durability and biocompatibility, even after long-term follow-up. DualMesh has the potential to become an ideal prosthesis for the bony chest wall as an alternative to conventional polytetrafluoroethylene or polypropylene grafts.
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Affiliation(s)
- Takeshi Nagayasu
- Division of Surgical Oncology, Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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Hameed A, Akhtar S, Naqvi A, Pervaiz Z. Reconstruction of complex chest wall defects by using polypropylene mesh and a pedicled latissimus dorsi flap: a 6-year experience. J Plast Reconstr Aesthet Surg 2008; 61:628-35. [PMID: 17656168 DOI: 10.1016/j.bjps.2007.04.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Revised: 12/24/2006] [Accepted: 04/23/2007] [Indexed: 01/04/2023]
Abstract
BACKGROUND Reconstruction of full thickness defects of the chest wall is controversial and presents a complicated treatment scenario for thoracic and reconstructive plastic surgeons. It requires close cooperation between the cardiothoracic and reconstructive surgeons to achieve an optimal outcome and reduce the incidence of complications. OBJECTIVE The purpose of this study is to evaluate our results in patients who underwent prosthetic bony reconstruction with polypropylene mesh and pedicle latissimus dorsi flap after chest wall resection. The principles of chest wall reconstruction include: wide excision of primary chest wall tumour with macroscopically healthy margins, wound excision and debridement of necrotic devitalised and irradiated tissues, control of infection and local wound care. STUDY DESIGN This is a descriptive study. It includes 20 patients who underwent chest wall resection due to various causes and followed by reconstruction with polypropylene mesh along with pedicled latissimus dorsi flap. PLACE AND DURATION OF STUDY The study was conducted at the Department of Plastic and Reconstructive Surgery, Federal Postgraduate Medical Institute, Sheikh Zayed Hospital Lahore, over a period of 6 years from August 1999 to August 2005. PATIENTS AND METHODS This study included 20 patients who underwent chest wall reconstruction using polypropylene mesh and pedicled latissimus dorsi flap from August 1999 to August 2005. Patient demographic data including age, sex, pathological diagnosis, extent and type of resection, size of defect, and outcome were recorded. All patients were followed up in our outpatients department for 1 year. RESULTS There was a total of 20 patients, 16 males and four females. The average age was 54 years (range 44-64 years). The indications for resection were primary chest wall tumours in 13 (65%) patients, local recurrence from breast tumours in one (5%) patient, post median sternotomy in three (15%) patients and radionecrosis in three (15%) patients. Ribs along with a part of sternum were resected in 14 (70%) patients, ribs along with clavicle in two (10%) patients and ribs only in four (20%) patients. The average area of chest wall defect after resection was 16.5 x 13 cm. In all patients, skeletal defect was reconstructed with polypropylene mesh. Soft tissue coverage was provided with a pedicled latissimus dorsi flap in all cases. Three patients with a chest wall tumour developed a recurrence within 6 months. Among these three, one patient died within 8 months of follow up due to myocardial infarction. CONCLUSION Chest wall resection and reconstruction with synthetic polypropylene mesh and local muscle flaps can be performed as a safe, effective one-stage surgical procedure for a variety of major chest wall defects.
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Affiliation(s)
- Abdul Hameed
- Department of Plastic and Reconstructive Surgery, Federal Postgraduate Medical Institute, Sheikh Zayed Hospital, Lahore, Pakistan.
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27
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Kilic D, Gungor A, Kavukcu S, Okten I, Ozdemir N, Akal M, Yavuzer S, Akay H. Comparison of mersilene mesh-methyl metacrylate sandwich and polytetrafluoroethylene grafts for chest wall reconstruction. J INVEST SURG 2006; 19:353-60. [PMID: 17101604 DOI: 10.1080/08941930600985694] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We report the outcomes of patients who underwent reconstruction with Mersilene mesh-methyl methacrylate (MM-MM) sandwich and polytetrafluoroethylene (PTFE) grafts after a large chest wall resection. Between June 1990 and September 2001, 59 consecutive patients (37 men, 22 women; mean age, 48.1 +/- 11.8 years; range 22-74 years) underwent large chest wall resection (greater than 5 cm diameter) and reconstruction with prosthetic material in our department. Twenty-one patients (33%) underwent reconstruction with a PTFE graft (group 2) between 1990 and 1994, and 38 patients (67%) underwent reconstruction with an MM-MM sandwich graft (group 1) between 1994 and 2001. Operative morbidity ratios were 5.2% (2/38) in group 1 and 24% (5/21) in group 2 (p = .036). The paradoxical respiration ratio was significantly higher (p = .018) in group 2 (5/21: 24%) than it was in group 1 (1/38: 2.6%). The operative mortality ratio was 4.5% (1/21) in group 2 and 0% in group 1. Mean hospital stay was 10.6 days (range 5-21 days) in group 1 and 13.3 days (range 7-36 days) in group 2 (p = .015). The MM-MM graft is inexpensive and easy to apply, provides better cosmetic options, and offers minimal morbidity. We therefore recommend that the MM-MM sandwich graft be used rather than the PTFE graft for large defects of the anterolateral chest wall and sternum where successful prevention of paradoxical respiration is required.
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Affiliation(s)
- Dalokay Kilic
- Department of Thoracic Surgery, School of Medicine, Baskent University Hospital, Baskent University, Adana, Turkey.
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Haraguchi S, Hioki M, Hisayoshi T, Yamashita K, Koizumi K, Shimizu K. Resection of sternal metastasis from endometrial carcinoma followed by reconstruction with sandwiched marlex and stainless steel mesh: report of a case. Surg Today 2006; 36:184-6. [PMID: 16440169 DOI: 10.1007/s00595-005-3106-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2004] [Accepted: 05/24/2005] [Indexed: 11/29/2022]
Abstract
We report the successful resection of sternal metastasis from endometrial carcinoma, followed by reconstruction of the chest defect, in an 87-year-old woman. We performed subtotal sternectomy and concurrent resection of the ribs and overlying soft tissue. The skeletal defect was then reconstructed with sandwiched Marlex and stainless steel mesh, and soft tissue coverage was accomplished by using a pectoralis major advancement flap. The patient had an uneventful postoperative course with no sign of recurrence during 5 years of follow-up. Thus, reconstruction with Marlex and stainless steel mesh could be an effective technique for preventing paradoxical movement of the thorax and protecting the intrathoracic organs.
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Affiliation(s)
- Shuji Haraguchi
- Department of Surgery, Nippon Medical School Second Hospital, 1-396 Kosugi-cho, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
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29
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Haraguchi S, Hioki M, Hisayoshi T, Yamashita K, Yamashita Y, Kawamura J, Hirata T, Yamagishi S, Koizumi K, Shimizu K. Resection of sternal tumors and reconstruction of the thorax: a review of 15 patients. Surg Today 2006; 36:225-9. [PMID: 16493530 DOI: 10.1007/s00595-005-3134-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2004] [Accepted: 07/12/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE We report our experience of resecting sternal tumors, followed by reconstruction of the skeletal and soft-tissue defects, and discuss the usefulness of sandwiched Marlex and stainless-steel mesh. METHODS Fifteen patients underwent resection of a sternal tumor and chest wall reconstruction with autologous bone grafts, sandwiched Marlex and stainless-steel mesh or a titanium plate, and musculocutaneous flaps. The sternal tumors were from locally recurrent breast carcinoma in ten patients, metastasis from other organs in three, and primary chondrosarcoma in two. RESULTS All patients were extubated without paradoxical respiration just after surgery. There was no operative mortality. A wound infection developed in the acute phase after a sandwiched Marlex and stainless-steel mesh reconstruction in one patient. A second repair with Marlex and stainless-steel mesh was required in two patients; for flail chest after an autologous bone graft in one; and following re-recurrence of breast carcinoma in another patient who had undergone a musculocutaneous flap repair. No signs of breakdown, dislodgment, severe depression, or deformity were seen in any of the six patients who underwent reconstruction with Marlex and stainless-steel mesh during a median follow-up period of 56 months. CONCLUSIONS Wide resection of sternal tumors provides good local control. Reconstruction with Marlex and stainless-steel mesh seems to be the most effective technique for repairing a wide anterior chest wall defect.
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Affiliation(s)
- Shuji Haraguchi
- Department of Surgery, Nippon Medical School Second Hospital, 1-396 Kosugi-cho, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
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Moscona RA, Fodor L, Ben-Nun A, Best LA. Never say no to a damaged muscle: the applications of previously damaged pectoralis major and latissimus dorsi muscles for chest wall reconstruction. Ann Plast Surg 2006; 56:156-9. [PMID: 16432323 DOI: 10.1097/01.sap.0000194552.35606.c4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The nondamaged latissimus dorsi and pectoralis major muscles are widely reported in the literature as being the most frequently used for chest wall reconstruction. In this study, we report a series of 9 patients with full-thickness chest wall defects who underwent reconstruction with previously damaged latissimus dorsi or pectoralis major muscles. Nine patients underwent chest wall reconstruction over a period of 3 years using previously damaged latissimus dorsi or pectoralis major muscles. The thoracic defect was posttraumatic in 3 patients and post-tumor resection in 6 patients. Three patients had previous radiation therapy. In 8 cases, the full-thickness chest wall defects were completely closed. The only failure encountered was in one patient who had a long lasting fistula. The proximal based island flap that was inserted into the tract showed good vascular supply and viability; however, it did not solve the clinical problem. Keeping in mind the basic rule of medicine ("Primum Non Nocere") and a thorough knowledge of the surgical anatomy of these muscles are essential for the successful application of these previously damaged muscles for chest wall reconstruction.
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Affiliation(s)
- Rony A Moscona
- Department of Plastic and Reconstructive Surgery, Rambam Medical Center, Haifa, Israel.
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31
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Weyant MJ, Bains MS, Venkatraman E, Downey RJ, Park BJ, Flores RM, Rizk N, Rusch VW. Results of Chest Wall Resection and Reconstruction With and Without Rigid Prosthesis. Ann Thorac Surg 2006; 81:279-85. [PMID: 16368380 DOI: 10.1016/j.athoracsur.2005.07.001] [Citation(s) in RCA: 203] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2005] [Revised: 06/29/2005] [Accepted: 06/05/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Chest wall resections are associated with significant morbidity, with respiratory failure in as many as 27% of patients. We hypothesized that our selective use of a rigid prosthesis for reconstruction reduces respiratory complications. METHODS The records of all patients undergoing chest wall resection and reconstruction were reviewed. Patient demographics, use of preoperative therapy, the location and size of the chest wall defect, performance of lung resection if any, the type of prosthesis, and postoperative complications were recorded. Predictor of complications were identified by chi2 and logistic regression analyses. RESULTS From January 1, 1995, to July 1, 2003, 262 patients (median age, 60 years) underwent chest wall resection for tumor in 251 (96%), radiation necrosis in 7 (2.7%); and infection in 4 patients (1.3%). The median defect size was 80 cm2 (range, 2.7 to 1,200 cm2) and the median number of ribs resected was 3 (range, 1 to 8). Major lung resection was performed in 85 patients (34%). Prosthetic reconstruction was rigid (polypropylene mesh/methylmethacrylate composite) in 112 (42.7%), nonrigid (polytetrafluoroethylene or polypropylene mesh) in 97 (37%), and none in 53 patients. Postoperatively, 10 patients died (3.8%), 4 of whom had pneumonectomy plus chest wall resection. Respiratory failure occurred in 8 patients (3.1%). By multivariate analysis, the size of the chest wall defect was the most significant predictor of complications. CONCLUSIONS Our incidence of respiratory failure is lower than previously reported and may relate to our use of rigid repair for defects likely to cause a flail segment. Pneumonectomy plus chest wall resection should be performed only in highly selected patients.
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Affiliation(s)
- Michael J Weyant
- Department of Surgery, Thoracic Service, Memorial Sloan Kettering Cancer Center, New York, New York 10021, USA
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Fujiwara M, Nakamura Y, Sano A, Nakayama E, Nagasawa M, Shindo T. Delayed vertical rectus abdominis myocutaneous flap for anterior chest wall reconstruction. Aesthetic Plast Surg 2006; 30:120-4. [PMID: 16402161 DOI: 10.1007/s00266-005-0145-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Not only is a radiation ulcer nonviable itself, but the surrounding irradiated tissue also shows poor healing. Therefore, healing in an irradiated field cannot be expected if a flap used for reconstruction fails even partially. For repair of radiation ulcers, a flap with a stable blood supply is required. A superiorly based vertical rectus abdominis myocutaneous (VRAM) flap is commonly used for chest wall reconstruction. Because the VRAM flap is nourished only by the superior epigastric vessels, the blood supply to the distal part of the flap often is precarious. CASE REPORT A case is reported in which a delayed VRAM flap was used successfully to treat a radiation ulcer on the anterior chest wall. RESULTS Consecutive angiograms showed that the delay procedure augmented the blood supply to the VRAM flap. The flap showed complete take without any postoperative complications. CONCLUSIONS A delay procedure may make the VRAM flap more reliable for anterior chest wall reconstruction. This flap may be a valuable option for reconstruction of intractable ulcers such as radiation ulcers, and may be applicable for breast reconstruction after radiation therapy.
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Affiliation(s)
- Masao Fujiwara
- Department of Plastic and Reconstructive Surgery, Tenri Hospital, 200, Mishima, Tenri, Nara, 632-8552, Japan.
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Ezzoubi M, Benbrahim A, Ettalbi S, Elmonjid S, Boukind EH. Reconstruction de la paroi thoracique antérieure par lambeau fibulaire libre et latissimus dorsi. ANN CHIR PLAST ESTH 2005; 50:92-5. [PMID: 15695017 DOI: 10.1016/j.anplas.2004.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2004] [Accepted: 10/21/2004] [Indexed: 10/26/2022]
Abstract
In order to preserve the respiratory function of the thorax the reconstruction must be immediate and must answer currently to principles of repair very codified. We reported a case of thoracic reconstruction by an association of flaps, free fibular and pedicled of the latismus dorsi, after a resection of a shrewd tumour of the thoracic partition. This reconstruction has permitted the contribution of a musculocutaneous cover of good quality and the contribution of a skeletal support satisfying at a time. The association of flaps can be considered like one of the solutions for the reconstruction of the big losses of substance of full thickness of the thoracic partition requiring a restoration of the thoracic skeleton.
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Affiliation(s)
- M Ezzoubi
- Association des médecins enseignants, service des brûlés et de chirurgie plastique, CHU Ibn-Rochd, Casablanca, Maroc.
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Abstract
Clinical experience supports a role for palliative procedures in patients with locally advanced or recurrent breast cancer, yet numerous challenges are entailed in both the extirpation and reconstruction of the chest wall in these cases. The defects may be profound and complicated by prior surgery, radiation therapy, or patient-related variables. The reconstructive techniques employed must neither encumber nor delay any necessary postoperative therapy and must not result in unacceptable morbidity or compromise quality of life. Our surgical approach to these cases incorporates a team of specialists from a broad spectrum of medical and surgical disciplines. Each operative plan is tailored to the specific needs and requirements of the individual patient.
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Affiliation(s)
- Elisabeth K Beahm
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, TX
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Watanabe A, Watanabe T, Obama T, Ohsawa H, Mawatari T, Ichimiya Y, Takahashi N, Abe T. New material for reconstruction of the anterior chest wall, including the sternum. J Thorac Cardiovasc Surg 2003; 126:1212-4. [PMID: 14566281 DOI: 10.1016/s0022-5223(03)00933-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Atsushi Watanabe
- Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
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Vascularized Iliac Bone Flap Used for Sternum Reconstruction after Resection of Chondrosarcoma. Plast Reconstr Surg 2002. [DOI: 10.1097/00006534-200209150-00014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hosalkar H, Thatte MR, Yagnik MG. Chest-wall reconstruction in spondylocostal dysostosis: rare use of a latissimus dorsi flap. Plast Reconstr Surg 2002; 110:537-40. [PMID: 12142673 DOI: 10.1097/00006534-200208000-00026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Harish Hosalkar
- Division of Plastic Surgery and Pediatric Orthopaedics, the Bai Jerbai Wadia Hospital for Children, Mumbai, India.
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Williamson BE, Stanton CA, Levine EA. Chest Wall Metastasis from Recurrent Meningioma. Am Surg 2001. [DOI: 10.1177/000313480106701011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Meningiomas are generally considered benign lesions. A minority, however, are capable of metastasis. The ones most likely to do so are commonly recurrent or frankly malignant in nature. The optimal management of such metastases is unclear. This is the first reported case of meningioma presenting as an isolated metastasis to the chest wall. This case involves a 64-year-old woman without significant medical or family history who underwent resection of a meningioma of the right cerebral hemisphere. She was treated 10 years later for recurrence by stereotactic radiosurgery. Three years after that, the patient's family noticed a mass on the left chest wall. A CT scan revealed destruction of the ninth rib laterally and subpleural extension. The patient subsequently underwent resection of full-thickness chest wall for a presumed soft-tissue sarcoma. Further pathologic evaluation including electron microscopy and immunohistochemistry revealed metastatic meningioma. The patient received adjuvant radiation to the chest wall and is currently free of disease at the chest wall one year after surgery. This case illustrates the difficulty in establishing an accurate diagnosis of metastatic meningioma. Consequently in selected patients with a history of the disease the diagnosis of metastatic meningioma must at least be considered. Resection of an isolated metastasis in this setting appears warranted.
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Affiliation(s)
| | - Constance A. Stanton
- Departments of Pathology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina 27157
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Nahabedian MY, Riley LH, Greene PS, Yang SC, Vander Kolk CA. Sternal stabilization using allograft fibula following cardiac transplantation. Plast Reconstr Surg 2001; 108:1284-8. [PMID: 11604633 DOI: 10.1097/00006534-200110000-00029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M Y Nahabedian
- Division of Plastic and Reconstructive Surgery, the Department of Orthopaedic Surgery, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.
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40
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Lardinois D, Müller M, Furrer M, Banic A, Gugger M, Krueger T, Ris HB. Functional assessment of chest wall integrity after methylmethacrylate reconstruction. Ann Thorac Surg 2000; 69:919-23. [PMID: 10750784 DOI: 10.1016/s0003-4975(99)01422-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND All patients with extensive resection of the anterolateral chest wall and the sternum followed by reconstruction with methylmethacrylate substitutes were assessed prospectively 6 months after the operation to delineate chest wall integrity with pulmonary function and cine-magnetic resonance imaging. METHODS Twenty-six patients underwent chest wall reconstruction by use of methylmethacrylate between 1994 and 1998 due to primary tumors in 35%, metastases in 27%, T3 lung cancer in 19%, and debridement for radionecrosis and osteomyelitis in 19% of patients. Three to eight ribs were resected and additional sternum resection was performed in 39% of patients. RESULTS There was no 30-day mortality. All patients were extubated after the operation without need for reintubation. Prosthesis dislocation occurred in 1 patient and infection in 2 patients during follow-up. Nineteen patients (73%) suffered no restrictions of daily activities. Clinical examination revealed normal shoulder girdle function in 77% of patients. There was no significant difference between preoperative and postoperative FEV1 (forced expiratory volume in 1 second) measurements in patients with lobectomy or wedge resections. Cinemagnetic resonance imaging revealed concordant chest wall movements during respiration in 92% of patients without paradoxical movements or implant dislocations being observed. CONCLUSIONS Large defects of the anterolateral chest wall and sternum can be reconstructed efficiently with methylmethacrylate substitutes with minimal morbidity and excellent cosmetic and functional outcome.
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Affiliation(s)
- D Lardinois
- Department of Thoracic and Cardiovascular Surgery, University Hospital, University of Bern, Switzerland
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Downey RJ, Rusch V, Hsu FI, Leon L, Venkatraman E, Linehan D, Bains M, van Zee K, Korst R, Ginsberg R. Chest wall resection for locally recurrent breast cancer: is it worthwhile? J Thorac Cardiovasc Surg 2000; 119:420-8. [PMID: 10694599 DOI: 10.1016/s0022-5223(00)70119-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The effectiveness of chest wall resection for locally recurrent breast cancer as cancer treatment remains poorly defined, possibly because of the general impression that locally recurrent disease is a harbinger of rapidly progressive metastatic disease and that extensive surgical treatment in these patients is inappropriate. Reports to date have focused on technical feasibility, not long-term outcome. METHODS We reviewed our experience with 38 women who underwent chest wall resection for locally recurrent breast cancer between October 1987 and May 1997. Overall survival was calculated by the Kaplan-Meier method and the significance of prognostic variables evaluated by log-rank and Cox regression analyses. RESULTS The operative mortality rate was 0%. Overall survival at 1, 3, and 5 years after chest wall resection was 74%, 41%, and 18%, respectively, and the proportion of patients free of local recurrence at 1, 3, and 5 years was 59%, 42%, and 13%, respectively. Regional nodal disease and size of largest tumor nodule (>4 cm) were significant predictors of local re-recurrence (P <.01, P =.04); lymph node metastasis was the only predictor of long-term survival (P <.01). Patients with and without synchronous sites of metastatic disease had near-identical 3-year survivals. CONCLUSIONS Chest wall resection for locally recurrent breast cancer has a low mortality. However, a significant number of patients have the development of local re-recurrence or metastases, and 5-year survival is limited. It is unlikely that complete resection of all locally recurrent disease improves survival. Future studies should focus on the quality of palliation achieved.
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Affiliation(s)
- R J Downey
- Divisions of Thoracic Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Tunçözgür B, Elbeyli L, Güngör A, Işik F, Akay H. Chest wall reconstruction with autologas rib grafts in dogs and report of a clinic case. Eur J Cardiothorac Surg 1999; 16:292-5. [PMID: 10554846 DOI: 10.1016/s1010-7940(99)00237-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Nowadays, in chest wall reconstruction prosthetic materials are generally used. However, the rejections of prosthetic materials and infections frequently occur in chest wall reconstruction, especially after radiotherapy or resection that is performed due to infections. METHODS We used 10 mongrel dogs and performed resections of 8 cm diameter on their chest walls. In the reconstruction of these defects, in five of the subjects, we used two free rib grafts with periosteum to be resected from the contralateral side and in other five subjects, we used free rib grafts without periosteum. After this experimental study, sternal resection was performed in a 24-year-old man because of sternal osteomyelitis. First to obtain rib grafts with periosteum, partial resection was performed to 5th, 7th, and 9th ribs of the lateral left side. After, total sternal resection, end to end anastomosis was performed to the 2nd, 3rd, 4th and 5th anterior ends of the ribs. RESULTS Autogeneous rib grafts were found to be enough to provide chest wall stabilization. CONCLUSIONS The contralateral autogeneous free rib grafts can successfully be used in reconstruction of wide chest wall defects. This method is found to be effective and sufficient to prevent infection, rejection and to provide stabilization.
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Affiliation(s)
- B Tunçözgür
- Department of Thoracic and Cardiovascular Surgery, Gaziantep University School of Medicine, Kolejtepe, Turkey.
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Deschamps C, Tirnaksiz BM, Darbandi R, Trastek VF, Allen MS, Miller DL, Arnold PG, Pairolero PC. Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 1999; 117:588-91; discussion 591-2. [PMID: 10047664 DOI: 10.1016/s0022-5223(99)70339-9] [Citation(s) in RCA: 166] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this report is to evaluate our results in patients who underwent prosthetic bony reconstruction after chest wall resection. METHODS We retrospectively reviewed all patients who underwent chest wall resection and reconstruction with prosthetic material at the Mayo Clinic. RESULTS From January 1, 1977, to December 31, 1992, 197 patients (109 male patients and 88 female patients) underwent chest wall resection and reconstruction with prosthetic material. Median age was 59 years (range, 11-86 years). The indication for resection was recurrent chest wall malignancy in 65 patients (33.0%), primary chest wall malignancy in 62 patients (31.5%), contiguous lung or breast carcinoma in 58 patients (29.4%), and other reasons in 12 patients (6.1%). Three patients (1.5%) each had an open draining wound. This review covers 2 time periods. Sixty-four patients (32.5%) underwent reconstruction with polypropylene mesh during the period from 1977 to 1986. One hundred thirty-three patients (67.5%) underwent reconstruction with polytetrafluoroethylene from 1984 to 1992. Soft tissue coverage was achieved with transposed muscle in 116 patients (58.9%), local tissue in 81 patients (41.1%), and omentum in 3 patients (1.5%). There were 8 deaths (operative mortality rate, 4.1%). Ninety-one patients (46.2%) experienced complications. Seromas occurred in 14 patients (7.1%). Wound infections occurred in 9 patients (4.6%; 5 patients with polypropylene mesh and 4 patients with polytetrafluoroethylene). The prosthesis was removed in all 5 patients with polypropylene mesh and in none of the patients with polytetrafluoroethylene. Follow-up was complete in 179 operative survivors (94.7%) and ranged from 1 to 204 months (median, 26 months). A well-healed asymptomatic wound was present in 127 patients (70.9%). CONCLUSIONS Chest wall resection and reconstruction with prosthetic material will yield satisfactory results in most patients. Little difference exists between polypropylene mesh and polytetrafluoroethylene.
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Affiliation(s)
- C Deschamps
- Section of General Thoracic Surgery and Division of Plastic and Reconstructive Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
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Macedo-Neto AV, Santos LV, Menezes SL, Paiva DS, Rocco PR, Zin WA. Respiratory mechanics after prosthetic reconstruction of the chest wall in normal rats. Chest 1998; 113:1667-72. [PMID: 9631809 DOI: 10.1378/chest.113.6.1667] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Prosthetic reconstruction of the chest wall may yield several respiratory changes. Nevertheless, to our knowledge, no comprehensive analysis of respiratory mechanics under this condition has been hitherto performed. METHODS Respiratory mechanics were evaluated in two groups of rats. In one group (n=8), a polytetrafluoroethylene (PTFE) patch was used; in another group (n=8), a polypropylene mesh (Marlex) associated with methylmethacrylate (PPMM) was employed. All animals were sedated, anesthetized, paralyzed, and mechanically ventilated before and after the prosthetic reconstruction of the chest wall. After airway occlusion at end inspiration, respiratory system, pulmonary, and chest wall resistive pressures (deltaP1rs, deltaP1L, and deltaP1cw, respectively) and viscoelastic/inhomogeneous pressures (deltaP2rs, deltaP2L, and deltaP2cw, respectively) were determined. Respiratory system, lung, and chest wall static (Est(rs), EstL, and Est(cw), respectively), and dynamic elastances (Edyn(rs), EdynL, and Edyn(cw), respectively), and the corresponding delta elastances (deltaE, calculated as Edyn-Est) were also obtained. RESULTS In both groups, significant increases in deltaP2rs, deltaP2cw, deltaErs, deltaEcw, Est(rs), EstL, and Est(cw) were observed after chest wall reconstruction. However, deltaP2rs, deltaP2cw, deltaErs, deltaEcw, Est(rs), and EstL were significantly higher in the PPMM group than in the PTFE group. CONCLUSIONS Prosthetic reconstruction of the chest wall yields not only elastic changes, but also there is also an important increase of pressure dissipated against viscoelastic/inhomogeneous segments of the chest wall. Furthermore, taking into account respiratory mechanics, the PTFE patch might be preferred to the PPMM patch.
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Affiliation(s)
- A V Macedo-Neto
- Laboratory of Respiration Physiology, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, RJ, Brazil
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Katoh N, Hatano Y, Sasamoto S, Shimatani S, Okuyama N, Takagi K, Yamazaki S, Ohsaki M, Sawaizumi M, Maruyama Y. [Resection and reconstruction of sternum]. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 1998; 46:338-43. [PMID: 9619032 DOI: 10.1007/bf03217752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In case of sternal resection, it is necessary to preserve bone material indispensable for the stability of the anterior chest wall and air tightness of the thoracic cavity, and the support of the chest wall integrity must be restored by some means. Various techniques have been applied to the reconstruction of the chest wall following resection. During the last 10 years, we have performed reconstructive operation for 6 cases of the chest wall following resection of the sternum in recurrent cases of breast cancer or invaded case of primary breast cancer. In these patients, the chest wall was reconstructed using a rib-latissimus dorsi osteomyocutaneolus flap or a latissimus dorsi myocutaneous flap. The sternum was totally resected in 3 cases, and in all 3 cases, reconstructed using a rib-latissimus dorsi osteomyocutaneous flap. Although postoperative pulmonary function decreased, all cases could be relieved from endotracheal intubation within 17 hours after operation, and had no problems in activities of daily living or occurrence of chest flailing or paradoxical movement of the chest. An artificial material (expanded polytetrafluoroethlene patch) was used in only one patient for the reconstruction of the osseous thorax, but this case developed infection during postoperative chemotherapy. After this experience, we used only biological materials for the reconstruction of the chest wall and postoperatively performed radiotherapy and/or chemotherapy on all cases. We have observed no flap infection or detachment since then. One characteristic of using the latissimus dorsi myocutaneous flap is that it is easily elevated and rarely causes serious postoperative esthetic or functional problems. The flap is also easily utilized to reinforce the osseous thorax because ribs immediately below the latissimus dorsi muscle are readily mobilized as a pedicle graft. Reconstruction of the chest wall following resection of the sternum, described in this report, allowed us to perform radiotherapy and/or chemotherapy without serious postoperative complications on the cases relapsing after treatment of breast cancer. The 2-year survival rate is 50% and one of these cases survived up to 10 years after resection of the sternum. Thus we prefer to perform resection of the sternum for sternal recurrence of breast cancer if there are no metastatic lesions in other organs.
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Affiliation(s)
- N Katoh
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Toho University, Tokyo, Japan
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Affiliation(s)
- P L Faries
- Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, N.Y. 10467, USA
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48
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Zer M, Freud E, Grozovski S. Oesophageal plastic repair for symptomatic ballooning following circular oesophageal myotomy and correction of oesophageal atresia. Thorax 1997; 52:487-8. [PMID: 9176545 PMCID: PMC1758553 DOI: 10.1136/thx.52.5.487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Two patients with refractory anastomotic stenosis and symptomatic ballooning of the upper oesophageal pouch following repair of long gap oesophageal atresia are described. In both cases a circular myotomy had been used to elongate the proximal oesophageal segment at the time of primary repair. Both patients were successfully treated by Y-V plasty of the oesophageal stenosis and tailoring of the dilated segment.
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Affiliation(s)
- M Zer
- Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel
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49
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Abstract
The case history is presented of a patient with neurofibromatosis with a chest wall defect present from birth. Abnormal rib development had resulted in a flail segment with painful paradoxical movement and unsightly costal cartilage protrusion. Chest wall reconstruction using Marlex mesh resulted in an excellent cosmetic and functional repair.
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Affiliation(s)
- A G Heriot
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
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50
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González Muñoz JI, Córdoba Peláez M, Tebar Boti E, Téllez Cantero JC, Castedo Mejuto E, Varela de Ugarte A. [Thoracic reconstruction with polytetrafluoroethylene prosthesis]. Arch Bronconeumol 1997; 33:27-30. [PMID: 9072129 DOI: 10.1016/s0300-2896(15)30674-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Thoracic wall resections are performed to treat a wide variety of conditions. Reconstruction techniques have varied considerably since the introduction of synthetic prosthesis, the most recent of which are made of polytetrafluoroethylene (PTFE, or Gore-Tex). We describe our department's experience with PTFE prosthesis. PTFE was used in 21 patients treated for various diseases. Thirteen reconstructions were of the thoracic wall, 4 were of the diaphragm and 4 of the pericardium. Three of the 13 thoracic wall reconstructions involved bilateral myoplasty of the pectoralis major, 2 involved omentoplasty and 1 required use of a wide musculocutaneous flap. Complications included pneumonia in 2 cases and 1 seroma with chronic cutaneous fistula that required removal of the prosthesis after 9 months. Two patients died, 1 after 19 days and the other after 9 months, both as a result of causes unrelated to reconstruction. Follow-up of these patients ranged from 3 to 54 months. We recommend the prosthetic use of PTFE for thoracic wall reconstruction, along with plasty or musculocutaneous flaps when necessary.
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Affiliation(s)
- J I González Muñoz
- Servicio de Cirugía Torácica y Cardiovascular, Clínica Puerta de Hierro, Madrid
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