Chest wall reconstruction: impact of Gore-Tex(®) dual-mesh prosthesis on respiratory function

Expanded polytetrafluoroethylene mesh in chest-wall reconstruction: A 27-year experience

OBJECTIVE

The study objective was to evaluate the success of expanded polytetrafluoroethylene mesh in chest-wall reconstruction.

METHODS

We retrospectively reviewed patients who underwent expanded polytetrafluoroethylene (Gore-Tex) chest-wall reconstruction. The main outcome was a mesh-related event, defined as a mesh-related reoperation (eg, mesh infection requiring debridement with/without explant, tumor recurrence with explant) or structural dehiscence/mesh loosening with/without a hernia. Demographics and surgical outcomes were reported.

RESULTS

A total of 246 reconstructions met inclusion (1994-2021). Fifty-five reconstructions (22.4%) had mesh-related events within a median of 1.08 years (interquartile range, 0.08-4.53) postoperatively; those without had a stable chest for a median of 3.9 years (interquartile range, 1.59-8.23, P < .001). Forty-one meshes (16.6%) became infected, requiring reoperation. Eighty-eight percent (36/41) were completely explanted; 8.3% (3/36) required additional mesh placement. Predictors of mesh-related events were prior chest-wall radiation (odds ratio, 9.73, CI, 3.47-30.10, P < .001), higher body mass index (odds ratio, 1.08, CI, 1.01-1.16, P = .019), and larger defects (odds ratio, 1.48, CI, 1.02-2.17, P = .042). The risk of mesh-related events with obesity was higher with prior chest-wall radiation.

CONCLUSIONS

Most patients (78%) with an expanded polytetrafluoroethylene mesh had a stable reconstruction after a median of 4 years. Obesity, larger defects, and prior chest-wall radiation were associated with a higher risk of a mesh-related event mostly due to mesh infections. Seventeen percent of reconstructions had reoperation for mesh infection; 88% were completely explanted. Only 8% required replacement mesh, suggesting that experienced surgeons can safely manage them without replacement. Future studies should compare various meshes for high-risk patients to help guide the optimal mesh selection.

Total Humeral Endoprosthetic Reconstruction: A Systematic Review

BACKGROUND

Total humeral endoprosthetic reconstruction (THER) is a rare reconstruction option for limb salvage surgery for large humeral neoplasms or bone destruction.

MATERIALS AND METHODS

Because of the limited data and need for this procedure, we reviewed the literature surrounding THER and assessed functionality, complications, and revisions using the PubMed, Embase, Ovid, and Scopus databases.

RESULTS

Among 29 articles and 175 patients, the most common indication was neoplasm (n=25, 86%), mean follow-up was 61.98 months (SD=55.25 months), and mean Musculoskeletal Tumor Society score was 73.64% (SD=10.69%). Reported complications included 26 (23%) revisions in 7 studies, 35 (36%) cases of shoulder instability in 7 studies, and 13 (13.54%) cases of deep infection in 4 studies.

CONCLUSION

THER should be considered with a thorough knowledge of outcomes and potential complications to guide patient and clinician expectations. [Orthopedics. 2024;47(3):e106-e113.].

Diaphragm reconstruction by GORE DUALMESH in patients undergoing resection for thoracic malignancies

Background

We used GORE DUALMESH for the reconstruction of diaphragms in patients with thoracic malignancies. Here, we report the results.

Methods

Between July 2015 and August 2017, diaphragm reconstruction using 2-mm GORE DUALMESH was performed in 7 patients undergoing surgical resection for thoracic malignancies. After resection of the diaphragm, the mesh was trimmed to the size of defect and placed with the smooth surface facing the chest cavity and the rough surface facing the abdomen. It was fixed with interrupted sutures consisting of synthetic monofilament nonabsorbable 1–0 to 2 threads.

Results

Indications for resection were malignant pleural mesothelioma and primary lung cancer in 5 and 2 patients, respectively. Patients with malignant pleural mesothelioma underwent pleurectomy with decortication; patients with primary lung cancer underwent lung lobectomy. Right and left diaphragm reconstruction was performed for 4 and 3 patients, respectively. Neither complications related to diaphragm reconstruction nor displacement of mesh occurred during a follow-up period ranging from 11 days to 37 months.

Conclusions

GORE DUALMESH is a good synthetic material for diaphragm reconstruction, because its smooth surface prevents adhesions to the lung and its rough surface allows adherence to abdominal tissue.

Chest wall resection for non-small cell lung cancer: A case-matched study of postoperative pulmonary function and quality of life

BACKGROUND

To assess the pulmonary function and quality of life (QOL) after chest wall resection for non-small cell lung cancer.

MATERIAL AND METHODS

One hundred and thirty-five patients (cases) who underwent pulmonary resection with chest wall removal were identified from January 1997 to December 2015. Propensity score matching (1:3) was applied to balance known confounders for pulmonary function and QOL between the cases and the control group who underwent pulmonary resection without chest wall invasion. Matched analyses were performed to compare perioperative mortality and morbidity, postoperative pulmonary function, overall QOL, and specific symptoms.

RESULTS

Perioperative mortality and morbidity did not differ significantly between cases and controls, but the hospital stay was longer in cases than in controls (mean, 12.8 vs 8.9days; p<0.001), The decline of postoperative pulmonary forced vital capacity (FVC) and the percentage of predicted FVC (FVC%) was more obvious in cases than in controls at 6 months and 2 years after surgery, but there was no obvious decline in the forced expiratory volume in one second (FEV1), the percentage of predicted FEV1 (FEV1%), the diffusion capacity of the lung for carbon monoxide (DLCO) and the percentage of predicted DLCO (DLCO%) in cases compared with controls. No significant difference was observed between the two groups in scores for overall QOL, pain, fatigue, cough, dyspnea, appetite, hemoptysis, lung cancer symptoms, and normal activities.

CONCLUSIONS

When chest wall resection is inevitable, it does not worse the QOL and pulmonary function of patients who underwent pulmonary resection with chest wall removal obviously compared with patients underwent pulmonary resection without chest wall invasion.

Surgical management of a giant sternal chondromyxoid fibroma: a case report

Background

A primary chondromyxoid fibroma (CMF) arising from sternum is quite uncommon tumor in thoracic surgery. Removal of giant sternal tumors requires extensive resection of the anterior chest wall, and results in deformity and paradoxical movement.

Case Presentation

A 40-year-old female presented a progressively enlarging mass of her anterior chest wall. Computed tomography revealed an osteolytic lesion with discrete calcification in the bone marrow of the sternum. The tumor extended across the destroyed cortex to the parietal and visceral soft aspects, involving some of the costal cartilage and most of the sternal body. Partial sternal resection was performed successfully and an individual-specific stainless steel plate was used to reconstruct the anterior chest wall. The early result was good, however, nine months after the first surgery, fractures of plate were found at bilateral plate-clavicular junction. The plate had to be removed, and a titanium mesh was used to reconstruction of the chest wall. The patient has been of disease free for more than 18 month after the second surgery.

Conclusions

Our experience indicated that the individual-specific plate may not be suitable for reconstructing both the anterior chest wall as well as the sternoclavicular joint after subtotal sternum resection.

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

Background

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

Methods

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

Results

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

Conclusion

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

Bioactive nanocomposite for chest-wall replacement: Cellular response in a murine model

Chest-wall invading malignancies usually necessitate the resection of the respective part of the thoracic wall. Gore-Tex® is the material of choice that is traditionally used to repair thoracic defects. This material is well accepted by the recipient; however, though not rejected, it is an inert material and behaves like a ‘foreign body’ within the thoracic wall. By contrast, there are materials that have the potential to physiologically integrate into the host, and these materials are currently under in vitro and also in vivo investigation. These materials offer a gradual but complete biodegradation over time, and severe adverse inflammatory responses can be avoided. Here, we present a novel material that is a biodegradable nanocomposite based on poly-lactic- co-glycolic acid and amorphous calcium phosphate nanoparticles in comparison to the traditionally employed Gore-Tex® being the standard for chest-wall replacement. On a mouse model of thoracic wall resection, that resembles the technique and localization applied in humans, poly-lactic- co-glycolic acid and amorphous calcium phosphate nanoparticles and Gore-Tex® were implanted subcutaneously and additionally tested in a separate series as a chest-wall graft. After 1, 2, 4 and 8 weeks cell infiltration into the respective materials, inflammatory reactions as well as neo-vascularization (endothelial cells) were determined in six different zones. While Gore-Tex® allowed for cell infiltration only at the outer surface, electrospun poly-lactic- co-glycolic acid and amorphous calcium phosphate nanoparticles were completely penetrated by infiltrating cells. These cells were composed mainly by macrophages, with only 4% of giant cells and lymphocytes. Total macrophage count increased by time while the number of IL1-β–expressing macrophages decreased, indicating a protective state towards the graft. As such, poly-lactic- co-glycolic acid and amorphous calcium phosphate nanoparticles seem to develop ideal characteristics as a material for chest-wall replacement by (a) having the advantage of full biodegradation, (b) displaying stable chest-wall structures and (c) adapting a physiological and integrating graft compared to Gore-Tex®.