Chest wall stabilization with synthetic reabsorbable materials as originally published in 1992: Updated in 1999 by

Abstract

The present paper is an updated report concerning our experience in chest wall reconstruction using reabsorbable prosthetic material. From December 1986 to June 1998, 66 reconstruction procedures were done in 65 patients. Reparative techniques were reviewed, and long-term results achieved in the patients who had reconstruction with reabsorbable material were analyzed. Absorbable material was used in 22 patients. Stabilization of the rib cage was achieved by anchoring a grid of polydioxanone band to the adjacent uninvolved ribs. The prosthetic reconstruction was always covered with a layer of vital tissue, with myoplasty or omentoplasty when needed. Long-term follow-up was possible in 12 patients. Excellent chest wall stabilization was achieved in 11 patients. Results were poor in 1 patient who had sternal resection; this patient had inadequate protection of the mediastinal organs and a moderate respiratory paradox with coughing. In extensive chest-wall resection, reabsorbable material used as a support for an overlying myoplasty appears to be an effective alternative to synthetic nonabsorbable prostheses. After sternal resection, however, reabsorbable material is not suitable. In 1992 we published an experimental study and preliminary clinical experience of chest wall reconstruction with synthetic reabsorbable material [1Puma F. Ragusa M. Daddi G. Chest wall stabilization with synthetic reabsorbable material.Ann Thorac Surg. 1992; 53: 408-411Abstract Full Text PDF PubMed Scopus (30) Google Scholar]. Since the technique is still in use, we retrospectively analyzed our experience in reconstruction after chest wall resection to redefine the role of reabsorbable material in light of long-term results. From December 1986 through June 1998, 66 reconstructive procedures were done in 65 patients who had chest wall resection, mostly for malignancies (92%). Only direct invasion beyond the parietal pleura was considered as an indication for skeletal resection in lung cancer. Thirty-five patients had reconstruction with only soft tissues; Marlex mesh was used in 7, bone heterograft for sternal reconstruction in 2 [2Puma F. Avenia N. Ricci F. Guiducci A. Fornasari V. Daddi G. Bone heterograft for chest-wall reconstruction after sternal resection.Ann Thorac Surg. 1996; 61: 525-529Abstract Full Text PDF PubMed Scopus (23) Google Scholar]. In 22 patients chest wall reconstruction was done with synthetic reabsorbable material with the following indications: non-small-cell lung cancer in 13 patients, primary chest wall tumor in 7, and metastatic involvement in 2. Clinical data and long-term results in this subgroup of patients were analyzed. The following resections were done in the subgroup treated with reabsorbable material: isolated chest wall resection in 4 patients, en bloc pulmonary and chest wall resection in 16, en bloc diaphragmatic and pulmonary resection in 1, and partial sternal resection in 1. The average number of consecutive ribs resected was 2.9 (range, 2 to 4); intercostal muscles and parietal pleura were included in the resection in all patients, and the overlying muscular layers in 2 patients. Stabilization of the thoracic wall was achieved as previously described, by bridging the gap with a grid of polydioxanone band (PDS-Band; Ethicon, Somerville, NJ) anchored to the adjacent uninvolved ribs. A thick layer of vital tissue was always sutured over the prosthesis, and for this purpose muscular flaps were created in 4 patients and omentum was used in 2. In 4 patients with larger defects, 4 or 5 pericostal stitches of heavy nonabsorbable material were added to the polydioxanone band grid to ensure more reliable long-term stability. Six patients received radiotherapy, 4 preoperatively and 2 postoperatively. There were no perioperative deaths. There were three minor postoperative complications, including one transient pleural effusion (as previously reported) and two postoperative atelectases from mucus retention. A slight degree of ventilatory paradox was observed postoperatively in about one third of the patients (generally those with larger defects), but it did not cause functional impairment and usually disappeared in the early postoperative period. The average postoperative hospital stay was 13.6 days. A follow-up longer than 12 months (range, 12 to 96 months; median, 26 months) was possible in 12 patients, all of whom had a healed wound. Eleven patients had good chest wall stabilization. In one patient, unsatisfactory long-term results after sternal resection occurred because there was inadequate protection of the mediastinal organs and a moderate flail chest persisted with coughing. The material was well tolerated in all patients, and no late infections occurred. Soft-tissue reconstructive procedures are usually adequate both for apical and posterior chest wall defects. Similarly, resections involving the basal region can be repaired simply by suturing the diaphragm to the lowest rib. The anterior, the lateral, and the sternal chest wall regions more frequently need prosthetic stabilization. In extensive resection of lateral or anterior chest wall, reabsorbable material as support for an overlying myoplasty appears to be an effective alternative to synthetic nonabsorbable prostheses. A relatively curved surface of the lateral chest wall region can be obtained with the reabsorbable grid, which can be reinforced by heavy pericostal nonabsorbable stitches when needed. With that technique, the use of nonabsorbable prostheses is rarely required. In our experience Marlex mesh was used in 7 patients (10.6%), two of whom had sternal defects, who were operated on in the early part of the series before the introduction in the clinical use of bone heterografts. In 1 patient a late infection of the Marlex mesh was observed, which required removal 13 months after implantation. Prosthetic reconstruction after sternal resection was necessary to protect the underlying mediastinal organs, and for this purpose absorbable material was not considered suitable. In our experience excellent results were achieved after extensive sternal resection with bone heterografts.