Patients Underwent Chest Wall Reconstruction Research Articles

Three-dimensional printed pure-titanium implantation for chest wall reconstruction involving the sternum and ribs: a novel approach.

Chest wall reconstruction is challenging due to the complex shape and large defect size. The three-dimensional printing technology enables the fabrication of customized implants, and 3D-printed pure-titanium could provide superior mechanical properties to conventional materials. The aim of this study was to evaluate long-term outcomes of patients undergoing chest wall reconstruction with a 3D-printed pure-titanium implant. Between August 2018 and May 2021, 5 patients underwent surgery due to sternal metastasis (n = 3), postoperative sternal wound infection (n = 1) and deformity (n = 1). The customized implant was designed and constructed based on the size and shape of the chest wall defect measured on computed tomography. All patients demonstrated uneventful recovery without complications during the hospital course. During the median follow-up of 20 months, 1 patient underwent revision surgery due to implant breakage, and 1 removed the implant due to trauma-related chest wall infection. One patient died from cancer progression, while 3 patients are alive without any implant-related complications. Chest wall reconstruction using a 3D-printed pure-titanium implant could be a novel alternative for patients with various conditions affecting the sternum and ribs.

Chest Wall Reconstruction Utilizing Ovine-derived Reinforced Tissue Matrix

BackgroundChest wall reconstruction can be a challenge. The perfect material does not exist to restore chest wall stability. Synthetic materials have been the mainstay for reconstruction. Biological material use has increased. Recently, we initiated the use of a biosynthetic material for chest wall reconstruction that is composed of ovine-derived extracellular tissue matrix and monofilament polypropylene suture. MethodsWe respectively reviewed all patients who underwent chest wall reconstruction with a biosynthetic material from January 2020 to June 2021. ResultsTwenty-five patients underwent chest wall reconstruction. Median age was 35 years (range, 18 to 68); 64% were men. Indication for reconstruction was tumor resection in 10, chest wall defect after pectus repair in 7, radiation necrosis in 5, chest wall infection in 2, and lung herniation in 1. Infection was present in 28%. Median chest wall defect was 7 × 10 cm (range, 3.5 to 22.5 cm). Bioabsorbable bars were used in combination with the biosynthetic material patch in 15 patients (60%) and biosynthetic material alone in 10; 5 patients underwent myocutaneous advancement flaps. There were no operative deaths. Postoperative complications occurred in 6 patients (24%). Median hospital stay was 5 days (range, 3 to 14). Late complications occurred in 4 patients (16%). No patient had paradoxical motion, chest wall instability, or required biosynthetic material removal at a median follow-up of 12 months (range, 1 to 18). ConclusionsThis novel biosynthetic material combines the benefits of biologic material and polymer reinforcement to provide a more natural chest wall reconstruction compared with mesh products made of synthetic material alone. Early results are promising in this first series in the literature.

Multidisciplinary reconstructive management of residual recalcitrant empyema cavity: A retrospective observational cohort study

Patients with stage III empyema require chest wall fenestration to enable lung re-expansion and continuous drainage of the persisting empyema cavity. This chronic wound negatively affects patients' exercise tolerance, ability to carry out activities of daily living, and quality of life. Eight consecutive patients underwent chest wall reconstruction following fenestration and were followed up over a minimum of 12 months. This study included adult patients (over 18 years of age). There were no exclusion criteria. Data were collected retrospectively. Eight patients (six male and two female), with a mean age of 56 years (range, 22-76), were included. All of them had comorbidities including history of neoplasia (n=6), atrial fibrillation (n=3), and hypertension (n=2). Aetiology of empyema included lung cancer resection complicated by bronchopleural fistula (n=4), pneumonia (n=2), and pleural effusion (n=2). Five patients had a low metabolic reserve evident by a low BMI (range, 16-22), and a median malnutrition universal screen tool (MUST) score of 2 (range, 1-4). Following intensive infection control and nutritional support, patients underwent reconstruction 11 months (median; range 5-51) after fenestration. Seven patients were followed up and had no recurrence of empyema and bronchopleural fistula. They all reported significant improvements in their quality of life, and their Eastern Cooperative Oncology Group (ECOG) performance status improved from three to one. One patient died 56 days post-reconstruction from cardiorespiratory failure, which required readmission to hospital. We demonstrate that free tissue reconstruction including multidisciplinary input and optimisation at all stages of care successfully closes residual recalcitrant empyema cavity without recurrence and leads to significant improvements in the quality of life.

Primary paediatric chest wall tumours necessitating surgical management.

Limited literature exists on oncological chest wall reconstruction in the paediatric population, with the field still largely undecided on the best surgical reconstructive techniques to employ. The use of biological grafts/meshes is gaining popularity in certain adult surgical procedures but their use in paediatric procedures is rarely reported in the literature. We present the outcomes of our institution's multidisciplinary approach to managing paediatric chest wall tumours as well as our experience with the use of biological grafts for chest wall reconstruction following oncological resections. Data were analysed retrospectively from eight paediatric patients who were treated for primary chest wall tumours between 2010 and 2018. The tumours comprised two lipoblastomas, three Ewing's sarcomas, an undifferentiated sarcoma with osteosarcomatous differentiation, a high grade undifferentiated sarcoma and a myofibroma. Seven of the eight patients underwent chest wall reconstruction with a biological graft. There were no postoperative mortalities and no evidence of recurrence in any of the patients in the series. No further chest wall operations were required and there were no postoperative infection related complications. We support the use of biological grafts for chest wall reconstruction after oncological resections and maintain that a multidisciplinary approach is essential for the management of paediatric chest wall tumours.

Prognostic factors following complete resection of non-superior sulcus lung cancer invading the chest wall.

Locally advanced non-small-cell lung cancer (NSCLC) with chest wall invasion carries a high risk of recurrence and portends poor survival (30-40% and 20-50%, respectively). No studies have identified prognostic factors in patients who underwent R0 resection for non-superior sulcus NSCLC. A retrospective review was conducted for all chest wall resections for NSCLC from 2004 to 2018. Patients with superior sulcus tumours, partial (<1 rib) or incomplete (R1/R2) resection or distant metastasis were excluded. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Cox proportional hazards modelling was used to determine factors associated with DFS and OS. A total of 100 patients met inclusion criteria. Seventy-three (73%) patients underwent induction therapy, and all but 12 (16%) patients experienced a partial radiological response. A median of 3 ribs was resected (range 1-7), and 67 (67%) patients underwent chest wall reconstruction. The 5-year DFS and OS were 36% and 45%, respectively. Pathological N2 status [hazard ratio (HR) 3.12, confidence interval (CI) 1.56-6.25; P = 0.001], intraoperative blood transfusion (HR 2.24, CI 1.28-3.92; P = 0.005) and preoperative forced vital capacity (per % forced vital capacity, HR 0.97, CI 0.96-0.99; P = 0.013) were associated with DFS. Increasing pathological stage, lack of radiological response to induction therapy (HR 7.35, CI 2.35-22.99; P = 0.001) and cardiovascular comorbidity (HR 2.43, CI 1.36-4.36; P = 0.003) were associated with OS. We demonstrate that blood transfusion and forced vital capacity are associated with DFS after R0 resection for non-superior sulcus NSCLC, while radiological response to induction therapy greatly influences OS. We confirm that pathological nodal status and pathological stage are reproducible determinants of DFS and OS, respectively.

Chest wall reconstruction using a new titanium mesh: a multicenters experience.

Many new surgical techniques and materials have been introduced in the last decade for chest wall reconstruction or stabilization with the purpose of improving the incorporation, maintaining chest wall stability with reduction of infections. However, none of them are yet considered a gold standard procedure. The aim of this work is to evaluate the initial experience using a new titanium mesh for chest wall reconstruction in four Italian Thoracic Surgery Departments. A review was performed of all patients undergoing chest wall reconstruction using a new titanium mesh between January 2014 and September 2018. Surgical indications, the location and size of the chest wall defect, intraoperative variables and postoperative complications were analyzed. A total of 26 consecutive patients were included. The most common indications for surgery were primary or secondary chest wall tumors (38%) followed by lung cancer invading chest wall (31%). The most common localization of chest wall defect was anterolateral (46%). Sternal reconstruction was required in 3 patients (12%). The average size of the defect was 9.3×7.8 cm. The median number of resected ribs was 3.6. No perioperative deaths occurred. Mean hospital stay was 11.9 days. Overall morbidity was 19%. One failure of reconstruction (4%) was reported during follow up. In our early clinical experience chest wall reconstruction using titanium mesh can be performed as a safe and effective surgical procedure. This mesh has excellent biomechanical characteristics between rigid and malleable materials, it's easy to trim and fix for optimal adaptation without necessity of dedicated instruments. The early and mid-term results are satisfactory with low incidence of complications related to the titanium mesh implant.

Chest wall reconstruction still has place in Today’s modern practice:" a tertiary center experience"

Background: The key factor following chest wall resection is the preservation of the stability and integrity of the chest wall to support the respiration and protect the underlying organs. The present study aims to evaluate the use of the available grafts and prosthetic materials at our center in chest wall reconstruction with adherence to the proper surgical techniques, good perioperative and postoperative care to obtain good results.&#x0D; Methods: This is a retrospective single center study that concludes all patients underwent chest wall reconstruction for a variety of defects resulting from resection of tumors, trauma due to primarily firearms or motor car accidents, resection of radio necrotic tissues, infection and dehiscence of median sternotomy wounds after cardiac surgery.&#x0D; Results: Study population consisted of 30 patients between January 2015and may 2018, among them were 20 male (70%) and 10 female patients (30%), with a median age of 43 ± 16.3 years, resection and reconstruction was performed in 23 cases (15 neoplastic,5 infective and 3 firearm cases) while reconstruction alone was performed in 7 (traumatic flail chest) cases. Eighteen patients, underwent rib resection with an average 4.18 ± 2.2 ribs (range 2-6). Associated lung resection was performed in 5 patients (27.8 %): diaphragmatic resection was done in 2 cases in addition total sternal resection was performed in 5 cases. Most of the patients (96.7%) had primary healing of their wounds. there was one death (3.3%) in the early postoperative period. The average length of hospital stay for all patients was 8.7 days (range: 5–15). Respiratory complications occurred in three cases in the form of atelectasis and pneumonia at the ipsilateral side of reconstruction. Three cases suffered wound seroma which successfully managed by daily dressing and antibiotic coverage.&#x0D; Conclusions: according to our study and the analysis of similar studies, adequate perioperative preparation of patient undergoing chest wall resection and reconstruction with adherence to effective surgical techniques allowed us to use the available materials at our center for chest wall reconstruction with good and effective results without adding burden in terms of cost on the patient.

Post-sternotomy deep wound infection following aortic surgery: wound care strategies to prevent prosthetic graft replacement†.

The aim of this study was to evaluate the early and long-term outcomes of our multidisciplinary strategy for treating deep sternal wound infection after aortic grafting, which consisted of debridement by a plastic surgeon, negative pressure wound therapy with continuous irrigation and chest wall reconstruction. We performed a retrospective analysis of 18 patients who had a deep sternal wound infection following aortic grafting through a median sternotomy between January 2009 and December 2017. All patients had organisms cultured from mediastinal tissue within 2 months from the initial aortic surgery. The prosthetic grafts were exposed in 15 patients during resternotomy. Our protocol involved repeat debridement and negative pressure wound therapy with continuous irrigation twice a week until the results of the culture were negative and chest wall reconstruction was complete. The mean duration from primary aortic surgery to resternotomy was 23.7 ± 15.9 days. Except for 1 patient, 17 patients underwent chest wall reconstruction. The mean duration from resternotomy to chest wall reconstruction was 31.1 ± 28.0 days. The hospital mortality rate was 16.7% (3 patients), although no patients died of wound-related causes. The mean follow-up period was 2.9 ± 2.5 years. Overall survival was 69.6 ± 11.4% at 1 year and 54.2 ± 13.3% at 5 years. Freedom from reoperation for reinfection was 94.4 ± 5.4% at 5 years. Our wound care strategy achieved acceptable early and late survival in patients who had deep sternal wound infection following aortic grafting. This strategy may benefit those who experience this devastating complication.

Optimal Reconstruction Method for Large Radionecrosis Following Breast Cancer Treatment: Utility of Free Transverse Rectus Abdominis Myocutaneous Flap Using Contralateral Internal Mammary Artery as Recipient.

In extensive radionecrosis following radiotherapy for breast cancer (BC) treatment, the defect after excision can be reconstructed with a transverse rectus abdominis myocutaneous (TRAM) flap. In this study, we report outcome of free TRAM flap using contralateral internal mammary artery (IMA) as a recipient in comparison with pedicled TRAM. We reviewed cases of chest wall radionecrosis following BC treatment during the past 8 years. Radionecrosis involving full-thickness soft tissue with defect sizes greater than 10 × 10 cm were included. We compared the outcomes of patients who underwent reconstruction with either pedicled TRAM flaps or free TRAM flaps. We used IMA as a recipient for free TRAM flap, whereas we used contralateral superior epigastric artery-based flap for pedicled TRAM. A total of 14 BC patients underwent chest wall reconstruction due to radionecrosis: 7 received pedicled TRAM flaps, 5 received free TRAM flaps, and 2 were excluded because of the small defect size. The pedicled and free TRAM groups were similar in patient demographics and defect size. However, distal flap loss rate was significantly higher in the pedicled TRAM group compared with the free TRAM group (P = 0.028). There was no difference in abdominal hernia incidence between the 2 groups (P = 0.100). Wide chest wall defects caused by radionecrosis following BC treatment can be successfully reconstructed with a free TRAM flap that uses a contralateral IMA as a recipient. The free TRAM flap demonstrates a lower rate of distal flap loss than the pedicled TRAM flap, hence reduces the risk of severe morbidity.

Chest Wall Reconstruction for Sternal Dehiscence After Open Heart Surgery

Sternal dehiscence is a grave complication after open heart surgery. Sternal debridement and flap coverage are the mainstays of therapy, but no consensus exists regarding the appropriate level of debridement. More recently, the use of vacuum-assisted closure devices has been advocated as a bridge to definitive closure, but indications for use remain incompletely defined. A retrospective review of all chest wall reconstructions performed from January 2000 to December 2010 was conducted. The type of operative management was evaluated to assess morbidity, mortality, and length of hospital stay. Fifty-four patients underwent chest wall reconstruction for poststernotomy mediastinitis. Of these patients, 24 underwent conservative sternal debridement with flap closure, 24 underwent radical sternectomy including resection of the costal cartilages followed by flap closure, and 6 underwent radical sternectomy with vacuum-assisted closure therapy followed by flap closure in a delayed fashion. There were 15 patients in the conservative group and 8 patients in the radical sternectomy group who developed postoperative complications (62.5% vs 33.3%, P < 0.05). The conservative sternectomy group had more serious complications requiring reoperation compared to the radical sternectomy group (86.7% vs 25.0%, P < 0.05). The most common complication in the former group was flap dehiscence (8/15, 53.3%), whereas that in the latter group was a superficial wound infection (6/8, 75.0%). There was no significant difference in mortality (25.0% vs 25.0%, P > 0.05%) or length of hospital stay. Radical sternectomy including the costal cartilages is associated with lower rates of surgical morbidity and reoperation, but not mortality.

Reconstruction with fascia lata after extensive chest wall resection: results

Following extensive chest wall resection, the reconstruction technique should fulfill two opposing functional requirements: adequate rigidity and flexibility of the chest wall during the breathing phases. Reconstruction with fascia lata enables a balance between these two parameters, thus favouring the patients' respiratory dynamics and producing low morbidity and good functional results. Sixty patients underwent chest wall reconstruction using fascia lata alone or in combination with titanium plates between 2006 and 2011, due to primary tumours in 28 patients, metastases in 23 and local recurrences in 9. The mean area of resected tissue was 107.7 cm(2), distributed among the anterior, anterolateral, lateral and posterior zones. One-to-eight ribs were resected, and additional sternum resection was performed in 75% of patients. Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were evaluated in 33 patients. 46.6% of patients underwent reconstruction with fascia lata alone, 1.6% with fascia lata, DualMesh® and titanium plates and 51.6% with fascia lata and titanium plates. There was no 30-day mortality. All patients were extubated after the operation with no need for reintubation. Five patients had postoperative complications: 2 wound dehiscences, 2 haematomas and 1 seroma. There were no significant differences between preoperative and postoperative FEV1 and FVC measurements in patients with or without lobectomy and wedge resections. Chest wall reconstruction with fascia lata, alone or in combination with titanium plates, allows the surgeon to perform a dynamic reconstruction without flail chest in extensive exeresis. Risks of infection associated with the use of prosthetic materials are also minimized. In addition, the characteristic flexibility of this tissue makes it a precious tool in paediatric chest wall reconstruction, since fascia lata naturally adapts to the physiological growth of younger bodies, thus reducing the risk of scoliosis and local deformities.

Chest wall reconstruction using implantable cross-linked porcine dermal collagen matrix (Permacol)

Background/PurposeChest wall reconstruction in children is typically accomplished with either primary tissue repair or synthetic mesh prostheses. Primary tissue repair has been associated with high rates of scoliosis, whereas synthetic prostheses necessitate the placement of a permanent foreign body in growing children. This report describes the use of biologic mesh (Permacol; Covidien, Mansfield, MA) as an alternative to both tissue repair and synthetic prostheses in pediatric chest wall reconstruction. MethodsA retrospective chart review was performed identifying patients undergoing chest wall reconstruction with biologic mesh at our tertiary referral children's hospital between 2007 and 2011. Data collection included patient demographics, indication for chest wall resection, number of ribs resected, the administration of postoperative radiation, length of follow-up, postoperative complications, and the degree of spinal angulation (preoperatively and at most recent follow-up). ResultsFive patients (age, 9.0-21.7 years; mean, 15.4 years) underwent resection for primary chest wall malignancy followed by reconstruction with biologic mesh (Permacol) during the study period. There were no postoperative mesh-related complications, and none of the patients developed clinically significant scoliosis (follow-up, 1.1-2.6 years; mean 1.9 years). ConclusionBiologic mesh offers a safe and dependable alternative to both primary tissue repair and synthetic mesh in pediatric patients undergoing chest wall reconstruction.

Never Say No to a Damaged Muscle

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.

Functional assessment of chest wall integrity after methylmethacrylate reconstruction

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. Cine-magnetic 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.