Dr. Ashraf Ahmed EsmatProf. Cardio-thoracic Surgery Cairo University
Background Chest wall defects continue to present a complicated treatment scenario for thoracic and reconstructive surgeons. The surgeon is eager to rid the patient of all possible malignant, contaminated, or irradiated tissues while leaving a defect that should be closed to maintain life itself. A thorough knowledge of reconstructive techniques with a clear operative plan is most desirable.
BackgroundThree tenets of surgical resection should be maintained1. First, a sufficient amount of tissues must be resected to dispose all devitalized tissues.2. Second, a replacement must be found to restore the rigid chest wall to prevent paradoxical motion during respiration.3. Third, healthy soft tissue coverage is essential to seal the pleural space and prevent infection.
Background Anterior chest wall defects were defined as being located between the sternum to the anterior axillary line. Lateral defects located between the anterior and posterior axillary lines. Posterior defects as located between the spine and posterior axillary line. There is some controversy to which chest wall defects to be reconstructed but, generally, lesions less than 5 cm in size in any location, and those up to 10 cm in size posteriorly do not need reconstruction for functional reasons.
BackgroundTechniques of Reconstruction: Historically, bone, diced cartilage, metal sheets, autogenous rib graft, fascia lata, Teflon, and numerous other substances were used with minimal success. the ideal characteristics of a prosthetic material: rigidity to abolish paradoxical chest motion, inertness to allow in- growth of fibrous tissue and decrease the likelihood of infection, malleability so that it can be fashioned to the appropriate shape at the time of operation, and radiolucency to allow radiographic follow-up of the underlying problem.
BackgroundTechniques of Reconstruction While some authors advocate Prolene or Marlex mesh, others advocate the use of polytetrafluroethylene (Gore-Tex) soft tissue patch reconstruction of all defects. In cases where structural integrity is necessary for preventing chest wall collapse, methyl methacrylate sandwich, silicone, Teflon, or acrylic materials have been utilized.
BackgroundTechniques of Reconstruction: Rigid reconstruction: Polypropylene mesh- methylmethacrylate sandwich (PMM). methylmethacrylate is applied within double layer of mesh tailored to the size and contour of the defect. we managed to create strips of the methylmethacrylate that mimics the natural ribs. Non-rigid reconstruction using Polypropylene mesh (PM) alone to reconstruct the chest wall. Soft tissue reconstruction using myocutaneous flaps were used, in cases of radiation necrosis of chest wall.
Patients & Methods We are presenting our experience in 28 patients who underwent chest wall resection and reconstruction at Cairo University hospitals from January 2007 to January 2011. Patients with fewer than two rib resections, routine pectus resections, acute sternal infections after median sternotomy for cardiac surgery were not included in the present series. Patients demographics, the location of the chest wall defect, performance of lung resection if any, the type of prosthesis and postoperative complications were recorded.
ResultsTable 1: Pts’ Demography & Medical history No. of Patients Percentage• Age 32 – 65 years• Sex (M/F) (18/10) (65.5%/34.5%)• Hypertension 11 37.9%• Diabetes Mellitus 7 24.1%• COPD 2 6.8%• Ischemic Heart 2 6.8%Disease
ResultsTable2: Indications for chest wall resection Number of Percentage patients Bronchogenic 8 28.5 % Carcinoma Primary Chest 14 50 % wall Tumor Radiation 5 17.8 % Necrosis Breast Carcinoma 1 3.5%
ResultsFactors associated with postoperative complications were analyzed.Multivariate analysis identified patient age, size of chest wall defect, and lung resection to be significant predictors of postoperative complications.
ConclusionChest wall resection and reconstruction with or without prosthesis can be performed as a safe, effective one- stage surgical procedure for a variety of major chest wall defects.