Chest Wall Resections and Reconstruction: A 25-Year Experience

Transcription

1 Chest Wall Resections and Reconstruction: A 25-Year Experience Kamal A. Mansour, MD, Vinod H. Thourani, MD, Albert Losken, MD, James G. Reeves, BS, Joseph I. Miller, Jr, MD, Grant W. Carlson, MD, and Glyn E. Jones, MD Joseph B. Whitehead Department of Surgery, Divisions of Cardiothoracic Surgery and Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Georgia Background. Chest wall defects continue to present a complicated treatment scenario for thoracic and reconstructive surgeons. The purpose of this study is to report our 25-year experience with chest wall resections and reconstructions. Methods. A retrospective review of 200 patients who had chest wall resections from 1975 to 2000 was performed. Results. Patient demographics included tobacco abuse, hypertension, diabetes mellitus, alcohol abuse, coronary artery disease, chronic obstructive pulmonary disease, and human immunodeficiency virus. Surgical indications included lung cancer, breast cancer, chest wall tumors, and severe pectus deformities. Twenty-nine patients had radiation necrosis and 31 patients had lung or chest wall infections. The mean number of ribs resected was 4 2 ribs. Fifty-six patients underwent sternal resections. In addition 14 patients underwent forequarter amputations. Immediate closure was performed in 195 patients whereas delayed closure was performed in 5 patients. Primary repair without the use of reconstructive techniques was possible in 43 patients. Synthetic chest wall reconstruction was performed using Prolene mesh, Marlex mesh, methyl methacrylate sandwich, Vicryl mesh, and polytetrafluoroethylene. Flaps utilized for soft tissue coverage were free flap (17 patients) and pedicled flap (96 patients). Mean postoperative length of stay was days. Mean intensive care unit stay was 5 9 days. In-hospital and 30-day survival was 93%. Conclusions. Chest wall resection with reconstruction utilizing synthetic mesh or local muscle flaps can be performed as a safe, effective one-stage surgical procedure for a variety of major chest wall defects. (Ann Thorac Surg 2002;73:1720 6) 2002 by The Society of Thoracic Surgeons Since the first known chest wall resection in the 18th century, improvements in surgical technique and anesthesia, critical care units, antibiotics, and the development and refinements in reconstruction techniques have allowed extensive chest wall resections to be performed with acceptable morbidity and mortality. The most common indications for chest wall resection include primary or metastatic chest wall neoplasms, tumors contiguous from breast or lung cancer, radiation necrosis, congenital defects, trauma, or infectious processes from osteomyelitis or median sternotomy or lateral thoracotomy wounds [1]. After radical en bloc chest wall resection, skeletal reconstruction when appropriate and adequate skin coverage to preserve the reconstruction are the essential elements for successful management of these complex chest wall defects. If chest wall integrity is compromised, synthetic mesh (eg, Marlex [knitted polypropylene] by Davol and Bard, Cranston, RI; Prolene by Ethicon, Inc, Somerville, NJ; PTFE [polytetrafluoroethylene] by W.L. Gore & Associates, Inc, Flagstaff, AZ; Vicryl [polyglactin 910] by Ethicon, Inc, Somerville, NJ; Presented at the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8 10, Address reprint requests to Dr Mansour, 1365 Clifton Rd, The Emory Clinic, Atlanta, GA 30322; kamalmansour@emoryheathcare.org. methyl methacrylate sandwich [polymethyl methacrylate] by Stryker Howmedica Osteonics, Mahwah, NJ) can be utilized for attaining rib cage or sternal stability. Although primary closure of muscle and skin after chest wall resection is attainable in most cases, many patients commonly require more sophisticated reconstructive soft-tissue and skin coverage. A variety of techniques including pedicled muscle transposition, free muscle flaps, and omental flaps have been used to provide adequate wound coverage that allows for quick healing, rehabilitation, and cosmesis. The purpose of this study is to retrospectively review our 25-year experience with chest wall resections and reconstruction at one institution by two thoracic surgeons. Patients and Methods A retrospective review was performed on the available charts of 200 consecutive patients who underwent chest wall resection and reconstruction at Emory University Hospital and Crawford Long Hospital of Emory University between 1975 and 2000 by two thoracic surgeons (KAM and JIM). All patients with more than two rib resections were included in the present series. Patients with fewer than two rib resections, routine pectus resec by The Society of Thoracic Surgeons /02/$22.00 Published by Elsevier Science Inc PII S (02)

2 Ann Thorac Surg MANSOUR ET AL 2002;73: CHEST WALL RESECTIONS AND RECONSTRUCTIONS 1721 Table 1. Significant Medical History of Patients Tobacco abuse 114 (57%) Hypertension 54 (27%) Diabetes mellitus 30 (15%) Alcohol abuse 41 (21%) Coronary artery disease 20 (10%) Chronic obstructive pulmonary disease 18 (9%) Human immunodeficiency virus 4 (2%) tions, acute sternal infections after median sternotomy for cardiac surgery, or primary Eloesser procedures were not included in the present series. Mean age was years (range 13 to 86); 106 (53%) were men and 94 (47%) were women. Prior to undertaking sternal resections we routinely perform pulmonary function tests. All patients received conventional chest roentgenography, which occasionally detects a defect or mass. For patients with a mass, a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan of the chest was done to evaluate the extent and exact nature of the lesion and a tissue diagnosis utilizing fine needle aspiration was attempted. In patients with suspected distant metastases CT and MRI were used. Patients charts were retrospectively reviewed for age, sex, medical history (specifically history of previous cancer or cancer surgery), surgical history, history of tobacco or alcohol abuse, anatomic defect during the surgical resection, the number of ribs or the portion of sternum resected, and the surgical reconstruction technique (immediate or delayed, skeletal defect reconstruction, soft tissue coverage). The in-hospital outcomes reviewed were mortality, length of stay (overall, postoperative, and intensive care unit), and morbidity. Chest wall tumors were resected to gross negative margins when possible. All major reconstructions were performed by members of the Division of Plastic and Reconstructive Surgery of Emory University School of Medicine. The significant medical history of the study group is presented in Table 1. The three most common indications for surgery were primary lung cancer (75 patients, 38%) with extensions into the chest wall or with recurrent lung tumors to the chest wall, primary chest wall tumors (53 patients, 27%), and primary breast cancer with recurrence or metastasis to the chest wall (43 patients, 22%; Table 2). Chest wall resection was performed for 29 patients (15%) with radionecrosis of the chest wall. Fortysix patients (23%) of the study group underwent reoperative chest wall resection for recurrent tumors and 68 patients (34%) underwent concomitant lung surgery and chest wall resection. For the infected chest wall requiring resection Vicryl mesh has been used in addition to muscle flap coverage. In some instances where chest wall resection was done for radionecrosis only muscle flaps were used as the chest wall was fixed and the underlying tissue scarred down. Postoperative chest wall infections were managed Table 2. Indications for Chest Wall Resection utilizing intravenous antibiotics and by removing the foreign material usually several months postoperatively, leaving a strong, smooth fibrotic surface that furnished chest wall stability. Results Lung cancer 75 (38%) Chest wall tumor 53 (27%) Breast cancer 43 (22%) Pectus 6 (3%) Miscellaneous 23 (12%) Upper extremity tumor 7 (4%) Laryngeal tumor 4 (2%) Trauma 4 (2%) Ovarian tumor 2 (1%) Malignant thymoma 2 (1%) Tracheal tumor 2 (1%) Tonsillar tumor 1 (0.5%) Thyroid tumor 1 (0.5%) Radiation necrosis 29 (15%) Lung/chest wall infections 31 (16%) The 200 patients underwent chest wall resection with an average of 4 2 ribs (range 2 to 9). The anterior and lateral ribs were the most commonly resected (143 patients, 72%; Table 3). A total of 56 patients underwent sternal resection; the most common was a total sternectomy, in 16 patients (8%, Table 3). Seven patients (44%) required total sternectomy for chronic infections. Fourteen patients (7%) underwent forequarter amputation in addition to chest wall resections. Immediate closure was performed in 195 (98%) of the patients and 5 patients (3%) underwent delayed closure at an average of 10 days after chest wall resection (Table 4). Delayed repairs were Table 3. Chest Wall Resections: Anatomic Defects Recurrent surgery 46 (23%) Combined lung/chest wall surgery 68 (34%) Rib defects Anterior rib resection 66 (33%) Anterolateral rib resection 40 (20%) Lateral rib resection 37 (19%) Posterior rib resection 25 (13%) Posterolateral rib resection 25 (13%) Sternal defects Upper sternal resection 15 (8%) Middle sternal resection 4 (2%) Lower sternal resection 3 (2%) Hemisternectomy 18 (9%) Sternectomy 16 (8%) Forequarter amputation 14 (7%) Mean number of ribs resected 4 2 ribs (range 2 to 9).

3 1722 MANSOUR ET AL Ann Thorac Surg CHEST WALL RESECTIONS AND RECONSTRUCTIONS 2002;73: Table 4. Chest Wall Reconstruction: Synthetic Materials Immediate reconstruction 195 (98%) Delayed reconstruction 5 (3%) Primary chest wall closure 43 (22%) Prosthetic replacements Prolene mesh 49 (25%) Marlex mesh 21 (11%) Methyl methacrylate 11 (6%) Vicryl mesh 11 (6%) PTFE 1 (0.5%) Autogenous replacements Pedicle flap 96 (48%) Free flap 17 (9%) Latissimus muscle 40 (20%) TRAM 33 (17%) Pectoralis muscle 31 (16%) Serratus muscle 17 (9%) Deltoid muscle 4 (2%) Trapezius muscle 3 (2%) Omentum 20 (10%) STSG 23 (12%) PTFE polytetrafluroethylene; TRAM transverse rectus abdominis musculocutaneous; STSG split thickness skin graft. performed secondary to the hemodynamic instability of the patients and to ongoing infectious processes. Primary repair of the soft tissue and skin was performed in 43 patients (22%) and synthetic materials were used for chest wall integrity reconstruction in 93 patients: Prolene mesh (49 patients, 25%), Marlex mesh (21 patients, 11%), methyl methacrylate sandwich (11 patients, 6%), Vicryl mesh (11 patients, 6%), and PTFE (1 (0.5%; Table 4). Ninety-six patients (48%) underwent pedicled muscle flap transposition and 17 patients (9%) underwent free muscle flap transposition. The three most common muscle groups utilized were latissimus flap (40 patients, 20%), pectoralis flap (31 patients, 16%), and transverse rectus abdominis musculocutaneous (TRAM) flap (33 patients, 17%; Table 4). Some patients required more than one muscle flap for complete reconstruction. The omentum was used in 20 patients (10%) and splitthickness skin grafts were utilized in 23 patients (12%). In-hospital outcomes are presented in Table 5. The overall length of stay (LOS) was days (range 3 to 99, median 10) and the postoperative LOS was days (range 2 to 98). A total of 168 patients (84%) required Table 5. Outcomes Overall LOS days (3 to 99) Postoperative LOS days (2 to 98) ICU postoperatively 168 patients (84%) ICU LOS 5 9 days (1 to 83) Hospital mortality 13 patients (7%) Forequarter procedures 1 of 14 patients (7%) Combined lung/cw surgery 5 of 68 patients (7%) LOS length of stay; ICU intensive care unit; CW chest wall. Fig 1. Left-side chest wall defect and deltoid flap are shown after en bloc chest wall resection including the entire forequarter, first six ribs, and the involved chest wall. the intensive care unit postoperatively for an average of 5 9 days (range 1 to 83). Thirteen of 200 patients (7%) died during their hospital stay of multisystem organ failure, including 1 of the 14 patients who underwent a forequarter amputation and 5 of the 68 patients (7%) undergoing concomitant lung surgery and chest wall resection. Shown is an example of a successful repair of a patient with left axillary and chest wall fibrosarcoma requiring en bloc removal of the entire forequarter, the first six ribs, and the involved chest wall (Fig 1). The defect was repaired with a double fold of Marlex mesh (Fig 2) and a deltocervical flap was tailored for closure of the chest wound (Fig 3). Forty-seven patients (24%) had complications during their hospital stay (Table 6). The most common complications were pneumonia (27 patients, 14%), acute respiratory distress syndrome ([ARDS] 11 patients, 6%), and flap loss (10 patients, 5%). Comment In the treatment of patients requiring chest wall resection, three tenets of surgical resection should be main-

4 Ann Thorac Surg MANSOUR ET AL 2002;73: CHEST WALL RESECTIONS AND RECONSTRUCTIONS 1723 Table 6. Surgical Complications Pneumonia 27 (14%) Acute respiratory distress syndrome 11 (6%) Flap loss 10 (5%) Infection/sepsis 9 (5%) Atrial fibrillation 5 (3%) Flap hematoma 3 (2%) Mesenteric ischemia 1 (0.5%) Pancreatitis 1 (0.5%) Acute renal failure 1 (0.5%) Donor site hernia 1 (0.5%) Fig 2. Double-thickness Marlex mesh coverage of the chest wall defect is shown. tained [2]. First, a sufficient amount of tissue must be resected to dispose of all devitalized tissue. Second, in segments of large chest wall resections a replacement must be found to restore the rigid chest wall to prevent physiologic flail. Third, healthy soft-tissue coverage is essential to seal the pleural space, to protect the viscera and great vessels, and to prevent infection. As is evident by the current series, a combined multidisciplinary approach with plastic and reconstructive, thoracic surgeons, and critical care medicine specialists affords acceptable functional and cosmetic results after chest wall resections. Chest Wall Resection Sternal resection and reconstruction is a major surgical technique incorporating a substantial undertaking which has been performed more commonly with the advent of mechanical positive-pressure ventilation, antibiotics, thoracic suction drainage, blood product availability, improved anesthesia and modern reconstructive techniques. The pulmonary status of the patient should be evaluated to anticipate postoperative complications, predict the need for ventilatory support, and maximize the Fig 3. Closure of the chest wall was performed using a deltocervical flap. patient s pulmonary capabilities. Although the majority of patients do not undergo concomitant lung resections and chest wall resections (34% in the current series), the loss in ventilatory capacity in those with a preexisting marginal respiratory function may lead to prolonged respiratory support and pulmonary complications in the postoperative period. In the current series the mortality rate was the same for the 68 patients who underwent concomitant lung surgery and chest wall resection (5 of 68 patients, 7%) compared with those with chest wall resection without lung surgery (8 of 132 patients, 6%). However, the postoperative pneumonia rate in this 68 patient subpopulation was increased (14 of 68 patients, 21%) compared with those 132 patients undergoing chest wall resection alone (13 of 132 patients, 10%, p 0.059). Despite the increased rate of postoperative pneumonia, the overall, postoperative, and intensive care unit length of stay was not significantly increased in patients with lung and chest wall surgery compared with those with chest wall surgery alone (18 15 days, days, 5 7 days versus days, days, 5 10 days, respectively). After careful preoperative screening and as indicated, we do not hesitate to perform concomitant pulmonary resections with chest wall resections. A basic tenet prior to the initiation of chest wall reconstruction is an appropriate and thorough chest wall resection that leaves healthy, viable margins to which materials and tissues used in a reconstruction may be anchored securely. Careful preoperative assessment for the extent of disease in patients with primary or metastatic malignancies is necessary prior to chest wall resection or reconstruction [3]. This is particularly important in patients with breast and lung cancer locally invading the chest wall and in patients with metastatic disease to the ribs or sternum. For patients in whom combined pulmonary and chest wall resection may be required we agree with Pairolero [4] that if the mediastinal lymph nodes are not positive, an en bloc resection is warranted as the 5-year mortality is more associated with the extent of the pulmonary cancer than with the extent of chest wall resection. In contrast Magdeleinat and colleagues [5] do not consider N2 disease a contraindication to en bloc resection and have recently reported an actuarial 5-year survival after complete en bloc resection of lung cancer invading the

5 1724 MANSOUR ET AL Ann Thorac Surg CHEST WALL RESECTIONS AND RECONSTRUCTIONS 2002;73: chest wall at 25% in T3N0 patients, 20% in T3N1, and 21% in T3N2. Although nodal status (N0-1 versus N2) and the number of ribs resected (fewer than 2 versus more than 2) were long-term survival predictors in an univariate analyses, Chapelier and colleagues [6] found that only histologic differentiation (well versus poorly differentiated) and the depth of chest wall invasion (parietal pleura versus other) were independent predictors of long-term survival in multivariate analyses. We believe that chest wall resection for local failure provides palliation for pain and removal of an ulcerated, occasionally pungent mass, thus potentially improving quality of life. Moreover it may give the best opportunity for local control when combined with adjuvant chemotherapy and radiation therapy. However, we caution that careful preoperative selection should be exercised in patients with recurrent local tumor owing to their high mortality rate [7]. In the era of superb technologic advances in radiation and chemotherapy and if no distant metastatic disease is present we believe that chest wall resection and reconstruction after or before chemoradiation should be the standard of care in patients with chest wall tumors regardless of the cell type. Persisting or recurring chest wall involvement with breast carcinoma after local excision and radiation therapy may require chest wall resection to achieve local control [7 9]. Chest wall recurrences were found in 1% to 2% of stage I and in 10% to 12% of stage II breast carcinomas surgically treated with an extremely variable disease-free interval [10]. The criteria we use for resection of the chest wall for local recurrence after breast cancer surgery includes (1) isolated chest wall recurrence with a disease-free interval of more than 2 years, (2) excision of a cosmetically displeasing and painful ulcerated mass, and (3) nonhealing radiation-induced ulcers. In the current series radical transmediastinal forequarter amputation and chest wall resection is indicated mainly in the treatment of malignant tumors involving the upper part of the arm, shoulder, or scapula and was performed as previously described by Mansour and Powell [11]. A variety of other nonneoplastic conditions may also warrant forequarter amputations, including (1) trauma with irreparable damage; (2) unresectable metastatic carcinoma (ie, neurovascular invasion or chest wall extension); (3) failure of conservative management; (4) severe intractable pain with loss of limb function; and (5) one or more of the following local tumor-related complications: paralysis, tumor fungation, hemorrhage, sepsis, severe lymphedema, venous gangrene, and radiationinduced complications including brachial plexopathy [12]. Of the 14 patients who underwent forequarter amputations in the current series, 1 patient (7%) died of sepsis and multisystem organ failure and in 2 patients (14%) postoperative pneumonia developed. Chest Wall Reconstruction: Prosthetic Replacement With modern surgical technique a wide range of reconstructive options are at the surgeon s disposal and hence it is imperative that the appropriate procedure be selected in a given patient. For small defects (less than 5 cm) or those located posteriorly under the scapula above the fourth rib (after resection of Pancoast tumors) the skeletal component can be ignored and the defect closed with only soft tissue. For patients undergoing large chest wall defects or pulmonary collapse, stabilization of the chest wall defect may be indicated. LeRoux and Shama [12] have set forth 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. Historically, bone, diced cartilage, metal sheets, superstructures with autogenous rib graft, fascia lata, Teflon, and numerous other substances were used with minimal success [2]. Although no substance has been found to fulfill all criteria, synthetic or alloplastic materials (eg, Prolene and Marlex mesh) are satisfactory if the condition of rigidity is not considered, the defect is medium sized, and all contaminated tissue is resected. While some authors advocate Prolene or Marlex mesh, others [13] advocate the use of polytetrafluroethylene (Gore- Tex) soft tissue patch reconstruction of all defects. For the most part, the choice of prosthetic material is based on surgeon s preference, as Deschamps and associates [14] have shown that no significant difference in the rate of postoperative outcome or complications exists between the use of Prolene mesh or PTFE soft tissue patch for chest wall reconstruction. In cases where structural integrity is necessary for preventing chest wall collapse, methyl methacrylate sandwich, silicone, Teflon, or acrylic materials have been utilized [1]. While it is still unclear of the importance of rigidity in chest wall reconstruction, observations of chest wall trauma give much significance to the presence of paradoxic motion of the chest wall. However, this uncoordinated motion during respiration is seen in almost every major resection of the chest wall but it is not associated with pulmonary insufficiency, which is seen with its traumatic counterpart, flail chest. We and others [2, 15] have commonly used methyl methacrylate sandwich (with Prolene or Marlex mesh) with excellent physiologic and aesthetic success. Although a variety of synthetic materials can be used to reconstruct the chest wall defect, there is no consensus on the most physiologic or efficacious material. Chest Wall Reconstruction: Autogenous Replacement Once the chest wall has been stabilized soft tissue coverage can be utilized to complete the reconstruction of complex thoracic defects. Although reports of transposition of the latissimus dorsi muscle for chest wall coverage had been described in 1896 by Tansini [16], it was not until the rediscovery of the musculocutaneous concept in 1977 by Jurkiewicz and associates [17] that stimulated the resurgence of the muscle and musculocutaneous flap approach to thoracic reconstruction. Whereas superficial defects of the chest wall are easily closed with local flaps or skin grafts, full thickness defects are more challenging

6 Ann Thorac Surg MANSOUR ET AL 2002;73: CHEST WALL RESECTIONS AND RECONSTRUCTIONS 1725 and often require close interaction between the thoracic and plastic surgeons. The indications for soft tissue free or pedicled muscle reconstruction are to provide vascularized tissue to cover a thoracic wound, control infection, obliterate dead space, and to potentially provide coverage of synthetic mesh used to stabilize the chest wall. The availability of numerous reconstructive techniques with well-vascularized tissue enables the extirpative surgeon then to take the wide and appropriate resections to ensure successful long-term management. The numerous advances in chest reconstruction over the years with the introduction of muscle and musculocutaneous flaps have made them the mainstay in chest wall reconstruction [2, 7, 13, 18]. The thoracic trunk is well suited for vascularized coverage given the many local muscle flaps (eg, latissimus dorsi, pectoralis major, rectus abdominis, trapezius, or deltoid muscles) or greater omentum (used alone or in combination as options for wound coverage) [13, 19, 20]. With the bountiful methods of pedicled muscle transfer and uncommon pedicled muscle flap loss, the necessity for free flap in the reconstruction of the thoracic wall defect is minimal. Therefore, in our experience free tissue transfer flap is seldom utilized for chest wall reconstruction and is generally used when pedicled flaps are unavailable. In the rare situation of pedicled muscle flap loss, the pedicled omental flap has been useful as a salvage procedure in those instances. Free muscle flap failure generally requires a repeat free flap as pedicled muscle flaps would be unavailable. In conclusion, the key to a successful outcome in these complex cases is the coordinated effort by the surgical teams in individualizing the care of these patients utilizing total resection of the disease process, reconstruction of the chest wall integrity, and soft tissue coverage of the defect. The team of surgeons should be well versed in chest wall reconstruction utilizing prosthetic materials and free or pedicled muscle flaps and must plan and work together to achieve optimal results. References 1. Graeber GM, Langenfeld J. Chest wall resection and reconstruction. In: Franco KL, Putman JR, eds. Advanced therapy in thoracic surgery. London: BC Decker, 1998: McCormack PM. Use of prosthetic materials in chest-wall reconstruction. Surg Clin North Am 1989;69: Azarow KS, Molloy M, Seyfer AE, Graeber GM. Preoperative evaluation and general preparation for chest-wall operations. Surg Clin North Am 1989;69: Pairolero PC. Extend resections for lung cancer. How far is too far? Eur J Cardiothorac Surg 1999;16:S48 S Magdeleinat P, Alifano M, Benbrahem C, et al. Surgical treatment of lung cancer invading the chest wall: results and prognostic factors. Ann Thorac Surg 2001;71: Chapelier A, Fadel E, Macchiarini P, et al. Factors affecting long-term survival after en-bloc resection of lung cancer invading the chest wall. Eur J Cardiothorac Surg 2000;18: Mansour KA, Anderson TM, Hester TR. Sternal resection and reconstruction. Ann Thorac Surg 1993;55: Anderson BO, Burt ME. Chest wall neoplasms and their management. Ann Thorac Surg 1994;58: Seyfer AE. Breast cancer invasion into the chest wall with resection and reconstruction. Semin Thorac Cardiovasc Surg 1999;11: Picciocchi A, Granone P, Cardillo G, Margaritora S, Benzoni C, D ugo D. Prosthetic reconstruction of the chest wall. Int Surg 1993;78: Mansour KA, Powell RW. Modified technique for radical transmediastinal forequarter amputation and chest wall resection. J Thorac Cardiovasc Surg 1978;76: LeRoux BT, Shama DM. Resection of tumors of the chest wall. Curr Probl Surg 1983;20: Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of 500 consecutive patients. Plast Reconstr Surg 1996;98: Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 1999;117: McCormack P, Bains M, Martini N, Burt M, Kaiser LR. Methods of skeletal reconstruction following resection of lung carcinomas invading the chest wall. Surg Clin North Am 1987;67: Tansini I. Nuovo processo per amputations della mammella per cancro. Reform Med 1896;12: Brown R, Fleming W, Jurkiewicz M. An island flap of the pectoralis major muscle. Br J Plast Surg 1977;30: Cohen M, Ramasastry SS. Reconstruction of complex chest wall defects. Am J Surg 1996;172: Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results. Ann Plast Surg 2001;46: Jurkiewicz MJ, Arnold PG. The omentum: an account of its use in the reconstruction of the chest wall. Ann Surg 1977; 185: DISCUSSION DR THOMAS A. D AMICO (Durham, NC): Dr Thourani, that was an excellent series and an outstanding presentation. I just have two questions. Most series separate sternal tumors from chest wall tumors, although there is some overlap. I wonder if you analyzed the complications afterwards to look at patients with sternal tumors versus chest wall tumors? And second, most surgical series have a much higher use of PTFE. I wonder why your group does not use PTFE more often. Thank you very much. DR THOURANI: Thank you, Dr D Amico, for those insightful comments. To answer your last question first, we use Gore-Tex (PTFE) for diaphragmatic and pericardial reconstruction on a routine basis for its smoothness. On the other hand, we use Prolene mesh (doubled or quadrupled on itself) with or without methyl methacrylate sandwich for reconstruction of chest or sternal defects and we are pleased with the results. We have chosen Prolene mesh mainly and Marlex mesh occasionally (both polypropylene meshes and musch cheaper than Gore-Tex) for their in-growth and their pliability. As far as your first question goes, we did not separate the sternal tumor complication rate from the chest wall defects. We consider the sternum as obviously a very integral portion of the chest wall, but we did not compare those two groups.

7 1726 MANSOUR ET AL Ann Thorac Surg CHEST WALL RESECTIONS AND RECONSTRUCTIONS 2002;73: DR JAMES JONES (Scranton, PA): What were your indications for using the Vicryl mesh and were your results with that as good as with the other techniques? DR THOURANI: We use Vicryl mesh more commonly in situations where there was more surgical wound contamination or infection. In our series, Vicryl mesh was taken out occasionally after the immediate infection was cleared up; this represents some of the patients who had delayed closure. DR PETER PAIROLERO (Rochester, MN) Dr Thourani, I appreciated your excellent presentation detailing the use of muscle transposition in thoracic surgery. Although muscle flaps had been used in other areas of the body including the chest for some time, its rebirth in thoracic surgery occurred at Emory University in the early 1970s. Doctor M. J. Jurkiewicz was chief of plastic surgery at Emory and was surrounded by a group of energetic young plastic surgery residents. Armed with the techniques of chest wall reconstruction utilizing muscle transposition, these surgeons moved to other institutions in the United States where these techniques were refined to include intrathoracic transposition and their contributions have been adopted by a number of other surgeons. I have been fortunate to work with one of these residents, Dr P. G. Arnold, for the past 25 years and from my perspective, muscle transposition has been one of the best things that has happened in general thoracic surgery. DR THOURANI: Thank you, Dr Pairolero, for your eloquent comments. We are aware of your and Dr Arnold s contributions to chest wall resections and reconstruction. We agree that Dr Jurkiewicz s popularization of muscle flaps at Emory University was a milestone in the reconstruction of chest wall defects and that Dr. Arnold was one of his trainees. We are obviously very grateful for these contributions. The authors thank the Association for the privilege of presenting our data. Thank you. Requirements for Recertification/Maintenance of Certification in 2002 Diplomates of the American Board of Thoracic Surgery who plan to participate in the Recertification/ Maintenance of Certification process in 2002 must hold an active medical license and must hold clinical privileges in thoracic surgery. In addition, a valid certificate is an absolute requirement for entrance into the recertification/maintenance of certification process. If your certificate has expired, the only pathway for renewal of a certificate is to take and pass the Part I (written) and the Part II (oral) certifying examinations. The American Board of Thoracic Surgery will no longer publish the names of individuals who have not recertified in the American Board of Medical Specialties directories. The Diplomate s name will be published upon successful completion of the recertification/maintenance of certification process. The CME requirements are 70 Category I credits in either cardiothoracic surgery or general surgery earned during the 2 years prior to application. SESATS and SESAPS are the only self-instructional materials allowed for credit. Category II credits are not allowed. The Physicians Recognition Award for recertifying in general surgery is not allowed in fulfillment of the CME requirements. Interested individuals should refer to the 2002 Booklet of Information for a complete description of acceptable CME credits. Diplomates should maintain a documented list of their major cases performed during the year prior to application for recertification. This practice review should consist of 1 year s consecutive major operative experiences. If more than 100 cases occur in 1 year, only 100 should be listed. Candidates for recertification/maintenance of certification will be required to complete all sections of the SESATS self-assessment examination. It is not necessary for candidates to purchase SESATS individually because it will be sent to candidates after their application has been approved. Diplomates may recertify the year their certificate expires, or if they wish to do so, they may recertify up to two years before it expires. However, the new certificate will be dated 10 years from the date of expiration of their original certificate or most recent recertification certificate. In other words, recertifying early does not alter the 10-year validation. Recertification/maintenance of certification is also open to Diplomates with an unlimited certificate and will in no way affect the validity of their original certificate. The deadline for submission of applications for the recertification/maintenance of certification process is May 1 each year. A brochure outlining the rules and requirements for recertification/maintenance of certification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201; telephone number: (847) ; fax: (847) ; abts_ evanston@msn.com. This booklet is also published on the website: by The Society of Thoracic Surgeons Ann Thorac Surg 2002;73: /02/$22.00 Published by Elsevier Science Inc