Chest Wall Tumors and Reconstruction: Lateral Chest Wall. Dr. Robert Kelly

Chest Wall Tumors and Reconstruction: Lateral Chest Wall Dr. Robert Kelly

THORACIC PROGRAMME: ADVANCES IN CHEST WALL SURGERY AND OSTEOSYNTHESIS

Dr. José Ribas Milanez de Campos Assistant, Professor, Department of Thoracic Surgery, Hospital das Clínicas INCOR University of São Paulo, Thoracic Surgery Staff of the Hospital Israelita Albert Einstein São Paulo - BRAZIL

Chest Wall Tumors and Reconstruction: Lateral Chest Wall 1) Reconstruction of full thickness defects of the lateral chest wall is controversial and presents a complicated treatment scenario for thoracic and plastic surgeons. 2) It requires close cooperation to achieve an optimal outcome and reduce the incidence of complications.

Chest Wall Tumors and Reconstruction: Lateral Chest Wall Purpose of this presentation: to evaluate our results in patients who underwent prosthetic bony reconstruction with polypropylene mesh, different plates and pedicle latissimus dorsi flap, serratus anterior flap or pectoralis major flap, after lateral chest wall resection.

If the defect after resection exceeds 4 to 5 ribs and stabilization was necessary, methyl methacrylate sandwich graft were sometimes used in the beginning of our experience.

Different affections: Tumors Infections Actinic Trauma General concepts - reconstruction: Integrity of pleural cavity No residual space No ischemic tissues Stabilization Protection Aesthetical results Respiratory physiology No complications

Chondrosarcoma: Female patient, 47 years Pain left HT, exercises 6 months of evolution 2 ribs resected

General concepts - reconstruction: Integrity of pleural cavity OK No residual space OK No ischemic tissues OK Stabilization Protection OK Aesthetical results OK Respiratory physiology OK No complications OK SURGICAL TECHNIQUE: Polypropylene mesh Pectoralis major flap

Osteosarcoma: Male patient, 54 y Pain & tumor right HT 7 months of evolution 6 ribs resected

SURGICAL TECHNIQUE: Polypropylene mesh Latissimus dorsi flap

General concepts - reconstruction: Integrity of pleural cavity OK No residual space OK No ischemic tissues OK Stabilization Protection NO Aesthetical results NO Respiratory physiology?? No complications OK 10 YEARS AFTER

Soft Tissue Sarcoma (Fibrosarcoma - low grade): Male patient, 33 y Pain & tumor left HT 2 months of evolution 5 ribs resected

SURGICAL TECHNIQUE: Polypropylene mesh - double layer Latissimus dorsi flap Methyl methacrylate sandwich graft

General concepts - reconstruction: Integrity of pleural cavity OK No residual space OK No ischemic tissues OK Stabilization Protection NO Aesthetical results NO Respiratory physiology OK No complications OK 11 YEARS AFTER =>

CASUISTIC: from more than 350 operated patients HC.FMUSP DR. Angelo Fernandez It includes 67 patients Underwent to lateral chest wall resection Due to various causes Period of 19 years Aug/95 to Aug/2015 All patients followed up - At least 1 year after the procedure 47 males & 20 females Average age = 53 years (range 31-74 years) Average area of chest wall defect = 17 x 11cm

General concepts - Reconstruction: Complications??? SURGICAL TECHNIQUE: Muscle flap + Polypropylene mesh = 3.5% (2 Patients) + Methyl methacrylate sandwich graft??? - YEARS AFTER

SURGICAL TECHNIQUE: Polypropylene mesh - double layer Pectoralis major flap - bilateral 1983 Methyl methacrylate sandwich graft

Late complications: 10 years Partial absorption, fracture and displacement Methyl methacrylate sandwich graft removed.

Late follow-up: 25 years Only with polypropylene mesh - double layer

Late complications: Infections Methyl methacrylate sandwich graft

General concepts - reconstruction: Complications: 57 analyzed patients 11 (19.3%) with Methyl methacrylate sandwich graft 2 (18%) Infections 2 (18%) Fractures 2 (18%) Displacement 54% = YEARS AFTER!!!

Chondrosarcoma: Female patient, 67 y, 3 years of evolution, 8 ribs resected. Extension of the chest wall resection is important?

It s necessary to restore the rigidity of the chest wall to prevent physiologic flail??

SURGICAL TECHNIQUE: Polypropylene mesh double layer Latissimus dorsi flap 14.240 kg

Results: Post operative period 1 year of follow-up, no symptoms It is still unclear of the importance of rigidity in chest wall reconstruction. Paradoxical motion is seen in almost every major resection, but is not associated with pulmonary insufficiency.

Chest Wall Tumors and Reconstruction: Lateral Chest Wall Alternative technique = Omentum: Ability to reach = anterior and lateral chest wall Excellent blood supply from gastroepiploic vessels No structural stability necessary additional support Adheres to the wound and readily accepts and supports an overlying skin graft.

Alternative technique = Omentum: Exceedingly helpful in situations in which the muscle flaps have been used, salvage procedure. Fibrosarcoma, highgrade, male, 37 y, recurrence after 1 year.

Chest Wall Tumors and Reconstruction: Lateral Chest Wall Alternative technique = TRAM : Transverse rectus abdominis musculocutaneous flap: reconstruction of the breast and of radiation injuries of the antero-lateral chest wall. Radiation necrosis: female, 39 y, recur. breast carcinoma.

Alternative technique = TRAM : The flap is based on the integrity of the rectus abdominis muscle, ready to be transfer into the thoracic defect. The muscle, subcutaneous tissue and skin can all be transposed underneath the bridge of intact abdominal wall.

Alternative technique = STRATOS: Reconstructive surgery: defect bridging after tumor removal or related to the rigidity of chest wall, to abolish paradoxical motion. Chondrosarcoma, female, 31 y, no recurrence after 1,5 years.

STRATOS PATIENTS IN BRAZIL STRASBOURG - FRANCE - 2007

STRATOS PATIENTS IN BRAZIL Male patient, 44 years old, Chest Wall Tumor, 03 Ribs were removed, Dr. Benoit Bibas.

STRATOS PATIENTS IN BRAZIL Chest Wall Tumor, Chondrossarcoma, Alive 3 years after.

STRATOS PATIENTS IN BRAZIL THORACIC TUMORS WITH STRATOS TECHNIQUE Male patient, 52 years old, Metastatic tumor of the sternum, Osteosarcoma, controlled since 2009 on the left lower limbs.

STRATOS PATIENTS IN BRAZIL Magnetic resonance of the tumor.

STRATOS PATIENTS IN BRAZIL Surgical aspect of the tumor before the resection of the sternum.

STRATOS PATIENTS IN BRAZIL Surgical aspect of the resected tumor.

STRATOS PATIENTS IN BRAZIL Surgical aspect of the reconstruction of the chest wall with Stratos bar and double layer of marlex mesh.

STRATOS PATIENTS IN BRAZIL Surgical aspect of the reconstruction of the chest wall with three Stratos bar and double layer of marlex mesh.

STRATOS PATIENTS IN BRAZIL Respiratory distress syndrome, flail chest, anterior chest wall, necessitating mechanical ventilation, with 3 bars??

STRATOS PATIENTS IN BRAZIL Reoperation of the reconstruction of the chest wall, now using four Stratos bars.

STRATOS PATIENTS IN BRAZIL Chest X-Ray with four Stratos bar + marlex mesh.

STRATOS PATIENTS IN BRAZIL After 31 days, the surgical aspect of the reconstruction of the chest wall.

SOFT TISSUE SARCOMA LOW GRADE R0

DISCHARDED FROM THE HOSPITAL - 4 PO

Large resections of the chest wall, including the ribs, sternum, and/or surrounding soft tissue, are performed for the curative and palliative treatment of malignant and benign tumors, radiation necrosis, and deep sternal wound infections. Resections of defects greater than 5 cm in diameter require skeletal reconstruction to maintain physiologic respiratory function and protect vital intrathoracic organs. Paradoxical respiration may occur without proper stabilization causing: pain, respiratory distress, and often necessitating long term mechanical ventilation.? The main goals of reconstruction are: prevention of flail chest, maintenance of physiologic respiration, protection of thoracic organs, and an acceptable cosmetic result.

Chest Wall Tumors and Reconstruction: Lateral Chest Wall

GORE DUALMESH Biomaterial is the first dual-surface material that encourages host tissue ingrowth while minimizing tissue attachment in soft tissue, and fascial reconstruction. The GORE-TEX Soft Tissue Patch is a specialty biomaterial designed to meet the needs of the most demanding soft tissue repairs with minimal complications. ETHICON PHYSIOMESH Flexible Composite Mesh

Follow-up: Only four (7%) patients with a lateral chest wall tumor developed a recurrence. Among these three (5%) were reoperated with success. In Conclusion: The chest wall resection and reconstruction with synthetic polypropylene mesh, or others, different plates and local muscle flaps can be performed as a safe, effective onestage surgical procedure for a variety of major lateral chest wall defects. When a methyl methacrylate sandwich graft were used, we expect more complications.

Conductor in Vienna -- The Captain of the Carrier in Norfolk Dr. J.M.Wihlm Dr. R. Kelly