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Discussion on methods of massive chest wall resection and reconstruction
Shu Jun, Xue Yang, Cong Wei, Chen Fan, Gan Chongzhi, Xie Jiayong, Zeng Fuchun
(Sichuan Academy of Medical Sciences·Sichuan Provincial People’s Hospital Department of Cardiothoracic Surgery, Chengdu 610072, Sichuan)
【Abstract】 ObjectiveTo investigate the method and effect of massive chest wall resection and repair and reconstruction of chest wall defect. Methods A retrospective analysis of 11 cases of primary chest wall tumors and other lesions involving the chest wall required massive chest wall resection, and multiple methods were used for reconstruction during the operation. Bone thoracic reconstruction is carried out with artificial materials such as Gore mesh and mesh titanium alloy plate, and subcutaneous soft tissue repair mainly uses layered direct suture or transfer of myocutaneous flap. ResultsThe largest chest wall area was resected (15×20) cm2, 5 cases of primary chest wall tumor (1 benign, 4 malignant), 2 chest wall tuberculosis, 3 peripheral lung cancer, and postoperative breast cancer 1 case of recurrence. All patients underwent massive chest wall resection and reconstruction surgery. There was no operative death in the whole group, postoperative respiratory function was good, and there was no abnormal respiratory movement. Conclusions According to the location and size of the chest wall defect, different repair materials and autologous muscle flap coverage are reliable methods for repairing and reconstructing the chest wall.
【Key words】 Chest wall lesions (primary and secondary) ; Surgical treatment; Chest wall reconstruction
【Middle image Classification number] R 6551. 1 [Document identification code] A [Article number] 1004-051( 2012) 10-1698-03< /p>
Exploration on the reliable reconstruction methods after massive resection of chest wall. SHU Jun, XUE Yang, CONG Wei, et al. The People’s Hospital of Sichuan, Chengdu, Sichuan 610072, China
【Abstract】 Objective To investigate the methods and efficacy of massive resection and reconstruction of chest wall． Methods 11 cases including primary chest wall tumors and other lesions involving massive resection of chest wall were analyzed retrospectively. Various reconstruction methods were used intraoperatively. We used bony thorax with artificial material such as gore patches and mesh titanium alloy plate in reconstruction of chest wall. And the reparation of subcutaneous soft tissue layers were with direct layer suture or muscle flap transfer. Results The maximum retraction area of chest wall was 15cm×20cm. Five pa- tients were diagnosed with primary chest wall tumor (one case of benign and the other four were malignant), two with chest wall tuberculosis, three with peripheral lung cancer, and one with breast cancer recurrence. They all underwent massive resection and re-construction of chest wall. There was no operative mortality. The postoperative respiratory function of all patients was well, without abnormal respiratory movement. Conclusion It would be a reliable reconstruction method that combining autologous muscle flap coverage and various repair materials based on the location and size of the defect of chest wall．
【 Key words 】 chest wall lesions primary and secondary; surgical treatment; reconstruction of chest wall
The treatment of chest wall tumors (primary and secondary), peripheral lung cancer invading the chest wall and chest wall tuberculosis is still the first choice for surgery, but surgery Large chest wall defects may be left behind, destroying the integrity, stability and tightness of the chest wall. Especially the surgical treatment of malignant lesions often requires extended resection, and the size of the surgical resection is closely related to the prognosis. The repair of the defect is very important. The reconstruction of the bony thorax is the key to the operation. From January 2005 to January 2011, our department performed massive chest wall resection and chest wall defect repair and reconstruction for 11 cases of different chest wall lesions. Its clinical data, discuss the method of chest wall defect reconstruction.
1 Materials and methods
1. 1 < /span>General information: There were 11 cases in this group, including 4 males and 7 females, with an average age of 50.6 (20-71) years old. The clinical data of 11 patients with chest wall lesions are shown in Table 1.
1.2 Surgical methods: The surgical methods in this group are shown in Table 2. All patients were treated with general anesthesia (single-lumen or double-lumen tube) After successful anesthesia, the appropriate body position (supine or lateral position) should be adopted according to the different parts of the lesion, and the selection of the surgical incision should be determined according to the location of the tumor. Large chest wall Resection (5cm from the tumor edge), including normal upper and lower ribs and intercostal muscles. Lung cancer patients should undergo lobectomy+mediastinal lymph node dissection. For large chest wall defects caused by massive resection of the chest wall, especially in the anterior or lateral chest wall, autologous and artificial materials should be used for reconstruction of the chest wall defect. Our department mainly uses Gore mesh and mesh titanium alloy sheet for the reconstruction of chest wall defects, and when necessary, muscle flap transfer is performed to fill the defects of the soft structures of the chest wall. Routine thoracic drainage was performed postoperatively, and local compression bandaging was performed.
2 Results
All 11 patients in this group underwent radical resection, and there was no surgical complication or death in the whole group. Postoperative chest wall stability was good, and there was no obvious paradoxical breathing. The quality of life after reconstruction of the defect caused by benign tumor and chest wall tuberculosis was good, and there was no recurrence or other long-term complications. The follow-up of the patients in this group is shown in Table 2.
3 Discussion
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With the development of science and technology, many biomaterials with good histocompatibility are used in clinical treatment. Therefore, the radical treatment of many diseases requires massive excision of the chest wall. chest wall reconstruction possible. Chest wall reconstruction includes bony thoracic reconstruction and soft tissue repair. The former uses artificial materials to maintain the firmness and stability of the chest wall, and the latter sometimes uses pedicled tissue to achieve tightness and better appearance of the chest wall.
3.1 Defining the scope of surgical resection: Benign lesions of the chest wall, metastases, peripheral lung cancers that directly invade the chest wall, and some low-malignancy primary chest wall tumors can be En bloc resection was performed about 1 to 3 cm outside the tumor. The extent of surgical resection of primary chest wall malignancies is closely related to prognosis. Most scholars believe that the normal tissue should be at least 5 cm away from the tumor edge, including a rib above and below the involved muscle space [1]. Resection, the 5-year survival rate of tumor recurrence-free patients can reach more than 50%, and limited resection ( < 5cm ), the 5year survival rate is only20 %～30%[2].
3.2 Principles and surgical methods of chest wall reconstruction: try to keep the uninvolved chest wall tissue as a pedicled skin-muscle flap during surgery Metastasis and reconstruction of the chest wall lay the foundation. Before surgery, detailed incision design and chest wall reconstruction plan should be carried out. If skin-muscle flap transfer is required, a surgical plan should be jointly formulated with a plastic surgeon. Mastering the reliable method of chest wall reconstruction after massive resection of the chest wall is a strong guarantee for improving the prognosis of surgical treatment [3]. It is generally believed that the defect area of the anterolateral chest wall exceeds 6 cm × 6 cm, and there are more than 2 rib defects, while the posterior chest wall is protected by the scapula and thicker muscles, and the defect area reaches 10 cm × 10 cm. According to the above principles, except for 2 cases with relatively small defects and the use of soft materials to repair the defects, the remaining 9 cases used mesh titanium alloy plates to reconstruct the bony chest wall. Among them, 3 cases with larger muscle defects were used for reconstruction. Transfer the latissimus dorsi muscle flap to seal the thoracic cavity [4,5].
Peripheral lung cancer and breast cancer recurrence after surgery mostly directly invade the chest wall, and the resection method of the invaded chest wall depends on the degree of chest wall invasion. In addition to specialist surgical resection, complete resection of the invaded chest wall in addition to lymph node dissection is the key to radical treatment in such patients. In the past, due to the limitation of reconstruction materials and lack of experience, the resection area of the chest wall was often conservative, and it was difficult to achieve radical resection. In recent years, this field has attracted the attention of many scholars. It is believed that with the continuous accumulation of experience and richness, massive chest wall resection and reconstruction surgery will gradually mature and increase in number.
Criteria for chest wall reconstruction should meet: ①enclosed chest; ②stabilized chest wall to reduce or/and eliminate paradoxical breathing; ③acceptable Exterior.
3. 3 Prognosis of chest wall reconstruction: benign lesions and benign tumors The patients survived for a long time and had a high quality of life. The prognosis of primary malignant tumors varies greatly depending on the pathological type. The prognosis of primary chest wall malignant tumor directly invading the chest wall is related to the pathological type, malignancy and metastasis of the primary tumor. Lung cancer invading the chest wall belongs to IIB or IIIA type. According to literature reports, the 5-year survival rate of surgical treatment of this type of lesions ranges from 11.1% to 32% [6,7]. The number of cases in this group is small, and it is difficult to judge the value of the surgical prognosis of these patients after massive resection and reconstruction of the involved chest wall. However, the author believes that if the surgical resection of the primary disease can achieve radical resection, then the mass resection and reconstruction of the involved chest wall can achieve a meaningful clinical outcome.
References:
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( Received date: 2012-02-24)