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Ann Thorac Surg 2002;73:1720-1726
© 2002 The Society of Thoracic Surgeons

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Original article: general thoracic

Chest wall resections and reconstruction: a 25-year experience

^a Joseph B. Whitehead Department of Surgery, Divisions of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia USA
^b Joseph B. Whitehead Department of Surgery, division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Georgia USA

* Address reprint requests to Dr Mansour, 1365 Clifton Rd, The Emory Clinic, Atlanta, GA 30322 USA
e-mail: kamalmansour{at}emoryheathcare.org

Presented at the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8–10, 2001.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
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 14 ± 14 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.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
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; 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

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
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 resections, acute sternal infections after median sternotomy for cardiac surgery, or primary Eloesser procedures were not included in the present series. Mean age was 54 ± 16 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. Forty-six 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.

	Results

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
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 performed secondary to the hemodynamic instability of the patients and to ongoing infectious processes.

In-hospital outcomes are presented in Table 5. The overall length of stay (LOS) was 18 ± 16 days (range 3 to 99, median 10) and the postoperative LOS was 14 ± 14 days (range 2 to 98). A total of 168 patients (84%) required 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.

View larger version (140K): [in this window] [in a new window]   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.

View larger version (149K): [in this window] [in a new window]   Fig 2. Double-thickness Marlex mesh coverage of the chest wall defect is shown.

View larger version (125K): [in this window] [in a new window]   Fig 3. Closure of the chest wall was performed using a deltocervical flap.

	Comment

Top Abstract Introduction Patients and methods Results Comment Discussion References

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 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, 16 ± 15 days, 5 ± 7 days versus 18 ± 17 days, 13 ± 13 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 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 radiation-induced 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 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.

	Discussion

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
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.

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.

	References

Top Abstract Introduction Patients and methods Results Comment Discussion References

 

1. Graeber G.M., Langenfeld J. Chest wall resection and reconstruction. In: Franco K.L., Putman J.R., eds. Advanced therapy in thoracic surgery. London: BC Decker, 1998:175-185.
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kamal A. Mansour Joseph I. Miller, Jr Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mansour, K. A. Articles by Jones, G. E. Search for Related Content PubMed PubMed Citation Articles by Mansour, K. A. Articles by Jones, G. E.