Ann Thorac Surg 2006;81:285
© 2006 The Society of Thoracic Surgeons
Original article: General thoracic
Invited commentary
Joe B. Putnam, Jr, MD
Department of Thoracic Surgery, Vanderbilt University, 2971 The Vanderbilt Clinic, 1301 22nd Ave S, Nashville, TN 37232-5734
(Email: bill.putnam{at}vanderbilt.edu).
Optimal management to improve early clinical outcomes after chest-wall resection (CWR) reflects the variable cause, presentation, and treatment options for this surgical problem. Chest wall neoplasms (primary, metastatic, or local involvement by lung cancer) can involve any aspect of the boney thorax and sternum, and can be highly variable in size and biological virulence. Such variability limits prospective clinical investigations. In this article, a contemporary large retrospective review of early (postoperative) outcomes after CWR is presented that provides additional insights into relating these early outcomes to treatment decisions.
Approximately one third of the patients had either metastatic or recurrent tumors to the chest wall or primary chest-wall tumor, or had chest wall involvement by direct extension of lung cancer. In addition to CWR, major lung resection (lobectomy or greater) was performed in 34% of all patients. Areas of CWR were anatomically defined, accurately measured (cm2, not number of ribs), and analyzed. In general, patients with anterior CWR and sternal resections were reconstructed with rigid prostheses.
The low number of patients with pulmonary events (29 patients; 11%) reflect reconstruction with rigid prostheses and improved general pulmonary care in this series. The mortality was 3.8% (10 patients); respiratory events were the cause of 7 of 10 deaths, including 4 patients with pneumonectomy plus CWR. Multivariate analysis identified older age, concomitant anatomical lung resection, and larger defect size as significant adverse variables. Attenuation of early postoperative respiratory events will further improve clinical outcomes. Correlation with preoperative spirometry could be helpful in assisting with patient selection, preparation for resection, determination of the extent of resection, and the technique of reconstruction.
This review of early clinical outcomes after CWR provides a basis for improving perioperative and intraoperative care processes [1]. Iterative improvements are possible and could be focused on precise choice of reconstruction technique and improving perioperative pulmonary function. The use of rigid reconstruction seems to enhance early postoperative pulmonary function, particularly after larger CWRs. The current and future use of The Society of Thoracic Surgeons general thoracic surgery database will provide further insight into reconstruction techniques and outcomes from patients undergoing chest wall resection, a variable and challenging population.
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- Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis Ann Thorac Surg 2006;81:279-287.[Abstract/Free Full Text]
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