Ann Thorac Surg 2009;87:e31-e33. doi:10.1016/j.athoracsur.2008.12.096
© 2009 The Society of Thoracic Surgeons
How To Do It
Reconstruction of the Thorax With Ley Prosthesis After Resection of the Sternum
Thais A.L. Pedersen, MD*,
Hans K. Pilegaard, MD
Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
Accepted for publication December 30, 2008.
* Address correspondence to Dr Pedersen, Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, DK-8200, Denmark (Email: thais.a.pedersen{at}ki.au.dk).
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Abstract
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The Ley prosthesis is a titanium plate, which has been used in the past few years for sternum stabilization after postoperative mediastinitis and sternal dehiscence. There is no previous description of the use of this device in chest wall reconstruction after tumor resection. We describe the surgical technique for reconstruction of the skeletal defects with the Ley prosthesis in 3 patients operated on for a sternal chondrosarcoma. We propose the application of the Ley prosthesis for optimal reconstruction of skeletal tissue after sternal resection.
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Introduction
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Primary sternal tumors account for approximately 1% of all primary bone tumors [1]. Several surgical techniques have been described for chest wall reconstruction after resection of sternal tumors [2]. Among them, there are autologous bone grafts, musculocutaneous flaps, and alloplastic materials [3]. The decision to determine which method to choose depends on the location of the defect, depth, cause of the disease, and the surgeon's preference [4]. All methods have advantages and disadvantages. All of them carry the underlying risk of ischemia (especially pedicled musculocutaneous flaps), chronic chest pain, and respiratory dysfunction. Besides, persistent sternal instability can occur, because they may not provide the necessary support of the chest wall and protection of the intrathoracic contents [2, 3, 5].
The Ley prosthesis is a new device among the alloplastic materials. Its use has been documented since 2001 in stabilization of the sternum after postoperative mediastinitis [6] and in sternal dehiscence [7]. It is made of a 0.5-mm thick titanium alloy plate shaped as a step ladder [6]. It is flexible and adapts to the sternal contour. There is no previous description of the use of the Ley prosthesis in chest wall reconstruction and stabilization after tumor resection. We describe our experience after resection of sternal chondrosarcoma in 3 patients.
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Technique
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In all three reported cases, resection of the sternum was performed with the incision extending from 2 cm to 3 cm below the jugular notch down to the upper part of the abdomen. The subcutaneous and muscular tissues bordering the sternum were laterally mobilized. The resection encompassed the whole body of the sternum and the bordering costal cartilages, including a 3-cm margin from the macroscopic limitations of the tumor. The involved ribs were excised and the tumor was totally removed. A Ley prosthesis was placed in the defect, as described by Austudillo and colleagues [6], and it was fixed with steel wires around the end of the resected ribs, as in Figure 1. Soft tissue coverage was achieved using a pectoralis major and rectus abdominis musculocutaneous flap. Two drains were placed in the mediastinum. The subcutaneous tissue was sutured with a nonabsorbable filament. The skin was closed with clips.
Patient A
An 81-year-old woman was referred to surgery in August 2004, due to a sternal chondrosarcoma degree III. Imaging computer tomographic and magnetic resonance imaging scans showed a 10-cm sternal tumor located close to the pericardium, but with no pericardial or pulmonary invasion. The tumor involved the internal mammary artery bilaterally and the majority of the sternum, with the exception of a few centimeters of the cranial manubrium. The day after the operation, she was discharged from the intensive care unit. On postoperative day 10, she presented with hydrothorax, which was drained without further complications. The total length of stay at the hospital was 23 days.
Patient B
A 50-year-old man was referred to surgery in June 2005, due to a degree I-II sternal chondrosarcoma. A computed tomographic scan showed a left-sided 6 x 7 cm tumor involving the lower sternum and the adjacent costal cartilages. No other structures were involved. The patient was discharged from the recovery unit the day after surgery. A hematoma developed under the musculocutaneous flap, but no signs of infection; therefore, the hematoma was left untouched. He was discharged from the hospital on postoperative day 16 for further treatment in the day clinic of the oncology department. He was operated on 1 year later for lung cancer, which was uneventful.
Patient C
A 44-year-old woman was referred to surgery in October 2005, with a degree II chondrosarcoma. Imaging computed tomographic scan showed a confined 3-cm tumor in the lowest part of the sternum, with no invasion of other thoracic structures. The day after surgery, she was discharged from the recovery unit. Twice, a subcutaneous seroma developed, which was drained by using a thin percutaneous catheter; no complications occurred. On postoperative day 14, a superficial surgical wound infection developed, caused by various Staphylococcus species. She was orally treated with dicloxacillin, with a good result. The length of stay at the hospital was 22 days (Fig 2).
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Fig 2. (A) Front view chest roentgenogram of patient C after the operation. (B) Side view chest roentgenogram of patient C after the operation.
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Comment
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Surgery is the treatment of choice for primary sternal tumors [8]. Nevertheless, sternal tumors have long been considered a surgical challenge due to the complexity of performing an extensive resection without endangering the stability of the anterior chest wall [1], in view of the fact that sternal instability compromises pulmonary function and chest wall mechanics [3]. New improvements in surgical techniques, including the use of prosthetic materials are now making it possible to perform wide resections with relief of the symptoms, prevention of the flail chest, and good long-term survival [3].
We achieved satisfactory surgical results in all three cases with a follow-up time of 4, 3, and 2.5 years for patients A, B, and C, respectively. We had no major complications, no incidents of chronic pain, and the incidence of minor complications was similar to what has been described in larger series in which other methods for chest reconstruction was used [1, 3, 4].
In conclusion, the application of the Ley prosthesis can be extended for stabilization of the anterior chest wall after wide resection of sternal tumors.
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References
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- Lequaglie C, Massone PPB, Giudice G, Conti B. Gold standard for sternectomies and plastic reconstructions after resections for primary or secondary sternal neoplasms Ann Surg Oncol 2002;9:472-479.[Medline]
- Skoracki RJ, Chang DW. Reconstruction of the chestwall and thorax J Surg Oncol 2006;94:455-465.[Medline]
- Haraguchi S, Masafumi H, Hisayoshi T, et al. Resection of sternal tumors and reconstruction of the thorax: a review of 15 patients Surg Today 2006;36:225-229.[Medline]
- Losken A, Thourani VH, Carlson GW, et al. A reconstructive algorithm for plastic surgery following extensive chest wall resection Br J Plast Surg 2004;57:295-302.[Medline]
- Voss B, Bauernschmitt R, Brockmann G, Lange R. Osteosynthetic thoracic stabilization after complete resection of the sternum Eur J Cardiothorac Surg 2007;32:391-393.[Abstract/Free Full Text]
- Astudillo R, Vaage J, Myhre U, Karevold A, Gaardlund B. Fewer reoperations and shorter stay in the cardiac surgical ward when stabilising the sternum with the Ley prosthesis in post-operative mediastinitis Eur J Cardiothorac Surg 2001;20133–19.
- Szerafin T, Osama J, Gyory F, Peterffy A. Surgical treatment of sternal dehiscence after sternotomy using Ley prosthesis Magy Seb 2001;54:375-378.[Medline]
- Chapelier A, Macchiarini P, Rietjens M, et al. Chest wall reconstruction following resection of large malignant tumors Eur J Cardiothorac Surg 1994;8:351-356.[Abstract/Free Full Text]
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Abstract
Introduction
