Ann Thorac Surg 2009;87:1630-1632. doi:10.1016/j.athoracsur.2008.09.068
© 2009 The Society of Thoracic Surgeons
How To Do It
Extrapleural Pneumonectomy With Reconstruction of Diaphragm and Pericardium Using Autologous Materials
Hironori Kobayashi, MD, PhD,
Hiroaki Nomori, MD, PhD*,
Takeshi Mori, MD, PhD,
Hidekatsu Shibata, MD,
Kentaro Yoshimoto, MD,
Yasuomi Ohba, MD
Department of Thoracic Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
Accepted for publication September 23, 2008.
* Address correspondence to Dr Nomori, Department of Thoracic Surgery, Graduate School of Medical Sciences, Kumamoto University, Honjo 1-1-1, Kumamoto, 860-8556, Japan (Email: hnomori{at}qk9.so-net.ne.jp).
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Abstract
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The procedures and results for extrapleural pneumonectomy through a lower door open thoracotomy with reconstruction of the diaphragm and the pericardium using a reversed latissimus dorsi muscle flap and a fascia lata graft, respectively, for the treatment of malignant pleural mesothelioma are reported. A posterolateral thoracotomy was extended along the anterior costal arch with cutting of the sixth to ninth costal cartilages. Defects of the diaphragm and the pericardium were reconstructed using reversed latissimus dorsi muscle flaps and fascia lata grafts, respectively. We conducted this procedure for seven patients with malignant pleural mesothelioma, with successful outcome.
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Introduction
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For extrapleural pneumonectomy (EPP) in patients with malignant pleural mesothelioma (MPM), prosthetic materials have often been used for reconstructions of the diaphragm and the pericardium, although they are associated with risks of graft dehiscence or infection [1, 2]. We previously reported a patient that underwent an EPP through a lower door open (LDO) thoracotomy with reconstructions of the diaphragm and the pericardium using autologous materials consisting of a reversed latissimus dorsi muscle flap for the diaphragm and a fascia lata graft for the pericardium [3]. Here, we present the surgical procedures in detail and review the results of the 7 patients.
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Technique
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Patients
Between November 2005 and August 2008, 7 patients with MPM underwent extrapleural pneumonectomy (EPP) through a LDO thoracotomy at the Kumamoto University Hospital. The MPM was on the right side in 5 patients and on the left side in 2 patients. According to the classifications of the International Mesothelioma Interest Group [4], the clinical tumor stages were IA in 1 patient, IB in 4 patients, and II in 2 patients. The histologic types were epithelioid in 6 patients and sarcomatoid in 1 patient.
Surgical Procedure
The posterolateral skin incision was extended along the anterior costal arch (Fig 1). A reversed latissimus dorsi muscle flap was prepared by cutting near the tendon at the humerus, followed by mobilizing down to just below the tenth rib. The thoracotomy was performed at the fifth rib bed, followed by the cutting of the sixth through ninth costal cartilages and the division of the external and internal oblique abdominal muscles just below the anterior costal arch. The anterior lower chest wall was pulled posteriorly using a reel (Fig 2).
The EPP was performed with resections of the diaphragm and the pericardium. The surgical margin was usually confirmed to be negative during operation at the remained tissue where the tumor was vigorously invaded. A reversed latissimus dorsi muscle flap was placed in the thorax through the tenth intercostal space. The diaphragm defect was reconstructed using a reversed latissimus dorsi muscle flap with a continuous suture as follows:- 1 Medially, the flap was sutured to the remaining rim of the diaphragm along the diaphragmatic-pericardial border.
- 2 Laterally, the flap was sutured around the ninth or tenth ribs. With the patient in the same position, the fascia lata graft was harvested from the lateral side of the thigh and was sutured over the pericardial defect (Fig. 3). The bronchial stump was covered with the fourth intercostal muscle flap.
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Fig 3. Reconstruction of the diaphragm and the pericardium using a reversed latissimus dorsi flap and a fascia lata graft. (FL = fascia lata; ICM = intercostal muscle; RLDM = reversed latissimus dorsi muscle.)
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The thorax was closed after placement of one intrathoracic and two subcutaneous drains.
The mean operating time was 552 ± 28 min, and the mean blood loss was 1508 ± 265 mL. Compared with a posterolateral thoracotomy, the LDO thoracotomy offered a sufficient operation field, especially for the costophrenic and cardiophrenic angles; tumor involvement at these sites is often severe. A reversed latissimus dorsi flap could be held in the normal position for the diaphragm without size limitations in all 7 patients (Fig 4).
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Fig 4. Postoperative chest roentgenogram taken 1 month postoperatively. Black arrowheads show the fascia lata (FL) and white arrowheads the reversed latissimus dorsi muscle (RLDM).
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Reconstruction of the pericardium using a fascia lata graft did not cause any heart complications, such as herniation, tachycardia, arrhythmia, or hypotension, during a mean postoperative follow-up of 217 ± 43 days. Although 3 patients required subcutaneous drainage from the posterior site for 4 to 6 weeks because of exudates amounting to more than 100 mL/d, no other complications, including paralysis of the upper or lower extremities, occurred.
The pathologic tumor stages were IB in 1 patient, II in 2 patients, and III in 4 patients.
Within 6 weeks after the operation, hemithoracic radiation therapy was typically done using a total dose of 54 Gy delivered in 30 fractions of 1.8 Gy. Postoperative hemithoracic radiation with 54 Gy could be conducted in 5 patients without severe complications.
Three patients with pathologic tumor stages II, III, and III died of systemic recurrences of MPM at 6, 5, and 7 months postoperatively, respectively. One patient had a relapse in the chest wall after 13 months. The other 3 patients are alive without recurrences at 1, 7, and 10 months postoperatively.
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Comment
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The operative procedure presented here has two points:- 1 EPP was performed through an LDO thoracotomy. This allowed both the costophrenic and cardiophrenic angles, where MPP is often most vigorously involved, to be sufficiently seen.
- 2 Defects in the diaphragm and pericardium were reconstructed using autologous materials consisting of a reversed latissimus dorsi muscle flap for the diaphragm and a fascia lata graft for the pericardium.
Most surgeons use prosthetic materials, such as a Gore-Tex patch (W. L. Gore and Associates, Flagstaff, AZ) or Prolene mesh (Ethicon, Somerville, NJ), to reconstruct diaphragmatic and pericardial defects, but such procedures are associated with risks of graft dehiscence or infection [1, 2]. Sugarbaker and colleagues [2] reported that infectious complications occurred in 8 of 328 patients (2.4%) that required the removal of the prosthetic patches.
A reversed latissimus dorsi muscle flap has been used for the reconstruction of diaphragmatic defects after the combined resection of the diaphragm for malignant tumors as well as for congenital diaphragmatic defects [5]. Compared with prosthetic materials, a reversed latissimus dorsi muscle flap and a fascia lata graft have better adaptability and a lower risk of infection.
Hemithoracic radiation after EPP for MPM patients has been conducted in a phase II trial to decrease local recurrence [6]. For the hemithoracic radiation, reconstruction of the diaphragm should be placed at a low level, especially posteriorly, to maximize the radiation field and to minimize the dose of radiation to the adjacent abdominal organs such as the liver to the right and the stomach to the left. Reconstruction of the diaphragm using a reversed latissimus dorsi flap in our procedure prevents the elevation of the abdominal organs, thus maximizing the radiation field and minimizing radiation toxicity for abdominal organs.
EPP through a LDO thoracotomy with reconstruction of the diaphragm and the pericardium using a reversed latissimus dorsi muscle flap and a fascia lata graft offers a sufficient operation field, especially for the costophrenic and cardiophrenic angles, and also prevents infection or graft dehiscence through the use of autologous materials.
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References
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- Stewart DJ, Martin-Ucar AE, Edwards JG, West K, Waller DA. Extra-pleural pneumonectomy for malignant pleural mesothelioma: the risks of induction chemotherapy, right-sided procedures and prolonged operations Eur J Cardiothorac Surg 2005;27:373-378.[Abstract/Free Full Text]
- Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies J Thorac Cardiovasc Surg 2004;128:138-146.[Abstract/Free Full Text]
- Yoshioka M, Nomori H, Mori T, et al. Extrapleural pneumonectomy via a lower door open thoracotomy with reconstruction of the diaphragm and pericardium using autologous materials for mesothelioma Surg Today 2006;36:1036-1038.[Medline]
- Rusch VW, Venkatraman ES. The importance of surgical staging in the treatment of malignant pleural mesothelioma J Thorac Cardiovasc Surg 1996;111:815-826.[Abstract/Free Full Text]
- Wallace CA, Roden JS. Reverse, innervated latissimus dorsi flap reconstruction of congenital diaphragmatic absence Plast Reconstr Surg 1995;96:761-769.[Medline]
- Rusch VW, Rosenzweig K, Venkatraman E, et al. A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma J Thorac Cardiovasc Surg 2001;122:788-795.[Abstract/Free Full Text]
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Abstract
Introduction
