胸壁肿瘤的外科治疗

目的探讨胸壁肿瘤的切除和胸壁缺损的重建方法。方法自1985年7月至2004年10月对113例胸壁肿瘤患者进行了手术治疗,其中良性肿瘤47例,恶性肿瘤66例,48例肿瘤切除后遗留巨大胸壁缺损而采用转移肌瓣、钢丝网、有机玻璃、牛心包片和巴德复合补片等进行修复重建。结果全组无手术死亡,无严重并发症发生。恶性肿瘤术后1、3、5年生存率分别为73.1%(38/52),52.2%(24/46)和28.9%(11/38)。结论胸壁肿瘤不论良恶性均首选手术切除,恶性肿瘤应进行胸壁扩大切除并修复胸壁缺损,其效果满意。     

胸壁缺损的修复重建现状及进展

无论何种原因引起的胸壁缺损,特别是广泛胸壁缺损,若不进行有效的修复重建可引起胸壁软化、反常呼吸及纵隔摆动等生理病理变化。重建手术方法技术和材料的选择是影响胸壁修复重建效果的主要因素。随着对胸壁缺损认识的深入以及重建手术技术的进步和重建材料的发展,许多以往无法完成的巨大胸壁缺损重建正变为可能。本文主要就胸壁缺损特点,修补方法及重建材料现状及进展等进行综述。     

胸壁肿瘤切除后胸壁缺损的修复

目的探讨胸壁肿瘤切除后胸壁缺损的修复方法。方法 2011年5月至2018年5月共收治胸壁肿瘤患者31例,其中原发胸壁良性肿瘤6例,原发胸壁恶性肿瘤14例,转移性胸壁恶性肿瘤11例。胸壁缺损类型包括单纯骨性缺损16例,单纯软组织缺损4例,全层缺损11例。骨性胸壁缺损采用补片(7例)、Prolene网片(3例)、网格状钛合金钢板(17例)进行重建。胸壁软组织缺损采用直接对拢缝合(11例)、皮瓣修复(20例)。结果本组患者均顺利完成手术,术后呼吸功能良好,无反常呼吸运动。2例带蒂背阔肌肌皮瓣边缘部分坏死,1例带蒂腹直肌肌皮瓣远端部分坏死,1例游离腹壁下动脉穿支皮瓣边缘部分坏死,经换药后伤口均愈合。结论外科手术是胸壁肿瘤治疗的主要方法,术后的胸壁缺损按照大小、位置和复杂程度选择合适的材料进行修复,重建胸壁结构的稳定性及密闭性,是手术成功的关键。     

胸壁肿瘤切除后胸壁大块缺损的修复重建

目的探讨胸壁肿瘤切除后胸壁大块缺损的修复重建方法。方法回顾性分析近10年来24例胸壁肿瘤切除后胸壁大块缺损患者的临床资料,24例患者均联合应用不锈钢丝和绦纶补片进行胸壁重建。结果全组无手术死亡,无胸壁软化及反常呼吸运动,无切口感染,1例术后发生伤口局部积液。全组患者术后随访1月～10年,无1例钢丝断裂及反常呼吸,胸壁凹陷畸形不明显,胸廓外形的满意率达95.8%（23/24）。结论不锈钢丝和涤纶补片是修复重建胸壁大块缺损的一种很好材料,取材方便,操作简便,胸廓稳定性良好,临床疗效确切。     

整形外科技术在面部肿瘤切除修复中的应用

目的:探讨应用整形外科的原则和技术切除修复面部肿瘤的方法和效果。方法:对337例面部肿瘤患者应用整形外科微创技术彻底切除病变组织后,采用直接缝合、皮片或皮瓣移植等方法修复面部缺损。结果:修复皮片皮瓣全部成活,术后随访3个月～5年,所有患者面部功能及外形恢复良好,无明显瘢痕和器官移位。结论:整形外科的原则和技术治疗面部肿瘤是一种有效的方法。     

胸壁肿瘤切除后的一期修复重建

目的 观察胸壁肿瘤切除术后胸壁缺损一期修复重建的临床效果。方法 1998年1月～2003年3月外科治疗胸壁肿瘤31例。男20例，女11例。年龄8～72岁。原发性胸壁肿瘤21例，肺癌侵犯胸壁6例，乳腺癌术后复发2例，放射性坏死和皮肤癌各1例。切除肋骨2～7根，平均3．6根。缺损面积20～220cm^2，平均97．1cm^2。合并肺切除10例，部分膈肌切除2例，胸骨下段切除1例。单纯软组织修复7例(背阔肌 大网膜，背阔肌肌皮瓣，背阔肌肌瓣)，单纯骨性重建5例(涤纶布或Prolene网)，骨性合并软组织修复19例(背阔肌、胸大肌、背阔肌 阔筋膜或大网膜，与涤纶布或Prolene网修复)。结果 术后发生并发症3例(9．7％)，其中切口感染1例，软组织与修复物之间积液2例。无手术死亡。26例获5～57个月随访，术后生存时间6～57个月，中位生存时间22个月。结论 胸壁肿瘤切除术后造成的巨大缺损，采用胸壁修复重建术可获得良好的临床效果。     

胸壁重建材料的选择与评价

各类胸壁切除术 ,通常情况下包括 :①胸壁及胸膜肿瘤 (原发或转移性 )的切除 ,②胸壁严重且久治不愈的局灶性感染病变切除 ,③胸壁严重的放射性溃疡坏死灶的切除 ,④先天性胸廓畸形矫正术 ,⑤严重外伤伤口的清创等。而上述手术治疗后 ,常常造成胸壁深层组织甚至全层组织的大块缺损 ,进而破坏了胸廓的完整性、坚固性和稳定性 ,以及胸膜腔的密闭性 ,导致胸壁软化、反常呼吸、气胸及纵隔摆动等一系列病理生理改变 ,严重影响患者的呼吸循环功能 ,因此胸壁大块缺损的修复 ,胸壁稳定性的重建是一个十分重要的问题[1～ 2 ] 。大多数胸科医生认为 ,…     

皮肤牵张系统在局部晚期乳腺癌切除术后胸壁重建中的临床研究

目的探讨皮肤牵张系统在局部晚期乳腺癌切除术后胸壁重建中的临床应用价值。方法回顾性分析2014年3月~2015年10月收治的26例局部晚期乳腺癌患者,其中19例为原发肿瘤,7例为复发肿瘤。肿瘤扩大切除后,患者的胸壁软组织缺损均选用TopClosure~皮肤牵张系统来辅助修复。结果 26例患者胸壁重建创面愈合良好,无明显并发症发生,患者及其家属对治疗结果满意。结论对于可以接受手术治疗的局部晚期乳腺癌患者,TopClosure~皮肤牵张系统是辅助修复胸壁皮肤巨大缺损的有效手段,治疗效果满意,易于学习。     

全层胸壁修复材料的研究进展

大面积的全层胸壁缺损重建,一直是整形外科、心胸外科目前尚未完全解决的难题.胸壁重建的效果往往直接影响患者术后的生存率与生存状态.临床上胸壁全层缺损常见原因包括：①恶性肿瘤切除术,包括转移性非小细胞肺癌、原发性胸壁软组织肉瘤等;②贯穿全层的胸壁热压伤;③胸壁严重的放射伤切除;④严重外伤等.而影响胸壁重建的因素很多,主要包括缺损的部位、深度和大小.一般认为,全层大面积胸壁缺损范围超过6 cm×6 cm且相邻3根以上肋骨受损时,或者胸骨大部分切除的患者,应考虑行胸壁骨性重建,当缺损在前壁或者侧壁时尤其重要.     

口腔颌面-头颈肿瘤术后缺损游离皮瓣修复的观察与护理

随着显微外科技术日趋成熟,运用游离皮瓣修复头颈肿瘤术后组织缺损较为广泛,它既保证了肿瘤切除的彻底性,又可有效地进行局部功能的重建与容貌的修复。我院于2008年4月～2012年3月共运用多种游离皮瓣、肌皮瓣修复颌面部组织缺损30例,经过手术后密切的观察与护理,皮瓣均愈合良好,无并发症发生。现将护理体会总结如下。     

Principles of chest wall resection and reconstruction

Despite significant improvements in surgical technique and perioperative care, the management of patients requiring chest wall resection and reconstruction is an ongoing challenge for thoracic surgeons. A successful approach includes a thorough assessment of the patient and the lesion, an adequate biopsy to confirm tissue diagnosis, and a well-established treatment plan. In the case of a primary tumor of the chest wall, the extent of the resection should not be limited by the size of the resulting defect. Following resection, chest wall reconstruction mandates an appreciation for restoration of functional and structural components. An algorithmic approach to chest wall reconstruction begins with the assessment of the nature of the defect, taking into consideration factors such as infection, tumor location, previous radiation therapy, and surgical intervention. The latter factors bear influence on the type of tissue required as well as whether reconstruction can be performed in a single stage or whether it is better delayed. Finally, patient factors including lifestyle and work, as well as prognosis, are considered to determine the best reconstructive option.     

Reconstructive management of advanced breast cancer

To evaluate morbidity, quality of life, and oncological outcomes of patients with advanced breast cancer, recurrence, or sequelae secondary to radiotherapy, the authors present their experience with 21 patients at the Instituto Nacional de Cancerología in Mexico City, who underwent resection of the lesion and reconstruction using thoracoepigastric fasciocutaneous, rectus abdominis, or latissimus dorsi musculocutaneous flaps. Complications included partial flap necrosis and bronchopleural fistulae in 2 of 7 patients with whole-thickness chest wall resection. The remaining patients progressed nicely, with a short recovery period. The patients and the surgical team evaluated results in terms of aesthetics and function using questionnaires. The results were from fair to good according to Sneeuw's scale. Pedicled musculocutaneous and fasciocutaneous flaps are an excellent reconstructive option in patients with advanced, recurrent breast cancer and in those with radionecrotic complications, which sometimes require resection of the whole-thickness chest wall.     

Malignant chest wall tumors in children and young adults

PURPOSE: Primary chest wall malignancies, which occur infrequently in children, can pose complex technical challenges to the surgeon. This study was undertaken to evaluate the pathology, treatment approaches, role of surgical resection and reconstruction, and outcomes of patients with these tumors. METHODS: This is a retrospective review of all patients with malignant primary chest wall tumors treated at our institution between February 1983 and July 1998. RESULTS: Nineteen cases were identified: malignant small round cell type (MSRCT, also called Ewing's sarcoma, primitive neuroectodermal tumor [PNET], and Askin's tumor; n = 8), rhabdomyosarcoma (RMS; n = 6), and other tumors (n = 5). Three patients underwent "upfront" complete resections. Sixteen patients underwent initial biopsy, followed by chemo- or radiotherapy. Nine of these 16 survived to undergo delayed chest wall resections. Six of the 12 "resected" patients required en bloc resection of adjacent muscles or organs; 7 required complex chest wall reconstruction. Eight of 19 patients (42%) have survived (median follow-up of survivors, 4 years), all with no evidence of disease; the remaining 11 patients died of progressive disease. Local invasion did not alter chance of survival. Two of the 10 patients with metastases at diagnosis (20%) survived. Six of the 9 patients (67%) with localized disease survived. All five patients with tumor types other than MSRCT or RMS, metastatic or not at diagnosis, are alive with no evidence of disease. There were no local recurrences. CONCLUSION: Surgical resection, with en bloc removal of involved structures and chest wall reconstruction, provides excellent local control of malignant chest wall tumors.     

Multidisciplinary Approach to the Management of Extensive Dermato-fibro-sarcomas Involving the Chest Wall

Dermato-fibro-sarcomas are known for high-recurrence rates. The gold standard of management is surgical excision with clear margins. Such margins on the chest results in large defects which require complex reconstructive procedures. We report a case series of patients managed by a multidisciplinary team with good outcomes. A total of 12 patients with extensive dermato-fibro-sarcoma of the anterior chest wall were treated over a period of 5 years in our setting. The age range was 25 to 54 years. Skeletal defects were reconstructed with Prolene mesh and methyl acrylate cement in 10 of the 12 patients. Pedicle flaps were used in nine patients. All margins were clear of tumors, with the nearest margin being 1.5 cm. One patient had a recurrence. No donor-site morbidity was recorded in any of the patients.In conclusion, a multidisciplinary approach provides improved outcomes in the management of large dermato-fibro-sarcomas of the chest wall. With this approach, extensive dissection of the tumor is achieved, and reconstruction is performed with minimal complication.     

Decision making,treatment planning and technical considerations in patients undergoing surgery for locally recurrent rectal cancer

The oncological outcomes of patients with locally recurrent rectal cancer (LRRC) have improved dramatically in recent decades due to the evolution of extended radical surgical techniques and the development of expert multi-disciplinary teams at specialist units. LRRC is now considered a salvageable and potentially curable situation in selected patients. Careful patient selection and meticulous treatment planning should be developed in a multi-disciplinary setting, where consideration is given to the ability to achieve clear resection margins, the presence of unresectable metastatic disease, the potential morbidity and functional outcomes associated with radical surgery and the impact on quality of life, as well as the individual patient's goals and treatment priorities. Radical multi-visceral resection is the cornerstone of treatment and clear (R0) margins is the most important predictor of long term survival, which can be expected in 40–50% of patients if R0 resection is achieved. The development of radical techniques for lateral neurovascular and composite bony resections have facilitated improved R0 resection rates at the periphery of the pelvis giving a larger number of patients the chance of cure. Teamwork and preparation are critical when undertaking complex multi-visceral pelvic resections with input from urological, vascular, plastic and orthopaedic surgeons, particularly during the reconstruction phase.     

Plastisch-chirurgische Rekonstruktion von Defekten der Thoraxwand nach onkologischen Resektionen

In defect reconstruction following radical oncologic resection of malignant chest wall tumors, adequate soft-tissue reconstruction must be achieved along with function, stability, integrity, and aesthetics of the chest wall. The purpose of this retrospective analysis was to evaluate the oncoplastic concept following radical resection of malignant chest wall infiltration with an interdisciplinary approach. Between 1999 and 2005, 36 consecutive patients (nine males, 27 females, mean age 55 years, range 20-78) were treated with resection for malignant tumors of the chest wall. Indications were locally recurrent breast carcinoma (patient n=22), thymoma (n=1), and desmoid tumor (n=1). Primary lesions of the chest wall were spinalioma (n=1), sarcoma (n=7), and non-small-cell lung cancer (n=2). There were distant metastases of colon and cervical cancer in one patient each. Soft-tissue reconstruction was carried out using primary closure (n=1), external oblique flap (n=1), pectoralis major myocutaneous flap (n=3), latissimus dorsi myocutaneous flap (n=18), vertical or transversal rectus abdominis myocutaneous flap (n=9), free tensor fascia lata- flap (n=6), trapezius flap (n=1), serratus flap (n=1), and one filet flap. In 15 reconstructive procedures microvascular techniques were used. An average of 3.4 ribs were resected. Stability of the chest wall was obtained with synthetic meshes. The latissimus dorsi flap is considered the flap of choice in chest wall reconstruction. However, alternatives such as pectoralis major flap, VRAM/TRAM flap, free TFL flap, and serratus flap must also be considered. Low mortality and morbidity rates allow tumor resection and chest wall reconstruction even in a palliative setting.     

Elbow reconstruction after excision of proximal ulna tumors: Challenges and solutions

Most malignant bone tumors are treated with surgical excision, adhering to oncologic principles, followed by reconstruction to preserve form and function whenever feasible. Primary bone tumors around the elbow are rare accounting for <1% of all skeletal tumors. They pose a reconstructive challenge, due to the complex interplay between the osseous & capsulo-ligamentous structures which is essential for elbow stability and function. Tumors affecting the proximal ulna are rare and reconstruction of the defects following these tumors is extremely challenging. Various reconstruction options like arthrodesis, autogenous bone grafts, allografts, re-implantation of sterilized tumor bone, pseudoarthrosis, and endoprosthesis have been tried with variable success. However, due to lack of standardization and the rarity of the site, surgeons are often in a dilemma to choose the correct option. This can lead to suboptimal functional outcomes and long-term failures. In this article, we reviewed the published literature on proximal ulnar tumors and noted the pros and cons of various reconstructive procedures. We have also attempted to formulate reconstruction recommendations based on the level of resection of proximal ulna.     

Operative Interdisziplinarität—Extremitäten

Interdisciplinary reconstructive surgery of the extremities involves a variety of indications ranging from IIIB/C open fractures with major segmental loss of bone and soft tissue, to arterial vessel injury necessitating vascular repair, and to biological, plastic reconstruction following resection of musculoskeletal tumors. The multidisciplinary approach involving trauma/orthopedic surgery combined with vascular, plastic, and neuro- resp. microsurgery has significantly increased the rate of limb-sparing operations and improved morbidity, function, quality of life, and long-term oncological outcome. The multidisciplinary treatment of both complex trauma and malignant bone/soft tissue sarcoma of the extremity is an integral task of surgical trauma and tumor centers. Close interactive communication between the individual surgical disciplines has decisively influenced prognosis and is the precondition for priority-adapted therapeutic strategies.     

Long-term outcome after en bloc resection and reconstruction of the spinal column and posterior chest wall in the treatment of malignant tumors

BackgroundMalignant tumors occurring around both the spinal column and posterior chest wall are uncommon. Surgical resection of chest wall tumors adjacent to the spinal column is still challenging due to the surrounding anatomical structures. The purpose of the present study was to evaluate the long-term outcomes of surgical management in malignant tumors involving the spinal column and posterior chest wall.MethodsBetween 1999 and 2007, 10 consecutive patients underwent en bloc resection combined with the posterior chest wall in the treatment of malignant tumors around the spinal column. There were 6 males and 4 females with a mean age at the surgery of 40.9 years old (range, 14–62 years old). The mean postoperative follow-up period was 159.7 months (range, 84–245 months). The clinical history, physical examination, laboratory data, radiological findings, and operative findings for each patient were retrospectively reviewed.ResultsAll surgeries were performed via a combined anterior and posterior approach. The mean numbers of partially resected vertebrae and ribs were 3.1 and 4.1, respectively. Lower or upper lobectomy was performed in four patients, and the diaphragm was partially resected in two patients. The surgical margin was wide in seven patients and marginal in two patients. Although five patients had postoperative respiratory problem, all patients improved immediately without life-threatening complications. There were no patients with respiratory insufficiency after surgery. One patient with osteosarcoma died of lung metastases 99 months after surgery. At the final follow-up, only one patient had local recurrence, five had been continuously disease-free, and three were alive with no evidence of disease.ConclusionsEn bloc resection and reconstruction in selected patients with malignant tumors involving both the spinal column and posterior chest wall demonstrated good long-term results for local control and the respiratory function.     

Chest Wall Reconstruction in Pediatric Patients with Chest Wall Tumors: A Systematic Review

BackgroundResection of pediatric chest wall tumors can result in large defects requiring reconstruction for function and cosmesis. Multiple reconstructive methods have been described. We performed a systematic review of the literature to describe commonly used approaches and outcomes.MethodsA systematic literature search was performed for English-language publications describing chest wall tumor resection and reconstruction using implantable materials in patients ≤21 years, excluding soft tissue resection only, sternal resection, and reconstruction by primary repair or muscle flaps alone. Data were collected on diagnoses, reconstructive method, and outcomes. Rigid chest wall reconstruction was compared to mesh reconstruction.ResultsThere were 55 articles with 188 patients included. The median age was 12 years. Most tumors were malignant (n = 172, 91.5%), most commonly Ewing's sarcoma (n = 65, 34.6%), followed by unspecified sarcomas (n = 34, 18.1%), Askin's tumor (n = 16, 8.5%; a subset of Ewing's sarcoma) and osteosarcoma (n = 16, 8.5%). A median of 3 ribs were resected (range 1–12). Non-rigid meshes were most common (n = 138, 73.4%), followed by rigid prostheses (n = 50, 26.6%). There were 19 post-operative complications (16.8%) and 22.2% of patients developed scoliosis. There were no significant differences in complications (20.5% rigid vs. 10.6% non-rigid, p = 0.18) or scoliosis (22.7% vs. 14.0%, p = 0.23) by reconstruction method, but complications after rigid reconstruction were more likely to require surgery (90.0% vs. 53.9%, p = 0.09). The median follow-up duration was 24 months.ConclusionsIn this review of the literature, there were no significant differences in overall post-operative complications or scoliosis development by reconstruction method, yet complications after rigid reconstruction were more likely to require surgical intervention.Level of evidenceLevel IV.