肺癌根治术后胸壁缺损重建方法的探讨

目的 探讨肺癌直接侵犯胸壁的根治性手术和胸壁重建的不同方法和效果.方法 回顾性总结27例肺癌直接侵犯胸壁根治手术的临床资料,行肺叶切除24例,全肺切除3例,所有患者手术中同时切除肺癌直接侵犯的胸壁,胸壁切除范围从6.5 cm×5.4 cm×5.0 cm至15.5 cm×12.5 cm×10.0 cm,切除肿瘤所侵犯的肋...     

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。     

Subscapularis muscle flap for reconstruction of posterior chest wall skeletal defect

IntroductionChest wall skeletal defects are usually closed using muscle flaps or prosthetic materials. Postoperative prosthetic infections are critical complications and often require plastic surgery support. We report a new surgical technique, involving a subscapular muscle flap, for covering posterior chest wall defect.Presentation of caseA 75-year-old man was admitted to our hospital. We performed a right upper lobectomy with posterior chest wall resection between the third and sixth ribs. The resulting chest wall defect was covered with a polytetrafluoroethylene mesh that became infected postoperatively. We removed the infected mesh and used the subscapularis muscle, the nearest muscle to the defect, to cover the chest wall defect. The scapular tip was lifted and the lower half of the muscle was dissected. The free end of the flap was sutured to the stumps of the anterior serratus and rhomboid major muscles. Computed tomography, 1 month later, revealed that the flap was engrafted to the chest wall.DiscussionNo previous study has reported the use of a subscapularis muscle flap for chest wall reconstruction. The lower third of the scapula was excised since blood supply to the scapula tip may be reduced after dissection of the subscapularis muscle, and to prevent the scapula tip from falling into the thoracic cavity.ConclusionThe use of a subscapularis muscle flap to repair chest wall defect is a simple and safe technique that can be conducted in the same surgical field as the initial reconstruction surgery and does not require plastic surgery support.     

膨体聚四氟乙烯补片在胸壁重建中的应用

目的分析膨体聚四氟乙烯(Gore-Tex)补片在胸壁重建中的注意事项,总结临床应用经验。方法回顾性分析第二军医大学长海医院2001年1月至2010年l2月期间33例使用Gore-Tex补片进行修复巨大胸壁缺损的临床资料,男19例,女14例;平均年龄45.7(20～73)岁。根据肿瘤位置、大小选择不同的手术切口;术中尽量保留正常的胸壁软组织,骨性胸壁缺损采用Gore-Tex补片进行重建,软组织直接对拢缝合,全层胸壁缺损采用转移肌皮瓣覆盖创面。结果全组33例均手术顺利,围术期无死亡患者;恶性肿瘤25例,良性肿瘤8例,均被完整切除,切除瘤体直径8～20 cm。随访5～60个月,失访3例(9.09%),无排斥反应及反常呼吸,无异物感,感染率3%(1/33)。结论 Gore-Tex补片具有极佳的生物相容性,是安全有效的胸壁重建材料;选择合适的肌皮瓣覆盖补片,能够减少并发症发生。     

Wide resection of the upper right hemithorax combined with amputation of the right arm for a recurrent desmoid tumor

A 66-year-old woman had a recurrent desmoid tumor in the right thoracic apex. The tumor infiltrated the brachial plexus and eventually rendered the upper right extremity functionless. The tumor was removed by aggressive wide resection of the right upper hemithorax with simultaneous amputation of the functionless right arm. Reconstruction of the chest wall was accomplished, utilizing the soft tissues of the remnant arm as a pedicled flap to cover the full-thickness defect. Aggressive wide resection of the chest wall with limb amputation is technically challenging but unavoidable in some cases of recurrent desmoid tumor.     

修复上胸壁巨大肿瘤切除后缺损一例的早期效果

目的应用钛网、重建钢板及背阔肌带蒂肌皮瓣,修复上胸壁乳腺肉瘤样癌切除后巨大缺损1例,观察术后早期效果。方法于2006年2月收治1例56岁女性上胸壁乳腺肉瘤样癌患者,行肿瘤切除后缺损约20cm×15cm,钛网覆盖胸壁缺损,重建钢板连接双侧锁骨残端,右侧背阔肌带蒂肌皮瓣约20cm×15cm移位修复软组织缺损。结果患者术后3d脱呼吸机,反常呼吸较明显。2周皮瓣血运稳定后,用胸带固定胸廓,反常呼吸渐消失,皮瓣血供良好。复查胸片,钛网及重建钢板位置良好。术后1个月转入肿瘤科化疗。随访3个月,局部及全身无不适;双肩活动度前屈90°,外展90°;肿瘤未见复发。结论胸壁巨大缺损重建时应选择质地较硬的材料,重建钢板维持双侧锁骨的解剖位置,肩关节功能恢复好,背阔肌带蒂肌皮瓣可适当扩大切取。     

胸壁缺损修补重建方法探讨

胸壁肿瘤切除后，缺损的修补与重建是手术成败的关键。重建时使用的材料多样，方法各异。我们总结７５例胸壁肿瘤术后缺损修补的经验，比较自体组织与替代品修补重建的优缺点，认为使用自体组织作为缺损重建材料优点为取材容易方便，术后不易感染，值得推荐。     

Novel titanium constructs for chest wall reconstruction in children

Purpose

We have previously reported the use of the vertical expandable prosthetic titanium rib (VEPTR) for treatment of thoracic dystrophy. This report describes our experience with this device and other novel titanium constructs for chest wall reconstruction.

Methods

This is a retrospective chart review of all children and adolescents undergoing chest wall reconstruction with titanium constructs between December 2005 and May 2010.

Results

Six patients have undergone chest wall reconstruction with VEPTR or other titanium constructs. Four had chest wall resection for primary malignancy, 1 had metastatic chest wall tumor resection, and 1 had congenital chest wall deformity. There were no immediate complications, and all patients have exhibited excellent respiratory function with no scoliosis.

Conclusions

Chest wall reconstruction after tumor resection or for primary chest wall deformities can be effectively accomplished with VEPTR and other customized titanium constructs. Goals should be durable protection of intrathoracic organs and preservation of thoracic volume and function throughout growth. Careful preoperative evaluation and patient-specific planning are important aspects of successful reconstruction.     

Reconstruction of Chest Wall Using a Two-Layer Prolene Mesh and Bone Cement Sandwich

Wide surgical resection is the most effective treatment for the vast majority of chest wall tumors. This study evaluated the clinical success of chest wall reconstruction using a Prolene mesh and bone cement prosthetic sandwich. The records of all patients undergoing chest wall resection and reconstruction were reviewed. Surgical indications, the location and size of the chest wall defect, diaphragm resection, pulmonary performance, postoperative complications, and survival of each patient were recorded. From 1998 to 2008, 43 patients (27 male, 16 female; mean age of 48 years) underwent surgery in our department to treat malignant chest wall tumors: chondrosarcoma (23), osteosarcoma (8), spindle cell sarcoma (6), Ewing''s sarcoma (2), and others (4). Nine sternectomies and 34 antero-lateral and postero-lateral chest wall resections were performed. Postoperatively, nine patients experienced respiratory complications, and one patient died because of respiratory failure. The overall 4-year survival rate was 60 %. Chest wall reconstruction using a Prolene mesh and bone cement prosthetic sandwich is a safe and effective surgical procedure for major chest wall defects.     

Chest wall resection and reconstruction: a case series of 20 patients in Hospital Kuala Lumpur,Malaysia

Chest wall resection is defined as partial or full-thickness removal of the chest wall. Significant morbidity has been recorded, with documented respiratory failure as high as 27%. Medical records of all patients who had undergone chest wall resection and reconstruction were reviewed. Patients’ demographics, length of surgery, reconstruction method, size of tumor and chest wall defect, histopathological result, complications, duration of post-operative antibiotics, and hospital stay were assessed. From 1 April 2017 to 30 April 2019, a total of 20 patients underwent chest wall reconstructive surgery. The median age was 57 years, with 12 females and 8 males. Fourteen patients (70%) had malignant disease and 6 patients (30%) had benign disease. Nine patients underwent rigid reconstruction (titanium mesh for sternum and titanium plates for ribs), 6 patients had non-rigid reconstruction (with polypropylene or composite mesh), and 5 patients had primary closure. Nine patients (45%) required closure with myocutaneous flap. Complications were noted in 70% of patients. Patients who underwent primary closure had minor complications. In total, 66.7% of patients who had closure with either fasciocutaneous or myocutaneous flaps had threatened flap necrosis. Two patients developed pneumonia and 3 patients (15%) had respiratory failure requiring tracheostomy and prolonged ventilation. There was 1 mortality (5%) in this series. In conclusion, chest wall resections involving large defects require prudent clinical judgment and multidisciplinary assessments in determining the choice of chest wall reconstruction to improve outcomes.     

Giant primary liposarcoma of the chest

Liposarcomas are the most common soft tissue sarcomas in adults, although liposarcomas of the chest are uncommon. We report two cases of giant liposarcoma in the mediastinum and chest wall, respectively. An 82-year-old man presented with a mass in the right upper mediastinum, as seen by computed tomography (CT). He had a past history of subcutaneous lipoma resection on his back (19 years previously). The patient underwent tumor resection with a right thoracotomy. A 58-year-old woman presented with an enlarging mass of the right lateral chest, involving the diaphragm and ribs, as seen by CT. She had a past history of subcutaneous lipoma resection of the right chest (18 years previously). The patient underwent an en bloc resection that included the tumor and a part of the right diaphragm and ribs. Histological examination of both patients’ tumors revealed a well-differentiated liposarcoma, with no pathological relation to the previous lipoma resected in either case.     

Pedicled full‐thickness abdominal flap combined with skin grafting for the reconstruction of anterior chest wall defect following major electrical burn

Successful reconstruction of extensive anterior chest wall defect following major electrical burn represents a very challenging surgery. Herein we report the first case using pedicled full‐thickness abdominal flap combined with skin grafting to treat this injury with severe infection and exposure of pericardium and ribs in a Chinese patient. Following the performance of chest debridement to remove necrotic and infected tissues and the injection of broad‐spectrum antibiotics to reduce infection, a pedicled full‐thickness abdominal flap was used to cover the exposed pericardium and ribs, and skin grafting from the right leg of the patient was done to cover the exposed vital tissues. The patient was followed up for a total of 3·5 years, and satisfactory cosmetic and functional outcomes were obtained without complications. This report provides an effective method for the surgeons who encounter similar cases where reconstruction of extensive anterior chest wall is required.     

Clear cell sarcoma arising from the chest wall: a case report

Clear cell sarcoma is a rare malignant soft tissue neoplasm that usually arises adjacent to tendons or aponeuroses. The clinical course is rather slow, with repeated local recurrences followed by late metastases and eventual death. The principal sites of this neoplasm are the extremities, but tumors do occur in the trunk on rare occasions. We report a case of clear cell sarcoma arising from the chest wall. The patient, a 20-year-old woman, had noticed a chest wall mass and pain for 2 years. Biopsy of the mass showed abundant nests of round cells with clear cytoplasm. On immunohistochemical examination, tumor cells were strongly immunoreactive for S-100 and HMB-45. A diagnosis of clear cell sarcoma was confirmed. There was no other lesion found in the patient through routine imaging studies. She was treated with two courses of chemotherapy using ifosfamide, carboplatin, and etoposide. Subsequently, the tumor, including adjacent tissue, the chest wall, and sternum, was resected with a wide margin; and the defect of the chest wall was covered with Marlex mesh fabric, regin, and a musculocutaneous flap. She has shown no symptoms or signs of recurrence during 2 years of follow-up.     

Large Chest Wall Reconstruction Using a Pedicled Osteomuscle Composite Flap: Report of a Case

A 67-year-old man with diabetes mellitus and chronic renal failure underwent resection of a grade 1 chondrosarcoma. We performed chest wall reconstruction of the massive defect, using a pedicled osteomuscle composite flap comprising the 6th, 8th, and 10th ribs, and the latissimus dorsi and serratus anterior muscles. This flap is ready to mobilize as a pedicled graft to cover a large chest wall defect; it is strong enough to buttress the chest cage without the need for artificial materials, and it is associated with a lower risk of infection than prosthetic materials.     

胸壁肿瘤的外科治疗（附57例报告）

胸壁肿瘤以良性居多，但胸骨肿瘤以恶性为主。胸痛和肿块是本病两大征象：Ｘ线胸片是诊断骨性胸壁肿瘤的主要方法；术前经皮穿刺活检可选用于胸壁软组织肺瘤。胸壁广泛切除和胸壁重建术是恶性胸壁肿瘤治疗成功的关键。多孔有机玻璃板是转理想的廉价的胸壁重建材料。对于术后复发者，只要无远处较移，应尽力再次手术切除。     

Reconstruction of sternal and abdominal wall defects in a case of desmoid tumor.

A case of desmoid tumor of the anterior chest and abdominal wall is presented. The entire body of the sternum along with the upper abdominal wall and inner parts of both breasts was resected. The resulting defect over the pericardium and abdomen was reconstructed by the omentum and Marlex mesh. The large skin defect was covered by bilateral thoracoabdominal tube pedicles. The patient had a stable chest wall with uncompromised respiratory function 1 week after the operation. Prevention of local recurrences of desmoid tumors requires wide excision of the involved soft tissues and bony structures. The principles of wide resection of soft tissue tumors, reconstruction of the anterior chest and abdominal wall defects, and planning the skin coverage over the resulting defect are discussed.     

Chondrosarcoma of the chest wall: a clinical analysis

Purpose. To discuss the management of different histological types of chondrosarcoma (CS) in the chest wall based on our clinical experience. Methods. The subjects of this study were 16 patients with CS of the chest wall surgically treated by resection at our institute between September 1981 and August 2000. There were 11 men and 5 women ranging in age from 23 to 74 years. The median follow-up period was 54 months. The tumor was located only in the ribs in ten patients, in the sternum and ribs in three, only in the sternum in two, and in the ribs and spine in one. The surgical margins were wide in 12 patients and marginal in four. Reconstruction using Marlex mesh combined with moldable metal plates was carried out to prevent flail chest in nine patients, resection alone was performed in five patients, and a muscular flap was used in two patients. Results. The survival rate was 86% after a median follow-up period of 54 months. One operative death (6.2%) occurred, and another required temporary tracheostomy. There were no infections in this series. Oncological outcome was clinically related to surgical margins and recurrence. The postoperative respiratory function test result was 10% less than the preoperative one. Conclusion. This series demonstrated that wide resection is the treatment of choice for chest wall CS and that Marlex mesh combined with metallic mouldable plates is a reliable technique for reconstruction. Received: April 3, 2001 / Accepted: November 20, 2001     

Osteosarcoma of the rib: A challenge of diagnosis and surgical intervention: A case report

Introduction and importanceChest wall tumour could grow from various tissues composing the chest wall. Diagnosis and treatment of patients with chest wall tumour pose several challenges.Case presentationWe present a case of 55 year old woman with chief complaint of a painfull mass on her chest wall. Patient was diagnosed with osteosarcoma of the ribs. Patient underwent surgery and was hospitalized for seven days before discharged.Clinical discussionOsteosarcoma of the ribs is a rare case with wide resection as the main treatment. In this case, chest wall reconstruction was needed to prevent impaired chest wall mechanical function in respiration.ConclusionDiagnosis and treatment of osteosarcoma of the ribs pose challenges. The main treatment of the osteosarcoma of the ribs is wide resection, followed by reconstruction of chest wall when needed. Reconstruction could be performed with autologous tissue, gore-tex, and mesh. The adjuvant chemotherapy was considered to give for better outcome.     

Dedifferentiated chondrosarcoma of the chest wall: reconstruction with polypropylene mesh using a transverse rectus abdominis myocutaneous flap

We report a case of dedifferentiated chondrosarcoma of the chest wall. After resection, the chest wall defect was reconstructed using polypropylene mesh and a transverse rectus abdominis myocutaneous flap. A 61-year-old woman presented with a 16-year history of a slow-growing mass underneath the right chest wall. After percutaneous biopsy, preoperative cytopathological examination of the large mass revealed dedifferentiated chondrosarcoma. The tumor was resected with a wide margin along with the chest wall including skin, the right seventh to tenth ribs, and part of the diaphragm. The chest wall defect was reconstructed with a polypropylene (Marlex) mesh sheet followed by a left-side transverse rectus abdominis myocutaneous flap.     

Chest wall resection and reconstruction for recurrent breast cancer – A multidisciplinary approach

BackgroundDespite therapeutic advances in the management of breast cancer, a significant number of patients present with locoregional recurrence. Treatment with hormonal, chemo or radiotherapy remains standard in such cases. However, in selected patients of recurrent breast cancer involving chest wall, multidisciplinary surgical approach could be considered.MethodsBetween 2010 and 2018, 21 patients with recurrent breast cancer, involving chest wall, were treated at a tertiary care center with resection and reconstruction. The mean age of the patients was 55 years (22–77 years).ResultsThe median interval from first breast resection to chest wall resection (CWR) for recurrent disease was 6 years (1–24 years). Eighteen patients underwent bony resection and 3 patients required extensive soft tissue resection. Complete resection was achieved in 90% of patients. All patients had chest wall reconstruction. There was no in-hospital mortality. During follow-up, 8 patients died, of which 7 were due to distant metastases. The 1 year and 3-year overall survival were 90% (95% CI 66–97) and 61% (95% CI 31–81) respectively. The disease-free survival at 1 and 3 years was the same at 70% (95% CI 45–86). At a mean follow up of 23 months, the average survival in patients operated for local recurrence is 51.7 months (95% CI 37.7–65.7) and 24.5 months (95% CI 7.3–41.7) for patients with distant metastatic recurrence.ConclusionA multidisciplinary oncoplastic approach for recurrent breast cancer, which includes chest wall resection and reconstruction is a useful adjunct in selected group of patients. This improves local disease control, symptoms and possibly disease-free survival.