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...     

A new method of reconstruction for chest wall resection

Sixteen patients who involved in chest wall disease underwent major chest wall resection between April 1995 and January 1999. The underlying diseases were 6 recurrence of breast cancers, 4 direct invasion by primary lung cancer, 2 metastatic chest wall tumor, one direct invasion by metastatic lung tumor, one direct invasion by metastatic mediastinal tumor, one radio-induced-necrosis of the chest wall, and one chest wall infection. In 9 patients, the thoracic cage reconstruction was performed using double sheets of absorbable mesh (Dexon mesh), cross string sutures and autologous ribs grafts. None of the patients had major respiratory failure and chest wall unstability. No late complications including infections, pains, recurrence and others related to reconstruction materials have been observed.     

Prosthetic reconstruction of the chest wall

Chest wall reconstructions can be complex and challenging procedures, especially when huge thoracic defects have been generated by radical excisions. Nonrigid reconstructions with meshes or patches have the goal of avoiding a lung hernia caused by the chest wall defect, or preventing the impaction of the scapula in case of posterior chest wall resections, especially when the resection is extended down to the 5th and 6th ribs. Large anterior and lateral resections result in thoracic instability and alteration of pulmonary physiology, and render intrathoracic structures vulnerable to external impact. They necessitate rigid reconstructions according to several techniques using alloplastic materials (eg, methyl methacrylate-based customized plates or neo-ribs, osteosynthesis systems, or dedicated prosthesis). Nowadays, the availability of these multiple, possibly combined, more adapted, and better tolerated materials have pushed past the limits of resection to those involving soft tissue coverage.     

Primary hydatid disease of chest wall mimicking chest wall mass-case report

IntroductionHydatid cyst is a parasitic disease caused by echinococcus granoulosis. It is endemic in Mediterranean areas, south America, north Africa and Australia. The disease is most common in the liver and then in lung, the chest wall involvement by hydatid disease is a very rare condition.Presentation of caseWe present a case of chest wall mass in a 65-years old man, who intra operatively diagnosed as primary hydatid cyst. Cystectomy done and patient followed up for 2 months.DiscussionThe diagnosis of echinococcus infection mainly depends on the clinical history of the patient, serologic tests, and diagnostic radiological findings. Operative procedures for chest wall hydatid disease are cystectomy, cystotomy, evacuation, and chest wall resection.ConclusionChest wall hydatid disease should be considered in the differential diagnosis of chest wall masses even in a patient who has not been operated for hydatid disease.     

胸壁大块缺损外科重建71例报告

目的 探讨胸壁大块缺损后不同外科技术重建的效果.方法 1995年9月至2005年9月对71例不同病因的胸壁大块缺损患者采用多种方法 进行胸壁重建.骨性胸廓重建采用自体组织(肋骨条、阔筋膜、肌瓣)或人工材料(Dacron片、聚四氟乙烯网片 钛合金条、金属丝支架加大网膜片、Dacron和骨水泥构成的三明治式复合体).皮下软组织修复主要应用转移皮瓣、肌皮瓣或大网膜瓣.结果 全组无手术死亡和局部肿瘤复发,2例因感染摘除金属植入物.术后呼吸功能良好,无反常呼吸运动.结论 背阔肌瓣和大网膜瓣修复软组织效果较好,后者对因感染引起的胸壁缺损效果更佳.Dacron片和骨水泥构成的三明治式复合体适用于大块骨性胸廓缺损的重建.     

Current techniques for chest wall reconstruction: expanded possibilities for treatment

Myocutaneous flaps and prosthetic materials have greatly facilitated reconstruction after massive chest wall resection. This series includes 112 such procedures. Latissimus dorsi, rectus abdominis, omental, pectoralis major, and contralateral breast flaps were used in 80 patients. Early in the series, 3 flaps were lost because of technical problems. Minor areas of incomplete healing that resolved completely with local wound care occurred in 16 of 80 flaps. Skeletal reconstruction was performed in 82 patients without complication. Marlex mesh was used for flat surfaces, and Marlex mesh with methyl methacrylate was used for the sternum and the curved surface of the lateral chest wall. These results have allowed an expansion of the indications for chest wall resection to include the curative treatment of primary chest wall tumors and palliative treatment for breast cancer patients with osteoradionecrosis, local recurrence (in select patients), chest wall infection, and tumors metastatic to the chest wall.     

Reconstruction of the chest wall with e-PTFE following major resection.

Nine patients underwent major chest wall resection at Thomas Jefferson University Hospital (Philadelphia, PA) over a 19-month period. Chest wall reconstruction was performed with an expanded polytetrafluoroethylene (e-PTFE) soft tissue patch (Gore-Tex) and vascularized flaps in all patients. The size of the skeletal defects ranged in area from 60 to 400 cm2. The primary indications for resection included chest wall sarcoma and radiation ulcer. Aggressive chest wall resection may be a patient's only opportunity for cure and an improved quality of life. In this series, chest wall resection was able to be performed with a low morbidity and no mortality. This study also demonstrates many of the advantages of e-PTFE as a chest wall substitute compared with other previously described prosthetic materials. The use of a Gore-Tex patch along with described flaps for soft tissue coverage provides good functional and aesthetic results.     

Evaluation of chest wall resection in the patients with breast cancer involving chest wall]

Twenty-three patients with advanced or recurrent breast cancer involving bony chest wall were treated by extended full-thickness chest wall resection and immediate reconstruction. The results were as follows: 1) Distant metastases were found concurrently or subsequently in more than half of the patients. Therefore, we should regard chest wall lesions as a systemic disease. 2) Long term result was encouraging, with 73.9% local control rate. 3) Post-surgical prognosis of the patients with sternal metastasis and solitary chest wall lesions were favorable, in that order. 4) Both local control rate and survival of the patients with mediastinal invasion, however, were fairly poor. 5) Disease-free interval (D.F.I.) after mastectomy longer than 5 years correlated significantly with a long survival after chest wall resection. As a result, we confirmed that chest wall resection was the treatment of choice for the patients with long D.F.I. and solitary chest wall lesion without mediastinal invasion nor metastasis, but the postoperative systemic therapy was indispensable to improve the patient's survival.     

Primary chest wall tumors

A retrospective study of 53 primary chest wall tumors, 26 benign and 27 malignant, was carried out to review their clinical radiological and pathological features. Forty-nine of the 53 lesions presented in the ribs and the remaining 4, in the sternum. The overall 5-year survival for patients with primary malignant neoplasms of the chest wall was 33.3%, and the 10-year survival was 18.5%. All of the deaths were disease related. All of the patients with benign tumors were treated by excision without recurrence or death. Distinction between benign and malignant chest wall tumors was not possible using radiographic criteria unless cortical destruction and involvement of soft tissues were visualized. On the basis of our analysis, we believe that all tumors of the chest wall should be considered malignant until proven otherwise and that wide excision should be carried out. This is necessary not only to obtain an adequate diagnosis but also to provide the best chance for cure in both benign and malignant lesions.     

Reconstruction of the chest wall following extended interscapulothoracic amputation and chest wall resection

Summary Extended interscapulothoracic amputation is a major operative procedure indicated in the treatment of malignant primary bony and soft tissue tumors involving the shoulder girdle and chest wall. The technique of chest wall resection and its reconstruction is described in two patients with recurrent malignant fibrous histiocytoma following extended interscapulothoracic amputation some months earlier. The stability of the chest wall was restored by using marlex mesh as a sandwich of two layers of mesh with methylmethacrylate interposed. Because of damage of the tissue around the chest wall resection by previous radiation therapy, free myocutaneous flaps were used for closure of the defects. Using this technique for reconstruction of large areas of the chest wall, it is feasible to restore sufficient pulmonary function and to obtain closure under unfavorable conditions. This operative technique can be used as a curative or palliative treatment following interscapulothoracic amputation of recurrent musculoskeletal tumors.     

胸壁全层缺损的修复重建

目的探讨胸壁全层缺损的修复重建方法及疗效。方法 2006年1月-2010年12月,收治14例胸壁全层缺损患者。男8例,女6例;年龄23～65岁,平均42岁。恶性肿瘤切除术后继发胸壁全层缺损12例,乳腺癌术后继发放射性损伤1例,热压伤1例。缺损范围为8 cm×5 cm～26 cm×14 cm。所有患者均伴肋骨缺损(1～5根),3例伴胸骨缺损。术中10例患者应用涤纶网或聚四氟乙烯补片行骨性重建,4例未作骨性重建。分别采用双叶皮瓣、胸大肌肌皮瓣、背阔肌肌皮瓣、腹直肌肌皮瓣修复软组织缺损,皮瓣切取范围为10 cm×7 cm～25 cm×13 cm。供区直接拉拢缝合或游离植皮修复。结果术后2例发生创面愈合不良,经再次彻底清创、肌皮瓣修复和补充植皮后愈合;其余皮瓣均顺利成活,创面Ⅰ期愈合。术后患者均获随访,随访时间6～36个月,平均8个月。除1例骨肉瘤患者因肝转移于术后6个月死亡,其他肿瘤患者随访期间均无复发。热压伤患者未同期行胸壁骨性重建,术后5 d出现短暂轻度反常呼吸,其他患者术后胸廓稳定性良好,无明显反常呼吸及呼吸困难。结论根据胸壁缺损病因、面积和部位,单独或联合应用局部皮瓣或肌皮瓣进行胸壁软组织缺损修复,必要时应用人工材料行胸壁骨性重建,可有效修复严重胸壁全层缺损。     

Surgical management of chest wall tumors

A new technique for reconstruction of the chest wall providing immediate chest wall stability was employed in six patients who required extensive chest wall resection for a variety of neoplasms. Despite preoperative impairment of pulmonary function, early extubation was possible in all patients. Pulmonary function was well preserved on follow-up examination.     

Donor cryopreserved rib allografts for chest wall reconstruction

Reconstruction after large chest wall resections must ensure not only anatomical coverage but a normal respiratory function, specially in the case of associated ventilatory disturbance. Since prosthetic reconstruction can present some problems such as rejection, excessive rigidity or infection, bone grafts have been proposed as an alternative to synthetic materials, due to their effectiveness and capability of integration with host tissues. Although iliac bone allograft or autologous ribs harvested from the opposite operative side are described for reconstruction, we present here the first reported clinical case of donor cryopreserved rib allografts use after extensive chest wall resection in a patient with severe COPD, showing excellent short-term results in the absence of pulmonary function impairment.     

An atypical congenital chest wall deformity

An 11-year-old girl with an asymmetric chest wall deformity demonstrated an excavation in the flank combined with partial synergy of costae 4 and 5. She was treated by an innovative partial chest wall reconstruction consisting of rib remodeling and internal osteosynthesis. The reconstruction regained symmetry and cosmesis. Special cases of chest wall deformity require an individualized management.     

Mesenchymoma of the chest wall in children

Benign chest wall mesenchymoma in children is an extremely rare disease. Only 20 patients have been reported in the world literature. We report a chest wall mesenchymoma in a 2-year-old boy who was admitted to the hospital after a routine chest roentgenogram showed a mass in the right upper chest wall. The patient was asymptomatic. Clinical examination was negative, but chest roentgenograms and computed tomography showed a mass in the right upper chest wall involving the third rib. A 2 x 2 x 1.5-cm tumor was excised totally with partial resection of the third rib. The histology of the lesion corresponded to a mesenchymoma (hamartoma) of the chest wall. Our patient has been followed up for 8 years without recurrence.     

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.     

Necrotizing fasciitis of the chest wall

Necrotizing fasciitis is a highly morbid soft tissue infection that rarely involves the upper torso. An extremely unusual case of necrotizing fasciitis of the chest wall is reported, including the method by which an open thoracic cage was managed. This represents the second reported case of a patient surviving necrotizing fasciitis of the chest wall requiring rib resection and chest wall reconstruction.     

胸壁外科疾病的治疗进展

胸壁外科曾是传统胸外科亚专业学科,具有古老的研究和临床实践历史,近年逐渐走向独立,成为一个崭新专业领域.由于观念发生变化及边缘学科的进步深入了对相关疾病认识,胸壁外科疾病的治疗涌现出新特点.本文从胸壁外科专业角度对胸壁外科所属的5类疾病(胸壁创伤、胸壁畸形、胸壁肿瘤、胸壁感染及胸壁缺损)治疗进展予以综述.     

Primary posterior chest wall echinococcosis

Hydatid cyst is not mentioned among the chest wall tumours in areas not known to harbour echinococcosis. One of the uncommon sites for echinococcosis even in endemic countries is the chest wall. The striking resemblance between neoplasm and hydatid cysts forms a diagnostic dilemma and makes the correct diagnosis essential before surgery.     

胸壁结核的外科治疗

目的 探讨胸壁结核的临床特点及疗效。方法 回顾性分析28例胸壁结核患者的临床资料。所有患者均行病灶清除术治疗，术后抗结核治疗9—12个月。结果 所有患者均获得治愈，随访1-2年无复发。结论 胸壁结核是以胸壁冷脓肿为主要特点，其主要治疗方法是手术治疗结合术前、术后抗结核药物治疗，而手术成功的关键是彻底清除病灶，消灭死腔。