Reconstruction after major chest wall resection: Can rigid fixation be avoided?

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• 作者：Wael C. Hanna MD ; MBA  ; ;   ; ^{wael.hanna@me.com} ; Lorenzo E. Ferri MD ; PhD ; Katherine M. McKendy MD ; Robert Turcotte MD ; Christian Sirois MD ; David S. Mulder MD
• 刊名：Surgery
• 出版年：2011
• 出版时间：October 2011
• 年：2011
• 卷：150
• 期：4
• 页码：590-597
• 全文大小：254 K

文摘

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Background

Rigid fixation is advocated as the best method to achieve good respiratory outcomes after chest wall resection at the expense of a high complication rate. The following study aims to examine the role of myocutaneous pedicled flaps, with or without soft prosthesis, in the reconstruction of small and large chest wall defects.

Methods

All patients who underwent resection of chest wall tumors between 2003?010 were identified from a prospectively entered database. Operative and postoperative outcomes were documented. Patients were stratified into 2 separate groups based on the size of the residual chest wall defect; the Small Defect (SD) group (<60 cm²) and the Large Defect (LD) group (&gt;60 cm²).

Results

Thirty-seven patients were identified over a 7-year period: 9 in the SD group and 28 in the LD group. Primary sarcoma was the most common indication for resection (57 % ). The mean size of the chest wall defect was 50.8 cm² in the SD group and 149.4 cm² in the LD group (P = .001). All patients underwent reconstruction with autologous tissue, nonrigid prosthesis, or a combination of the two. Prosthesis was used in 11 % of patients in the SD group and 61 % of patients in the LD group (P = .018). The rate of immediate postoperative extubation was 100 % in the SD group and 89 % in the LD group (P = .42). The rate of postoperative pneumonia was 7 % in the LD group vs 0 % in the SD group. The rate of surgical site infection was 7 % in the LD group and 0 % in the SD group. A subgroup analysis of the LD group demonstrated no statistical differences in any of the measured outcomes between patients in whom mesh prosthesis was used and patients in whom a myocutaneous flap alone was used. However, there was a clinical suggestion of prolonged ventilation in the subgroup where mesh was not used and of higher infection rates in the subgroup where mesh was used.

Conclusion

Small chest wall defects can be reconstructed with pedicled myocutaneous flaps alone without compromising respiratory outcomes. In carefully selected patients with moderate size defects larger than 60cm², reconstruction with pedicled myocutaneous flap alone offers similar postoperative outcomes as reconstruction with nonrigid prosthesis, at the expense of a possible need for a short period of mechanical ventilation.