Eur J Cardiothorac Surg 2001;20:669-673
© 2001 Elsevier Science NL
Chestwall resection: a new and simple method for stabilization of extended defects
L. Lampl
I. Chirurgische Klinik, Zentralklinikum Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
Received 22 November 2000;
received in revised form 28 May 2001;
accepted 4 July 2001.
Tel.: +49-821-400-2988; fax: +49-821-400-4572
e-mail: dr_ludwig_lampl{at}hotmail.com
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Abstract
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Objective: Postresectional chestwall defects can usually be stabilized by reconstructions under tension. Only few extended defects require combined stabilizing methods. The one used mostly is Marlex®-Sandwich, despite some disadvantages. An alternative method using alloplastic material/metal bar is presented. Material and methods: Between 1986 and 1999, 189 chestwall resections were performed either for infiltrating bronchogenic carcinoma (Type I, n=67), tumors originating from chestwall or bony metastases (Type II, n=88), or local recurrences and infiltration by breast cancer or sequelae of its treatment (Type III, n=34).The standard reconstruction is performed with non-absorbable alloplastic meshes or patches under some degree of tension. For defects exceeding 250 cm2, usually Type-II cases, a reconstruction under tension is no longer appropriate. Therefore we developed a procedure which we used in six cases. Alloplastic mesh or patch gets sutured in the same way as is done in smaller defects. Then a metal bar (Grob-Stab®, Ulrich, Herrlingen/Blaustein, Germany) is threaded through the alloplastic material and is fixed at the adjacent ribs by Parham steel bands (Ethicon, Sommerville, KY, USA). Results: In all cases we achieved excellent stability. All of the patients were extubated on the operating table. There was no morbidity or mortality. In three cases the metal bars were removed after 3, 6 and 16 months postoperatively (dynamization). Conclusion: The new procedure is safe, simple and quickly performed. The additional costs are low (160 euro). The patient's comfort is excellent; borderline problems as described for Marlex®-Sandwich can be avoided, so that this procedure can be considered as an alternative to Marlex®-Sandwich.
Key Words: Extended chestwall defect • Combined stabilization
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1. Introduction
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Chestwall resections are procedures with a long tradition. Parham's [1] report in 1899 comprises 48 cases, beginning in 1778 (Aimar, Paris). The perioperative mortality reached 30%. Since then continuous progress in anesthesia, intensive care and in antisepsis as well as the development of appropriate alloplastics [2,3] and the elaboration of tissue transfer techniques [4–7] have improved the mortality associated with these procedures.
Due to this progress major chestwall resections can also be performed with low mortality. Smaller defects, up to around 200 cm2, can be reconstructed using various alloplastic materials under tension. In contrast to these, the relatively rare large chestwall defects require reconstructions with rigid materials in order to maintain the geometry of the thoracic cage and to achieve a sufficient stabilization. The best known of the latter type is Marlex®-Sandwich, where methacrylate is molded between two layers of Marlex®-mesh. But it incurs some problems at the junctions of the ribs with the prosthetic material.
Therefore we developed another procedure, which is technically easy, quick to perform and does not show these disadvantages, and can be ‘dynamized’ if the patient requires it. The reconstruction itself fullfills the same purpose as a rigid reconstruction: maintenance of geometry and stability.
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2. Material and methods
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2.1. Patients
From January 1986 up to now (September 2000) we performed 189 chestwall resections (Fig. 1)
.- Type I
- Centrifugal growth of lung tumors, usually bronchogenic carcinoma T3 requiring anatomical lung resection with additional skeletal resection. Chestwall stabilization, no special means for soft tissue coverage: n=67
- Type II
- Tumors originating from chestwall, bony metastases of ribs or sternum. Full thickness chestwall resection eventually additional peripheral lung resection. Complex reconstruction with soft tissue transfer and chest wall stabilization: n=88
- Type III
- Breast cancer, recurrences, treatment-related lesions. Centripetal tumor growth, skin defects more extensive than soft tissue defects, soft tissue transfer, (myo-) cutaneous flaps. Due to postradiation fibrosis only occasionally need for stabilization: n=34
Among the 189 patients there were only six (all of them Type II lesions) with extended defects, who fulfilled the criteria we set for the combined stabilization (Table 1).
2.2. Indications
Indications for this procedure are (1) if the defect exceeds 300 cm2; (2) if the defect exceeds one third of the circumference of the involved thoracic side; (3) if the defect exceeds four ribs and/or (1) or (2). For these we developed in 1992 [8] the procedure involving a reversible combination of non-absorbable alloplastic material and a metal bar.
2.3. Technical details
After en bloc resection of bony chestwall, underlying lung (usually peripheral wedge resection) and overlying muscle, any non-absorbable alloplastic material, either mesh or patch, is sutured in under moderate tension, as we do in smaller defects. Then a rib-strut (Grob-Stab®, Ulrich, Herrlingen-Blaustein, Germany) is threaded through the alloplastic material and fixed at the adjacent ribs by Parham steel bands (Ethicon, Sommerville, KY, USA) (Fig. 2) . In order to increase the tension to the alloplastic material the adjacent ribs can be spread by a small retractor before the steel bands are tightened and the reconstruction is fixed.
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Fig. 2. Sketch of the new reconstruction type. Alloplastic material is transfixed by the rib-strut. Fixation of the rib-strut secures the distance between the adjacent ribs.
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In this way we maintain the shape of thoracic cage and achieve a sufficient tension essential for stabilization (Fig. 3)
. The additional time consumed for threading through and fixing the rib strut is 5–10 min, the additional costs for the rib strut and the two Parham steel bands are about 160 euro. As in all the other cases where we use alloplastic materials we perform a thorough soft tissue coverage either by muscle flaps or by greater omentum.
After 2–3 months, if there is an additional stabilization created by scar tissue formation, the rib-strut can be removed easily under a short general anesthesia. We do not recommend local anesthesia for this procedure.
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3. Results
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Excellent stabilization was achieved in all six cases. All patients were extubated at the operating table. All patients could be moved from the intensive care unit (ICU) to peripheral stations on the first postoperative day. Artificial ventilation was not required during the postoperative course. Adequate sputum expectoration was seen in all cases. Bronchoscopy was not required for removal of retained mucus. There was no wound infection. The postoperative hospital stay ranged between 9 and 12 days.
In three cases the rib-struts were removed by a minor operation (dynamization) 3, 6, and 16 months postoperatively, by which time the chestwall was stabilized by scar tissue formation. The other patients did not request removal of the metal bar.
To this day only one local recurrence has been observed among these patients in the case of a malignant fibrous histiocytoma with six preceding operations. Survival ranges between 16 months (malignant fibrous histiocytoma) and 48+ months (Ewing sarcoma).
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4. Discussion
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The importance of chest wall resections can be highlighted best by the following data. About 7% of all primary bone tumors are localized at chestwall [9]. About 5% of all patients with bronchogenic carcinoma experience chestwall infiltration by the tumor [10]. Long-term survival after en bloc resection of lung and chestwall was reported as early as 1948 by Coleman [11] after en bloc pneumonectomy.
The general task is to preserve as much as possible of preoperatively just impaired mechanical lung function by a stable reconstruction, not only in patients with whom we have to perform a major en bloc resection such as lobectomy or bilobectomy.
A second problem is that patients can neutralize or abolish the tension of a simple reconstruction by bending and extending their trunks, especially if the defects are localized laterally in the lower parts of thoracic cage (Fig. 4)
. In 1923 Müller [12] measured meticulously the different intercostal distances in bended and extended trunk, demonstrating substantial changes. Using the new technique these movements can be blocked (temporarily).
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Fig. 4. Changing distances between the ribs in a sideward bended trunk means loss of tension for the reconstruction.
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A third problem which should be considered is that every material sutured under tension takes the shortest way between two points or lines. So in more extended defects the use of simple reconstructions under tension creates a loss of volume. In reality, moreover, it is nearly impossible to achieve an appropriate tension of alloplastic material in extended defects.
Eschapasse [3] solved the problem of stabilization by the ingenious combination he called Marlex®-Sandwich. But also this very ingenuous combination shows a weak point. Postoperatively every thoracic cage shrinks to some extent. The exact amount cannot be predicted precisely. As a result some patients complain of an unpleasant feeling of stiffness or respiratory impediment. In more marked cases tilting or extrusion of the prosthesis can be observed.
Instead of rib struts autologous ribs [13–16] have been used for a long time in pediatric surgery [17], but we assess the creation of an additional donor site defect as an important disadvantage of this technique.
Paris [18] uses rib-struts for his type of reconstruction. In contrast to him we do not use them as anchors for a rigid plate at the adjacent rib. We use them to reinforce tension, like we would use a ridgepole for a tent. In this way we can prevent the loss of tension by changes of posture. The most important difference between the two methods is that we use the rib-strut only as a temporary aid for the immediate postoperative period. After 2 or 3 months, when there is sufficient scar tissue, it can be removed because additional strength is achieved by the scar tissue.
The value of an appropriate stabilization has been undisputed for more than 20 years, when the first series with alloplastic materials were reported. Piehler et al. [19] published larger series in 1982. They observed a substantial reduction of both mortality and need for tracheotomy when postresectionally an appropriate stabilization of the chestwall could be achieved, which also comprises the length of ICU stay as well as the overall costs for the hospital stay [20].
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5. Conclusion
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The procedure described above guarantees maintenance of thoracic shape and efficiency of respiration, as well as efficiency of coughing. Due to the appropriate stabilization a reduction of postoperative pain can also be achieved. The procedure described above is technically easy, stable and not time-consuming. The patient‘s comfort is excellent. The particular advantage is the possibility of dynamization by a minor intervention after 2–3 months. It should be considered as an alternative to Marlex®-Sandwich.
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Acknowledgments
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The author thanks his colleagues Drs Walter Klepetko, Vienna, and Georgios Stamatis, Ruhrlandklinik Essen, for their valuable advice, as well as Kumarasingham Jeyasingham for his editorial assistance.
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Footnotes
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Presented at the 8th European Conference on General Thoracic Surgery of the European Society of Thoracic Surgeons, London, UK, November 1–4, 2000.
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References
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Abstract
1. Introduction
