Omental Flap and Titanium Plates Provide Structural Stability and Protection of the Mediastinum...

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mental Flap and Titanium Plates Providetructural Stability and Protection of theediastinum After Extensive Sternocostal

esectionaetano Rocco, MD, FRCS(Ed), Flavio Fazioli, MD, Carmine La Manna, MD,ntonello La Rocca, MD, Stefano Mori, MD, Raffaele Palaia, MD, Nicola Martucci, MD,nd Rosario Salvi, MDepartment of Thoracic Surgery and Oncology and Department of Surgery, National Cancer Institute, Pascale Foundation,

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ajor tenets in the reconstruction of the anterolateralhest wall include preservation of structural stability andunction and coverage of the mediastinal contents. Toeach these goals, a rigid support has been advocated byeveral authors. We describe a patient with extensiventerolateral defect after sternocostal resection of chon-

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nd Oncology, National Cancer Institute, Pascale Foundation, Via Sem-ola 81, Naples, 80131 Italy; e-mail: gaetano.rocco@btopenworld.com.

2010 by The Society of Thoracic Surgeonsublished by Elsevier Inc

sing three metallic transverse plates and an omental flaprapped onto the plates. This method simplifies recon-

truction in comparison with previously described tech-iques concerning complete solid coverage and leaveseveral options intact in the event of future recurrences.

(Ann Thorac Surg 2010;90:e14–6)

econstruction of large anterolateral chest wall defectspresents multiple challenges often requiring a mul-

idisciplinary approach [1]. Through the years there haveeen several techniques and materials proposed tochieve structural stability and protect the mediastinalisceral compartment [2, 3]. A consensus exists for theeed of rigid support and for the use of viable flaps to

acilitate incorporation and preserve cardiorespiratoryunction [2]. We propose a simplified approach for first-ime reconstruction after extensive sternocostal resectionor chest wall neoplasm.

echnique

56-year-old man was referred to us for an enlargementf a sternal mass that had been followed up by hisrimary care physician for 4 years. After admission in ourepartment, a chest computed tomographic scan wasone showing a sizeable mass involving the body of theternum and ribs 3 to 7 on the right side (Fig 1). Albeitmpinging of the heart and the heart vessels, the tumoras not deemed to infiltrate any mediastinal structures.through-cut biopsy yielded poorly differentiated chon-

rosarcoma, and the patient’s preoperative work-up didot show extrathoracic disease. Pulmonary function testshowed forced expiratory volume in 1 second and aorced vital capacity value of 1.83 L (69% of predicted)nd 2.63 L (77% of predicted), respectively. In addition,

ccepted for publication April 15, 2010.

ddress correspondence to Dr Rocco, Department of Thoracic Surgery

reoperative peak maximal oxygen consumption was0.2 mL/kg/min.During the operation, the patient’s corresponding left

hondrosternal cartilages and xyphoid were removed toxpose the mass and separate it from the mediastinum.n the right side, the anterior bony ribs were divided (3

o 4 cm) from the tumor margin. At this point, the mosteripheral part of the right middle lobe, which washown to be firmly adherent to the chondrosarcoma, wasesected. After ligation of both internal mammary ves-els, the sternum was divided from the manubrium andhe specimen was removed.

Three titanium rib plates (Synthes, Solothurn, Switzer-and) were cut and shaped to fit the curvature of the chestall defect outlined by the remaining lateral ribs 3 to 5

nd the manubrium. Each plate was anchored to by threeitanium screws gauged to the corresponding rib thick-ess (Fig 2A). Through a supra-umbilical, midline lapa-otomy, an omental flap (based on the left gastroepiploicrtery) was raised and passed under and over the tita-ium plates to wrap them in a vascularized environmentnd to separate them for the underlying heart and greatessels (Fig 2B). The omental wrap was laterally suturedo the pectoralis muscles and the skin was closed over it.he postoperative course of the patient was uneventful,part from an episode of atrial fibrillation responding tomiodarone. The patient was discharged home 3 weeksfter surgery on sinus rhythm. The objective findings oformal healing and structural stability were confirmedy a postoperative chest computed tomographic scan and

he patient’s respiratory dynamics, along with an excel-

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e15Ann Thorac Surg HOW TO DO IT ROCCO ET AL2010;90:e14–6 SIMPLIFIED RECONSTRUCTION OF ANTERIOR CHEST WALL

orced expiratory volume in 1 second and a forced vitalapacity value at 3 weeks after the surgery were 1.37 L52% of predicted) and 2.16 L (63% of predicted), respec-ively, demonstrating 17% and 13% respective reductionsompared with the preoperative values.

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everal materials have been introduced into clinicalractice to bridge anterolateral chest wall defects androvide rigid support, including methylmethacrylateMM), polytetrafluoroethylene, ceramic, bone ho-

ografts, and, metallic plates [1–6]. The use of each ofhese materials yields potential advantages and draw-acks that have been emphasized in the literature [1, 7].n the other hand, current management of chest wall

umors may force the surgeon to consider repeated

ig 1. Preoperative chest computed tomographic reconstructionhowing the extension of the chest wall neoplasm.

esections that will consume the available reconstructiveptions aimed at granting functional and structural res-oration. The materials to be used for reconstructionf the anterolateral chest wall could be prioritized, basedn their simplicity of use (and surgeon’s preference), hostolerance, cost and availability (ie, cryopreserved cadav-ric homografts). In addition, the ability to protect theediastinum and the increasing extension of the defect

ue to re-resection of recurrences may also dictate theype of reconstructive material [1, 2]. Titanium platesave been successfully used to bridge lateral chest wallefects of variable size [8]. When they were used toeconstruct the anterior chest wall after a partial oromplete sternal resection, a polytetrafluoroethyleneesh or methylmethacrylate sandwich was sutured over

he plates or between the plates and the mediastinum [3,]. The addition of prosthetic material to the plates mayontribute to the overall structural stability, but mayinder the potential to leave the mediastinum exposed in

he event of prosthesis contamination. Indeed, by onlysing a total of three or four titanium plates, the presencef foreign bodies is limited. In fact, the resort to titaniumlates has been reported to bridge severe postsurgicalternal dehiscence complicated by mediastinitis [6]. Inur patient, the plates were isolated by the viable,ensely vascularized omental tissue endowed with su-reme plastic potential; hence facilitating incorporation

nto the host [4]. In addition, any friction on the medias-inal vessels and the lungs was avoided by the omentalap interposition. In this context, the renown protectiveole of omentum is emphasized, irrespective of the ma-erial used for structural stabilization [2, 8].

Should the acceptable functional outcome demonstratedn our patient be confirmed by further experiences, theombination of titanium plates and omental flap may beuccessfully used for both primary and secondary opera-

Fig 2. (A) Titanium plates bridging the chestwall defect. (B) The omental flap is wrappedaround the plates.

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e16 HOW TO DO IT ROCCO ET AL Ann Thorac SurgSIMPLIFIED RECONSTRUCTION OF ANTERIOR CHEST WALL 2010;90:e14–6

ions. In this setting, the basic titanium plates omentumombination could be used as an alternative to more tradi-ional materials (ie, polytetrafluoroethylene or methyl-

ethacrylate) for sternocostal resections and anterior chestall reconstruction. As already described with the methyl-ethacrylate sandwich [4], plates may also be used in the

uture to favor osteosynthesis between cadaveric implantsnd the receiver’s ribs or sternum, or a combination thereof.n fact, such an appealing option will be possible due to the

alleability of the plates, which will facilitate a close repro-uction of the desired chest wall curvature, and to the

ncreased stability of the reconstruction resulting from theirauged-to-rib thickness locking system.

eferences

. Weyant MJ, Bains MSD, Venkatraman E, et al. Results ofchest wall resection and reconstruction with and without rigid

. Rocco G, Fazioli F, Scognamiglio F, et al. The combination ofmultiple materials in the creation of an artificial anterior chestcage after extensive demolition for recurrent chondrosarcoma.J Thorac Cardiovasc Surg 2007;133:1112–4.

. Hamad AM, Marulli G, Bulf R, Rea F. Titanium plates supportfor chest wall reconstruction with Gore-Tex dual mesh aftersternochondral resection. Eur J Cardiothorac Surg 2009;36:779–80.

. Lee TY, Estrera AL, Safi HJ, Khalil KG. Total sternal recon-struction using a titanium plate-supported methyl methacry-late sandwich. Ann Thorac Surg 2007;84:664–6.

. Watanabe A, Watanabe T, Obama T, et al. New material forreconstruction of the anterior chest wall, including the ster-num. J Thorac Cardiovasc Surg 2003;126:1212–4.

. Huh J, Bakaeen F, Chu D, Wall MJ. Transverse sternal platingin secondary sternal reconstruction. J Thorac Cardiovasc Surg2008;136:1476–80.

. Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early andlong-term results of prosthetic chest wall reconstructionJ Thorac Cardiovasc Surg 1999;117:588–92.

. Marulli G, Hamad AM, Schiavon M, Azzena B, Mazzoleni F, ReaF. Geometric reconstruction of the right hemi-trunk after resec-