Update Course Rewind: Chest Wall Reconstruction 2024
With Dr. Margaret Mutch · hosted by Dr. Lizzie Lee · StayCurrentMD
Cued at 3:37 · stops at 4:22 · press play
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What the experts said
Doctor Margaret Mutch's team has about 10 years of experience with chest wall reconstructions.
Examination revealed an incomplete cord injury with absent lower limb reflexes and altered motor and sensation below the level of T6.
The patient underwent an emergency posterior laminectomy and partial tumor debulking initially for cord decompression between the levels of T3 and T7.
PET scan showed a PET avid lesion on the right-hand side just next to the sternum.
Radio guided occult lesion localization using technetium 99 was performed, followed by anterior thoracotomy to remove the lesion, which confirmed aggressive osteosarcoma replacing a lymph node.
Most of the reconstruction needs to be tailored to the needs of each individual, location and size of defects, and the particular type of material used.
A lot of the literature on chest wall reconstruction is coming from adults.
The spinal surgeons removed all of the vertebral bodies between T4 and T7 and inserted a cage, and the thoracic team resected ribs 4 to 7.
During surgery, a tumor thrombus was found in the azygos, which extended into the SVC.
Doctor Mutch's team tends to use resorbable and biosynthetic materials to do the reconstruction.
In Australia, two systems are used for chest wall reconstruction: one by Stryker and one by KLS, using resorbable plates that are molded in a water bath to reconstruct the rigid part of the chest wall.
Following plate placement, Permacol is placed on top of the implant, and subsequently a muscular flap, in this case the latissimus dorsi, is used to cover the Permacol.
The delta plates or the sonic weld system are polylactide and polyglycolide and polylactide plates with a strength of 78% at 2 months and 50% at 6 months.
The patient had a relapse 18 months following surgery close to his sternum.
The patient is currently having adjuvant chemotherapy.
In the team's 10-year experience, there was early postoperative wound infection in one patient, which was treated with IV antibiotics.
There were sterile seromas in two patients in the early stages, one at 2 months and one at 8 months, both treated with IR drainage.
The histopathology report confirmed an aggressive osteosarcoma.
There is a lack of clear evidence-based guidelines for reconstructive materials, but the priority is long-term durability, aesthetics, function, and accommodating future growth.
Instead of using screws that came packaged with the plates, they used a K-wire drill to drill through the remaining ribs and then used Prolene sutures to secure the implant.
Permacol is a surgical implant made of a porcine dermal collagen matrix that allows device placement.
Doctor Mutch performed a further chest wall reconstruction where they excised the entire sternum, costochondral cartilages, and anterior ribs and replaced it with a cement mesh.
There was one case of minor scoliosis on follow-up, which is being followed by the spinal team and so far has not needed intervention.
Bioengineering of tissue replacement and 3D printing may be the way of the future in chest wall reconstructions.