Update Course Rewind: Chest Wall Reconstruction 2024

Would you know how to reconstruct a chest wall if you needed to? We discuss it here in today's video. I'm Lizzie Lee from Cincinnati Children's Hospital Medical Center. Today, Doctor Margaret Mutch, pediatric surgeon in Australia, presents a patient case discussing chest wall reconstruction. We have about a 10 year experience with our chest wall reconstructions. We will focus today on the case of a 14 year old male with osteosarcoma. He presented with, Back pain and difficulty walking. Examination revealed an incomplete cord injury with absent lower limb reflexes and altered motor and sensation below the level of T6. The bottom image shows the size of a large tumor arising from the 6th rib and extending into the spinal canal. He underwent an emergency posterior laminectomy and partial tumor debulking initially for his cord decompression. Um, between the levels of T3 and T7. The histopathology report confirmed an aggressive osteosarcoma. He subsequently went on to have further imaging with a PET scan, which you can see in the upper two images, and commencement of neoadjuvant chemotherapy. In the top right-hand corner on the PET scan, you can see a PET avid lesion on the right-hand side just next to the sternum. He then under Went a radio guided occult lesion localization using technetium 99. We did an anterior thoracotomy to remove that lesion, and that confirmed aggressive osteosarcoma, replacing that lymph node. Following his adjuvant chemotherapy, the next step was to consider how to proceed with his oncological surgical management. Most of the reconstruction needs to be tailored to the needs of each of the individuals, location and size of defects. Associated with your um impact, your influence of the particular type of material you use. There's a lack of clear evidence-based guidelines for reconstructive materials, but the priority is long-term durability, aesthetics, function, and accommodating future growth. And a lot of the literature is coming from adults. Let's talk through the technique used for this child's surgery. This was a long combined case. With our spinal surgeons and a thoracic team. Um, the spinal surgeons removed, uh, all of the vertebral bodies between T4 and T7 and inserted a cage, and we resected ribs 4 to 7. The tumor came from the 6th rib. When they were planning for the resection, they did initial mapping that showed a few right lower lobe nodules that they resected during the surgery. And during surgery, we found a tumor th thrombus in the azagus, which extended into the SVC. These operative photos show the extent of the resection and the placement of a Gore-Tex soft tissue patch. The photo in the middle shows a cage of the spinal canal. We tend to use resorbable and biosynthetic materials to do the reconstruction. We learned from Doctor Mutch that they have two systems in Australia, one by Stryker and one by KLS where they use The resorbable plates, which you can see being molded in the water bath to reconstruct the rigid part of the chest wall. Instead of using screws that came packaged with the plates, they used a K-wire drill to drill through the remaining ribs. They then used prole sutures to secure the implant. Following this, we, um, place a permcol on top of that, uh, implant, and, uh, subsequently, uh, use a muscular flap, in this case, the latissimus dorsi to cover the permacle. A pedicled flat. Permacol is a surgical implant that allows device placement. It is made of a porcine dermal collagen matrix, and from there we close. In general, the delta plates or the sonic weld system are uh polyol lactide and polyglycolide and polydactide plates. They have a strength of 78% at 2 months and 50% at 6 months. Here are early post-op images where you can see the cage on the vertebral column and his outcome on a CT chest scan. The photo on the right shows his post-op X-ray immediately after surgery. And how is the patient doing most recently? Unfortunately, he's had a relapse 18 months following this surgery close to his sternum. Doctor Matt Ntin did a further chest wall reconstruction. where they excised his entire sternum, costochondrocartilages, and anterior ribs and replaced it with a cement mesh. He's currently having adjuvant chemotherapy. What are some of the complications you've seen on reconstructive surgeries considering your experience in the past 10 years? We've had early postoperative wound infection in one patient, which was treated with IV antibiotics. We've had. Sterile seromas in two of our patients in the early stages, one at 2 months and one at 8 months. Both of these patients were treated with IR drainage. They had one case of minor scoliosis on follow-up, which is being followed by the spinal team and so far has not needed intervention. In summary, chest wall reconstruction in children is a complex procedure and it should be tailored to the individual patient. There is a lack of clear evidence-based guidelines for reconstructive materials. Doctor Mutch's team in Australia used a combination of reusable materials, mesh, and muscle flaps for reconstruction. Complications and long-term outcomes of chest wall reconstruction in children can vary from sterile seromass to mild scoliosis. Moving forward, bioengineering of tissue replacement and 3D printing may be the way of the future in our chest wall reconstructions. Global Cat MD along with Cincinnati Children's Hospital sharing knowledge to improve child health around the globe.