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 am Lizzie Lee from Cincinnati Children's Hospital Medical Center today doctor Margaret Much pediatric surgeon in Australia presents a patient case discussing chest wall reconstruction We have about a 10-year experience with our chest wall reconstruction 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 increased eight-chord injury with absent lower Elimory flexes and altered motor and sensation below the level of T6 the bottom image shows the size of a large tumor Arising from the sixth rib and extending into this final canal He underwent an emergency posterior laminectomy and partial tumor debulking initially for his core decompression Between the levels of T3 and T7 the histophysology 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 new adjuvant 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 underwent a radio guided occult lesion localization using Technician 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 an 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 Impact your influence of the particular top of material you use There's a lack of clear evidence-based guidelines for reconstructive materials But the priority is long-term durability aesthetic 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 the rustic team the spinal surgeons removed all of the vertebral bodies between T4 and T7 and inserted a cage and We were section ribs for just seven the two were came from the sixth rib When they were planning for the resection they did initial mapping that showed a few right lower load nodules that they resected during the surgery And during surgery we found a tumor thromus in the as it gets which extended into the SBC These operatives photos show the extent of the Refection in 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 back too much that they have two systems in Australia one by striker 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 sprues that came packaged with the plates They used a K wire drill to drill for the remaining rib They then used curling sutures to secure the implants following this we slice the permacol on top of that implant and subsequently Use a muscular flap in this case to let a smist or so to cover the permacol A pedicule flap permacol is a surgical implant that allows device placement It is made of a porcine dermal collagen maverick and from there we close In general the Delta plates or the sonic weld system are Poli L lactide and poly glycolod and polyd lactide plates They have a strength of 78% at two months and 50% at six months Here 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 during most recently? Unfortunately, he's had a Relapse 18 months following this surgery close to his sternum Dr. Mott Chirchine did a further chest wall reconstruction where the excise takes entire sternum caustocondrocardaliges and interior ribs and replaced it with a cement sash He's currently having a adjunt 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 post-operative 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 two months and one at eight 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 this final team and so far has not needed intervention In summary chest wall reconstruction and children is a complex procedure and it should be tailored to the individual patients There's a lack of clear evidence-based guidelines for reconstructive material Dr. Much's team in Australia used a combination of reasonable materials mesh and muscle flaps for reconstruction complications and long-term outcomes of chest wall reconstruction in children can vary from sterile seromas to mild scoliosis Moving forward bioengineering of tissue replacement and 3D printing may be the way of the future in our chest wall reconstruction Global cast MD along with Cincinnati children's hospital sharing knowledge to improve child health around the globe