And this is about chess wall pathologies, uh, Patricio Camano. Um, we have, we, we, we have Patricio Herrera who comes from Chile, um, and what's that? Another Chilean. We have so many Chileans here, uh, taking over. Um, Wit Holcomb is gonna be moderating, um, but we also, we timed it perfectly. We had someone from Australia. At bedtime and now we have someone from Australia at morning time 5:30 a.m. So, uh, uh, do we have, is Margaret much, are you, is she on the call there? I don't know if she's on yet. She'll be coming in as soon as they uh bring her. You'll let us know when she's on. So, uh, why don't you guys take on there you have the mics there. So let us know when Margaret's on. All right. So I'm uh uh I'm moderating this uh there she is, I'm moderating this uh final session, um. And uh I'll let Doctor Mut uh go on and present uh uh present her uh talk to the group. Go ahead, Margaret. Good morning everyone, or good afternoon, I should say. Um, yes, correct. Uh, apologies, I can't be there in person, but thank you for having me. Um, I guess I wanted to present, uh, more our experience here at the Children's Hospital at Westmead in Sydney. I work alongside Professor Jonathan Karpolaski, um, and we have about a 10 year experience with our chest wall reconstructions. I'm sorry, I can't see the slides. Can you not see the slides still? I can see them now. Thank you very much. Um, so essentially I wanted to present just one case because it's quite a short time frame and I understand you guys are running a little bit behind schedule. It's of a 14-year-old boy with osteosarcoma. I'll go into more detail of his case. Um, what our current practice is and our experience over the case of the last 10 years, and maybe touch on future innovations or have a discussion amongst, um, all of us on what's happening out there and where we think things are headed. Next slide, please. So I present you with a case of a 14-year-old male from country Australia, so he lives 5 hours from our institution. He presented with back pain and inability to walk. He was otherwise fit and well, and he was transferred to our institution where examination revealed an incomplete cord injury with absent lower limb reflexes and altered motor and sensation below the level of T6. Um, if you look to the bottom images, I haven't given a lot of images, but, ah, you can get an idea of, ah, the massive tumor that was existing. Um, and he underwent, uh, it was arising from the 6th rib and had extension into the, um, spinal canal, and he underwent an emergency posterior laminectomy and partial tumor debulking initially for his cord decompression, um, between the levels of T3 and T7. That histopathology, uh, confirmed an aggressive osteosarcoma, and he subsequently went on to have further imaging, um, with a PET scan, which you can see in the upper two images, and, uh, a commencement of neoadjuvant chemotherapy on the protocol of AOST 0331. Um, from there, I don't know if you can appreciate in the top right-hand corner on the PET scan, you can see a, a, a PET avid lesion. Um, on the right hand side, just next to the sternum, he underwent a, um, radio guided occult lesion localization, um, using technesium 99, and we did an anterior thoracotomy, um, to remove that lesion, and that confirmed also, um, aggressive osteosarcoma replacing that lymph node. Next slide, please. Following his adjuvant chemotherapy, obviously we had our MDT and we had to consider what was next in terms of his surgical, oncological surgical management. Um, so I guess I put this poll to you guys to get an idea of what people feel are the most important and critical factors when choosing a reconstruction method in our pediatric population. You leave that slide up. I was just gonna ask our uh in studio audience what they thought uh. That the answer or the best answer should be there's. It's a difficult case. Dan, do you have a thought on this? Yeah, I think, uh, first of all, it's a tumor case, so the first priority is to make sure you do what you need to do to control the tumor, um, and then the slides down, but, but I think structural integrity and long-term viability are probably the most important thing, more important than cosmetic result. Coconut ice Yeah, I, I agree with that, and this is an osteo, but in the UN that is much more common, uh, we need to. To use something that we can use with radiotherapy also, so it's much more important. So that that's the main we have the poll results. Come here. Very, so, uh, next slide. I'm sorry. Perfect. I can't read that, so maybe you guys could, um, tell me which, which colors associated, which, with which, um, which answer of the poll. So D is, uh, long-term durability, structural integrity, and, uh, C is impact on respiratory function and quality of life. So, um, yeah, I think. Long term durability is about 2/3 of the answer. Next slide, please. So I think, um, you know, from what we've discovered and, and what we're seeing, these are all kind of rare and challenging cases and most of the reconstruction needs to be tailored to the needs of each of the individuals, and I guess um location and size of defects associated with your um resection are going to impact your influence of the particular type of material you use. Um, there's, Not a right or a wrong answer, I don't think in this case, and there's a lack of clear evidence-based guidelines for reconstructive materials, and a lot of the literature is coming from adults. I think, uh, I'm not sure who mentioned, but also you need to apart from these three things, you also need to consider radiolucency, so in terms of surveillance and adjuvant radiotherapy as discussed. Next slide. I might talk you through a bit of this kid's surgery. So essentially this was a very long combined case with our spinal surgeons and, and our thoracic team. Um, the spinal surgeons commenced and removed all of the vertebral bodies between T4 and T7 and inserted a cage, um, and we resected ribs 4 to 7. The tumor itself was arising from the 6th rib. Uh, Evidence on the initial mapping for planning for the resection showed, uh, a few lung nodules on the right lower lobe which we resected, uh, and during surgery, we found a tumor th thrombus in the azagus which extended into the SVC. So these operative photos can show on the. The, the extent of the resection and in and in this next slide, you can see us placing a Gore-Tex patch. The cage of the spinal canal in the middle photo, and then we tend to use resorbable and biosynthetic materials to do the reconstruction, and we have two systems here in Australia, one by Stryker and one by By KLS, um, where they use the resorbable plates, which you can see being molded in the water bath to fit or to reconstruct the chest wall, the rigidity, the rigid part of the chest wall. Next slide. You can see we secure these. We don't use the, um, the recommended, uh, resorbable screws that come with the plates, but we use the K wire drill to drill through the remaining, um, ribs, the 2 millimeter, and use, um, prolean or, or PDS sutures to secure the, the implant. Next slide. Following this, we um place a permcol on top of that, ah, implant and ah subsequently, ah, use a muscular flap, in this case the latissimus dorsi to cover the permacle. A petticled flap that is, um, and from there we close. Next slide. So just in general, um, the delta plates or the sonic weld system are, ah, polyal lactide and polyglycoli and polydactide plates. They, um, have a strength of sort of 78% at 2 months and 50% at 6 months, and I think most people are familiar with Permacol, which is the porcine dermal collagen matrix. Next slide. This is some of this child's postoperative images in the early stages where you can see the cage on the on the vertebral column, um, and his outcome and his uh CT chest and his immediate postoperative X-ray. Next slide. In terms of our 10 year experience, most of our resections have been oncological. Um, we have 8 patients, most of them male, mean age of 4 years, and our follow-up's a little bit extended on from this, but we don't have the new data yet. Next slide. In terms of complications, we've had early post-operative wound infection in one patient, which was treated with IV antibiotics. We've had sterile seromass in two of our patients in the early stages, one at 2 months and one at 8 months. Again, both treated with IR drainage and one case of scoliosis on the follow-up, which is being, um, um, which is minor and being followed by our spinal team here, um, but the child hasn't had any intervention to date. And unfortunately we've had one death from metastatic Ewings. However, um, this was, uh, we, we maintain persistent local control in this patient. Next page. Um, and I've just, uh, put up a couple of the more recent, uh, articles that I found, um, in the literature search. Most of them, uh, we have, there's two systematic. Reviews in kids, they're, um, with minimal patience, and, uh, use of a multitude of, uh, varying, uh, subs, uh, tissue replacements. And next slide. In terms of recommendations going forward, I think in our institution, these are rare cases. Again, I think they're challenging. I think the reconstruction should be tailored to the individual patient. Um, there's again a lack of high quality output. Evidence out there and we don't really have any long term follow up on the outcomes of these patients. Uh, we tend to choose, like I said, uh, semi-rigid materials which are bioabsorbable and biosynthetic, um, more flexible materials in terms of our reconstructions. I think in terms of moving forward, bioengineering of tissue, um, replacement and 3D dimensional printing may be the way of the future in, in our chest wall reconstructions. Oh, that was fantastic. Thank you so much uh for sharing your experience with us. The patient that you presented, uh, uh, how is he doing? Uh, he, I didn't go on because the talk was meant to only be 5 minutes, but unfortunately he's had a, a relapse, um, just under 18 months, uh, following this surgery close to his sternum, and we did a further, um, uh, chest wall reconstruction where we. his entire sternum and uh, costochondral cartilages and, um, uh, anterior ribs and replaced it with a, a cement mesh. Um, he's currently having ongoing, uh, adjuvant chemotherapy. Well, that's uh fantastic. Anyone in the audience have, have a question for Doctor Blanch? OK, well, listen, thank you so very much. Um, please give, uh, Jonathan my best. He's an old friend of mine, so, uh, tell him a little. No problem. Thank you. You're welcome. All right. Last but not least today, uh, Patricia is gonna, uh, talk also about, uh, uh, new, uh, new strategies for chest wall problems. Hi everyone, thank you very much for the invitation. Uh, I'd like to uh talk about. A quite rare pathology, but you now and then you see one, and if you run into it, you're gonna have a strategy, right? So we're gonna we're, we're gonna talk about asymmetric pectus arquaarum. Uh, what to do with it? How do we do it? What to do with the asymmetry. And finally, how to stabilize after resecting. Next, please. Does anyone in the audience have any experience with 3D modeling and Organs, tumors, or cutting guides. Yeah, good. Um Do we have the poll results? It's coming. There it is. Nice. That's very nice. Yeah, there's a there's a lot more, um, experience than you might have thought. I would have thought. Sure, sure. Next, next, please. So we start with the with the CT scan. We, we manage the, the DICOM data to make a model, a, a virtual model of the sternum where you can uh appreciate the asymmetry. Next, please. Has anybody had problems with, uh, sternal symmetry during surgery? I mean, uh, can you define sternal asymmetry? The question was, can you define sternal asymmetry? Oh, you have an aquatum, right, but one of the sides of the sternum is much more curved than the other one, so the which that you should take out is not symmetric, OK. So how, how asymmetric do you do it? Yeah, I, I had 4 last year, but they were all symmetrical. OK, yeah, so here we go, um, do we widen the wedge on one side? Do we widen the wedge regardless of bone gap? Do we resect costal cartilage on the protruding side, uh, or do we compress afterwards? Uh, what we, what we can see here is a patient, uh, with a. Quite striking uh angle in the, in the sternum which is not symmetric. 11 of the sides is much more curved than the other. Next one please. So we start with the Next, please. So you, with the reconstruction, you, you make a perpendicular uh line to each one of the plates or the uh flat surfaces and you make a triangle on each side of the sternum. With the sides of this triangle, you make cutting planes. And with those planes, you. Delineate your wedge. Uh, the, yeah, that's, that's the way. So these planes are not even, it's not, it's, it's not easy to, when, when it's asymmetric, it's not easy to uh do it uh like. Spontaneously in the OR. So we do it over and over as to produce the lesser gap in the posterior cortex. Next one, please. Then when you have your planes you mount them on a mold of the anterior surface of the sternum of the asymmetric sternum. So this, this, uh, green, uh, piece of plastic which is 3D printed will have 1 ft and 1 ft only on the anterior surface. Then you stitch it with, um, I mean you screw it with the screws on, on the anterior surface and you pass the, uh, the, uh, piezoelectric scalpel. On these ridges So, next, please. Uh, is that, that's a video. Could you play, yeah, so you have this. Simulation beforehand before the OR where you can see that the posterior cortex is barely scratched. Next please. So you get this, uh, the, the, the one on the right side it's a video if you might please this is an actual cutting guide that's already been used. You can see the, the scratches on the surface, um, so you see the, the the lines next please. On the left side you see the plate in place. We are using the piezoelectric scalpel which gives you a really fine line cutting on the bone. And on the right you have the, the plates in place. Next please. You can do a straight uh straight bars or these figures uh to stabilize the sternum. Next, please. So if after resecting the bone wedge, you still have. The rib arches to be. Uh, asymmetric with one side protruding more than the other, what would you do? Would you further resect sternal bone? Would you do bracing after surgery? Would you do rib repositioning or periconndral resection and suture rib shortening? So I think this is an interesting problem. And for those, uh, pediatric surgeons who see a lot of chest wall pathology, whether it's excavatum or carotum. The first time you see one of these, you'll think it's a car onto. But, but you're obviously wrong and it's the wrong treatment, and I've, I've only, John has more experience than I do. I've only seen 3 in my career, but it was, it's striking how different it looks like from a, from a car on. Uh, but you can't, you can't brace it. Yeah, yeah, but it's, it, uh, the surgery itself is, um, is, is not easy to do. So before you, you do it, be sure you, you know what you're doing or send it to somebody who does know what they're doing. Absolutely. Well, the, the methodology we use, you know. Left side, you see the angle on the sternum. On the right side you see the same patient after surgery and you have pretty much 19,080 degrees uh on of the correction. This is, these are uh two different patients with uh postoperative uh results which both are very uh happy about it. Next one. Thank you very much. Yeah. Really good results. Do you use this tech technique for a symmetrical, uh, uh, just asymmetrical. OK, John, do you have any, any comments, thoughts? Yeah, I, I, I wish I knew about that technique, um, but. Um, I, I like it because it's what, what I've done with these is essentially. Because I noticed in your post-operative photo, there's a, that, that the costal cartilages are still a little bit prominent on each side. So I, I kind of start with a ravage procedure. I remove all the costal cartilages. And then I actually I completely resect that whole anterior projection so the so the issue of asymmetry um is kind of gone because I completely excised that and and I noticed you use the Zimmer system which is beautiful they make a sternal closure system that has a loop wire that the cardiac guys use and if you turn it 90 degrees you can use that to take a completely. Bisected sternum and bring it together and it comes back extremely flat but that's much more involved than than this is a much more elegant way to do it. I'm, I'm curious that you mentioned uh, a ser a scalpel, like an electrical scalpel that cuts the bone. PS electric. The PS electric, is is the one this is the one that, uh, maxillofacial surgeons use in, uh. In the maxilla or in the in the jaw on the jaw because that was, I, that's, that's a beautiful way, it's a beautiful line, yeah, yeah, yeah, they may have. I just use the hammer and the chisel, I guess that's what I used to, that's what I used to hammer and chisel. Yeah, all right, thank you very much. Beautiful work. Thank you. All right, thank you. Well, Todd, that about wraps it up from here and another great, uh, update course. Congratu congratulations. No, thank you. This was a great way to end it.
Click "Show Transcript" to view the full transcription (17398 characters)
Comments