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Indian Journal of Plastic Surgery, Vol. 38, No. 1, January-June, 2005, pp. 46-47 Case Report Large lateral thoracic defect by chondrosarcoma resection.............................. Ahuja Rajeev B Department of Burns, Plastic, Maxillofacial & Microvascular Surgery, Lok Nayak Hospital and associated Maulana Azad Medical College, New Delhi - 110 002 Correspondence Address: Dr. Rajeev B. Ahuja, Department of Burns, Plastic, Maxillofacial & Microvascular Surgery, Lok Nayak Hospital and associated Maulana Azad Medical College, New Delhi - 110 002 Code Number:pl05010
DISCUSSION Chest wall resection and reconstruction may be required for tumour, infection, radiation injury and trauma.[1] Notwithstanding the need for effective management of pleural cavity, the actual defect requires restoration of chest wall stability and soft tissue coverage. Maintenance of chest wall mechanics relies on both an airtight seal within the pleural cavity as well as skeletal support.[2] Introduction of muscle and myocutaneous flaps, development of reliable synthetic substances for skeletal support, and availability of newer artificial ventilatory support appliances have allowed the surgeons to be more aggressive in chest wall resections with tremendous refinement in reconstruction methods. So much so, massive chest wall resections with immediate reconstruction, are safe and have become a routine. Historically, the major concerns with massive chest wall resections were directed towards the respiratory mechanics than the actual pathology[3] and it still continues to dominate the reconstructive surgeon's concern. The most appropriate reconstructive option depends on the location of the defect (anterior, lateral or posterior), its etiology, and a thorough understanding of the chest wall mechanics[2]. Several large series[1],[2],[4] reporting experience on 100-500 chest wall reconstructions testify to the indications, safety of procedures, usefulness of certain flaps and complications, and also qualify the need for skeletal support. Unfortunately, authors of this 'case report'have omitted quoting these articles! Several factors influence the requirement
for skeletal reconstruction. Most patients can tolerate a loss of up to
4 ribs without skeletal reconstruction especially when the defect is covered
by a thick flap like the latissimus dorsi.[5] Similarly,
loss of lower portion of sternum is less critical.[5] Additional
factors that may influence are location of the defect and history of irradiation.[2] Lateral
defects require chest wall stabilization more often than the anterior defects
and similarly prior radiation offers some stability due to fibrosis.[2] Authors
themselves quote the article by Yokote and Osada[6] which
concludes that chest wall reconstruction is indicated when; (1) The area
of the defect is greater than 100 cm2., (2) Three or more ribs are resected
in the anterior thoracic aspect, (3) As many as four ribs are resected
in lateral chest wall. Authors also state that a decision has to be made
intra-operatively whether chest wall reconstruction needs to be carried
out or not, so that respiratory function is not compromised. It is indeed
baffling that they decided not to reconstruct the chest wall with a defect
of > 400cm2, involving 4 ribs, situated laterally on the chest wall, and without any history of prior irradiation! Fear of infection in 'mesh'reconstructions
with PTFE or polypropylene can not be the sole justification in not reconstructing
such a large chest wall defect when entire literature and large series
advise differently. Kroll et al[4] reporting
on long term follow up of 96 chest wall reconstructions with myocutaneous
flaps stated that synthetic mesh reconstructions were not used in a majority
of patients (average number of ribs resected 2.9) but at the same time
they did not find any evidence of increased infection or other complications
which would argue against the use of such synthetic stabilizing materials.
But, nothing succeeds like success! Several articles also support the view
that the pulmonary function may not be ultimately compromised even in large
chest wall resections, like resection of entire sternum without prosthetic
reconstruction, although, prosthesis may shorten hospitalization and the
ultimate time on ventilator. [7],[8],[9] Another
important factor to be considered is the reduction in forced vital capacity
following chest wall resection and reconstruction with 'Marlex'mesh.
This leads to reduced exercise tolerance, and if the chest wall is not
reconstructed there may be further loss of vital capacity.[10] May
be through this case report we are being conveyed the message that it is
safe enough to resect very large lateral chest wall defects without reconstruction
if latissimus dorsi flap is being used. How has one to decide the largest
chest wall defect that can be closed without chest wall reconstruction?
Authors have suggested to us one way i.e. try it out! On the contrary,
I think we need to have clarity in our objectives before making brave attempts
at closing such large(er) chest wall defects without chest wall reconstruction
because we may inadvertently have a patient who can not be weaned off the
ventilator! References
Copyright 2005 - Indian Journal of Plastic Surgery |
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