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Bioprosthetic Versus Synthetic Mesh For Reconstruction Of Oncologic Chest Wall Defects
Patrick B. Garvey, MD, FACS, Mark W. Clemens, MD, Johnathan P. Doolittle, BS, Hong Zhang, MS, Donald P. Baumann, MD, FACS, Charle E. Butler, MD, FACS.
The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
The traditional approach for reconstruction of thoracic defects following tumor extirpation has been to employ a synthetic prosthesis (i.e. polypropylene and/or methylmethacrylate). Because bioprosthetic mesh (e.g. porcine, bovine, or human acellular dermal matrix) has been demonstrated to have advantages over synthetic mesh in abdominal wall reconstruction (AWR), some surgeons are now also using bioprosthetic mesh in thoracic reconstruction, particularly in patients judged to be at increased risk for complications. However, while prior studies have demonstrated the advantages of bioprosthetic mesh in AWR, the benefits of bioprosthetic mesh over synthetic mesh for oncologic thoracic reconstruction are not well understood. We hypothesized that patients' outcomes will be superior with bioprosthetic chest wall reconstruction in comparison to synthetic mesh chest wall reconstruction.
We retrospectively compared surgical outcomes for all consecutive patients who underwent reconstruction of complex, composite thoracic defects following oncologic tumor resection with either bioprosthetic or synthetic mesh at a single center over a ten-year period. We only included chest wall defects reconstructed with both mesh and locoregional flaps. We excluded flap only or mesh only reconstructions and patients with <6 months follow-up. The primary outcome measures for the synthetic versus bioprosthetic groups included overall complications, surgical complications, medical complications, infection, and mesh removal. Logistic regression analysis identified potential associations between patient, defect, and reconstructive characteristics and surgical outcomes.
121 patients were included: 40 (33.1%) bioprosthetic versus 81 (66.9%) synthetic. Mean follow up was 36.7 months. Patient and defect characteristics were similar. Overall surgical complications were lower in the bioprosthetic (20.0%) versus the synthetic group (34.6%), although this was not statistically significant (p=0.14). Specific complications were also similar for the bioprosthetic versus synthetic groups, including medical complications (5.0% vs. 3.8%; p=1.0), infections (15.0% vs. 14.8%; p=1.0) and need for mesh removal (5.0% vs. 7.4%; p=1.0). Mulitvariate logistic regression analysis showed synthetic mesh to be an independent predictor of higher overall complications (OR=2.9; CI=1.0-8.6; p=0.055) in comparison to bioprosthetic mesh. Multivariate logistic regression also demonstrated preoperative radiation therapy, ≥ 4 ribs resected, and chronic obstructive pulmonary disease to be significant independent predictors for overall complications, infection, and mesh removal. Different types of biologics generally performed similarly, although the bovine acellular dermal matrix cases did experience significantly more infections requiring mesh removal (18.7%) than did the combined human and porcine acellular dermal matrix cases (0%; p=0.0498) and the synthetic cases (0%; p=0.0038).
To our knowledge, this study is the first to directly compare outcomes for synthetic versus bioprosthetic mesh repair of composite chest wall reconstruction when combined with soft tissue flap coverage. While synthetic mesh was found to be an independent predictor of overall complications, given the findings of this study, we believe that surgeons should not routinely employ costlier bioprosthetic mesh for chest wall reconstructions that include flap coverage. Rather, surgeons should consider selectively employing a bioprosthetic mesh for chest wall reconstruction in patients with co-morbid characteristics that appear to be associated with complications such as preoperative radiation therapy, ≥ 4 ribs resected, or chronic obstructive pulmonary disease.
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