|Program and Abstracts
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Chest Wall Reconstruction: Evolution over a Decade and Experience with a Novel Technique for Complex Defects
Saïd C. Azoury, MD1, Joshua C. Grimm, MD1, Sami H. Tuffaha, MD2, Justin M. Broyles, MD2, Anne C. Fischer, MD, PhD3, Stephen C. Yang, MD4, Anthony P. Tufaro, MD5.
1Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA, 2Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA, 3Department of Surgery, Division of Pediatric Surgery, Beaumont Health System, Royal Oak, MI, USA, 4Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA, 5Department of Plastic and Reconstructive Surgery, Department of Oncology, The Johns Hopkins Hospital, Baltimore, MD, USA.
PURPOSE: Resection and reconstruction of the chest wall is performed for various insults and pathologies. Reconstruction with acellular dermal matrices (ADMs) has gained popularity over the last decade, however data on this topic remains sparse. The aim of this study is to review the different methods and materials used for complex defect reconstruction while reviewing and highlighting a novel approach using a biologic inlay and synthetic onlay technique for complex high-risk defects.
METHODS: A retrospective review was performed of all patients who underwent full-thickness chest wall resection and reconstruction (CWR) during a 10-year period by the senior surgeons (SCY and APT) at The Johns Hopkins Hospital. Patient characteristics, comorbidities, surgical risk factors, operative data, and different reconstructive methods/ materials were reviewed and compared. Post-operative wound complications and outcomes were reviewed, as well as interventions used to manage the complications. Wound-related events were classified as major (i.e. requiring re-operation/surgery) or minor (complications necessitating non-surgical/conservative management).
RESULTS: From December 2003 to January 2014, a total of 81 patients underwent CWR. Thirty-five patients were male (43.2%) and the overall median age was 57 years (IQR, 44-64 years). Mean body-mass index (kg/m2) for the overall cohort was 26.4±5.6 kg/m2. The majority of patients were classified as American Society of Anesthesiology Class (ASA) 3 (n=55, 67.9%). The indications for resection/reconstruction included oncologic in 49 patients (60.5%), desmoids tumors in 10 (12.3%), bronchopleural fistula in 3 (3.7%), infection in 7 (8.6%) and anatomic deformity in 7 (8.6%). The mean number of ribs resected was 3±1.6 for the entire cohort. Synthetic and/or biologic acellular dermis reconstruction was used in 59 patients (10 biologic, 22 synthetic, and 27 biologic ADM inlay/synthetic onlay combination). Patients in the combination group had a greater number of ribs resected, though not statistically significant and more of those patients had a history of chemo- and/or radiation- therapy (P=0.03) than the synthetic or biologic alone groups. Risk analysis demonstrated an association between the number of ribs resected and post-operative chest wall complications. In total, nine major complications (11.1%) and eleven minor complications were reported (13.5%). The incidence of chest wall/wound complications in the synthetic, combination, and biologic groups was 31.8%, 22.2%, and 10%, respectively (P=0.47) (Table).
CONCLUSION: In the largest study comparing the use of different reconstructive materials including ADMs in chest wall reconstruction to date, the authors demonstrated that biologic materials can be used effectively for reconstruction of full-thickness defects. Furthermore, a synthetic onlay can be coupled with a biologic inlay for additional stability in high-risk complex defects with the potential for reduced morbidity when compared to synthetic reconstruction alone.
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