Geometric reconstruction of the right hemi-trunk after resection of giant chondrosarcoma.

Abstract

We present a case of a giant chondrosarcoma arising from the right anterolateral chest wall and extending to the abdomen. An extensive resection of the right lower chest wall, most of the right hemidiaphragm, and most of the anterior abdominal wall on the right side was carried out. A long titanium plate was used to reconstruct the right costal margin. This plate gave attachment to two polytetrafluoroethylene meshes that were used to cover the abdominal and chest wall defects. The patches were covered with pedicled muscles and omental flaps and subsequently with rotational skin flap.

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Geometric Reconstruction of the
Right Hemi-Trunk After Resection
of Giant Chondrosarcoma
Giuseppe Marulli, MD, Abdel-Mohsen Hamad, MD,
Marco Schiavon, MD, Bruno Azzena, MD,
Francesco Mazzoleni, MD, and Federico Rea, MD
Division of Thoracic Surgery, University of Padova, Padova,
Italy; Department of Cardiothoracic Surgery, University of
Tanta, Tanta, Egypt; and Division of Plastic Surgery,
University of Padova, Padova, Italy
We present a case of a giant chondrosarcoma arising from
the right anterolateral chest wall and extending to the
abdomen. An extensive resection of the right lower chest
wall, most of the right hemidiaphragm, and most of the
anterior abdominal wall on the right side was carried out.
A long titanium plate was used to reconstruct the right
costal margin. This plate gave attachment to two polytet-
rafluoroethylene meshes that were used to cover the
abdominal and chest wall defects. The patches were
covered with pedicled muscles and omental flaps and
subsequently with rotational skin flap.
(Ann Thorac Surg 2010;89:306–8)
© 2010 by The Society of Thoracic Surgeons
C
resection with a wide free margin is the mainstay of
treatment to guarantee long-term survival and to prevent
local recurrence [2]. A multidisciplinary approach involving
thoracicandplasticsurgeonsisofparamountimportanceto
obtain good surgical, functional, and cosmetic results.
hondrosarcoma represents the most common histo-
type among primary chest wall tumors [1]. Radical
A 44-year-old woman presented with a giant mass in-
volving the right anterolateral aspect of the chest and
abdominal walls. Magnetic resonance imaging (Fig 1A)
delineated the extent of the tumor and showed involve-
ment of the last seven ribs and the hemi-diaphragm. The
patient was operated on in collaboration with plastic
surgeons; the tumor was resected with a good safety
margin of more than 5 cm. However, to save the sternum,
the safety margin on the medial aspect of the mass was
only approximately 4 cm, hoping that the sternochondral
joints would act as a natural barrier against the spread of
the tumor. The resected mass measured 29 ? 19 ? 17 cm
and weighed 7 kg. The mass involved the anterolateral
part of the sixth to tenth ribs, the anterior part of the
eleventh and twelfth ribs, most of the right hemi-
diaphragm, and most of the anterior abdominal wall on
the right side (Fig 1B). At this stage, the greater omentum
flap was prepared to be used later (Fig 1C). Reconstruc-
tion was started by recreation of the artificial right costal
margin, and for this purpose a long titanium plate
(Synthes TM, Solothurn, Switzerland) was adequately
modelled to take the shape and configuration of the
costal margin, which was then fixed with screws to the
sternum anteriorly and the remnant of the tenth rib
posteriorly. Another plate was prepared in the same way
and was fixed to the sternum and the posterior part of the
seventh rib. A polytetrafluoroethylene dual-mesh patch
(Gore-Tex; W. L. Gore and Associates, Flagstaff, AZ) was
used to close the abdominal wall defect.
The patch was sutured to the muscular boundaries of the
defect (leaving a small gap for passage of the omental flap)
and was sutured to the residual part of the right hemi-
diaphragm (separating the abdominal from the thoracic
cavity). Then the free upper edge was sutured to the newly
constructed costal margin (Fig 1D). A second similar patch
was applied to cover the chest wall defect, which was
sutured to the borders of the defect and the newly formed
titanium costal margin inferiorly (Fig 2A). A chest tube was
inserted into the left pleural space without compromise of
the pectoralis major muscle. The tube was tunnelled sub-
cutaneously across the middle line and came out through
the skin on the right side of the chest.
The pectoralis major and latissimus dorsi muscle flaps
were prepared by the plastic surgeon and used together
withtheomentalflaptocoverbothGore-Texpatches(W.L.
Gore and Associates) (Fig 2B) with two small tubes placed
over the patches. A rotational skin flap from the abdominal
wall was used to definitely cover the reconstructed area
leaving a small defect in the lower abdominal wall. This
defect was temporarily covered with Integra dermal regen-
eration template (Integra, Plainsboro, NJ) that was replaced
with a dermo-epidermal autograft harvested from the right
leg and placed over the “neodermis” 2 months later. The
patient was extubated in the operating room. The postop-
erative course of the patient was uneventful. A pathologic
examination revealed a diagnosis of well-differentiated
chondrosarcoma with a free resection margin all around.
The postoperative chest roentgenogram demonstrated
good lung expansion and correct position of the titanium
plates (Fig 2C). At the patient’s 1-year follow-up, the patient
is doing well with no recurrence. The patient is active with
no respiratory or functional limitation, and the cos-
metic result is satisfactory (Fig 2D).
Comment
After an extensive chest wall resection, most thoracic
surgeons concentrate on prevention of the flail chest,
maintenance of ventilatory function, and protection of
underlying structures [3]. The cosmetic results and phys-
ical flexibility of the body are secondary in priority. For
many years, various surgical techniques and several
materials have been used to repair the defect after chest
wall resection and to restore the structural stability of the
chest [3, 4]. Unfortunately, in cases of wide chest wall
resection, each of the currently used materials has its
own limitations. Titanium plates are malleable and can
be modelled in different configurations.
In our case, the malleability of titanium allowed us to
model the plate to take the shape of the costal arch. This
Accepted for publication June 9, 2009.
Address correspondence to Dr Rea, Division of Thoracic Surgery, Uni-
versity Hospital of Padova, Via Giustiniani, 2, Padova, 35100, Italy; e-mail:
federico.rea@unipd.it.
306
CASE REPORT
COMPLEX CHEST WALL RECONSTRUCTION
MARULLI ET ALAnn Thorac Surg
2010;89:306–8
© 2010 by The Society of Thoracic Surgeons
Published by Elsevier Inc
0003-4975/10/$36.00
doi:10.1016/j.athoracsur.2009.06.075
FEATURE ARTICLES

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was the cornerstone in the reconstructive procedure.
First, the plate gives a geometric restoration of the body
shape. Second, the plate provides an attachment for the
prosthetic patches used to cover the abdominal wall,
diaphragm, and chest wall defects. Consequently, these
patches were applied in more or less normal anatomic
positions. Third, the plate provides enough stability to
the thoracic cage, which allowed us to use nonrigid
materials to cover the defect. The postoperative result is
the reflection of these advantages. In addition to the
outstanding cosmetic result, the maintenance of flexibil-
ity of the trunk allows the patient to carry out anterior
and lateral flexion of the body without limitation. More-
over, and importantly, is the maintenance of good elastic
and dynamic properties of the thoracic cage with preser-
vation of pulmonary function, as proved by negligible
Fig 1. (A) Magnetic resonance imaging shows
the giant mass involving the anterolateral
chest and abdominal walls with compression
of the liver. (B) Intraoperative view of the tu-
mor imprint on the liver is evident with no
infiltration. (C) The omental flap is prepared
for further use. (D) The newly constructed
titanium costal margin is in place; the dia-
phragmatic and abdominal wall defects are
restored with a Gore-Tex dual mesh (W. L.
Gore and Associates, Flagstaff, AZ).
Fig 2. (A) Coverage of the chest wall defect
with Gore-Tex dual mesh (W. L. Gore and
Associates, Flagstaff, AZ) after fixation of the
second titanium plate (B) The pectoralis major
and latissimus dorsi flaps together with the
omentum are then used to cover the patches.
(C) Lateral view of the postoperative chest
roentgenogram; note the correct position of the
lower plate and level of the diaphragm. (D)
Cosmetic and functional results 6 months after
the operation.
307
Ann Thorac Surg
2010;89:306–8
CASE REPORT MARULLI ET AL
COMPLEX CHEST WALL RECONSTRUCTION
FEATURE ARTICLES

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loss of lung volumes and capacity on spirometry per-
formed 6 months after the operation.
In conclusion, close cooperation between thoracic and
plastic surgeons is important to obtain good surgical and
cosmetic results, particularly in difficult cases. Titanium
plates are an important additive to the armamentarium
of surgeons; the feasibility to configure them in different
shapes allows their use as a substitute to ribs.
References
1. McCormack P. Chest wall tumors. In: Baue AA, Geha AS,
Hammond GL, et al, eds. Glenn’s thoracic and cardiovascular
surgery, 5th ed. Stamford, CT: Appleton and Lange, 1991.
2. Athanassiadi K, Kalavrouziotis G, Rondogianni D, Loutsidis
A, Hatzimichalis A, Bellenis I. Primary chest wall tumors:
early and long-term results of surgical treatment. Eur J Car-
diothorac Surg 2001;19:589–93.
3. Arnold PG, Pairolero PC. Chest-wall reconstruction: an ac-
count of 500 consecutive patients. Plast Reconstr Surg 1996;
98:804–10.
4. McCormack PM. Use of prosthetic materials in chest-wall
reconstruction. Surg Clin North Am 1989;69:965–75.
Pancreatic Herniation After
Transhiatal Esophagectomy
Shair Ahmed, MD, Jacques P. Fontaine, MD, and
Thomas Ng, MD
Division of Thoracic Surgery, The Warren Alpert Medical
School of Brown University, Providence, Rhode Island
Diaphragmatic herniation as a complication after esopha-
gectomyhasbeendescribed.Contentswithintheherniasac
have been mainly limited to the small bowel and colon. We
believe this is the first case report in the literature of a
pancreatic herniation after esophagectomy. The incidence,
presentation, technical risk factors, and treatment of post-
esophagectomy diaphragmatic hernias are discussed.
(Ann Thorac Surg 2010;89:308–9)
© 2010 by The Society of Thoracic Surgeons
E
stages. There are several approaches to an esophagectomy
that can be categorized as transhiatal or transthoracic (eg,
Ivor Lewis, McKeown, left thoracoabdominal). These ap-
proaches can also be performed with minimally invasive
techniques. Each approach has its specific advantages and
disadvantages. The transhiatal approach has been advo-
cated for patients who are not candidates for open thora-
cotomy. Advantages of using this approach include using
entrance into the abdomen without having to enter the
pleural cavity through a thoracotomy and the lack of an
anastomosis in the mediastinum, potentially leading to
mediastinitis. Although transhiatal esophagectomy is ad-
vantageous in select patient populations, complications do
sophagectomies have been performed for benign
esophageal disease and esophageal carcinoma in early
arise, including iatrogenic hemorrhage and tracheal injury,
anastomotic leak, recurrent laryngeal nerve injury, and
chylothorax and diaphragmatic herniation. Contents within
the hernia sac have been mainly limited to the small bowel
and colon; however, we report a case of pancreatic hernia-
tion after transhiatal esophagectomy and discuss the inci-
dence, presentation, and techniques to decrease incidence
and treatment. According to our literature search, there are
no prior reports of pancreatic diaphragmatic herniation
after an esophagectomy, irrespective of the approach.
A 57-year-old man presented with dysphagia. An upper
endoscopy was performed that demonstrated a lower
esophageal mass. Biopsy results revealed adenocarcinoma,
which was clinically staged T3N0. The patient underwent
neoadjuvant therapy. He received 5,040 cGy of radiation
with concomitant cisplatin (irinotecan; CPT-11 [Pfizer, New
York, NY]), because the patient was allergic to Taxol (pac-
litaxel; Bristol-Myers Squibb, New York, NY). Six weeks
after induction therapy he underwent a transhiatal esoph-
agectomy. The pathology report revealed foci of adenocar-
cinoma invading into the muscle layer with negative mar-
gins. His postoperative course was complicated by an
anastomotic leak, which was managed with neck drainage.
The remainder of his postoperative course was uneventful.
During a routine follow-up computed tomographic scan
performed 8 months after his esophagectomy, there was an
incidental finding of a diaphragmatic hernia with contents
including the pancreas (Fig 1). The patient was asymptom-
atic at that time. He had no evidence of bowel obstruction,
pancreatitis, or splenic infarct. The pancreatic hernia was
therefore not surgically corrected. The patient later was
found to have brain metastases and died approximately 10
months after his original operation.
Comment
To date, all reports in the literature of diaphragmatic
hernia after esophagectomy have involved the small
Accepted for publication May 20, 2009.
Address correspondence to Dr Fontaine, Division of Thoracic Surgery,
Brown University, 195 Collyer St, Suite 302, Providence, RI
e-mail: jfontaine2@lifespan.org.
02904;
Fig 1. Computed tomographic scan demonstrating pancreatic hernia-
tion through the hiatus.
308
CASE REPORT
PANCREATIC HERNIATION AFTER TRANSHIATAL ESOPHAGECTOMY
AHMED ET ALAnn Thorac Surg
2010;89:308–9
© 2010 by The Society of Thoracic Surgeons
Published by Elsevier Inc
0003-4975/10/$36.00
doi:10.1016/j.athoracsur.2009.05.087
FEATURE ARTICLES