Objective To investigate the surgical techniques and effectiveness for reconstruction of severe full-thickness chest wall defects. Methods Between January 2006 and December 2010, 14 patients with full-thickness chest wall defects were treated, including 12 cases caused by giant chest wall mal ignant tumor excision, 1 case by thermocompression injury, and 1 case by radiation necrosis. There were 8 males and 6 females with an average age of 42 years (range，23-65 years). The size of chest wall defects ranged from 8 cm × 5 cm to 26 cm × 14 cm. All patients compl icated by rib defect (1-5 ribs), and 3 cases by sternum defect. Thoracic skeleton reconstruction was performed with Vicryl mesh or polytetrafluroethylene mesh in 10 patients. Other 4 patients did not undergo thoracic skeleton reconstruction. The bilobed skin flaps, pectoral is major myocutaneous flap, latissimus dorsi myocutaneous flap, and rectus abdominis myocutaneous flap were util ized for repairing soft tissue defects. The size of the dissected flaps ranged from 10 cm × 7 cm to 25 cm × 13 cm. The donor sites were sutured directly or were repaired by free skin graft. Results Poor heal ing of incision occurred in 2 cases, which was cured after debridement, myocutaneous flap transfer, and skin graft. The other wounds healed by first intention. All patients were followed up 6-36 months (mean, 8 months). No tumor recurrence during follow-up, except 1 patient with osteosarcoma who died of l iver matastasis at 6 months after operation. Transient sl ight paradoxical respiration occurred in 1 patient who did not undergo thoracic skeleton reconstruction at 5 days after operation. Integrity of chest wall in other patients was restored without paradoxical respiration and dyspnea. Conclusion Depending on the cause, the size, and the location of defect, single or combination flaps could be used to repair soft tissue defect, and thoracic skeleton reconstruction should be performed when defect is severe by means of syntheticmaterials.
Objective To evaluate the results of chest wallreconstruction (CWR) in patients who underwent chest wall tumor resection accompanying huge chest wall defect. Methods From Jan. 1998 to Mar. 2003, 31 patients underwent CWR. Among them, 20 were male and 11 female. The age ranged from 8 to 72 years.The indications for resection were primary chest wall tumor in 21 patients, lung cancer with invasion of chest wall 6, recurrence of breast cancer 2, radiationnecrosis 1 and skin cancer 1. The number of rib resected was 2~7 ribs (3.6 in average). The defect was 20~220 cm2 (97.1 cm2 in average). Concomitant resectionwas done in 13 patients, including lobectomy or wedge resection of lung 10, partial resection of diaphragm 2, and partial sternectomy 1. Seven patients underwent soft tissue reconstruction alone(latissimus dorsi+greater omentum, latissimusdorsi myocutaneous flap, latissimus dorsi muscle flap), 5 patients bony reconstruction alone(Prolen web), and simultaneous BR and STR were performed in 19 patients(latissimus dorsi, pectorails major, latissimus dorsi+fascia lata, and Prolene web). Results Three patients (9.7%) developed postoperative complications. Postoperative survival period was 6~57 months with a median of 22 months. Conclusion A favorable clinical outcome can be achieved by CWR for the patients with hugechest wall defects that result from resection of chest wall tumors.
Objective To observe an early result after the repair of the large upper thoracic wall defect by a combined use of the titaniumnet, reconstruction nickelclad, and latissimus dorsi myocutaneous flap in a patient who underwent a breast sarcomatoid caricinoma resection on the upper thoracic wall. Methods A breast sarcomatoid carcinoma in the upper thoracic wall was removed in 1 56yearold female patient in February 2006. After the tumorectomy, a large thoracic wall defect was left, which was 20cm×15cm in size. The defect was covered by the titanium net, the bilateral stumps of the clavicles were connected by the reconstruction nickelclad, and the soft tissue defect was repaired with the right latissimus dorsi myocutaneous flap(20cm×15cm). Results The patient depended on the breathing machine for 3 days after operation. When the breathing machine was discontinued, the patient developed a severe paradoxical breathing. Two weeks after operation when theblood circulation of the flap was stabilized, the paradoxical breathing disappeared with the help of the chest bandage for fixation of the chest cavity, and the blood supply of the flap was improved. The chest X-ray film showed that the titanium net and the reconstruction nickelclad were well positioned. The patient received chemotherapy 1 month after operation, The follow-up for 3 months revealed that the patient’s local condition and physical condition were good, and ROMof both the shoulders was improved, with AF 90° and ABD 90°. No recurrence ofthe tumor was found. Conclusion A large thoracic wall defect should be repaired with solid materials. The normal anatomic locations of the clavicles should be maintained with fixation by the reconstruction nickelclad for a good function of the shoulders. The latissimus dorsi myocutaneous flap can be properly enlarged.
ObjectiveTo explore the role of chest wall arteriovenous graft (CWAVG) for establishing hemodialysis access in patients with end-stage renal disease.MethodsA retrospective analysis was made on the clinical data of 12 patients with end-stage renal disease who underwent CWAVG for establishing hemodialysis access between January 2014 and June 2015. There were 3 males and 9 females with an average age of 63.6 years (range, 54-82 years). The renal disease causes were chronic glomerulonephritis in 2 cases, hypertensive renal damage in 4 cases, diabetic nephropathy in 1 case, both kidney resection because of urinary tract tumors in 3 cases, and causes unknown in 2 cases. Hemodialysis time ranged from 1 to 144 months, with an average of 38.4 months. The 12 patients all underwent 1-14 times (mean, 4.2 times) anterior pathway failure in CWAVG, all of which were caused by repeated occlusion of dialysis pathway or poor vascular condition of upper extremity, resulting in the exhaustion of vascular pathway in upper extremity.ResultsAll patients were followed up 30-48 months (mean, 35.4 months). Two patients died, including 1 case of digestive tract hemorrhage, 1 case of heart failure. The other 10 CWAVGs were functionally useful for hemodialysis access about 6 weeks after operations. The primary patency rates at 6, 12, 18, 24, and 30 months were 83.3%, 75.0%, 33.3%, 33.3%, and 16.7%, respectively, and the cumulative patency rates at 6, 12, 18, 24, and 30 months were 83.3%, 75.0%, 50.0%, 33.3%, and 16.7%, respectively. Among 8 cases of CWAVG dysfunction, 6 cases had thrombosis, 1 case had seroma, and 1 case had vertebral artery stealing. Among them, 4 patients underwent hemodialysis using tunneled-cuffed catheter, 3 patients using fistula or graft on other limbs, and 1 patient was not treated with hemodialysis.ConclusionAlthough the long-term patency rate of CWAVG is yet to be further increased by improvement of treatment strategies, but it is still a supplementary option for end-stage renal disease patients with inadequate upper extremity venous access sites.
Objective To evaluate the application value of repairing the defects of the chest wall with the thoracico-abdominal skin flap and the muscle flap of the musculus rectus abdominis. Methods From January 2002 to June 2005, five patients with defects in the chest wall underwent the prothesis with the thoracico-abdominal skin flap and the muscle flap of the musculus rectus abdominis under general anesthesia. Focal cleaning was performed first; then, the skin flap was designed and taken (15 cm ×10 cm); and finally, the defects of the chest wall were repaired with the muscle flap of the musculus rectus abdominis. Results Of the 5patients, 4 had the flap healing by the first intention, and 1 had the delayed healing, with no complication. The skin flap had a good appearance, without edema orpigmentation. The X-ray examination showed that the shadow of the sternal sequestrum disappeared. There was no recurrence or complication during the follow-upfor 1-3 years (average, 18 mon). Conclusion The repairing of the defects in the chest wall with the thoracico-abdominal skin flap and the muscle flap of the musculus rectus abdominis is a simple and effective surgical treatment for defects of the chest wall around the sternum, and this kind of treatment is worth applying extensively in clinical practice.
ObjectiveTo explore the role of arteriovenous axillary loop graft (AVALG) on chest for establishing hemodialysis access in patients with chronic renal failure.
MethodsA retrospective analysis was made on the clinical data of 12 patients with chronic renal failure who underwent an AVALG on chest for hemodialysis access between December 2010 and May 2014. There were 2 males and 10 females with an average age of 65.25 years (range, 46-75 years). The main causes were chronic glomerulonephritis in 6 cases, diabetic nephropathy in 4 cases, and both kidney resection because of urinary tract tumors in 2 cases. The disease duration was 2-12 years (mean, 6 years). The 12 patients all underwent 5-14 times (mean, 7 times) failed prior vascular accesses [arteriovenous fistula (AVF）and arteriovenous graft (AVG)] leading to exhaustion of venous access sites on the upper extremities.
ResultsThe AVALG on chest were functionally useful for hemodialysis access, 2-3 times per week, and the blood flow was 250-350 mL/minute; the average time for the first dialysis was 48 days (range, 42-93 days). All patients were followed up 12-54 months (mean, 20.92 months). There was no death during perioperative period. The primary patency rates at 6 and 12 months were 91.7% and 83.3% respectively, and the secondary patency rates at 6 and 12 months were both 100%. After operation, infection (1 case), thrombosis (2 cases), bleeding (2 cases), and swollen (1 case) occurred, which were all cured after corresponding treatment.
ConclusionAVALG on chest is a supplementary option for chronic renal failure patients with inadequate upper extremity venous access sites after repeat occlusion.
ObjectiveTo explore the effectiveness of the modified designed bilobed latissimus dorsi myocutaneous flap in chest wall reconstruction of locally advanced breast cancer (LABC) patients.MethodsBetween January 2016 and June 2019, 64 unilateral LABC patients were admitted. All patients were female with an average age of 41.3 years (range, 34-50 years). The disease duration ranged from 6 to 32 months (mean, 12.3 months). The diameter of primary tumor ranged from 4.8 to 14.2 cm (mean, 8.59 cm). The size of chest wall defect ranged from 16 cm×15 cm to 20 cm×20 cm after modified radical mastectomy/radical mastectomy. All defects were reconstructed with the modified designed bilobed latissimus dorsi myocutaneous flaps, including 34 cases with antegrade method and 30 cases with retrograde method. The size of skin paddle ranged from 13 cm×5 cm to 17 cm×6 cm. All the donor sites were closed directly.ResultsIn antegrade group, 2 flaps (5.8%, 2/34) showed partial necrosis; in retrograde group, 6 flaps (20%, 6/30) showed partial necrosis, 5 donor sites (16.7%, 5/30) showed partial necrosis; and all of them healed after dressing treatment. The other flaps survived successfully and incisions in donor sites healed by first intention. There was no significant difference in the incidence of partial necrosis between antegrade and retrograde groups (χ2=2.904, P=0.091). The difference in delayed healing rate of donor site between the two groups was significant (P=0.013). The patients were followed up 15-30 months, with an average of 23.1 months. The appearance and texture of the flaps were satisfactory, and only linear scar left in the donor site. No local recurrence was found in all patients. Four patients died of distant metastasis, including 2 cases of liver metastasis, 1 case of brain metastasis, and 1 case of lung metastasis. The average survival time was 22.6 months (range, 20-28 months).ConclusionThe modified designed bilobed latissimus dorsi myocutaneous flap can repair chest wall defect after LABC surgery. Antegrade design of the flap can ensure the blood supply of the flap and reduce the tension of the donor site, decrease the incidence of complications.
