Latissimus Dorsi Flap Revisited: Coverage of Large Chest Wall Defects Following Mastectomy for Locally Advanced Breast Carcinoma and Angiosarcoma.

BACKGROUND:  The latissimus dorsi myocutaneous flap (LDMF) remains a significant tool in the armamentarium of the oncoplastic breast surgeon. Despite declining popularity for reconstruction, owing to the increasing use of implants and free flaps, it still has an important role in certain salvage situations and as a flap to cover large defects. We report our experience with the use of LDMF for immediate coverage of large mastectomy defects when options are limited. METHODS:  Retrospective series of prospectively collected patient records. Patient and tumour characteristics, length of stay, and post-operative and oncologic outcomes are reported. Patients with angiosarcoma were discussed at tertiary sarcoma centres as per national guidelines. Operations were carried out by oncoplastic breast surgeons. The case series was approved by the institutional information governance department in line with institutional requirements for patient data sharing. All patients provided written consent for photography. Descriptive statistics were used to report findings. Median (IQR) was used for continuous variables. RESULTS:  Six women were included, with a median age of 62.5 years, from December 2019 to October 2022. Follow-up ranged from 15 to 49 months. Median tumour size was 72.5 (16.25) mm. Four patients had locally advanced breast carcinoma (LABC), and two had breast angiosarcoma. The donor site and chest wall defects were closed primarily in all cases. Median length of stay was three nights. All mastectomy wounds healed without issues and any delay to their adjuvant treatment. One patient had a minor latissimus dorsi (LD) donor site wound breakdown managed conservatively. Three patients had adjuvant radiotherapy after surgery. Four patients, one after high-grade angiosarcoma and three after aggressive breast carcinoma, had a locoregional recurrence or distant metastases and succumbed within 20 months of surgery. CONCLUSION:  The LDMF can be a reliable option for the primary closure of large post-mastectomy wounds. Its use can lead to timely wound healing, allowing patients to undergo adjuvant treatment without delay. However, the overall oncologic outcomes in patients with LABC and angiosarcoma are poor due to the underlying aggressive tumour biology. Long-term outcomes are to be interpreted with caution due to the small number of patients with diverse pathologic features.

Robotic resection of a second rib osteochondroma.

A 43-year-old man presented with a several-month history of worsening left shoulder pain. On imaging, he was found to have an osseous mass arising from his left second rib and protruding into the soft tissues of his chest. The mass had radiographic characteristics consistent with those of an osteochondroma. He had point tenderness over the mass, and the area of point tenderness was consistent with his description of the location of his pain over the past several months. Based on his symptoms, he was taken to the operating room for robotic excision of this mass. He was placed in a right lateral decubitus position, and three robotic ports were inserted. The mass was identified based on landmarks and was dissected free. The bony attachment of the mass to the second rib was transected using a Kerrison rongeur. The mass was delivered into the chest and removed using an endobag. The patient was discharged the following day after removal of his Blake drain. His pain had completely resolved at the postoperative follow-up examination, and his final pathological report confirmed the benign diagnosis of osteochondroma.

Thoracic surgery in Israel.

During the past 74 years since its establishment, Israel has evolved into a modernized country with well-established and effective public health care system. Thoracic surgeons in Israel play a central role in the diagnosis and treatment of patients with diseases of the chest wall, diaphragm, mediastinum, airways, Lung, and esophagus as well are taking part in designated trauma teams. Between 2,500-3,000 cases are being performed in 16 designated thoracic surgical units and departments across the country annually, the majority of them being performed in a minimally invasive fashion. Lung cancer is the leading cause of cancer related mortality in Israel and the second most common cancer in Israel. All types of thoracic oncologic cases are being presented routinely during designated multi-disciplinary conferences and treatment plans are designed according to the most up to date international guidelines. Each surgeon undergoes at least 6 years of formal training, followed by certifying exams. Advanced training is usually obtained overseas in centers of excellence. Israeli thoracic surgeons are part of an international societies and are actively involved in academic research. Despite the advancement of the Israeli health care system, thoracic surgeons in Israel are still facing few challenges that are limiting the early diagnosis of thoracic surgical malignancies such as lack of established national lung cancer screening program in Israel although a pilot program is being tested during these days. Tasked with taking care of diseases of the chest, and in order to remain at the forefront of diagnosis and treatment similar to our colleagues across the globe, Thoracic surgeons in Israel are continuously seeking to learn and evolve in order to improve and provide better care to our patients.

Advances in the treatment of chest wall surgical diseases / 中国胸心血管外科临床杂志

@#Chest wall surgery used to be a subspecialty of traditional thoracic surgery, which has an ancient history of research and clinical practice. It has gradually become an independent professional field in recent years. With the change of concept and the progress of interdisciplines, we have deepened our understanding of related diseases, and the treatment of chest wall surgical diseases has also acquired new characteristics. This article reviews the progress in the treatment of chest wall surgical diseases including chest wall trauma, chest wall deformity, chest wall tumor, chest wall infection and chest wall defect from the perspective of chest wall surgery.

Outcome Analysis Of Primary Chest Wall Tuberculosis: A Series Of 32 Cases.

BACKGROUND: Chest wall tuberculosis is a rare disease, and although incidence has decreased further with advances in antituberculosis chemotherapy, it remains prevalent in developing countries. Diagnosis is difficult because pus smears or bacterial cultures of aspirate frequently fail to yield tuberculous bacilli. To discuss the characteristics of this rare disease and suggest an optimal strategy for management, we share our experience with 32 patients managed surgically and with antituberculosis chemotherapy. METHODS: In this descriptive case series we retrospectively reviewed the medical records of 32 patients managed from May 2006 to May 2016. RESULTS: Out of 32 cases of chest wall tuberculosis, 59.4% (n=19) patients had a current or previous history of tuberculosis. Presenting complaints were chest pain, a palpable mass and pus discharge in most patients. A preoperative bacteriologic diagnosis was positive in only 3 patients. Generous abscess debridement was done in 21 (65.63%) cases, abscess debridement and partial rib resection in 11 (34.38%), abscess debridement and partial sternum excision in 7 (21.88%), and clavicle excision in 2 (6.25%) patients. Postoperative wound infection was noted in 1 (3.13%) patient. There were no recurrences. CONCLUSION: Chest wall tuberculosis requires generous debridement of diseased tissue including under lying bone, meticulous obliteration of residual dead space by vascular muscle flap, and negative suction drainage in addition to antituberculosis chemotherapy for good post-operative results with acceptable morbidity and mortality.

Combined mitral valve replacement and ravitch procedures in a patient with previous pneumonectomy: case report and review of the literature

Abstract Introduction: Significant anatomical and functional changes occur following pneumonectomy. Mediastinal structures displace toward the side of the resected lung, pulmonary reserve is reduced. Owing to these changes, surgical access to heart and great vessels becomes challenging, and there is increased risk of postoperative pulmonary complications. Methods: We performed a mitral valve replacement combined with a Ravitch procedure in a young female with previous left pneumonectomy and pectus excavatum. Results: She was discharged on postoperative day 9 and remains symptom-free 3 months after surgery. Conclusion: Thorough preoperative evaluation and intensive respiratory physiotherapy are essential before performing cardiac operations on patients with previous pneumonectomy.

Reconstrução torácica com retalhos do músculo reto abdominal e grande dorsal: relato de casos / Chest wall reconstruction using abdominal rectus and latissimus dorsi muscle flaps: case report

INTRODUÇÃO: A reconstrução da parede torácica ainda permanece como um dos grandes desafios da cirurgia plástica reparadora. O presente estudo tem como objetivo apresentar o relato de pacientes submetidos à reconstrução de parede torácica com a utilização de retalhos miocutâneos, após ressecções de parede por tumores/osteomielite. MÉTODOS: Foram incluídos quatro pacientes, três deles portadores de osteomielite e o último apresentando-se com sarcoma, todas as afecções acometendo a parede torácica. Foram submetidos à ressecção de parede e reconstrução com retalhos miocutâneos do grande dorsal (dois casos) e reto abdominal (dois casos). RESULTADOS: Os retalhos utilizados foram suficientes para cobertura cutâneo-muscular e mantiveram boa vitalidade. Em apenas um caso, houve sofrimento parcial do retalho. Não houve recidiva precoce da doença. A estabilidade da caixa torácica foi preservada. CONCLUSÕES: A utilização dos retalhos citados no reparo dos defeitos torácicos mostrou-se satisfatória na intenção de prover revestimento cutâneo e músculo bem vascularizado, este fundamental no combate aos quadros infecciosos locais.

INTRODUCTION: Chest wall reconstruction remains one of the great plastic surgery repair challenges. The present work aims to report on cases of chest wall reconstruction using myocutaneous flaps after wall resection due to tumor/osteomyelitis. METHODS: Four patients were included, among which three presented with osteomyelitis and the other presented with sarcoma; both of these conditions affected the chest wall. Each patient underwent wall resection and reconstruction using myocutaneous flaps from the latissimus dorsi (two cases) and abdominal rectus (two cases). RESULTS: The flaps used were sufficient for skin-muscle covering and maintained good vitality. Partial flap injury occurred in one case. Chest cavity stability was preserved. CONCLUSIONS: The use of the above flaps to repair chest defects was satisfactory with the aim of covering the skin and providing well-vascularized muscles, the latter of which was fundamental to preventing local infection.

Accuracy of transthoracic ultrasound for the prediction of chest wall infiltration by lung cancer and of lung infiltration by chest wall tumours.

BACKGROUND: We wanted to determine the accuracy of transthoracic ultrasound in the prediction of chest wall infiltration by lung cancer or lung infiltration by chest wall tumours. METHODS: Patients having preoperative CT-scan suspect for lung/chest wall infiltration were prospectively enrolled. Inclusion criteria for lung cancer were: obliteration of extrapleural fat, obtuse angle between tumour and chest wall, associated pleural thickening. The criteria for chest wall tumours were: rib destruction and intercostal muscles infiltration with extrapleural fat obliteration and intrathoracic extension. Lung cancer patients with evident chest wall infiltration were excluded. Transthoracic ultrasound was preoperatively performed. Predictions were checked during surgical intervention. RESULTS: Twenty-three patients were preoperatively examined. Sensitivity, specificity, positive and negative predictive values of transthoracic ultrasound were 88.89%, 100%, 100% and 93.3%, respectively. Youden index was used to determine the best cut-off for tumour size in predicting lung/chest wall infiltration: 4.5cm. At univariate logistic regression, tumour size (<4.5 vs ≥ 4.5cm) (p=0.0072) was significantly associated with infiltration. CONCLUSIONS: Transthoracic ultrasound is a useful instrument for predicting neoplastic lung or chest wall infiltration in cases of suspect CT-scans and could be used as part of the preoperative workup to assess tumour staging and to plan the best surgical approach.

The use of soft silicone solid implant molded intraoperatively for pectus excavatum surgical repair / Utilização de silicone sólido de baixo índice de dureza moldado no período intraoperatório para a correção de pectus excavatum

Objective To describe a new surgical technique to treat pectus excavatum utilizing low hardness solid silicone block that can be carved during the intraoperative period promoting a better aesthetic result. Methods Between May 1994 and February 2013, 34 male patients presenting pectus excavatum were submitted to surgical repair with the use of low hardness solid silicone block, 10 to 30 Shore A. A block-shaped parallelepiped was used with height and base size coinciding with those of the bone defect. The block was carved intraoperatively according to the shape of the dissected space. The patients were followed for a minimum of 120 days postoperatively. The results and the complications were recorded. Results From the 34 patients operated on, 28 were primary surgeries and 6 were secondary treatment, using other surgical techniques, bone or implant procedures. Postoperative complications included two case of hematomas and eight of seromas. It was necessary to remove the implant in one patient due to pain, and review surgery was performed in another to check prothesis dimensions. Two patients were submitted to fat grafting to improve the chest wall contour. The result was considered satisfactory in 33 patients. Conclusion The procedure proved to be fast and effective. The results of carved silicone block were more effective for allowing a more refined contour as compared to custom made implants. .

Objetivo Descrever a técnica para reparação de pectus excavatum com o uso de bloco de silicone sólido de baixa dureza, que possibilita a adequação de suas dimensões no intraoperatório para melhor resultado estético. Métodos Entre maio de 1994 e fevereiro de 2013, pacientes do gênero masculino, portadores de pectus excavatum, foram submetidos à correção cirúrgica com bloco de silicone sólido de baixa dureza, de 10 a 30 Shore A, pré-fabricado em forma de paralelepípedo, com as dimensões da altura e da base coincidentes com as da falha óssea. Durante o ato cirúrgico, esse bloco foi esculpido até adequar-se ao formato do espaço dissecado. Os pacientes foram acompanhados por um mínimo de 120 dias de pós-operatório. Resultados Trinta e quatro pacientes foram operados. Destes, 28 foram de tratamento primário e 6 secundário a outras técnicas cirúrgicas, ósseas ou de uso de implantes. As complicações foram dois casos de hematoma e oito de seroma. Foi necessária a retirada do implante em um dos casos devido à dor. Em outro caso, foi a realizada revisão cirúrgica das dimensões da prótese. Dois pacientes foram submetidos a enxerto de gordura, para melhorar o contorno da parede torácica. Não ocorreu nenhum caso de infecção. O resultado foi considerado satisfatório em 33 pacientes. Conclusão O procedimento mostrou-se rápido e efetivo. Os resultados dos contornos obtidos foram considerados mais efetivos quando comparados aos obtidos com a utilização de próteses pré-moldadas. .