[Evaluation of long-term results in patients who underwent reconstruction of thoracic wall with curved metal plates].

Between 1992 and 2011, 22 patients underwent surgery of reconstruction of thoracic wall with curved metal plates for multiple rib fracture and resection of thoracic wall tumor. They were divided into 2 groups according to original disorders. Twelve cases of group A accepted surgical stabilization of traumatic multiple rib fractures with the metal plates fixed on the fractured ribs as an external brace. Ten patients of group B were suffered from thoracic wall tumors, including 1 fibrous dysplagia, 1 chondroma, 5 invasive lung cancer, 2 rib metastases and 1 primary chest wall cancer. After the resection of tumors, an average of 3.2 ribs were removed, the defects of full thickness chest wall were reconstructed using a combination of a polypropylene mesh and the metal plates. In both groups, there were no displacement of the plates and allergic reaction. Only 2 patients needed removal of the fixed plates due to pyothorax caused by pneumonia after crushing thoracic injuries. The long metal reconstruction plates with many perforations were very useful for reconstruction of chest wall because they were long enough to cover the whole length of widely resected chest defects and moderately soft enough to be appropriately bent or twist by hand at the time of operation. Moreover long-term result of the reconstructed chest wall was safe and satisfactory without severe complication.

[The radical minimal access thoracoplasty by funnel chest in adults].

A new technique of radical thoracoplasty, performed with a small size incision, using the sternocostal complex fixation with nitinol plates with shape memory and the surgical toolkit required for the purpose, has been successfully introduced. 23 patients underwent surgery using the technique. Tree patients had early postoperative complications: 2 cases of exudative pleurisy and 1 case of bronchitis aggravation. Good cosmetic results was achieved in all operated patients. The mechanical ground of the technique is based on the use of the effective force of the sternum traction and the pressure of the plate on the tissues below. The main advantage of the method is avoidance of the transverse sternotomy.

Surgical Treatment of Scoliosis Developed After Extended Chest Wall Resection Due to Askin Tumor During Childhood.

STUDY DESIGN: Report of four cases. OBJECTIVE: To describe a series of pediatric patients with surgical scoliosis after chest wall resections due to Askin tumors. SUMMARY OF BACKGROUND DATA: Askin tumors are a rare type of chest wall solid tumors that can develop in children. Treatment involves chemotherapy and extensive surgical resection, including disarticulation of several ribs. This can cause thoracogenic scoliosis, with very scarce data found in the literature regarding its treatment and prognosis. MATERIALS AND METHODS: Retrospective descriptive series of four cases of scoliosis in pediatric patients, secondary to extensive chest resections due to Akin's tumors. We analyzed the results of the surgical treatment. RESULTS: Three girls and one boy with a mean age of 8.7 ± 2.2 years and 7 ± 3.6 years of follow-up were included. In all cases, the convexity of the thoracic curvature was toward the area of chest resection, occurring a mean of 1.9±1.3 years after thoracic surgery. A distraction-based system (two vertically expandable prosthetic titanium rib [VEPTR], two traditional growing rods) was used to correct the scoliosis. The preoperative Cobb angle (68.7° ± 22.9°) was corrected to 32.6° ± 9.7° at final follow-up. Preoperative coronal imbalance was 2.95 ± 1.86 cm and was corrected to 0.3 ± 0.6 cm at final follow-up. No changes were observed regarding preoperative kyphosis 30° ± 8.7° (33°±8° final). T1-S1 initial length was 29.65 cm changing to 40.65 cm. T1-T12 height went from 18.25 to 23.67 cm. There was one complication secondary to the proximal anchoring. CONCLUSIONS: For treatment of scoliosis secondary to extensive chest resection in the growing children with Askin tumors, distraction-based growth-friendly treatment is an available surgical option. Seven years of follow-up showed more than 50% improvement of the Cobb angle, and an average thoracic and trunk growth of 5.42 and 11 cm, respectively. LEVEL OF EVIDENCE: Level IV.

Spine Deformity With Fused Ribs Treated With Proximal Rib- Versus Spine-Based Growing Constructs.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To compare the use of spine-based versus rib-based implants for the treatment of early-onset scoliosis (EOS) in the setting of rib fusions. SUMMARY OF BACKGROUND DATA: Treatment for severe early-onset spinal deformity with rib fusions includes growing spine devices with proximal rib or spine anchors. The results of treatment, however, have not been compared between spine-based versus rib-based proximal anchors. METHODS: 169 patients with rib fusions treated with rib-based or spine-based constructs and minimum two-year follow-up were included. Sixteen patients were treated with proximal spine-based anchors and 153 with proximal rib-based devices (VEPTRs). Overall, 104 of the patients with rib-based fixation underwent thoracoplasty at the index surgery. We evaluated change in T1-T12 and T1-S1 height, coronal Cobb angle, kyphosis, and number of lengthening/revision surgeries. RESULTS: Kyphosis increased a mean of 7° in the rib-based group and decreased a mean of 20 degrees in the spine-based group (p = .002). Major Cobb angle decreased in both groups (p < .0001); however, the spine-based group had greater Cobb angle improvement (24 vs. 11 degrees, p = .04). From implant and lengthening of distraction devices, there was a mean 3.3-cm (22%) increase in T1-T12 height and a mean of 8.0 lengthenings in the rib-based group compared with a 5.7-cm increase and 6.3 lengthening surgeries in the spine-based group. Patients with rib-based constructs had a mean of 11 total procedures, whereas spine-based patients had a mean of 8. CONCLUSIONS: Patients underwent a mean of eight lengthening surgeries before final fusion or cessation of lengthening with a modest 2.3-cm increase in T1-T12 height. Compared with proximal rib anchors, proximal spine anchors controlled kyphosis and improved Cobb angle correction for early-onset scoliosis with rib fusions.

Thoracoplasty in the surgical treatment of adolescent idiopathic scoliosis.

A consecutive series of 40 adolescents surgically treated between 1998-2001, by posterior spinal fusion and thoracoplasty were compared with a similar group of 40 adolescents treated in the same period by posterior only segmental fusion. Clinical and radiographic analysis was performed, including the SRS-30 questionnaire and Pulmonary Function Tests (PFT). Minimum five years follow-up was requested. No statistical differences were found between the two groups in PFT's both pre-operatively and at latest follow up. Our findings suggest that thoracoplasty did not adversely affected long-term PFT's in AIS patients treated by posterior spinal fusion alone.

[Experience of chest wall reconstruction with newly developed material].

After the chest wall resection, its reconstruction is often needed. A 45-year-old male lung adenocarcinoma patient with chest wall invasion underwent upper lobectomy of the right lung with partial resection of 4-6th ribs. The size of the removed chest wall was 11 x 6.5 cm. We reconstructed the chest wall with Bard Composix E/X Mesh. This prosthesis is consisted of a polypropylene mesh and an expanded polytetrafluoroethylene sheet This material is seems to be useful in the reconstruction of chest wall in both preventing pulmonary adhesion and enabling good wound healing.

Surgical Outcomes of Double Compression and Complete Fixation Bar System in Pectus Excavatum.

BACKGROUND: Minimally invasive repair of pectus excavatum is a widely used technique for correction of pectus excavatum. Yet despite the advancement in the surgical techniques, it is still associated with various complications, including bar displacement leading to reoperation. To overcome this problem, we developed the double compression and complete fixation bar (DCCF) system that consists of 2 metal bars that are inserted above and below the sternum and compressed to correct pectus excavatum. METHODS: Patients who underwent pectus excavatum correction surgery at this center between April 2006 and March 2017 were divided into a DCCF system group and a conventional Nuss procedure group and their demographic, clinical, and surgical characteristics were compared. RESULTS: A total of 220 patients underwent the DCCF system procedure and 306 patients underwent the conventional Nuss procedure. The DCCF system group had significantly shorter operation time (p < 0.001) and postoperative hospital admission time (p < 0.001) compared with the conventional Nuss procedure group. There were only 2 cases (0.9%) of postoperative complications in the DCCF system group, which was significantly less than that of the conventional Nuss procedure group (n = 64, 20.9%; p < 0.001). In particular, there were no cases of bar displacement in the DCCF system group. CONCLUSIONS: The DCCF system was applied to surgical correction of pectus excavatum, which led to significant reduction in the operation time and postoperative hospital admission period, as well as reduced minimally invasive repair of pectus excavatum complication and bar displacement rates. Therefore, we recommend the application of the DCCF system to the surgical correction of pectus excavatum.

Pigeon chest: comparative analysis of surgical techniques in minimal access repair of pectus carinatum (MARPC).

BACKGROUND: After minimally invasive repair for pectus excavatum (MIRPE), similar procedures for pectus carinatum were developed. This study aimed to analyse the various published techniques of minimal access repair for pectus carinatum (MARPC) and compare the outcomes. DATA SOURCES: Literature was reviewed on PubMed with the terms "pectus carinatum", "minimal access repair", "thoracoscopy" and "children". RESULTS: Twelve MARPC techniques that included 13 articles and 140 patients with mean age 15.46 years met the inclusion criteria. Success rate of corrections was n = 125, about 89% in cumulative reports, with seven articles reporting 100%. The complication rate was 39.28%. Since the pectus bar is placed over the sternum and has a large contact area, skin irritation was the most frequent morbidity (n = 20, 14.28%). However, within the complication group (n = 55), wire breakage (n = 21, 38.18%) and bar displacement (n = 10, 18.18%) were the most frequent complications. Twenty-two (15.71%) patients required a second procedure. Recurrences have been reported in four of twelve techniques. There were no lethal outcomes. CONCLUSIONS: MARPC techniques are not standardized, as MIRPE are, so comparative analysis is difficult as the only common denominator is minimal access. Surgical morbidity is high in MARPC and affects > 2/3rd patients with about 15% requiring surgery for complication management.

The use of growth-sparing instrumentation in pediatric spinal deformity.

The management of severe spinal deformity in the growing child remains a challenging problem. Nonoperative methods range from orthotics to casting to traction; however, in certain circumstances, these techniques cannot effectively prevent deformity progression or are not tolerated by the child and surgical methods are required. Current options for surgical management of spinal deformity in the growing child include definitive spinal fusion with or without instrumentation, selective fusion, growth modulation, spinal instrumentation without fusion, or more recently, the use of the vertical expandable prosthetic titanium rib. Historically, all of these methods have a significant complication rate and despite advances in technology and instrumentation, remain problematic. This article provides an overview of current methods and outcomes for spinal instrumentation in the growing spine.

Dynamic thoracoplasty for asphyxiating thoracic dystrophy.

The life-saving procedures to expand the chests of infants born with Jeune asphyxiating thoracic dystrophy provide a static solution incapable of responding to the growth demands of thriving patients. We describe an instrument that provided a dynamic solution for an infant, where an initial methyl methacrylate midsternotomy spacer placed at 4 months of age was followed at 11 months with recurrence of his difficulties. At 8 months after the second operation the patient was stable and thriving with no recurrence of symptoms. The instrument modifications, limitations, and possible complications are described.

Expansion thoracoplasty: the surgical technique of opening-wedge thoracostomy. Surgical technique.

BACKGROUND: Children with congenital thoracic scoliosis associated with fused ribs with a unilateral unsegmented bar adjacent to convex hemivertebrae will invariably have curve progression without treatment. Surgery has been thought to have a negligible growth-inhibition effect on the thoracic spine in such patients because it has been assumed that the concave side of the curve and the unilateral unsegmented bar do not grow, but we are unaware of any conclusive studies regarding this assumption. METHODS: The changes in the length of the concave and convex sides, anterior and posterior vertebral edges, posterior arch, and unilateral unsegmented bars of the thoracic spine were measured in the twenty-one children with congenital scoliosis and fused ribs after expansion thoracoplasty had been carried out with use of a vertical, expandable titanium prosthetic rib. Three of these children had undergone posterior spinal fusion previously. Measurements were made with use of a three-dimensional software program that analyzed baseline and follow-up computed tomography scans. The technique was validated through measurement of the thorax of a small female adult cadaver. RESULTS: The patients without spine fusion had an average age of 3.3 years at the time of the baseline computed tomography scan, and the average duration of follow-up was 4.2 years. On the average, these patients showed significant growth (p < 0.0001) of the concave side of the thoracic spine (an increase in length of 7.9 mm/yr, or 7.1%/yr) and the convex side (8.3 mm/yr, or 6.4%/yr) compared with the baseline lengths. There was no significant difference in the increases in length (p = 0.38) between the concave and convex sides. Eleven patients with an unsegmented bar had an average 7.3% increase in the length of the bar (p < 0.0001). In the three children with prior spinal fusion, the increase in length averaged only 4.6 mm/yr (3%/yr) on the concave side of the thoracic spine and 3.7 mm/yr (2.2%/yr) on the convex side; both increases were significant (p < 0.0001). CONCLUSIONS: Longitudinal growth of the thoracic spine in a normal child has been estimated to be 0.6 cm/yr between the ages of five and nine years. After expansion thoracoplasty, growth of the thoracic spine was approximately 8 mm/yr in our series of children with congenital scoliosis and fused ribs. After expansion thoracoplasty, both the concave and the convex side of the thoracic spine and unilateral unsegmented bars appeared to grow in these patients. When a thorax is already foreshortened by congenital scoliosis, control of spine deformity with expansion thoracoplasty allows growth of the thoracic spine, and it is likely that the longer thorax provides additional volume for growth of the underlying lungs with probable clinical benefit.

Postoperative local morbidity and the use of vacuum-assisted closure after complex chest wall reconstructions with new and conventional materials.

BACKGROUND: New materials (NM) such as titanium plates, cryopreserved grafts, and acellular collagen matrices are being increasingly used for chest wall reconstruction as a result of improved incorporation while maintaining structural stability and reduced need for removal from infected areas. Direct comparisons between NM and conventional materials (CM) in terms of local morbidity and need for prosthesis removal are lacking. METHODS: Between January 2005 and July 2013, 109 procedures were performed to remove chest wall tumors in 86 patients. Of these, 32 underwent complex chest wall reconstructions owing to either recurrence, defect extension (greater than 3 ribs or >100 cm2) or local conditions (ie, previous irradiation or infection). New materials and CM (ie, polytetrafluoroethylene and methyl methacrylate) were used in 17 (53%) and 15 (47%) patients, respectively. Of the 32 patients included in the high complexity group, 23 patients did not exhibit any postoperative complications (72%). However, 9 patients (28%) underwent both a first and a second reoperation after a median interval of 4 months from the first procedure (range, 7 days to 60 months). Vacuum-assisted closure (VAC) was instituted in all patients as a means to control sepsis and facilitate space obliteration with healthy tissue. RESULTS: In 7 patients the reason for reintervention was local wound complications. In 4 of 7 patients, the prosthesis had to be removed (3 CM and 1 NM, 4.6% of the whole series; 12.5% in the high complexity group, 5.9% for NM and 20% for CM). The median time to complete chest wall healing after VAC in patients with local sepsis was 14 months (range, 5 to 60 months). All patients are currently alive and well except for 1 who died 11 months after complete chest wall healing as a result of dissemination of metastatic chondrosarcoma. At univariate analysis, predictors of overall and grade 2 or less morbidity according to the Common Terminology Criteria for Adverse Events version 4.0 were first (p=0.038) and second (p=0.015) redo operations. Conversely, patients with a body mass index of less than 25 kg/m2 (p=0.049) undergoing one (p=0.032) or two reconstructions (p=0.00047) with combined materials (p=0.00029) were more likely to experience local wound complications and require VAC. On multiple regression analysis, redo operations (first, p=0.032; second, p=0.00047) and the use of combined (synthetic and biologic) materials (p=0.0029) were confirmed to be related to an increased incidence of wound complications. CONCLUSIONS: Multiple redo operations after complex chest wall reconstruction performed with a combination of NM and CM may be associated with an increased incidence of local wound complications. Nevertheless, in these cases, the use of NM and VAC yielded a low rate (5.8% versus 20% with CM) of prosthesis removal while achieving complete wound healing.

The thoracoplastic approach to chest wall reconstruction: preliminary results of a multidisciplinary approach to minimize morbidity.

BACKGROUND: Chest wall reconstruction remains challenging because of the variable nature of the defect. Muscle-sparing approaches have been described but are not widely applied today. The authors reviewed an institutional experience with chest wall reconstruction and describe the thoracoplastic approach, which aims to optimize flap selection. METHODS: A retrospective review was conducted identifying all patients undergoing chest wall reconstruction performed by the senior author. Demographic information and operative characteristics were detailed and factors were analyzed for association with postoperative outcomes. Outcomes were also compared for conventional versus thoracoplastic groups. RESULTS: Forty-five patients underwent chest wall reconstruction at an average age of 54.2 ± 16.3 years. Sarcomas were most common (51 percent), followed by breast (16 percent) and lung (11 percent). The average number of ribs resected was 3.2 ± 1.4, with an average defect size of 212 ± 185 cm2. The most commonly used flaps included the latissimus dorsi and pectoralis major (72 percent). Mesh was incorporated in 58 percent of repairs and operative time was 6.2 ± 2.5 hours. The incidence of surgical complications was 23 percent, most commonly wound infection and nonhealing wound (20 percent). The thoracoplastic approach, used in 14 patients, demonstrated no differences in outcomes with follow-up of 14 months. Operative time was nearly identical, and the thoracoplastic group required significantly less blood products when transfused. Latissimus dorsi and pectoralis major flaps were used more frequently in the thoracoplastic group, although this did not reach significance (78.6 percent versus 69.2 percent). CONCLUSIONS: The thoracoplastic approach appears to be safe and effective when compared with conventional methods. Although definitive conclusions cannot be drawn, the authors' early experience is promising. The authors believe applying these principles improves aesthetic and functional outcomes and preserves the oncologic safety profile.

A novel approach to eliminate cardiac perforation in the nuss procedure.

Pectus excavatum is the most common congenital abnormality of the chest wall. It may lead to adverse psychosocial development and preoccupation with a negative body image. The Nuss procedure is a minimally invasive approach for improving these patients' body image. The most dangerous complication is cardiac perforation from the insertion of the introducer. Our technique modifies this procedure to include a small subxiphoid incision and a novel sternal lift system that elevates the sternum. This facilitates the insertion of the introducer and placement of the pectus bar(s), and it reduces the risk of intraoperative cardiac perforation.

[Current development in therapy of congenital funnel chest].

OBJECTIVE: To review the current development in therapy of congenital funnel chest. METHODS: Recent literature concerning the development of the treatment method for congenital funnel chest was extensively reviewed and summarized. RESULTS: The main therapies for congenital funnel chest are thoracoplasty (Ravitch sternum elevation procedure and minimal invasive Nuss procedure) and prosthesis implantation. The magnetic mini-mover procedure and the vacuum bell are still in the research phase. CONCLUSION: Besides the improvement in function, the requirement in appearance after surgery is also improved in the treatment of congenital funnel chest. The minimally invasive surgery and non-invasive procedures could be expected in the future.

Oleotórax bilateral / Bilateral Oleothorax

No disponible

Congenital scoliosis with associated rib fusions: nursing care of patients following VEPTR insertion.

Congenital scoliosis with associated rib fusions, flail chest syndrome and hypoplastic thorax may create a progressive 3-dimensional deformity of the thorax, thereby inhibiting normal lung growth and respiratory function leading to respiratory insufficiency. The recently coined term for this condition is thoracic insufficiency syndrome (TIS). Traditional spine-based surgical procedures to correct congenital scoliosis with rib fusions inhibit the growth of the spine further, potentially worsening TIS and leading to respiratory problems during young adulthood. The dynamic interaction between the spine, ribs, and lungs was not addressed with these spine-focused procedures. This article explains TIS, discusses surgical treatment, and highlights unique aspects of postoperative nursing care. A case study is used for further explanation.