doi:10.1510/mmcts.2008.003277
Cryopreserved biomaterials for chest wall reconstruction Gaetano Roccoa,*, Flavio Faziolib a
Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Naples, Italy b
Service of Orthopaedic Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy Cryopreserved materials have characteristics which make them suitable for use in chest wall reconstruction. This contribution depicts the use of a cryopreserved bone homograft as a neosternum in conjunction with other materials to preserve anatomo-functional integrity and protect inner viscera. The final outcome and the emerging evidence in the literature support further utilization of these materials in the future.
Keywords: Chest wall; Chondrosarcoma; Cryopreserved homograft; Sternum Surgical technique The details of the clinical history of this particular patient were summarized in a previous report w1x. In brief, a low-grade chondrosarcoma of the right anterolateral chest wall had been resected previously. A massive recurrence of the neoplasm had been detected 10 months later and had led to consideration for surgical reexploration. Following an extensive anterolateral chest wall resection including sternum up to the manubrium (Video 1) and bilateral anterolateral segments from ribs 2 to 8, the anterior pericardium was opened and resected. The neoplastic mass was elevated along with the anterior chest wall and sternal body after division of the uppermost rectus abdominis muscles. At this level, the tumor infiltrated full thickness the central tendon and the diaphragm which were also largely removed on tumor-free macroscopic margins (Video 2). * Corresponding author: Via Terminio, 1 83028 Serino (Avellino), Italy. Tel.: q39-08-1590 3262; fax:q39-08-1804 1116. E-mail: [email protected] 䉷 2009 European Association for Cardio-thoracic Surgery
Following resection of the specimen and repair of the involved capsule of the liver, the diaphragm was replaced by a PTFE patch. At the center of the patch a small opening was made to accommodate an omental flap aimed at covering and protecting the mediastinal organs and creating a vascularized bed for the neosternum (Videos 3 and 4). The cryopreserved iliac bone homograft had been obtained from the Bone Bank of the Rizzoli Orthopedic Institute, Bologna, Italy (Photo 1). The cost of this homograft was 72000. The homograft had been preserved at –808 for three months prior to its use. The neosternum was cut to shape and incorporated to the residual manubrium by means of titanium screws and a single steel stitch to achieve mechanical stability (Video 5). Lateral holes in the iliac homograft had been drilled to accommodate heavy non-reabsorbable sutures to anchor two layers of Marlex (Video 6). In between the layers, two sheets of methyl-metacrylate were placed and adjusted to an acceptable geometrical configuration (Video 6). 1
G. Rocco and F. Fazioli / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2008.003277
Video 1. The manubrium is divided. The first left costochondral segments are elevated to respect the internal mammary pedicle. The resection is then taken caudally staying close to the hemiclavicular line by removing short costal segments (bone wax is placed on the rib stumps). Photo 1. Iliac bone homograft prior to its use as sternal replacement.
Video 2. The tumor mass is elevated and the central tendon of the diaphragm resected. Video 5. The cadaver homograft is prepared to create a sternal replacement.
Video 3. The operative field prior to reconstruction is shown (this sequence is looping 5 times). Video 6. The neosternum is fixed to the manubrium and lateral meshes are bilaterally anchored to the homograft sides to create methyl-metacrylate sandwiches. The myocutaneous part of the chest wall is reconstructed w1x.
Video 4. A hemostatic patch is positioned under the residual liver capsule. The diaphragm is reconstructed and an omental flap is transposed through a small breach in the PTFE patch. The omentum will protect the mediastinal organs and create a vascularized bed for the neosternum.
Results The postoperative outcome was uneventful w1x. No attempt was made at avoiding graft rejection through 2
immunosuppressants. From a functional point of view the final outcome was satisfactory and the patient was able to resume his daily activities, including opening the dances at his daughter’s wedding six months after surgery and swimming during the summer holidays.
Comment The search for the perfect material to be used during chest wall reconstruction after the creation of extensive defects is still ongoing. Ideally, reconstruction should provide structural resilience, protection to
G. Rocco and F. Fazioli / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2008.003277 internal organs and geometric configuration aimed at preserving cardiorespiratory function w2, 3x. Furthermore, these materials should be readily incorporated into the musculo-cutaneous receiving site and not constitute a pabulum for infections. In addition, especially if used in oncologic procedures, they should create an anatomic reference to identify possible local relapse of the primary disease. The surgical management of chest wall sarcomas often poses significant technical challenges due to the predisposition of these tumors to recur locally w4x. Major challenges are represented by coverage of anterior or anterolateral defects, since a flail chest physiology may ensue from extensive chest wall resections whereas small posterior defects can be left uncovered because they are protected by the scapula. Recently, the use of cadaveric cryopreserved homografts w1, 5, 6x such as iliac bone and ribs, independently implanted as sternal plate or, in combination with a PTFE patch, to cover anterolateral chest wall defects has been reported. The availability of these homografts from local bone banks is a crucial factor in expanding the utilization of these reconstructive materials w1, 6x. Orthopedic surgeons have been using cryopreserved homografts for a variety of clinical purposes with excellent results. Implants with homografts are preferred for the reduced immunogenicity and the remarkable resistance to viral infections. There is a growing body of evidence in the literature regarding the potential of cryopreserved bone homografts to show some cell growth in vitro and a concomitant angiogenicity which may facilitate incorporation in the receiver site w7, 8x. Moreover, the possible reduction in surgical times and the increased availability of bone render the use of these homografts particulary appealing in planning complex reconstructive procedures.
References w1x Rocco G, Fazioli F, Scognamiglio F, Parisi V, La Manna C, La Rocca A, Cerra R, Accardo R, De Lutio E. The combination of multiple materials in the creation of an artificial anterior chest cage after extensive demolition for recurrent chondrosarcoma. J Thorac Cardiovasc Surg 2007;133: 1112–1114. w2x Deschamps C, Tirnaksiz BM, Darbandi R, Trastek VF, Allen MS, Miller DL, Arnold PG, Pairolero PC. Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 1999;117:588–592. w3x Weyant MJ, Bains MS, Venkatraman E, Downey RJ, Park BJ, Flores RM, Rizk N, Rusch VW. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 2006;81:279–285. w4x Fisher S, de Perrot M, Sekine Y, Keshavjee S. Long-term survival after multiple resections of a fibrosarcoma involving the lung and the chest wall. Eur J Cardiothorac Surg 2001;20:421–423. w5x Garcia-Tutor E, Yeste L, Murillo J, Auba´ C, Sanjulian M, Torre W. Chest wall reconstruction using iliac bone allografts and muscle flaps. Ann Plast Surg 2004;52:54–60. w6x Aranda JL, Varela G, Benito P, Juan A. Donor cryopreserved rib allografts for chest wall reconstruction. Interact CardioVasc Thorac Surg 2008;7:858–860. w7x Judas F, Rosa S, Teixeira L, Lopes C, Ferreira Mendes A. Chondrocyte viability in fresh and frozen large human osteochondral allografts: effect of cryoprotective agents. Transplant Proc 2007;39:2531–2534. w8x Simpson D, Kakarala G, Hampson K, Steele N, Ashton B. Viable cells survive in fresh frozen human bone allografts. Acta Orthop 2007;78:26– 30.
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Cryopreserved biomaterials for chest wall reconstruction Gaetano Roccoa,*, Flavio Faziolib a
Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Naples, Italy b
Service of Orthopaedic Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy Cryopreserved materials have characteristics which make them suitable for use in chest wall reconstruction. This contribution depicts the use of a cryopreserved bone homograft as a neosternum in conjunction with other materials to preserve anatomo-functional integrity and protect inner viscera. The final outcome and the emerging evidence in the literature support further utilization of these materials in the future.
Keywords: Chest wall; Chondrosarcoma; Cryopreserved homograft; Sternum Surgical technique The details of the clinical history of this particular patient were summarized in a previous report w1x. In brief, a low-grade chondrosarcoma of the right anterolateral chest wall had been resected previously. A massive recurrence of the neoplasm had been detected 10 months later and had led to consideration for surgical reexploration. Following an extensive anterolateral chest wall resection including sternum up to the manubrium (Video 1) and bilateral anterolateral segments from ribs 2 to 8, the anterior pericardium was opened and resected. The neoplastic mass was elevated along with the anterior chest wall and sternal body after division of the uppermost rectus abdominis muscles. At this level, the tumor infiltrated full thickness the central tendon and the diaphragm which were also largely removed on tumor-free macroscopic margins (Video 2). * Corresponding author: Via Terminio, 1 83028 Serino (Avellino), Italy. Tel.: q39-08-1590 3262; fax:q39-08-1804 1116. E-mail: [email protected] 䉷 2009 European Association for Cardio-thoracic Surgery
Following resection of the specimen and repair of the involved capsule of the liver, the diaphragm was replaced by a PTFE patch. At the center of the patch a small opening was made to accommodate an omental flap aimed at covering and protecting the mediastinal organs and creating a vascularized bed for the neosternum (Videos 3 and 4). The cryopreserved iliac bone homograft had been obtained from the Bone Bank of the Rizzoli Orthopedic Institute, Bologna, Italy (Photo 1). The cost of this homograft was 72000. The homograft had been preserved at –808 for three months prior to its use. The neosternum was cut to shape and incorporated to the residual manubrium by means of titanium screws and a single steel stitch to achieve mechanical stability (Video 5). Lateral holes in the iliac homograft had been drilled to accommodate heavy non-reabsorbable sutures to anchor two layers of Marlex (Video 6). In between the layers, two sheets of methyl-metacrylate were placed and adjusted to an acceptable geometrical configuration (Video 6). 1
G. Rocco and F. Fazioli / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2008.003277
Video 1. The manubrium is divided. The first left costochondral segments are elevated to respect the internal mammary pedicle. The resection is then taken caudally staying close to the hemiclavicular line by removing short costal segments (bone wax is placed on the rib stumps). Photo 1. Iliac bone homograft prior to its use as sternal replacement.
Video 2. The tumor mass is elevated and the central tendon of the diaphragm resected. Video 5. The cadaver homograft is prepared to create a sternal replacement.
Video 3. The operative field prior to reconstruction is shown (this sequence is looping 5 times). Video 6. The neosternum is fixed to the manubrium and lateral meshes are bilaterally anchored to the homograft sides to create methyl-metacrylate sandwiches. The myocutaneous part of the chest wall is reconstructed w1x.
Video 4. A hemostatic patch is positioned under the residual liver capsule. The diaphragm is reconstructed and an omental flap is transposed through a small breach in the PTFE patch. The omentum will protect the mediastinal organs and create a vascularized bed for the neosternum.
Results The postoperative outcome was uneventful w1x. No attempt was made at avoiding graft rejection through 2
immunosuppressants. From a functional point of view the final outcome was satisfactory and the patient was able to resume his daily activities, including opening the dances at his daughter’s wedding six months after surgery and swimming during the summer holidays.
Comment The search for the perfect material to be used during chest wall reconstruction after the creation of extensive defects is still ongoing. Ideally, reconstruction should provide structural resilience, protection to
G. Rocco and F. Fazioli / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2008.003277 internal organs and geometric configuration aimed at preserving cardiorespiratory function w2, 3x. Furthermore, these materials should be readily incorporated into the musculo-cutaneous receiving site and not constitute a pabulum for infections. In addition, especially if used in oncologic procedures, they should create an anatomic reference to identify possible local relapse of the primary disease. The surgical management of chest wall sarcomas often poses significant technical challenges due to the predisposition of these tumors to recur locally w4x. Major challenges are represented by coverage of anterior or anterolateral defects, since a flail chest physiology may ensue from extensive chest wall resections whereas small posterior defects can be left uncovered because they are protected by the scapula. Recently, the use of cadaveric cryopreserved homografts w1, 5, 6x such as iliac bone and ribs, independently implanted as sternal plate or, in combination with a PTFE patch, to cover anterolateral chest wall defects has been reported. The availability of these homografts from local bone banks is a crucial factor in expanding the utilization of these reconstructive materials w1, 6x. Orthopedic surgeons have been using cryopreserved homografts for a variety of clinical purposes with excellent results. Implants with homografts are preferred for the reduced immunogenicity and the remarkable resistance to viral infections. There is a growing body of evidence in the literature regarding the potential of cryopreserved bone homografts to show some cell growth in vitro and a concomitant angiogenicity which may facilitate incorporation in the receiver site w7, 8x. Moreover, the possible reduction in surgical times and the increased availability of bone render the use of these homografts particulary appealing in planning complex reconstructive procedures.
References w1x Rocco G, Fazioli F, Scognamiglio F, Parisi V, La Manna C, La Rocca A, Cerra R, Accardo R, De Lutio E. The combination of multiple materials in the creation of an artificial anterior chest cage after extensive demolition for recurrent chondrosarcoma. J Thorac Cardiovasc Surg 2007;133: 1112–1114. w2x Deschamps C, Tirnaksiz BM, Darbandi R, Trastek VF, Allen MS, Miller DL, Arnold PG, Pairolero PC. Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 1999;117:588–592. w3x Weyant MJ, Bains MS, Venkatraman E, Downey RJ, Park BJ, Flores RM, Rizk N, Rusch VW. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 2006;81:279–285. w4x Fisher S, de Perrot M, Sekine Y, Keshavjee S. Long-term survival after multiple resections of a fibrosarcoma involving the lung and the chest wall. Eur J Cardiothorac Surg 2001;20:421–423. w5x Garcia-Tutor E, Yeste L, Murillo J, Auba´ C, Sanjulian M, Torre W. Chest wall reconstruction using iliac bone allografts and muscle flaps. Ann Plast Surg 2004;52:54–60. w6x Aranda JL, Varela G, Benito P, Juan A. Donor cryopreserved rib allografts for chest wall reconstruction. Interact CardioVasc Thorac Surg 2008;7:858–860. w7x Judas F, Rosa S, Teixeira L, Lopes C, Ferreira Mendes A. Chondrocyte viability in fresh and frozen large human osteochondral allografts: effect of cryoprotective agents. Transplant Proc 2007;39:2531–2534. w8x Simpson D, Kakarala G, Hampson K, Steele N, Ashton B. Viable cells survive in fresh frozen human bone allografts. Acta Orthop 2007;78:26– 30.
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