Surgery is
the treatment of choice in malignant neoplasms of the sternum. Major chest
defects resulting from sternal resections cause instability of the sternal-rib
cage which produces severe respiratory and cardiovascular disturbances.
Reconstructive plastic surgical procedures are needed to provide normal respiratory
function and to close the defects. Estimation of existing methods of chest
reconstruction using different kinds of auto- and allografts outlines a number
of practically important problems: 1) Using of insufficiently rigid prostheses
fails to provide full chest stability, which causes paradoxical respiration; 2)
Using of bone autotransplants increases traumatism and surgical extent of the
procedure; 3) Using of polymeric materials is sometimes accompanied by
inflammatory and allergic reactions resulting in graft rejection; 4) Stainless
steel prostheses cause discomfort, traumatize surrounding tissues, frequently
cause purulent complications; 5) Closure of a solid prosthesis by soft tissues
is mandatory.
Attempting
to solve these problems, we developed a new complex plastic procedure for
reconstruction of major defects of the sternum, clavicles, and ribs, which we
use since 1996. Our plastic procedure includes:
1. Internal closure of pleural defects
and anterior mediastinum by pedicled major omental graft , which provides
sufficient chest hermetization and creates optimal conditions of healing of
resected chest organs, and also protects them of a metallic prosthesis.
2. Stabilization of the sternal-rib cage by means of
nickelit-titanium prosthesis fixed to the ends of resected clavicles and / or
ribs by polyether band designed for
ligament alloplasty.
3. External closure of both metallic
prosthesis and soft tissue defect with a pedicled musculocutaneous flap
prepared of latissimus dorsi muscle, which optimizes tissue regeneration and
provides certain resistance to infection.
Since 1996,
this procedure was performed in 5 cases. 2 patients underwent surgery for
breast cancer metastases, 1 – for angiosarcoma of the sternum, 2 – for
metastatic osteogenous sarcomas of the sternum.
There was
no mortality; 1 patient (20%) developed edge necrosis of the musculocutaneous
flap.
All the
patients were examined in long terms, 4 – 25 months after surgery, using
clinical, examination, ECG and respiratory function tests. In all cases, good
chest stability was achieved without any impairment of respiratory and brachial
movements.
Thus,
results of our clinical observations demonstrate effectiveness of our method of
multi-layer chest wall reconstruction using major omental flap from inside,
nickelit-titanium prosthesis, and pedicled musculocutaneous flap of latissimus
dorsi muscle from outside.
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