Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 26  |  Issue : 1  |  Page : 15-18

Superior advancement of the diaphragm and rectus muscle flap as an alternative to prosthetic chest wall reconstruction following the excision of huge lower chest wall tumor


1 Department of Surgery, Cardiothoracic Surgery Division, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
2 Department of Surgery, Plastic and Reconstructive Surgery Division, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Date of Acceptance27-Jul-2016
Date of Web Publication20-Dec-2016

Correspondence Address:
Kelechi E Okonta
Department of Surgery, University of Port Harcourt Teaching Hospital, PMB 6173, Port Harcourt, Rivers State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1116-5898.196271

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  Abstract 

Chest wall reconstruction (CWR) is desirable, especially after the excision of huge chest wall tumor, and using mechanical prostheses for the closure of defects is fraught with some complications. We present a case of a 45-year-old man with a 6-week history of recurrent left-sided lower chest wall mass. Chest examination showed a linear surgical scar 8 cm lower and lateral to the left nipple with an underlying huge mass, whose histology from the previous excisional biopsy revealed dermatofibrosarcoma protuberance. He had the excision of the chest wall tumor and subsequently the superior advancement of the diaphragm and using rectus muscle for the CWR. This method was effective in closing the defect without the known complications.

Keywords: Chest wall tumor, diaphragm, reconstruction, rectus muscle flap


How to cite this article:
Okonta KE, Gbeneol TJ, Ocheli EO. Superior advancement of the diaphragm and rectus muscle flap as an alternative to prosthetic chest wall reconstruction following the excision of huge lower chest wall tumor. Niger J Surg Sci 2016;26:15-8

How to cite this URL:
Okonta KE, Gbeneol TJ, Ocheli EO. Superior advancement of the diaphragm and rectus muscle flap as an alternative to prosthetic chest wall reconstruction following the excision of huge lower chest wall tumor. Niger J Surg Sci [serial online] 2016 [cited 2019 Dec 12];26:15-8. Available from: http://www.njssjournal.org/text.asp?2016/26/1/15/196271


  Introduction Top


Chest wall reconstruction (CWR) is desirable, especially after the excision of large chest wall tumors which will create wide chest wall defects. The thoracic cage protects the intrathoracic structures and performs respiratory function. These are accomplished through the rigidity occasioned by the bony structures and the flexibility provided by the muscles, fascia, and the joints.

Therefore, there exist the bony and nonbony components of the chest wall. Equally, the repair for the bony component could be by the use of rigid or nonrigid materials and also by the use of mechanical prostheses or biological materials. Each repair method is fraught with its own complications. [1],[2] In all, there had not been any ideal prosthesis for CWR. [3] It is in bid to avoid the use of any of the listed options that the birth to this new surgical method of CWR was launched. This method clearly avoided the use of prosthesis of any kind, the achievement of airtight closure, and the maintenance of the rigidity of the chest wall as well as preventing flailing.


  Case Report Top


Mr. C.O. is a 45-year-old man who presented to the surgical outpatient clinic with a 6-week history of recurrent left-sided lower chest wall mass after the previous wide excision of the mass in a general hospital. The increase was rapid in size with stabbing chest pain aggravated by occasional cough. The chest examination showed a linear surgical scar 8 cm below the left nipple and 4 cm from the xiphisternum to the mid-axillary line with a huge mass measuring 8 cm in diameter, on the anterior axillary line and adhering to the surrounding structures [Figure 1]. It was firm in consistency and mildly tender. The chest percussion note was dull on the lower aspect of the left hemithorax with reduced air entry on the same side. He previously had an excisional biopsy in a general hospital with the histology revealing uniformly monotous small cells dispersed in sheets and punctuated in areas by bands of fibrous tissue and occasional blood vessel with a histological diagnosis of dermatofibrosarcoma protuberance. The chest radiograph showed an evidence of hypertensive disease and soft tissue shadow with multiple involvements of the lower 4 ribs (7-10) on the left hemithorax. The computerized tomography scan of the chest revealed a focal pedunculated nodule arising from the lateral thoracic wall in the anterior basal aspect of the left hemithorax which measured 2.3 cm in the anterio-posterior axis with intrathoracic extension of a huge heterogeneous mass occupying the left hypochondrial area, measuring about 15.1 cm (anterio-posterior axis) and 13.2 cm (transverse axis). The mass had poorly defined medial margin and continuous with the intercostal muscles of the left hemithorax and was seen herniating through the 5 th, 6 th, and 7 th intercostal spaces anteriorly. Full blood count revealed a parked cell volume of 37% with leukocytopenia and thrombocytosis.
Figure 1: (a-c) Recurrent lower left-sided chest wall and the chest wound after surgery

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Surgical technique

The surgery was carried out by combined teams of cardiothoracic surgery and plastic surgery units. General anesthesia was administered through the use of a single-lumen endotracheal tube. The patient was positioned supine with a slight rotation to the right side with a tilt of about 15°. Cleaning and draping were done to isolate the operation field. An elliptical skin incision was made to incorporate the previous scar which was deepened to the subcutaneous layer using diathermy. The portion of the ribs with the tumour was resected. That ensured the total removal of the tumour without breaching it and thus preventing spillage. The mass weighed 1.8 kg. A resection margin of 5 cm was maintained. Following the excision of tumor of 18 cm, the resilience and further gaping of the chest wall gap came up to 30 cm [Figure 2]. Mechanically, surgeons through pressure contracted the gap to status quo ante, leaving the 18 cm gap (size of the tumor with a healthy margin) between the excised chest wall gap. Planning in reverse was done, using gauze to use the ipsilateral rectus muscle flap (Type III muscle flap), superiorly based on the left epigastric artery. A 22 cm incision was further carried down through the subcutaneous tissue to the anterior rectus sheath to the rectus abdominus muscle, which by sharp dissection was incised and transected at 25 cm length. The epigastric vessels were divided sutured with silk 2. The free ends of the diaphragm, partly excised to have a safe margin of the tumor, were superiorly attached to the periosteum of the chest wall with nylon-interrupted sutures to secure an airtight thoracic cavity [Figure 3].
Figure 2: (a-c) The chest wall defect after resection of the tumor

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Figure 3: (a-c) The diaphragm moved superior and re-attached to the remnant of the resected ribs, and the rectus muscle was used to cover the lower chest wall and the upper abdominal wall defects

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Prior to the complete closure of the chest, the chest tube was inserted and connected to an underwater seal drainage, and the lung was completely inflated. The patient received a total of 3 units of whole blood intra- and post-operatively with a postoperative packed cell volume of 48%. The chest tube inserted intraoperatively drained a total of 1530 ml of fluid before it was removed on the 5 th postoperative day as the drainage reduced to <50 ml and became serous. He had recurrent nodular mass measuring about 4 cm × 4 cm which was further resected 2 months postinitial CWR. Chemotherapy was delayed for the patient who was under fertility treatment with his wife. After that, he had imatinib tablets 400 mg twice daily for 5 months as an adjuvant cytotoxic therapy, and the response was fair. The patient has remained stable following surgery and postoperative chemotherapy for 7 months now. The wife had successfully undergone in vitro fertilization with the achievement of pregnancy.


  Discussion Top


The problem with large chest wall tumors after resection is in being able to cover the wide defect created after the excision without compromising the integrity of the thoracic cage. Considering the fact that larger defects are created, especially when we are assessing malignancy, [4],[5] two problems may, therefore, arise: the reconstruction of the skeletal component and the reconstruction of the soft tissue component. Following tumor resection, most patients will require CWR. [2],[3],[4] The CWR is recommended to ensure the protection of intrathoracic and upper abdominal contents and maintenance of the respiratory function. [6] Equally, of importance is to ensure the airtight sealing of the pleural space so that open pneumothorax is not created. The need for rigid repair is to protect vital structures in the chest and to avoid paradoxical chest wall movement while allowing fairly normal function chest excursion. For this, musculo-cutaneous flaps alone have been used to achieve the same chest wall rigidity. [6]

However, the challenges become more pronounced when dealing with larger and more complex chest wall defects and a growing number of prosthetic options, the optimal reconstructive approach is not always clear. [3],[4] However, the problem emanating from the use of exogenous material is the increased incidence of infection that can be distressing to the patient and increase the length of hospital stay.

In general, the selection of reconstruction is based on the size and the location in terms of anterior or posterior and considering the lower-located chest wall defects as enabling special surgical attention by using the diaphragm and abdominal muscle to achieve CWR. To the best of our knowledge, this method of CWR has never been considered in the previous literature. Besides, the challenges of which materials to use, the availability and affordability of the prosthetic material are even of a greater concern in developing countries.

Large chest wall defects are usually stabilized by mechanical prosthesis such as methyl methacrylate composite meshes and covered with vascularized tissue while large defects with contaminated wounds are generally reconstructed with bioprosthetic mesh rather than synthetic mesh as mechanical materials can be the sources of infection. [7]

Importantly, we were able to completely avoid the use of exogeneous materials such as methylmethacrylate and Gore-Tex or polytetrafluoroethylene; airtight chest wall closure and some degree of cosmesis were achieved while avoiding infections. Equally, this method allowed us to achieve a wide excision that is the sine qua non for an oncologic surgery of the kind and also to achieve a desirable closure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Weyant MJ, Bains MS, Venkatraman E, Downey RJ, Park BJ, Flores RM, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 2006;81:279-85.  Back to cited text no. 1
    
2.
Nagayasu T, Yamasaki N, Tagawa T, Tsuchiya T, Miyazaki T, Nanashima A, et al. Long-term results of chest wall reconstruction with DualMesh. Interact Cardiovasc Thorac Surg 2010;11:581-4.  Back to cited text no. 2
    
3.
Nagayasu T, Yamasaki N, Tagawa T, Tsuchiya T, Miyazaki T, Nanashima A, et al. Long-term results of chest wall reconstruction with DualMesh. Interact Cardiovasc Thorac Surg 2010;11:581-4.  Back to cited text no. 3
    
4.
Tukiainen E. Chest wall reconstruction after oncological resections. Scand J Surg 2013;102:9-13.  Back to cited text no. 4
    
5.
Tahalele PL. Chest wall tumor and chest wall reconstruction surgery using Tahalele's method. J Cardiothoracic Surg 2013;8 Suppl 1:O232.  Back to cited text no. 5
    
6.
Leuzzi G, Nachira D, Cesario A, Novellis P, Petracca Ciavarella L, Lococo F, et al. Chest wall tumors and prosthetic reconstruction: A comparative analysis on functional outcome. Thorac Cancer 2015;6:247-54.  Back to cited text no. 6
    
7.
Mahabir RC, Butler CE. Stabilization of the chest wall: Autologous and alloplastic reconstructions. Semin Plast Surg 2011;25:34-42.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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