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Using a bioabsorbable copolymer plate for chest wall reconstruction
Using a Bioabsorbable Copolymer Plate for Chest Wall Reconstruction By David W. Tuggle, P. Cameron Mantor, David S. Foley, Michele M. Markley, and Nikola Puffinbarger Oklahoma City, Oklahoma
Reconstruction of the chest wall in a child is an uncommon problem for pediatric surgeons. The available material for chest wall reconstruction typically has been borrowed from the adult experience. The authors describe their recent experience with a commercially available bioabsorbable plate in a variety of conditions that require chest wall reconstruction.
J Pediatr Surg 39:626-628. © 2004 Elsevier Inc. All rights reserved.
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anterior chest wall resection was undertaken from the right border of the sternum at the second rib, inferiorly to the superior border of the fifth rib, and laterally to the anterior axillary line. This resection included bone and soft tissue. A skin flap was dissected for wound closure. The pleura was replaced with absorbable mesh. The ipsilateral sixth rib was harvested, split, and used to bridge the bony gap. A 6- ⫻ 8-cm perforated plate of bioabsorbable copolymer was warmed and molded to match the curves of the left chest wall (Fig 1). The plate was trimmed to exactly match the defect and then sutured to the bony edges and musculature overlying the bone graft with 3-0 monofilament absorbable sutures. The skin was closed and the patient recovered uneventfully. At 2 years’ follow-up, the child has a firm chest wall reconstruction with bone and fibrous tissue by computed tomography (CT) scan (Fig 2). There is no evidence of scoliosis or other growth abnormalities, and there is no evidence of tumor recurrence.
HEST WALL reconstruction in children can be especially difficult if a large tissue defect results from an extensive resection of the thoracic musculoskeletal system for tumor. Occasionally, a child might need reconstruction of the chest wall because of congenital anomalies or as a result of injury. A variety of techniques and materials have been used to close the tissue defects seen in these circumstances.1-3 Many of the materials that have been used are marginally appropriate for children who will continue to grow. We report 4 cases of chest wall reconstruction using a bioabsorbable copolymer plate.
INDEX WORDS: Chest wall reconstruction, chest wall tumor, trauma, bioabsorbable copolymer.
MATERIALS AND METHODS Four children underwent chest wall resection with reconstruction using a bioresorbable copolymer plate consisting of 82 L-lactic acid and 18 glycolic acid (Lactosorb Lorentz, Jacksonville, FL). This material has been used extensively in craniofacial reconstructions in children since 1996. This copolymer plate is completely resorbable, is malleable in warm water, can be cut with a hot knife or scissors, and has a tensile strength significant enough to provide protection and support. It comes in solid and perforated plates of various sizes and thicknesses, and there are absorbable screws of the same material available for bony fixation.
Case 2
Case 1
The second patient was an 8-year-old boy who had a large painful asymmetric chest wall defect on the right parasternal border without pectus excavatum. He underwent right-sided segmental cartilaginous rib resections 3 through 8, sparing the perichondrium. The resulting defect was elevated and reconstructed with copolymer plate sutured to the resection line. This allowed contouring of the resulting defect so that chest wall symmetry was achieved. The pectoralis major was used to cover the copolymer plate. Eleven months later, this patient has an excellent result of reconstruction with no evidence of recurrence or chest wall instability.
A 6-month-old child had a locally aggressive spindle cell tumor of the right anterior chest wall. Chemotherapy had little effect, and
Case 3
From the Section of Pediatric Surgery, Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK. Presented in part at the 54th Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, Boston, Massachusetts, October 18-20, 2002. Supported in part by the Paula Milburn Miller/ Children’s Medical Research Institute Chair in Pediatric Surgery. Address reprint requests to David W. Tuggle, MD, 940 NE 13th St, Rm. 2403, Oklahoma City, OK 73126. © 2004 Elsevier Inc. All rights reserved. 0022-3468/04/3904-0026$30.00/0 doi:10.1016/j.jpedsurg.2003.12.032
The third patient was a 19-year-old girl who had a recurrent primitive neuro-ectodermal tumor (PNET) tumor of the left anterolateral chest wall. The patient had previously undergone chemotherapy and local radiation therapy before excision. The tumor and surrounding chest wall and underlying tissue was removed including skin, subcutaneous tissue, muscle, ribs, and diaphragm. The chest wall was reconstructed in layers with an additional repair of the left diaphragm. An absorbable mesh provided the deep layer, followed by a 10- ⫻ 10-cm molded plate (nonperforated) of bioabsorbable copolymer, cut to fit the resulting defect. Skin andsubcutaneous tissue were closed over the plate. No drains were used. The patient was discharged within 6 days and has a firm chest wall at the resection site at 6 months of follow-up. There is no evidence of tumor recurrence at this time.
CASE REPORTS
626
Journal of Pediatric Surgery, Vol 39, No 4 (April), 2004: pp 626-628
BIOABSORBABLE COPOLYMERS FOR CHEST WALL RECONSTRUCTION
Fig 1. A perforated bioabsorbable plate in a chest wall wound ready for suture reconstruction.
Case 4 The fourth case involves a 14-month-old boy who presented with a midline sternal mass measuring 2.2 ⫻ 3.4 ⫻ 4.0 cm just superior to the xiphoid. The mass was enhanced on CT, and the differential diagnosis included osteochondroma and Ewing’s sarcoma. The mass was excised along with a portion of the sternum, and reconstruction of the sternum was undertaken with a trimmed copolymer plate, with the pectoralis and rectus abdominus muscles closed over the plate. Pathologic examination showed chronic granulation tissue with giant cells. The patient was discharged on the second postoperative day. The patient is now 9 months postsurgery and has good healing of his chest with no signs of instability.
DISCUSSION
Chest wall resection and reconstruction in children is an uncommon surgical event. Because of the size variations and anatomic differences between resections, a standard approach to pediatric chest wall reconstruction has not been identified. Commonly used techniques to repair the chest wall include using muscular pedicle and free flaps. Occasionally, methyl methacrylate and polypropylene mesh combinations have been described to cover large soft tissue defects. Other investigators have described reconstruction with polypropylene sheets, absorbable mesh, titanium alloy instrumentation, and fascia lata.3-5 All of these materials have been used with success, but none have been acknowledged as an ideal substitute for chest wall. Some of the problems associated with these reconstructive techniques include infection, poor chest wall stability, and a lack of adaptation for growth. Our 2-year experience with a bioresorbable copolymer plate has shown that the use of this material is an excellent addition to the available reconstructive techniques currently in use. This material, marketed as LactoSorb copolymer, is an absorbable copolymer consisting of 82% L-Lactic acid and 18% glycolic acid. Unlike the homopolymers in common use such as 100% poly-L-lactic acid (PLLA) or
627
100% poly-glycolic acid (PGA), the copolymer we used is substantially amorphous (without crystallinity), meaning that its degradation is uniform, precluding the crystalline release associated with degrading homopolymers that have been implicated in late inflammatory reactions. Furthermore, this copolymer ratio permits the polymer to retain most of its strength for 6 to 8 weeks, which is appropriate for healing. Mass loss, which always follows strength loss for absorbable polymers, occurs in about 12 months. This copolymer is used widely in pediatric craniofacial and maxillofacial reconstructions, so that the long-term effects of using this material in children are well understood. A similar copolymer was used in adult chest wall reconstructions but with some inflammatory side effects.6 The copolymer that we used did not have any inflammatory effects in the patients we cared for. One benefit of the plate is that it can be cut easily to the desired shape with scissors or a heating element. It can be molded to any desired shape with hot water and remolded instantly if not ideal. It provides immediate chest wall stability and rigidity. It does not require removal or replacement. It keeps its tensile strength for months after surgery. The resulting fibrous capsule that remains after the plate is resorbed provides a natural long-lasting chest wall replacement that does not appear to interfere with growth. This material can be used also with other materials to achieve chest wall closure. It does not interfere with chest imaging techniques like other materials do. The use of the bioresorbable plate may shorten operating times, because it requires minimal preparation and is ready to be used “off the shelf.” We believe that a bioresorbable copolymer plate is a good addition to other available methods to reconstruct the chest wall in children.
Fig 2.
Chest CT of case 1, 2 years after surgery.
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TUGGLE ET AL
REFERENCES 1. Athanassiadi K, Kalavrouziotis G, Rondogianni D, et al: Primary chest wall tumors: Early and long-term results of surgical treatment. Eur J Cardiothorac Surg 19:589-593, 2001 2. Walsh GL, Davis BM, Swisher SG, et al: A single-institutional, multidisciplinary approach to primary sarcomas involving the chest wall requiring full-thickness resections. J Thorac Cardiovasc Surg 121:48-60, 2001 3. Deschamps C, Tirnaksiz BM, Darbandi R, et al: Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 117:588-591, 1999
4. Ohno K, Kuwata K, Yamasaki Y, et al: Chest wall repair with a titanium instrument. Ann Thorac Surg 66:1805-1806, 1998 5. Incarbone M, Nava M, Lequaglie C, et al: Sternal resection for primary or secondary tumors. J Thorac Cardiovasc Surg 114:93-99, 1997 6. Matsui T, Kitano M, Nakamura T, et al: Bioabsorbable struts made from poly-L-lactide and their application for treatment of chest deformity. J Thorac Cardiovasc Surg 108:162-168, 1994
Reconstruction of the chest wall in a child is an uncommon problem for pediatric surgeons. The available material for chest wall reconstruction typically has been borrowed from the adult experience. The authors describe their recent experience with a commercially available bioabsorbable plate in a variety of conditions that require chest wall reconstruction.
J Pediatr Surg 39:626-628. © 2004 Elsevier Inc. All rights reserved.
C
anterior chest wall resection was undertaken from the right border of the sternum at the second rib, inferiorly to the superior border of the fifth rib, and laterally to the anterior axillary line. This resection included bone and soft tissue. A skin flap was dissected for wound closure. The pleura was replaced with absorbable mesh. The ipsilateral sixth rib was harvested, split, and used to bridge the bony gap. A 6- ⫻ 8-cm perforated plate of bioabsorbable copolymer was warmed and molded to match the curves of the left chest wall (Fig 1). The plate was trimmed to exactly match the defect and then sutured to the bony edges and musculature overlying the bone graft with 3-0 monofilament absorbable sutures. The skin was closed and the patient recovered uneventfully. At 2 years’ follow-up, the child has a firm chest wall reconstruction with bone and fibrous tissue by computed tomography (CT) scan (Fig 2). There is no evidence of scoliosis or other growth abnormalities, and there is no evidence of tumor recurrence.
HEST WALL reconstruction in children can be especially difficult if a large tissue defect results from an extensive resection of the thoracic musculoskeletal system for tumor. Occasionally, a child might need reconstruction of the chest wall because of congenital anomalies or as a result of injury. A variety of techniques and materials have been used to close the tissue defects seen in these circumstances.1-3 Many of the materials that have been used are marginally appropriate for children who will continue to grow. We report 4 cases of chest wall reconstruction using a bioabsorbable copolymer plate.
INDEX WORDS: Chest wall reconstruction, chest wall tumor, trauma, bioabsorbable copolymer.
MATERIALS AND METHODS Four children underwent chest wall resection with reconstruction using a bioresorbable copolymer plate consisting of 82 L-lactic acid and 18 glycolic acid (Lactosorb Lorentz, Jacksonville, FL). This material has been used extensively in craniofacial reconstructions in children since 1996. This copolymer plate is completely resorbable, is malleable in warm water, can be cut with a hot knife or scissors, and has a tensile strength significant enough to provide protection and support. It comes in solid and perforated plates of various sizes and thicknesses, and there are absorbable screws of the same material available for bony fixation.
Case 2
Case 1
The second patient was an 8-year-old boy who had a large painful asymmetric chest wall defect on the right parasternal border without pectus excavatum. He underwent right-sided segmental cartilaginous rib resections 3 through 8, sparing the perichondrium. The resulting defect was elevated and reconstructed with copolymer plate sutured to the resection line. This allowed contouring of the resulting defect so that chest wall symmetry was achieved. The pectoralis major was used to cover the copolymer plate. Eleven months later, this patient has an excellent result of reconstruction with no evidence of recurrence or chest wall instability.
A 6-month-old child had a locally aggressive spindle cell tumor of the right anterior chest wall. Chemotherapy had little effect, and
Case 3
From the Section of Pediatric Surgery, Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK. Presented in part at the 54th Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, Boston, Massachusetts, October 18-20, 2002. Supported in part by the Paula Milburn Miller/ Children’s Medical Research Institute Chair in Pediatric Surgery. Address reprint requests to David W. Tuggle, MD, 940 NE 13th St, Rm. 2403, Oklahoma City, OK 73126. © 2004 Elsevier Inc. All rights reserved. 0022-3468/04/3904-0026$30.00/0 doi:10.1016/j.jpedsurg.2003.12.032
The third patient was a 19-year-old girl who had a recurrent primitive neuro-ectodermal tumor (PNET) tumor of the left anterolateral chest wall. The patient had previously undergone chemotherapy and local radiation therapy before excision. The tumor and surrounding chest wall and underlying tissue was removed including skin, subcutaneous tissue, muscle, ribs, and diaphragm. The chest wall was reconstructed in layers with an additional repair of the left diaphragm. An absorbable mesh provided the deep layer, followed by a 10- ⫻ 10-cm molded plate (nonperforated) of bioabsorbable copolymer, cut to fit the resulting defect. Skin andsubcutaneous tissue were closed over the plate. No drains were used. The patient was discharged within 6 days and has a firm chest wall at the resection site at 6 months of follow-up. There is no evidence of tumor recurrence at this time.
CASE REPORTS
626
Journal of Pediatric Surgery, Vol 39, No 4 (April), 2004: pp 626-628
BIOABSORBABLE COPOLYMERS FOR CHEST WALL RECONSTRUCTION
Fig 1. A perforated bioabsorbable plate in a chest wall wound ready for suture reconstruction.
Case 4 The fourth case involves a 14-month-old boy who presented with a midline sternal mass measuring 2.2 ⫻ 3.4 ⫻ 4.0 cm just superior to the xiphoid. The mass was enhanced on CT, and the differential diagnosis included osteochondroma and Ewing’s sarcoma. The mass was excised along with a portion of the sternum, and reconstruction of the sternum was undertaken with a trimmed copolymer plate, with the pectoralis and rectus abdominus muscles closed over the plate. Pathologic examination showed chronic granulation tissue with giant cells. The patient was discharged on the second postoperative day. The patient is now 9 months postsurgery and has good healing of his chest with no signs of instability.
DISCUSSION
Chest wall resection and reconstruction in children is an uncommon surgical event. Because of the size variations and anatomic differences between resections, a standard approach to pediatric chest wall reconstruction has not been identified. Commonly used techniques to repair the chest wall include using muscular pedicle and free flaps. Occasionally, methyl methacrylate and polypropylene mesh combinations have been described to cover large soft tissue defects. Other investigators have described reconstruction with polypropylene sheets, absorbable mesh, titanium alloy instrumentation, and fascia lata.3-5 All of these materials have been used with success, but none have been acknowledged as an ideal substitute for chest wall. Some of the problems associated with these reconstructive techniques include infection, poor chest wall stability, and a lack of adaptation for growth. Our 2-year experience with a bioresorbable copolymer plate has shown that the use of this material is an excellent addition to the available reconstructive techniques currently in use. This material, marketed as LactoSorb copolymer, is an absorbable copolymer consisting of 82% L-Lactic acid and 18% glycolic acid. Unlike the homopolymers in common use such as 100% poly-L-lactic acid (PLLA) or
627
100% poly-glycolic acid (PGA), the copolymer we used is substantially amorphous (without crystallinity), meaning that its degradation is uniform, precluding the crystalline release associated with degrading homopolymers that have been implicated in late inflammatory reactions. Furthermore, this copolymer ratio permits the polymer to retain most of its strength for 6 to 8 weeks, which is appropriate for healing. Mass loss, which always follows strength loss for absorbable polymers, occurs in about 12 months. This copolymer is used widely in pediatric craniofacial and maxillofacial reconstructions, so that the long-term effects of using this material in children are well understood. A similar copolymer was used in adult chest wall reconstructions but with some inflammatory side effects.6 The copolymer that we used did not have any inflammatory effects in the patients we cared for. One benefit of the plate is that it can be cut easily to the desired shape with scissors or a heating element. It can be molded to any desired shape with hot water and remolded instantly if not ideal. It provides immediate chest wall stability and rigidity. It does not require removal or replacement. It keeps its tensile strength for months after surgery. The resulting fibrous capsule that remains after the plate is resorbed provides a natural long-lasting chest wall replacement that does not appear to interfere with growth. This material can be used also with other materials to achieve chest wall closure. It does not interfere with chest imaging techniques like other materials do. The use of the bioresorbable plate may shorten operating times, because it requires minimal preparation and is ready to be used “off the shelf.” We believe that a bioresorbable copolymer plate is a good addition to other available methods to reconstruct the chest wall in children.
Fig 2.
Chest CT of case 1, 2 years after surgery.
628
TUGGLE ET AL
REFERENCES 1. Athanassiadi K, Kalavrouziotis G, Rondogianni D, et al: Primary chest wall tumors: Early and long-term results of surgical treatment. Eur J Cardiothorac Surg 19:589-593, 2001 2. Walsh GL, Davis BM, Swisher SG, et al: A single-institutional, multidisciplinary approach to primary sarcomas involving the chest wall requiring full-thickness resections. J Thorac Cardiovasc Surg 121:48-60, 2001 3. Deschamps C, Tirnaksiz BM, Darbandi R, et al: Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 117:588-591, 1999
4. Ohno K, Kuwata K, Yamasaki Y, et al: Chest wall repair with a titanium instrument. Ann Thorac Surg 66:1805-1806, 1998 5. Incarbone M, Nava M, Lequaglie C, et al: Sternal resection for primary or secondary tumors. J Thorac Cardiovasc Surg 114:93-99, 1997 6. Matsui T, Kitano M, Nakamura T, et al: Bioabsorbable struts made from poly-L-lactide and their application for treatment of chest deformity. J Thorac Cardiovasc Surg 108:162-168, 1994