Imaging of the expanded polytetrafluoroethylene prosthetic diaphragm following extrapleural pneumonectomy for mesothelioma

Intra- and Extra-Thoracic Muscle Flaps and Chest Wall Reconstruction Following Resection of Thoracic Tumors

Improvements in surgical technique over the last decade enable surgeons to perform extensive resection and reconstruction in patients presenting with tumors involving the soft tissue or bony structures of the chest wall. The type of surgical resection and its size, depend on the type of tumor resected and its location. In addition to providing a better esthetic result, the reconstruction restores support and functionality of the thoracic cage. The approach to chest wall repair includes primary closure or reconstruction by using transposition flaps, free flaps, prosthetic material, or a mixture of a flap and prosthetic material.

The role of imaging in malignant pleural mesothelioma

Imaging plays an essential role in the diagnosis, staging, and follow-up of patients with malignant pleural mesothelioma (MPM). The diagnosis is often suggested by a unilateral pleural mass with a moderate to large pleural effusion seen on chest radiographs, but computerized tomography (CT) is the most frequently used technique for evaluation of the lungs in patients with MPM. CT not only suggests pulmonary metastases typically manifested as nodules or masses, but also can demonstrate underlying lung disease often caused by prior asbestos exposure. Magnetic resonance (MR) imaging may be helpful in selected patients with potentially resectable disease to further examine the local extent of tumor. Imaging with positron emission tomography (PET) using the radionuclide imaging agent (18)F fluoro-deoxyglucose (FDG) takes advantage of a basic property of tumor cells, increased glucose metabolism to identify malignant lesions. PET provides not only anatomic information, especially regarding mediastinal node metastasis, but also biochemical information about the lesion. These imaging modalities help triage patients to the most appropriate diagnostic and treatment options. Following patients after therapy usually relies on chest radiographs, although CT can more accurately describe response to therapy. This review will focus on radiologic evaluation in diagnosing, staging, and follow-up patients with MPM.

Latissimus dorsi reverse flap to substitute the diaphragm after extrapleural pneumonectomy

BACKGROUND

The standard procedure for diaphragm reconstruction after extrapleural pneumonectomy for a malignancy consists of the use of prosthetic patches. Our original technique utilizing the reverse flap of the latissimus dorsi is evaluated.

METHODS

Once the extrapleural pneumonectomy is performed, the distal portion of the latissimus dorsi, which has been divided with a standard posterolateral thoracotomy at the level of the fifth to sixth rib, is elevated into the chest through the passage obtained by resection of the tenth rib and sutured to the lower pericardium and to the chest wall. Nine patients were evaluated.

RESULTS

No operative death occurred. No flap-related complication nor infection was postoperatively assessed. Six patients received adjuvant radiotherapy. No late complication was observed.

CONCLUSIONS

The distal latissimus dorsi can be used for total reconstruction of one hemidiaphragm, ensuring a watertight separation between the pleural and peritoneal cavities and avoiding paradoxical respiratory motion. In our opinion, the technique was easier, faster, and more reliable than the standard procedure employing prosthetic materials. We recommend that the procedure be integrated with the standard technique of extrapleural pneumonectomy.