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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_747_Библиотеки_им_академика_М_И_Перельмана
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24 Thoracic trauma
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TRACHEOPLASTY/BRONCHORRHAPHY
Tracheal and bronchus injury are extremely rare and are most
often encountered within 2 cm of the carina. Management
and approach to trachea and bronchus injury depends on the
size and location of injury. Most cervical tracheal injuries can
The extent of mucosal injury is identified
10a–c
entire mucosal layer. The injury is closed in two layers. Repair
of the injury is performed with 3-0 interrupted absorbable
and the muscularis opened to expose the
10a
be repaired through a transverse cervical incision. Thoracic
tracheal and right bronchial injuries are approached through
a right fourth posterolateral incision. Left mainstem
bronchial injury is approached through a left fourth posterolateral incision.
sutures, with knots tied outside the bronchus or trachea.
After completion, the repair may be buttressed with a vascularized intercostals pedicle flap.
mucosal tear
'Pouting' mucosa
10b
Extent of
Normal
submucosa
10c
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ESOPHAGORRHAPHY
Patients with an esophageal injury may present insidiously or
in profound septic shock. Pain is the most common symptom
of esophagus perforation. Esophagography with barium contrast should be performed judiciously. These authors do not
recommend water-soluble contrast material because it is less
sensitive in confirming a diagnosis and, if aspirated, can contribute to a significant pulmonary reaction. Exposure of the
upper esophagus is facilitated by division of the azygous vein.
After the injury is identified, any necrotic mediastinal pleura
is excised, and the repair is performed in two layers. After
repair is completed, a musculopleural flap is mobilized based
on the intercostals neurovascular bundle and used to buttress
the repair. The area should be widely drained. In instances of
a longstanding mediastinal abscess and/or in a septic unstable
patient, the esophageal injury may be simply drained with the
aid of a very large T-tube placed into the esophagus and
brought out the side.
LUNG TWIST FOR HEMORRHAGE CONTROL
When uncontrolled bleeding from the lung is encountered
during an emergency center or operating room thoracotomy
and the patient is hemodynamically unstable, a damage control maneuver known as, “lung twisting” can control the
bleeding.
To begin, the inferior pulmonary ligament must be
11
released up to the level of the inferior pulmonary vein.
Any adhesions between the parietal and visceral pleura are
lysed.
11
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One hand is placed on the anterior aspect of the
12
the lower lobe. The apex of the lung is twisted 180 degrees to
the base of the pleural cavity, and the base of the lung is
rotated 180 degrees to lie at the apex of the cavity.
upper lobe and the other on the posterior aspect of
13
12
Once twisted, the apex of the lung will lie along the
13
cease. Laparotomy pads to hold the twisted lung in position
might be required.
diaphragm. Bleeding from the lung will completely
As circulation to the lung also is impaired because
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14
bronchus, lung twisting is analogous to a “medical pneumonectomy.” A formal pulmonary resection is performed
when the patient is stable.
the vascular structures will be twisted around the
Further reading 27
POSTOPERATIVE CARE
Patients with thoracic trauma requiring an operation need
monitoring in a surgical intensive care unit. Antibiotic and
deep vein thrombosis (DVT) prophylaxis for high-risk
patients must be considered. Ventilatory management is
carefully monitored and controlled. Extubation is accomplished using appropriate weaning protocols. Postoperative
complications are similar to those for other operations on the
organs which had been injured.
OUTCOME
The mortality and complications of the various operations
cited is variable, depending on specific organ(s) injured. For
patients surviving the initial traumatic insult and the first 3
days in the surgical intensive care unit, long-term survival is
good and usual. Some injuries, such as injury to the esophagus, have a higher morbidity and mortality rate.
14
FURTHER READING
Ahn SH, Cutry A, Murphy TP, Slaiby JM. Traumatic thoracic aortic
rupture: treatment with endovascular graft in the acute setting.
Journal of Trauma 2001; 50: 949–51.
Cohn SM, Heid MP, Augenstein JS, Bowen JC, McKenney MG, Duncan
Horton TG. Identification of trauma patients at risk of thoracic aortic
tear by mechanism of injury. Journal of Trauma 2000; 48: 1008–14.
Grocott HP, Scales G, Schinderle D, King K. A new technique for lung
isolation in acute thoracic trauma. Journal of Trauma 2000; 49:
940–2.
Hix WR, Mills M. The management of esophageal wounds. Annals of
Surgery 1970; 172: 1002–6.
Kiser C, O’Brien SM, Detterbeck FC. Blunt tracheobronchial injuries:
treatment and outcomes. Annals of Thoracic Surgery 2001; 71:
2059–65.
Shin DD, Jr, Wall MJ, Mattox KL. Combined penetrating injury of the
innominate artery, left common carotid artery, trachea, and
esophagus. Journal of Trauma 2000; 49: 780–3.
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Chest wall tumors
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ANNA MARIA CICCONE
Division of Thoracic Surgery, Universita La Sapienza, Rome, Italy
TIZIANO DE GIACOMO
Division of Thoracic Surgery, Universita La Sapienza, Rome, Italy
ERINO ANGELO RENDINA
Division of Thoracic Surgery, Universita La Sapienza, Rome, Italy
FEDERICO VENUTA
Division of Thoracic Surgery, Universita La Sapienza, Rome, Italy
3
HISTORY
The first known chest wall resection was reported by Aimar in
1778. Rehn at the beginning of this century reported a very
high incidence of complications and quoted a 20% mortality
rate, similar to that reported by Quenue and Longuet in 1989.
The first report of chest wall resection in the United States was
by Parham in 1889. From the early to the middle years of the
twentieth century, limited numbers of resections of chest wall
tumors were reported. In 1921, Hedgeblom described his
experience of 313 cases, of which 73% were malignant. Twenty
years later, O’Neal and Ackerman reported 96 cases of tumors
of the ribs and of the sternum. Another large experience was
reported by Hockemberg in 1953, who observed and treated
205 cases of chest wall tumors. Respiratory complications and
sepsis were the most common and serious problems at that
time. The modern era of chest wall resection began late in the
1960s, thanks to the improvement in surgical techniques and
anesthesia, the introduction of antibiotics and intensive care
units, and the development of new methods of reconstruction.
Extensive resection of the chest wall became possible with
more acceptable morbidity and mortality. Furthermore, better
understanding of the natural history, biological variability of
the cell types, and the use of radiation and chemotherapy,
allowed for better treatments and improved results.
from the cartilage or bone, but they can develop in any of the
histological elements of the thorax including muscle, nerve,
and soft tissue. Moreover, neoplasms of the external thorax
could be a metastatic lesion from a previously treated or
occult primary tumor. Approximately 60% of the time, primary chest wall tumors are malignant. The principal requirement for adequate local control of chest wall tumors remains
wide local excision. With the available skeletal and soft tissue
reconstructive techniques, even large lesions can be successfully resected with safe margins. Although the primary purpose of these operations is a curative resection, a significant
number of symptomatic patients can benefit from palliative
resection. A key element is a multidisciplinary approach by
the thoracic surgeon, the reconstructive surgeon, the medical
oncologist, and the radiotherapist.
Epidemiology and classification
Although chest wall tumors are uncommon, they consist of a
variety of both benign and malignant lesions. They may be
primary or metastatic or may involve the chest wall by contiguous spread from adjacent disease, most often lung or
breast cancer. Approximately 60% of all primary chest wall
tumors are malignant.
MALIGNANT PRIMARY TUMORS
PRINCIPLES AND JUSTIFICATION
Primary chest wall tumors have been estimated to represent
less than 1% of all tumors. The majority of them originate
In adults, the most common primary malignant lesions are
chondrosarcoma, plasmacytoma, and fibrosarcoma.
Chondrosarcoma frequently appears as a large lobulated
excrescent mass arising from a rib, with scattered calcification.
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As with other cartilaginous tumors, chondrosarcomas commonly develop from the costo-chondral junction, and radiographically they may be indistinguishable from an
osteochondroma or chondroma. Plasmacytoma is less frequent than chondrosarcoma, but the systemic disease, multiple myeloma, is frequently seen to involve several ribs as well
as the sternum. The lesions of plasmacytoma or multiple
myeloma typically appear as well-defined lytic lesions associated with extrapleural soft masses, similar to most metastatic
lesions. In advanced plasmacytoma, marked erosion, expansion, and destruction of the bony cortex is often present,
sometimes with a thick ridging around the periphery, causing
the “soap bubble” appearance. Fibrosarcoma is the most
common malignant tumor of the chest wall arising from the
soft tissue in adults. However, as reported in most earlier
series, the term fibrosarcoma probably includes many cases
that now would be classified as malignant fibrous histiocytoma, as well as spindle cell tumors such as malignant schwannoma or synovial sarcoma. Fibrosarcoma often presents as a
mass of soft tissue density associated with necrotic low density
areas; foci of calcification may be present. Approximately 15%
of malignant schwannomas develop in the trunk, and about
one-third are on the anterior chest wall. Like their benign
counterpart, they appear as rounded or elliptical masses adjacent to the rib. Any radiographic evidence of bony destruction
is indicative of a malignant process. Other less common primary chest wall tumors seen in the adult population are
osteosarcoma, liposarcoma, and angiosarcoma.
In children and adolescents, the most common primary
tumor of the chest wall is Ewing’s sarcoma that generally
presents as a lytic and sometimes expansive lesion of a rib or
clavicle with associated new bone formation and a soft tissue
mass. Frequently, pleural effusion, fever and general symptoms are present. Ewing’s sarcoma is also seen as the common
metastatic tumor of the bony thorax.
Other less common primary malignant tumors in the pediatric age group are osteosarcoma, rhabdomyosarcoma, and
mesenchymoma.
BENIGN TUMORS
Approximately half of all chest wall tumors are benign, and
the majority of them are of cartilaginous origin, namely
chondromas, enchondromas, and osteochondromas. These
lesions are often incidentally found on chest X-ray done for
unrelated purposes. Malignant degeneration is rare in solitary
lesions, but it may occur in as many as 5–20% of cases in
inherited syndromes such as multiple osteochondromatosis
or enchondromatosis. Fibrous dysplasia is the most common bone tumor or tumor-like condition of the ribs,
accounting for 20–30% of all benign bone tumors of the chest
wall. Fibrous dysplasia probably originates from the boneforming mesenchyme. The disease usually presents as a painless, lytic lesion, often with a localized area of bone
expansion, located in the posterior aspect of the rib. Less
common benign bone tumors of the chest wall include
eosinophilic granuloma, osteoblastoma, haemangioma
usually located in a vertebral body, and chondroblastoma.
The most common benign soft tissue tumor of the chest
wall is the lipoma, that generally occurs deep in the soft tissue, just outside the parietal pleura and often with an
intrathoracic and extrathoracic component connected by an
isthmus of tissue between the ribs.
Neurofibromas and schwannomas most commonly occur
in the posterior mediastinum, but they can originate from the
intercostal or other nerves of the chest wall. These tumors
usually appear as well-circumscribed spherical or elongated
masses, causing sometimes widening of the neural foramina,
as well as pressure, erosion, and rib spreading of adjacent ribs.
Evident bone destruction indicates a malignant differentiation.
METASTATIC DISEASE
Metastatic lesions are the most common tumors of the chest
wall and are seen more frequently than either primary malignant or benign tumors. In the adult population, the most common metastatic diseases are lung, breast, kidney, and prostate
carcinomas. With the exceptions of prostate and breast cancer, the large majority of metastatic tumors to the chest wall
are lytic. In children, neuroblastoma, leukemia, and Ewing’s
sarcoma are the most common metastatic lesions.
PREOPERATIVE ASSESSMENT AND
PREPARATION
Symptoms and physical findings
Approximately 20% of patients with chest wall tumor are
asymptomatic. The most common referred symptom is pain,
present in 50–60% of patients with enlarging masses. General
symptoms (weight loss, asthenia, fever) are inconstant.
Physical examination should be aimed to evaluate the tumor
location and size and the possible involvement of contiguous
organs. Malignant tumors are usually fixed to the bony thorax. Location of the lesion may suggest the histological type of
the tumor. Usually, cartilaginous tumors arise along the
costo-chondral junctions in the anterior wall of the chest.
Masses away from the osteo-cartilaginous structures are usually of soft tissue origin.
Diagnosis
Radiographic evaluation of the chest wall tumor is crucial to
determine the origin of the mass (cartilage, bone, soft tissue),
as well as planning for surgical or nonsurgical therapy. A
standard chest X-ray can be used to localize the lesion and to
obtain some information about the status of the lung fields
and the pleural cavity (pleural effusion). Computed tomog-
raphy (CT) is the most valuable tool in the evaluation of chest
wall neoplasms, because of its excellent contrast resolution
and the images in the axial plane. CT defines, albeit incom-
Operation 31
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pletely, the relations between the tumor and the contiguous
structures. Examination of the lung windows will help to discover eventual synchronous metastatic disease. Mediastinal
or bone windows provide the best information on the dimensions and density of the tumor and bone destruction. CT is
also valuable to assess the relation of the tumor to the chest
wall musculature, helping in chest wall reconstruction planning. Magnetic resonance imaging (MRI) can add significant information because of greater contrast resolution and
ability to image in multiple planes. Useful data can also be
recorded on the nature of the tumor. Bone scan should be
performed in all cases of chest wall tumor.
Current opinion suggests that all chest wall tumors should
be considered malignant until proven to be otherwise; and
when possible, wide excision should be carried out. Usually,
small lesions can be resected totally without preliminary
biopsy. For larger lesions, preoperative histological diagnosis
should be obtained. Fine needle aspiration biopsy or core cutting biopsy is used. The latter has higher accuracy (96%) than
fine needle aspiration. If these techniques do not yield a
definitive diagnosis, an incisional biopsy is justified and performed through a transverse incision which can easily be
excised at the time of the definitive resection.
CHEST WALL RESECTION AND RECONSTRUCTION
Planning the operation is dependent on the assessment of
several factors:
1 Exact histological diagnosis
2 The extent of chest wall involvement
3 History of previous radiation or surgical operation at the
site of the disease
4 Medical conditions of the patient
5 Aim of the treatment: cure or palliation.
A combined preoperative evaluation by both the thoracic
surgeon and the plastic surgeon is advisable to discuss the
need, the availability, and the feasibility of soft tissue coverage
in cases of wide chest wall resection.
In patients for whom palliative resection is planned and
who have incurable tumor, two main points should be considered: first, although long term survival is not expected,
local excision and tumor control can improve the quality of
life; second, patients whose symptoms are correlated to compression of the lung or other organs clearly show improvement in symptoms and quality of life after palliative
resection. These findings justify surgical treatment, especially
when nonsurgical options are of little or no benefit.
Preoperative evaluation
Chest wall resection and reconstruction is a major procedure
with a risk of life-threatening complication. Accurate preoperative assessment is therefore crucial, because it allows detection and treatment of correctable problems and permits the
surgeon to individualize the postoperative management. Risk
factors may be cardiovascular, pulmonary, or nutritional.
CARDIAC EVALUATION
In general, the cardiac risk for a chest wall operation is similar to that of any major surgical procedure. A history of recent
myocardial infarction or poorly congestive heart failure is a
contraindication to elective chest wall resection.
PULMONARY EVALUATION
A good history is essential and should include questioning for
smoking, chronic conditions, infections, dyspnea on exertion,
and any other symptoms suggesting respiratory impairment.
All patients undergoing chest wall resection have some degree
of postoperative ventilatory dysfunction. Routine preoperative evaluation should include chest X-ray, arterial blood gas
analysis, and spirometry before and after bronchodilation.
Patient’s position
Positioning of the patient for a chest wall resection depends
on the location of the chest wall tumor. The patient is positioned and draped on the operating table so that both resection and reconstruction are facilitated. For anterior lesions,
the patient may be kept in the supine position, with slight lateral elevation to assist in thoracotomy. The majority of the
chest wall lesions are most easily resected with the patient
positioned as for posterolateral thoracotomy.
ANESTHESIA
Standard inhalation and narcotic techniques can be used for
chest wall operations. Selective ventilation using a double
lumen tracheal tube is extremely useful, especially to define
any adhesions between the chest wall tumor and the underlying lung and to aid the exploration of the chest cavity as well
as the resection. Epidural analgesia is usually very useful in
the management of postoperative pain.
OPERATION
NUTRITIONAL ASSESSMENT
Malnourished patients have a higher incidence of postoperative complications. In general, it is advisable to delay the
operation as long as is required to correct malnutrition. Body
weight, serum protein levels, serum transferrin, and total
lymphocyte count can be useful.
Tumor resection
Traditionally, the skin incision was placed to avoid the
tumor, but it is well known nowadays that the incision can
safely be done over the tumor to improve the exposure and
reduce the vascular damage to the cutaneous area if the skin is
spared. In fact, resection of skin and subcutaneous tissues is
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necessary only if the tumor is adherent to or has penetrated
these structures or to excise previous scars, including biopsy
sites. The skin overlying previous irradiated tumors should be
resected. During the dissection, it is preferable to include one
The pleural cavity is usually entered one intercostal space
1
below or above the first uninvolved rib, and the intrathoracic extension of the tumor is evaluated by finger palpation.
The presence or absence of adhesions to the lung and pleural
effusion can also be assessed by this initial thoracotomy, as
well as the relation of the tumor to the ribs that will serve as
the superior, medial and lateral margins. Adhesions between
the lung and the chest wall should not be violated; they can be
easily divided after complete or almost complete mobilization of the chest wall mass.
normal musculofascial plane between the skin and the lesion.
However, muscle not adherent to the chest wall (latissimus
dorsi, pectoralis major, scapular muscles) should be spared if
not involved.
Chest wall to
be excised
Tumor in lung
involving chest wall
1
2
After the chest has been assessed, and the rib above
2
which the intercostal incision was made is judged to be
clear of tumor, the incision is extended anteriorly and posteriorly. The cephalad and caudad margins of the resection are
one normal rib superiorly and inferiorly. The extent of lateral
margins is controversial. Usually, 3–4 cm of grossly normal
tissue with microscopic evaluation of the margins by frozen
section is considered sufficient. The ribs are most easily
divided using a costotome or a guillotine bone cutter; the
intercostal bundle is encircled and divided between ties of
nonabsorbable suture. The intercostal muscle may be divided
between ribs using diathermy. When a rib is clearly involved
by the tumor, it should be completely excised with its cartilaginous articulation, because it is not possible to predict the
marrow extension of the tumor.
After all of the rib segments are resected and all inter-
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3
costal bundles are secured, the portion of the chest wall
should be completely free except for any attachments to the
lung or diaphragm. Segments of pleura and pericardium are
included in the resection if involved. With TA or GIA stapling
devices, the lung can be divided so the resection will include
any adhesions. The diaphragm can be widely excised and reapproximated using mattress sutures. Involvement of the
subscapular muscle or the scapula itself can be approached by
removing the scapula partially or totally, with re-suturing of
the uninvolved muscles to the residual chest wall. En bloc
removal of the tumor is an important criterion for a complete
resection.
Operation 33
4
3
Tumors of the sternum are evaluated preoperatively for
4
involvement of underlying structures. The skeletal resection of sternal tumors encompasses 2–4 cm of rib in addition
to the affected portion of the sternum. It is preferable to keep
part of the sternum intact if the margin of resection is safe. It
is advisable to save one or both superior epigastric vessels to
retain the option of using the rectus abdominis muscle flap
for the reconstruction.
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