title: Postoperative local morbidity and the use of vacuum-assisted closure after complex chest wall reconstructions with new and conventional materials.
abstract: BACKGROUND
  New materials (NM) such as titanium plates, cryopreserved grafts, and acellular collagen matrices are being increasingly used for chest wall reconstruction as a result of improved incorporation while maintaining structural stability and reduced need for removal from infected areas. Direct comparisons between NM and conventional materials (CM) in terms of local morbidity and need for prosthesis removal are lacking.
  
  
  METHODS
  Between January 2005 and July 2013, 109 procedures were performed to remove chest wall tumors in 86 patients. Of these, 32 underwent complex chest wall reconstructions owing to either recurrence, defect extension (greater than 3 ribs or >100 cm2) or local conditions (ie, previous irradiation or infection). New materials and CM (ie, polytetrafluoroethylene and methyl methacrylate) were used in 17 (53%) and 15 (47%) patients, respectively. Of the 32 patients included in the high complexity group, 23 patients did not exhibit any postoperative complications (72%). However, 9 patients (28%) underwent both a first and a second reoperation after a median interval of 4 months from the first procedure (range, 7 days to 60 months). Vacuum-assisted closure (VAC) was instituted in all patients as a means to control sepsis and facilitate space obliteration with healthy tissue.
  
  
  RESULTS
  In 7 patients the reason for reintervention was local wound complications. In 4 of 7 patients, the prosthesis had to be removed (3 CM and 1 NM, 4.6% of the whole series; 12.5% in the high complexity group, 5.9% for NM and 20% for CM). The median time to complete chest wall healing after VAC in patients with local sepsis was 14 months (range, 5 to 60 months). All patients are currently alive and well except for 1 who died 11 months after complete chest wall healing as a result of dissemination of metastatic chondrosarcoma. At univariate analysis, predictors of overall and grade 2 or less morbidity according to the Common Terminology Criteria for Adverse Events version 4.0 were first (p=0.038) and second (p=0.015) redo operations. Conversely, patients with a body mass index of less than 25 kg/m2 (p=0.049) undergoing one (p=0.032) or two reconstructions (p=0.00047) with combined materials (p=0.00029) were more likely to experience local wound complications and require VAC. On multiple regression analysis, redo operations (first, p=0.032; second, p=0.00047) and the use of combined (synthetic and biologic) materials (p=0.0029) were confirmed to be related to an increased incidence of wound complications.
  
  
  CONCLUSIONS
  Multiple redo operations after complex chest wall reconstruction performed with a combination of NM and CM may be associated with an increased incidence of local wound complications. Nevertheless, in these cases, the use of NM and VAC yielded a low rate (5.8% versus 20% with CM) of prosthesis removal while achieving complete wound healing.
authors.affiliation: Division of Thoracic Surgery, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy. Electronic address: gaetano.rocco@btopenworld.com.
authors.forename: Gaetano
authors.initials: G
authors.lastname: Rocco
authors.affiliation: Division of Thoracic Surgery, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Martucci
authors.affiliation: Division of Thoracic Surgery, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy.
authors.forename: Antonello
authors.initials: A
authors.lastname: La Rocca
authors.affiliation: Division of Thoracic Surgery, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy.
authors.forename: Carmine
authors.initials: C
authors.lastname: La Manna
authors.affiliation: Division of Thoracic Surgery, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: De Luca
authors.affiliation: Section of Orthopedics, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy.
authors.forename: Flavio
authors.initials: F
authors.lastname: Fazioli
authors.affiliation: Service of Reconstructive Surgery, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Mori
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D054843:Negative-Pressure Wound Therapy / Q000706:statistics & numerical data*; D019736:Prostheses and Implants; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000517:prevention & control*; D013899:Thoracic Neoplasms / Q000601:surgery*; D013905:Thoracoplasty / Q000009:adverse effects* / Q000295:instrumentation; D016896:Treatment Outcome; D055815:Young Adult