Reconstruction following major chest wall resection can be challenging. Conventional methods of using mesh are slowly being replaced by chest wall reconstruction prosthetic systems that use titanium plates or bars. However, the successful implantation of these titanium prosthetic systems requires the operator to be familiar with the limitations and potential pitfalls of the process. Emerging intraoperative real-time imaging and 3-dimensional printing technology, as well as development in biomaterials, have been allowing chest wall reconstruction to become increasingly personalized.
Polyether ether ketone (PEEK) is a colourless organic thermoplastic polymer in the polyaryletherketone (PAEK) family.
We intend to achieve our goal by accomplishing the following specific aims:
1. Produce a 3-D printed model of the chest wall from CT scan data of patients to build a personalized chest wall prosthesis.
2. Produce a novel chest wall prosthesis using PEEK material based on the 3-D printed personalized model.
2. Assess the ability of PEEK to repair the chest wall full-thickness defect, implanting the innovative custom-made prosthesis in patients with tumors invading the chest wall and measuring by CT scan the adaptability of the biomaterial.
Chest wall involvement occurs in approximately 5% of all primary lung neoplasms. A realistic chance to cure locally advanced tumors invading the chest wall is a surgical resection, consisting in the excision of the primary lung cancer along with the involved chest wall (sometimes an en-bloc resection) and an appropriate lymph-nodal dissection.
Chest wall reconstruction is a central time of the surgical procedure. The reconstructive principles are: (I) the maintenance of chest wall anatomy/structural stability; (II) the protection of vital organs exposed to rib resection; and (III) the preservation of the ventilatory mechanisms.
New materials, more prone to be rapidly incorporated into the host, are currently available for chest wall reconstruction: malleable or articulating titanium bars, cryopreserved homograft and acellular soft tissue patches of bovine, porcine or human derivation, the latter ones characterized by near-physiological properties.
Synthetic tissue materials usually provide strong tissue reinforcement, but are at high-risk for potential foreign body reactions, which can sometimes result into serious clinical complications.
Local infection is one of the most serious complications after chest wall resection/reconstruction: this may require reintervention for the removal of the prosthetic material, which is the most important way to control the infection sustained by a foreign body in situ. George et al. suggested the use of XCM Biologic Tissue Matrix (Depuy Synthes, Oberdorf, Switzerland), acquired from the abdominal surgery experience, when the need of using prosthesis to restore chest wall rigidity and to avoid paradoxical respiratory movements, is identified.
Seroma is another surgical complication that is commonly treated with an elective drainage (often placed under ultrasound guidance), without the need to remove/replace the mesh. Finally, paraplegia is rarely described following costovertebral disarticulation, when the tumor invades the paravertebral sulcus, but it should be taken into account when such intervention is proposed to the patient.
Previously published evidence has established major clinical benefits from using computer-aided design, computer-aided manufacturing, and additive manufacturing to produce patient-specific devices. However, custom devices produced using these methods are still not in routine use. Oft-cited reasons for this slow uptake include the following: a higher up-front cost than conventionally fabricated devices, material-choice uncertainty, and a lack of long-term follow-up due to their relatively recent introduction.
Emerging intraoperative real-time imaging and 3-dimensional printing technology, as well as development in biomaterials, will allow chest wall reconstruction to become increasingly personalized and less invasive with a lower rate of complications.