J Thorac Cardiovasc Surg 2010;139:1081-1083
© 2010 The American Association for Thoracic Surgery
Complex diaphragm reconstruction using dermal collagen matrix after multivisceral resection of retroperitoneal sarcoma
Nicholas J. Harms, MDa,
Sima Naderi, MDb,
Dariusz Borys, MDc,
Richard J. Bold, MDa,
Robert J. Canter, MDa,*
a Division of Surgical Oncology, University of California at Davis Cancer Center, Sacramento, Calif
b Department of Radiology, University of California at Davis Cancer Center, Sacramento, Calif
c Department of Pathology and Laboratory Medicine, University of California at Davis Cancer Center, Sacramento, Calif
Received for publication July 2, 2009; revisions received July 2, 2009; accepted for publication July 9, 2009.
* Address for reprints: Robert J. Canter, MD, Division of Surgical Oncology, Suite 3010, UC Davis Cancer Center, 4501 X Street, Sacramento, CA 95817. (Email: Robert.canter{at}ucdmc.ucdavis.edu).
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Introduction
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Successful en bloc resection of retroperitoneal sarcomas may require contiguous organ resection, including the diaphragm. Tension-free, primary repair of the diaphragm is not always technically possible when a large defect is created. Standard reconstruction of complex diaphragmatic defects involves implantation of polytetrafluoroethylene mesh (Gore-Tex; WL Gore and Associates, Newark, Del). However, in the setting of visceral organ resection such as colon or pancreas, implantation of prosthetic mesh may be contraindicated because of concerns of postoperative infection. We report successful implantation of acellular dermal matrix (AlloDerm; LifeCell Corp, Branchburg, NJ) to repair complex diaphragmatic defects in 2 patients after multivisceral resection of retroperitoneal sarcomas.
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Clinical Summary
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A 72-year-old woman presented with an approximately 32-cm recurrent left-sided retroperitoneal myxoid liposarcoma. Cross-sectional imaging suggested involvement of the distal pancreas, spleen, descending colon, and left hemidiaphragm (Figure 1
, A). Staging studies were consistent with localized disease.
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Figure 1. A, Preoperative computed tomography (CT) scan, coronal reconstruction, demonstrating recurrent left retroperitoneal sarcoma extending from hemidiaphragm to pelvis. Tumor (*), area suspicious for diaphragm involvement (arrow), and possible herniation of tumor (arrowhead) through foramen of Bochdalek hernia. B, Preoperative CT scan, coronal reconstruction, demonstrating left retroperitoneal sarcoma. Tumor (*) and area suspicious for diaphragm involvement (arrow). C, Scout film from CT 6 months after resection demonstrating intact left hemidiaphragm. D, Scout film from CT scan 6 months after resection showing intact left hemidiaphragm. Bilateral lung metastases are present (arrows).
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Resection of this large, recurrent sarcoma was performed with concurrent left hemicolectomy, distal pancreatectomy, splenectomy, partial psoas muscle, and left hemidiaphragm resection. An approximate 120-cm2 defect was created in the diaphragm, extending from the posterior portion of the central tendon to the posterolateral rib cage. Given the size of the defect, a tension-free, primary repair was not technically possible. In the setting of concomitant intestinal and pancreatic resections, implantation of prosthetic mesh was thought to be contraindicated because of the risk of mesh contamination.
Diaphragmatic reconstruction was accomplished with AlloDerm using interrupted 0-0 Prolene sutures to anchor the graft to the rib periosteum posterolaterally, to the left crus medially, and to the central tendon anteriorly (Figure 2
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Figure 2. Intraoperative photograph of diaphragm reconstruction in the first patient using AlloDerm (LifeCell Corp, Branchburg, NJ). Retractor (*) on duodenal-jejunal flexure; left psoas muscle (**). Lung parenchyma and pleural thoracostomy tube before completion of diaphragm repair (arrow).
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A 68-year-old man presented with a 12-cm left retroperitoneal mass that proved to be a renal angiosarcoma (Figure 1, B). At operation, the tumor was found to involve the tail of the pancreas, the spleen, and the diaphragm, necessitating a multivisceral en bloc resection. Resection of a portion of the left hemidiaphragm created an approximately 45-cm2 triangular defect, extending laterally and anteriorly from the left crus. Although a portion of the defect was repaired primarily, a complete, tension-free repair was not technically possible. A 3- x 7-cm piece of AlloDerm was used to repair the posterior-lateral defect using interrupted 0-0 Prolene sutures.
The patients were managed postoperatively with thoracostomy tube removal within 48 hours. After an uneventful early postoperative course, both patients re-presented with nausea, left upper quadrant pain, and mild dyspnea. Cross-sectional imaging revealed fluid collections that were drained percutaneously. In the first patient, a subphrenic abscess was diagnosed, whereas in the second patient, a sterile pleural fluid collection was drained. Each patient responded to conservative management with resolution of symptoms and clearance of postoperative fluid collections.
Six months postoperatively, radiographic evaluation showed an intact left hemidiaphragm repair in both patients (Figure 1, C, D), although the second patient had pulmonary metastases (Figure 1, D).
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Discussion
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Visceral, pulmonary, urologic, or gynecologic cancers may require en bloc resection of a portion of the diaphragm. Although standard reconstruction of complex diaphragmatic defects involves implantation of prosthetic mesh, this may be contraindicated in cases with bacterial contamination.1
Diaphragmatic reconstruction with autologous tissue muscle flaps has been successfully performed in cases involving significant bacterial contamination, but this approach is complex and introduces potential morbidities related to flap necrosis and donor-site complications.2
Biological grafts have gained acceptance for soft-tissue reconstruction, particularly when there is concern for potential bacterial contamination. Notable benefits include (1) their technical ease of use because they feel and suture much like native tissue; (2) their long-term vascularization and incorporation into native tissue; and (3) their permeability to the immunosurveillance host cells, which may reduce the risk of graft infection.3 The largest experience has been reported for abdominal wall reconstruction in the setting of complex abdominal wall hernias or enterocutaneous fistula.3 Additional reported uses include parastomal hernia repair, crural reinforcement after paraesophageal hernia repair,4 and repair of tracheoesophageal fistula.5 To our knowledge, this is the first report of the successful use of AlloDerm for diaphragm reconstruction after multivisceral retroperitoneal sarcoma resection.
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Conclusions
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The patients in this report have been followed for more than 6 months postoperatively, and they continue to do well with the structural integrity of their diaphragms confirmed radiographically. Although postoperative fluid collections (a subphrenic abscess and a sterile pleural fluid collection) developed in the patients, these collections were managed conservatively in both cases with good outcome and the AlloDerm was preserved. In future cases, consideration of more prolonged tube thoracostomy drainage may help avoid subsequent reaccumulation of fluid. AlloDerm seems to be a safe technique for complex diaphragmatic reconstruction after multivisceral resection of retroperitoneal sarcoma.
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Footnotes
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Disclosures: None.
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References
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- Fuks D, Dumont F, Berna P, et al. Case report-complex management of a postoperative bronchogastric fistula after laparoscopic sleeve gastrectomy. Obes Surg 2009;19:261-264.[Medline]
- McConkey MO, Temple CL, McFadden S, Temple WJ. Autologous diaphragm reconstruction with the pedicled latissimus dorsi flap. J Surg Oncol 2006;94:248-251.[Medline]
- Hiles M, Record Ritchie RD, Altizer AM. Are biologic grafts effective for hernia repair?: a systematic review of the literature. Surg Innov 2009;16:26-37.[Abstract/Free Full Text]
- Lee YK, James E, Bochkarev V, et al. Long-term outcome of cruroplasty reinforcement with human acellular dermal matrix in large paraesophageal hiatal hernia. J Gastrointest Surg 2008;12:811-815.[Medline]
- Su JW, Mason DP, Murthy SC, Rice TW. Closure of a large tracheoesophageal fistula using AlloDerm. J Thorac Cardiovasc Surg 2008;135:706-707.[Free Full Text]
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Introduction
Clinical Summary