الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
In Summary, Chest wall resection is one of the major surgical interventions, which the thoracic surgeon can be confronted with inside the operating room. Through history taking and physical examination are fundamental and are very important tools in achieving the diagnosis beside the more advanced laboratory and radiological tools. Majority of chest wall lesions are malignant in nature and most are metastatic lesions. Diagnosis of the chest wall lesions is very important to plan the best way of management. Radiological examination, like chest X- ray, CT, and MRI are not able to differentiate benign from malignant chest wall lesions in every case and still this point of difficulty even with the use of most recent advanced tools like PET.
Tissue biopsy remains the most important tool to get the right diagnosis. There are many ways to get a biopsy which include; FNA Cytology, Core Needle Biopsy, incisional biopsy, and exisional biopsy. FNA is not usually helpful and it is preferable to start with The most preferred is to start with the Core needle biopsy when accessible especially when the lesions are manifested with swelling. Following is the incisional biopsy which is preferred in case of large chest wall masses, and last, but not least the exisional biopsy which is used when the lesion is small and other manoeuvres could not reach a diagnosis where the total excision of the lesion with safety margin is performed and it is considered as a surgical treatment.
By reaching the diagnosis, thoracic surgeon should consult others medical and surgical specialties as chest wall resection and reconstruction is a co-operative work and necessitates collaboration of many specialities with special concern to the plastic surgeons, oncologist, pneumologist, rehabilitative medical doctors, orthopaedic surgeons or neurosurgeons in some instances. That is very important in chest wall resection and reconstruction as everyone of this team has a very important role which can affect the outcome of the patient significantly.
Operability and resectability should be assessed well before deciding the surgical resection as many of these lesions affecting the chest wall are metastatic or invasive lesions form adjacent structure; mostly the lungs. This can be achieved preliminarily from radiological investigations, and if difficult it could be done through the aid of the mediastinoscopy or thoracoscopy.
Every patient with chest wall neoplasm is different from the other and the management should be individualized, although there are general rules in chest wall resection ad reconstruction which should be followed like achievement of good resection margin as some surgeons try to restrict resection for their fear from large defects left after resection. Any chest wall defect can be reconstructed with satisfactory results.
Chest wall resection is one of the major operations in the thoracic surgery where the patient blood chemistry, cardio respiratory mechanics, liver function tests, renal function tests, Arterial blood gases, haemostasis mechanisms are altered and need well and close up observation postoperatively. Patients also lose a significant amount of blood during or post operatively which should be replaced when it appear to hazard the patient’s condition.
Chest wall reconstruction can be achieved by many ways including the rigid fixation with prosthesis, or muscle/ musculocutaneous flaps, or not reconstructed at all. When?, to whom should be done the reconstruction?, and what to use in reconstruction? are still difficult questions which seem to have no exact answer as every case is individualized and reconstruction or no depends on many factors, First; Location of the chest wall defects where anterior and lateral defects are the most lesions needed to be reconstructed while posterolateral and posterior are rarely needed to be reconstructed especially when they are covered by the scapula when they are located up in the chest wall and even when the are very low as diaphragm have a role also to support these defects to some extent especially on the right side; Second, surface area of the defect is one of the important deciding factors as large surface defects are usually needed to be reconstructed; Third, is sex as female has more necessity to the cosmetic appearance, Fourth, age and type of the work conducted by the patient where in some instances it is preferable to use synthetic materials in reconstruction instead to use muscle flap which may affect some movement of some part of the patient, Fifth; availability of the materials used in reconstruction of the chest wall; Sixth, the familiarity of the thoracic surgeon with different techniques of chest wall reconstruction, seventh, the nature of the thoracic lesion, Eighth, the general condition of the patient and his respiratory capacity which may be border line and should be reconstructed even for minor defects which usually not in need to be reconstructed in other patients.
Synthetic material used in reconstruction is safe to use and the incidence of infection and rejection is very low. The most convenient method for rigid chest wall reconstruction is methyl methacrylate sandwitched between two pieces of Marlex mesh where it gives both good desired rigid fixation and good acceptable and satisfactory cosmetic results. There is no advantages between different type of synthetic meshes used make any more preferable on the other, but the choice of the type of the synthetic used depends on its availability and the personal choice of the surgeon. All synthetic materials used in chest wall reconstruction should be covered either by muscles or by omentum to avoid disfigurement, reduces the incidence of infection and rejection of the synthetic material, and to avoid sloughing of the skin overlying especially if the patient is in need for postoperative radiotherapy.
Myocutaneous or muscle flaps are good tools in chest wall reconstruction especially when rigid fixation is not needed. It is important to use –when feasible- muscle sparing thoracotomy and avoid as you can muscle cutting approaches as muscle can be of help in reconstruction as a flap or even to be used is its place while it is intact to cover a synthetic material.
Chest wall resection yield a high degree of postoperative pain, which may precipitate many types of postoperative complications especially in patients with border line general condition and in those of old age. Good effective management of postoperative pain is essential after chest wall resection to avoid postoperative complications especially pulmonary ones. There are many types of postoperative complications, thoracic surgeon can met with but the most common are the pulmonary ones like lung atelectasis, postoperative pneumonia, respiratory insufficiency, while the most dangerous postoperative complications in those patients underwent chest wall resection and reconstruction is the occurrence of infection which may lead to failure of the plastic reconstructive procedure and leads to unfavourable outcome.
Postoperative rehabilitation of the patients with professional personnel is very important to achieve early good results. Respiratory physiotherapy and rehabilitation are very important and should be started as early as possible postoperatively. In those patients who underwent reconstruction using muscle flaps, it is important to start physiotherapy to prevent atrophy of the muscle and stiffness of the joint.
Chest wall resection remains the treatment of choice in most of instances either as a definitive treatment in cases of primary benign, malignant, or even metastatic lesions or as a palliative treatment to alleviate the pain and avoid skin necrosis in cases with radiation injury. For malignant neoplasm, the potential for cure depends on the completeness of resection, histologic type and tumour stage. Survival after chest wall resection for neoplastic lesions depends on many factors, first, the nature of the lesion either benign or malignant, or invasion from lung cancer where the most unfavourable survival found in cases with NSCLC invading the chest wall, second, sex of the patient where survival time is more long in females than in males, Third, age of the patient where the ages below 40 years have more long survival periods, fourth, surface area of the defect, where lesions surface areas more than 100 cm2 have less survival time, fifth, presence of infiltration, where infiltrative lesions are associated with shorter periods of survival, sixth, resection margin as free one is of favourable outcome, seventh, reconstruction as it was found that those patients underwent reconstruction have more better survival curves than those patients who did not undergo reconstruction.