The majority of patients were treated for TW reconstruction after surgical debulking procedure for thoracic malignancies or for extended abdominal tumors which interested the chest wall. TW reconstruction is a real challenge for thoracic surgeons as well. The reconstructive options are reduced under circumstances of potential of demonstrated wound infection. Biologic materials are specially indicated in potentially contaminated or contaminated surgical fields . Their resistance to the proteases activity either bacterial either human is demonstrated. Moreover they have the unique characteristic to promote the early revascularization of the regenerate tissue. This allows to antibiotics to early reach the infected zone and by reducing the bacterial possibilities to create biologic niches as in synthetic prosthesis it favors the infection healing. A mild inflammatory response to these materials encourages active tissue deposition and natural cytokine production with a consequent healing process and tissue repair. As organized tissue deposition occurs, bio-scaffold is gradually remodeled by host, yielding a repaired tissue structure that is entirely host derived [14, 19, 20].
The challenge in TW reconstruction is the complex mechanisms involved in respiration. It implies muscular and elastic forces whom combined work results in the respiratory equilibrium. It briefly consists in a mild intra-thoracic negative pressure. A prosthetic material have to maintain this equilibrium constant to allow the patient to breath. It also has to avoid at the same time the air passage through the prosthesis preventing the subsequent pneumo-thorax. The alteration of the respiratory equilibrium results in either obstructive or restrictive impairment. Thoracic reconstructive materials must have either enough rigidity to allow the thorax to move symmetrically either elasticity to be able to adapt to the thorax movement. When a big portion of TW have to be removed and consequently many ribs lack, the reconstruction process risks to create an additional respiratory death space. Some reconstructive methods insert metal devices to guarantee the necessary rigidity. However if infection is suspected or demonstrated the insertion of a foreign body becomes a risky procedure.
In infected fields two are the possibilities: anatomic reconstruction with flap transposition or the use of biologics. The use of synthetic materials have been widely described with very good results, but in our opinion is very risky in potentially contaminated or infected fields. Reported side effects of synthetic materials include secondary wound infection in up to 6% of cases, seroma formation, insufficient tensile strength with respiratory failure, long-term onset of restrictive lung disease, graft dehiscence, chronic pain, hemorrhage and wall deformities in pediatric patients [3, 21–23]. As counterpart, the experience in TW reconstruction with biologics is limited. Their use is progressively increasing and giving good results . No other cases have been reported in literature of thoracic reconstruction in trauma patients. However in selected cases such a kind of materials could offers a very trustworthy alternative. The present case demonstrated the possibility to treat infections also by multi-resistant bacteria with the contemporary implantation of a biologic mesh. The described case was very challenging for the necessity to repair TW and the impossibility to implant foreign body. The Pseudomonas Aeruginosa MRSA infected wound, in fact reduced the therapeutic options. The patients needed a procedure as shorter and as less invasive as possible. He could hardly tolerate a long TW reconstructive procedure as in elective patients.
If biologics demonstrated to have usefulness properties, as counterpart the main obstacle to their use is the cost. It is absolutely higher than synthetic mesh, and in patients without infected or, at least potentially contaminated field the use of biologics have not a clearly stated rationale.