Polytetrafluoroethylene or Acellular Dermal Matrix for Diaphragmatic Reconstruction?

Our plain-English summary of Polytetrafluoroethylene or Acellular Dermal Matrix for Diaphragmatic Reconstruction?, by J.K. Bassuner, D.C. Rice, M.B. Antonoff, et al (The Annals of Thoracic Surgery, 2017).

The study

• Authors: J.K. Bassuner, D.C. Rice, M.B. Antonoff, A.M. Correa, G.L. Walsh, A.A. Vaporciyan, N. Garg, B. Sepesi, S.G. Swisher, W.L. Hofstetter, J.A. Roth, R.J. Mehran
• Journal: The Annals of Thoracic Surgery
• Published: 2017;103(6):1710-1714
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: We aimed to evaluate the impact of collagen matrix in the reconstruction of the diaphragm.

Methods: We queried the electronic medical record for patients who had resection of the diaphragm and simultaneous pulmonary resection between 1999 and 2016. All reconstructions were performed with either polytetrafluoroethylene or acellular dermal matrix. We evaluated the rate of empyema and herniation in each group.

Results: A total of 208 patients met inclusion criteria. Polytetrafluoroethylene was used in 168 cases (80.8%) and dermal matrix in 40 cases (19.2%). Dermal matrix was used in 8 extrapleural pneumonectomies (5.4%), in 26 pleurectomy decortications (55.3%), and in 6 other types of resections (40%). Follow-ups were for a median of 15.0 months in the polytetrafluoroethylene group and 11.6 months in the dermal matrix group. Patients in the dermal matrix group had a chest tube for a median of 2.5 days longer than patients with polytetrafluoroethylene (p = 0.006). Empyema occurred in 11 polytetrafluoroethylene reconstructions (6.5%) and 3 dermal matrix reconstructions (7.5%) (p = 0.735). Seven patients (63.6%) with polytetrafluoroethylene infection required removal of the graft, whereas none in the dermal matrix group needed removal (p = 0.351). There were nine herniations in the polytetrafluoroethylene group and four in the dermal matrix group (p = 0.281), all were acute and due to anchorage failure.

Conclusions: Although infection rates were similar between polytetrafluoroethylene and acellular dermal matrix, re-operation for removal was not necessary in the latter. The use of a thick acellular dermal matrix may be a reasonable option when diaphragmatic reconstruction is potentially associated with a higher risk of infection.

Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This retrospective review of medical records at the University of Texas M.D. Anderson Cancer Center in Houston included 208 patients who, between 1999 and 2016, had part or all of the diaphragm removed along with lung surgery. Most had extrapleural pneumonectomy or pleurectomy decortication, and most had mesothelioma. The study compared two materials used to rebuild the diaphragm: synthetic polytetrafluoroethylene (PTFE, 168 patients) and bovine acellular dermal matrix (ADM, 40 patients). Asbestos exposure was not studied. Pleural infection (empyema) occurred in 11 PTFE patients (6.5%) and 3 ADM patients (7.5%), which was not a statistically significant difference. Seven of the 11 infected PTFE grafts had to be removed, compared with none of the infected ADM grafts; this difference was also not statistically significant. Herniation occurred in 9 PTFE patients (5.3%) and 4 ADM patients (10.0%), also not statistically significant. All hernias happened early and were caused by the anchoring failing. ADM patients kept chest tubes a median of 2.5 days longer. The authors concluded that thick bovine ADM may be a reasonable option when diaphragm surgery carries a high infection risk. They named the retrospective design and the small ADM group as limitations.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective single-institution review of electronic medical records (chart review)
• Who was studied: 208 patients (of 211 found by the record search) at the University of Texas M.D. Anderson Cancer Center, Houston, who had diaphragm resection combined with lung resection between 1999 and 2016. Procedures were extrapleural pneumonectomy in 146 patients (70.2%), pleurectomy decortication in 47 (22.6%), and other resections in 15 (7.2%). Most operations were for mesothelioma.
• Exposure: Not an asbestos exposure study. The comparison was between diaphragm reconstruction materials: 2-mm synthetic PTFE mesh (168 patients) versus 3- or 4-mm bovine acellular dermal matrix (SurgiMend; 40 patients). The surgeons chose the material.
• Main results:
  • Empyema occurred in 11 of 168 PTFE patients (6.5%) and 3 of 40 ADM patients (7.5%); p = 0.735, not statistically significant
  • Of the 11 PTFE patients with empyema, 7 (63.6%) needed graft removal 2 to 10 months after surgery. None of the ADM patients with empyema needed graft removal; the table gives p = 0.351.
  • Herniation occurred in 9 PTFE patients (5.3%) and 4 ADM patients (10.0%); p = 0.281. All were acute and due to anchorage failure, and there was no late herniation from ADM failure.
  • ADM patients had chest tubes for a median of 2.5 days longer than PTFE patients (p = 0.006)
  • 30-day mortality was 3% in the PTFE group and 2.5% in the ADM group
• The authors' conclusion: The authors concluded that infection rates were similar with both materials, but no ADM patient needed reoperation to remove the graft. They wrote that thick bovine ADM may be a reasonable option when diaphragm resection carries a high risk of infection, as in pleurectomy decortication.
• Limitations the authors state:
  • Retrospective design and small number of patients in the ADM group
  • Short follow-up, partly because most patients had mesothelioma and lived in another state
  • ADM was not commonly used at the institution until 2010. The authors report that empyema rates before and after 2010 did not differ.

Topics

Medical terms in this study, explained in our Lexicon: Collagen, Diaphragm, Empyema.

Related studies

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• Biological materials for diaphragmatic repair: initial experiences with the PeriGuard Repair Patch® — P. Zardo, R. Zhang, et al. (2011)
• Long term survival and perioperative propensity score matched outcomes of diaphragmatic resections compared to stripping in cytoreductive surgery + intra-peritoneal chemotherapy — B. Singh, G. Singh, et al. (2020)
• Morbidity of the abdominal wall resection and reconstruction after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) — M.F. Nunez, A. Sardi, et al. (2015)
• Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma — N. Zhou, D.C. Rice, et al. (2022)
• A new technique of diaphragmatic patch fixation in extrapleural pneumonectomy — M. Schiavon, A. De Filippis, et al. (2010)

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