Open repair of pectus excavatum and carinatum deformities with minimal cartilage resection

BACKGROUND: Numerous modifications of the Ravitch open repair of pectus excavatum (PE) and carinatum (PC) have been used by surgeons with inconsistent results. METHODS: During a 3-year period, 275 consecutive patients underwent open repair of PE and PC using a new less invasive technique. A small chip of costal cartilage was resected medially and laterally from each deformed cartilage, allowing it to barely touch the sternum and rib (laterally) after the sternum had been elevated or depressed, and twisted to the desired position. A support strut used for all patients was routinely removed within 6 months. RESULTS: With mean follow-up of 17 months, all but 5 patients regarded the results as very good or excellent. There were no major complications or deaths. CONCLUSION: Open repair using minimal cartilage resection is effective for all variations of PE and PC in patients of all ages, causes only mild pain, and produces good physiologic and cosmetic results.     

改良手术方法重建鸡胸胸壁的疗效观察

目的改进鸡胸的手术治疗方法. 方法 1990年～2003年收治鸡胸患者9例,年龄3岁6个月～16岁.采用传统手术方法治疗4例改进的手术方法治疗5例.改进的手术操作包括:①不缝合缩短肋骨床;②用金属支架固定矫正位置后的胸骨. 结果用传统方法治疗的4例随访1～5年,其中1例术后5年发生肋骨下陷、演变成漏斗胸;用改进方法治疗的5例随访2～4年,重建的胸廓双侧对称,胸骨及肋软骨无凸出或凹陷,外形满意. 结论改进的手术方法是有效而合理的,较传统方法疗效更佳.     

Management of a floating sternum after repair of pectus excavatum

PURPOSE: The aim of this study was to examine the authors' experience with patients who have floating sternum after correction of pectus excavatum via the classical Ravitch procedure. A floating sternum is defined as a sternum in which the only attachment to the chest wall is its superior (cranial) border, and in which the body is secured only by the manubrium and whatever lateral and inferior fibrous bands are present. Typically, a floating sternum is caused by either extensive resection of the costal cartilages and perichondrium during correction of pectus excavatum or failure of proper regrowth of these cartilages. METHODS: The authors retrospectively assessed the charts of all patients diagnosed with a floating sternum noting age at original correction of pectus excavatum, time from original correction of pectus excavatum to diagnosis of floating sternum, age at correction of floating sternum, complaints before stabilization of the sternum, methods of repair, and postoperative complications. RESULTS: Between July 1993 and June 1999, floating sternum was diagnosed in 7 patients. The mean age of patients who underwent operative correction of a floating sternum was 28.9 years (range, 16 to 42 years). The mean time interval between original correction of pectus excavatum, or "redo," and diagnosis of a floating sternum was 9.9 years (range, 2 to 20 years). Complaints before correction of the floating sternum included sternal pain and instability, exercise intolerance, and difficulty breathing. Operative repair consisted of mobilizing the lateral and inferior edges of the sternum, detaching the fibrous perichondrium, performing anterior sternal osteotomies, and finally supporting the sternum with substernal Adkins struts. All 7 patients had successful stabilization of the sternum. Two of 7 patients underwent 2 procedures to successfully stabilize the sternum. One patient has Adkins struts still in place because of hematopoetic malignancy. Six of 7 patients are now without symptoms. CONCLUSIONS: A floating sternum is a morbid phenomenon that may manifest many years after the original procedure. It can cause significant sternal pain, chest wall instability, and respiratory dysfunction, which are the hallmark indications for correction. Repair of a floating sternum can be accomplished successfully.     

Further experience with the operative management of asphyxiating thoracic dystrophy after pectus repair

Background/Purpose

Asphyxiating thoracic dystrophy (ATD) can occur years after a Ravitch-type repair of pectus excavatum, resulting in debilitating alteration in pulmonary function (PFT). An operation was devised to attempt repair of this deformity.

Methods

After institutional review board approval, the records of 10 children (ages 9-18 years) with ATD that developed 4 to 12 years postpectus operation who underwent attempted repair of ATD were reviewed. Data obtained before ATD operation and at 6, 12, and 24 months afterward included chest computed tomography, pulmonary functions (PFT), and a quality of life questionnaire. The operation consisted of sternal split with rib graft placement to permanently hold the sternum apart.

Results

All children survived and the bone grafts healed solidly. Computed tomography showed a change from a flat to a round chest contour on cross section, with increased anteroposterior dimension. Two patients had no change in PFT at 24 months whereas the other 8 had 21% to 30% improvement in PFT parameters. All patients reported improved exercise tolerance, and 3 began sports activities who were previously unable to do so. Two patients on oxygen, essentially bedridden, are now active, breathing only room air. Seven of 10 patients continue to have cosmetic concerns.

Conclusions

A small population of patients who had postoperative pectus repair developed severe, debilitating ATD. The repair described improves most patients, some dramatically, but does not significantly improve cosmetic appearance. The operation is undergoing further refinement to address these issues.     

Magnetic Mini-Mover Procedure for pectus excavatum : I. Development, design, and simulations for feasibility and safety

Background/Purpose

Correction of pectus excavatum (PE) results in measurable improvement in lung capacity and cardiac performance as well as improved appearance and self-image. The Nuss and modified Ravitch approaches attempt to correct the chest wall deformity by forcing the sternum forward in 1 step and holding it in place using a metal strut. The initial operation requires extensive manipulation under general anesthesia and results in postoperative pain, requiring hospitalization and regional anesthesia. Pain and disability may last for weeks. Both procedures are expensive.A better principle would be a gradual bit-by-bit repair via small increments of pressure applied over many months. We developed the Magnetic Mini-Mover Procedure and applied this strategy to correct PE.

Methods

The Magnetic Mini-Mover Procedure uses magnetic force to pull the sternum forward. An internal magnet implanted on the sternum and an external magnet in a nonobtrusive custom-fitted anterior chest wall orthosis produce an adjustable outward force on the sternum. Outward force is maintained until the abnormal costal cartilages are remodeled and the pectus deformity is corrected.

Results

We implanted a magnet in human skeletons and measured the force applied to the sternum when the distance between the internal and external magnets was varied in increments. With the 2 magnets 1 cm apart, the outward force was adequate to move the sternum at least 1 cm. We also mapped the magentic field in the two-magnet configuration and found that maximum field strengths at the surface of the heart and at the outer surface of the orthosis were at safe levels.

Conclusions

The Magnetic Mini-Mover Procedure allows correction of PE by applying magnetic force over a period of months. Crucial questions raised during our design, redesign, and simulation testing have been satisfactorily answered, and we have received a Food and Drug Administration Investigation Device Exemption (G050196/A002) to proceed with a phase I to II clinical trial.     

电视胸腔镜在小儿漏斗胸治疗中的应用

目的探讨胸腔镜在胸骨后钢板置入胸骨抬举法(Nuss技术)治疗小儿漏斗胸的价值.方法胸腔镜直视下Nuss技术治疗45例漏斗胸.术前,将特制钢板按胸廓自然弧度弯成"弓"状,亚甲蓝标记切口及凹陷最低点;术中,右胸腔置入电视胸腔镜,直视下将"弓"形支架引入胸骨下,缝合固定.结果45例支架安全置入,手术时间35～80 min,平均60min.术中出血量＜5 ml.术后住院4～10 d,平均7 d.40例随访3～30个月,平均16.5月.早期并发症2例,分别为气胸和肺炎.远期并发症3例,1例1年后因支架移位重新固定,2例术后胸骨持续疼痛,经口服及局部涂抹解热镇痛药,1年后症状消失.10例术后满2年取出钢板,胸廓塑形好.结论胸腔镜直视下Nuss技术治疗小儿漏斗胸安全可靠,手术时间短,操作简单,矫形满意,术中、术后并发症少,值得推广.     

Experience with FiberWire for pectus bar attachment

Background

Minimally invasive repair of pectus excavatum has become an established method for repair of pectus excavatum. Bar displacement or rotation remains the most common complication of this repair requiring return to the operating room.

Methods

Retrospective review of all patients at a single institution who underwent repair of pectus excavatum using FiberWire for bar stabilization between December 2009 and March 2013 was undertaken.

Results

93 patients underwent minimally invasive pectus repair using FiberWire during the study period. The patients included 73 males and 20 females, with an average age of 14.6 years (range 7–21 years). Mean operative time was 102 minutes (range 56–198 minutes). No patients developed wound complications, two patients developed pain because of bar migration and required return to the OR, and no patients had recurrence of their pectus defect because of bar migration during the study period. Median length of follow-up was 17 months (range 3–36 months).

Conclusion

Stabilization of pectus bars using circumferential rib fixation with FiberWire at multiple points on both sides of the bar appears to be effective in preventing bar rotation and displacement, and requires minimal change to the operation as it has been previously described. Early experience shows a low rate of complications.     

Costochondral changes in the chest wall after the Nuss procedure: ultrasonographic findings

Purpose

The Nuss procedure is one of the most popular surgeries for correcting pectus excavatum. However, little is known regarding stress and strain on the deformed ribs after inserting the pectus bar. We used ultrasonography to investigate costochondral changes before and after the Nuss procedure.

Methods

Ninety-five patients underwent the Nuss procedure between July 2007 and February 2008 at 2 institutions. Chest ultrasonography, specifically of the bones and cartilage, was performed 1 day before and 1 week after the operation.

Results

Postoperatively, all patients showed various degrees of deformation from the second to sixth cartilages bilaterally. The cartilages were not fractured. Of these patients, 28 (29.5%) had significant changes, including acute angulation of the costochondral junction and rib fractures near the pectus bar. These changes were associated with increased age (P < .01) and the degree of postoperative sternum elevation (P < .01). The pectus index and sex were not significant predictors of rib damage.

Conclusions

The Nuss procedure created significant stress and strain over the deformed cartilages. Approximately 29% of the patients showed localized, self-limited costochondral changes via chest ultrasonography.     

Open door approach by partial sternotomy and sterno-costo-chondroplasty for annuloaortic ectasia with pectus excavatum

A 32-year-old female patient with Marfan syndrome was admitted for repair of annuloaortic ectasia and severe pectus excavatum. Because the chest cage deformity was severe, concomitant reparative surgery of the chest wall was performed. Partial median sternotomy and left second-fifth rib division was made to obtain good surgical field. The patient underwent valve-sparing aortic root remodeling successfully. After complete neutralization of heparin, additional division of the right ribs was performed and each rib and the sternum was reshaped. Pectus excavatum was completely repaired by this method. We believe this approach is efficacious for intracardiac repair with severe pectus excavatum.     

Surgical correction of pectus excavatum

It has been observed that some patients who had correction of funnel chest deformity by methods which failed to provide fixed elevation of the involved sternal segment developed progressive sagging in later years in spite of looking good at the operating table. This has led to the adoption of a new technique of double sternal support. This procedure has resulted in 35 of 37 children (94%) being classified as excellent or satisfactory. This double support was initially established in 1959 by overlapping the upper transsected sternum while maintaining elevation of the lower end with a soft tissue sling of perichondrium and intercostal muscle. Beginning in 1961, a rigid bridge of rib or stainless steel bar was substituted at the lower end of the sternum. This has provided better support and the current preference of using the steel bar has been validated in this group of patients. The few disappointments were related to removal of the bar earlier than desired, failure to excise all the protruding sternal cartilage stumps or rib graft tips and inability to cover the lateral sternal edges with pectoral muscles. If possible, the steel bar should not be removed before 12 mo. When these pitfalls were avoided, the results were almost uniformly excellent. The wisdom of excising all depressed cartilaginous segments, as advocated by Ravitch in 1949,⁴ has been substantiated. A submammary transverse incision has provided an excellent cosmetic appearance. The morbidity has been low and the mortality zero.In spite of the absence of objective evidence of cardiopulmonary dysfunction, there seems to be an almost uniform improvement in appearance and in patient activity following successful correction of the funnel chest. The latter may be as much a psychological response as a physiologic one. The low morbidity, satisfactory long term results, and general improvement in the patient's body image and outlook on life indicate the need to offer correction of the severe pectus excavatum deformity to low risk children.     

Surgical correction of pectus excavatum: the Münster experience

Objectives: Pectus excavatum is the most common congenital hereditary chest-wall deformity. This study analyses a single-center experience of pectus excavatum– thoracic wall reconstruction using a uniform technique of internal stabilization employing stainless steel struts. Methods: From June 1984 to December 1997, we performed correction operations on 777 patients with pectus excavatum. The condition occurred more frequently in boys (621 patients) than girls (156 patients). Surgical repair was performed using a standard method of double bilateral chondrotomy parasternally and at points of transition to normal ribs. This was followed by detorsion of the sternum, retrosternal mobilization and correction of the inverted ribs. The anteriorly displaced sternum was stabilized by one trans-sternal and two bilateral parasternal metal struts. Results: The corrections were completed with successful repair in 765 pati-ents (98.5%) with a low complication rate of 6.7%. The follow-up period ranged from 4 weeks to 12 years, mean 6.4 years. Major recurrences were observed in 12 patients (1.5%) and mild recurrence were observed in 35 patients (4.5%). Conclusion: Significant reduction in postoperative cardiorespiratory disorders, low lethality, improvement of subjective complaints, satisfactory long-term results and improvement in psychological problems indicate the need to offer this method of surgical correction to low-risk children. Received: 23 July 1998 Accepted: 26 November 1998     

儿童微创Nuss手术相关并发症的处理及预防

目的 总结微创Nuss手术治疗儿童漏斗胸的相关并发症的预防及处理原则.方法 2005年5月～2011年12月采用Nuss手术治疗280例漏斗胸患儿,其中8例为复发漏斗胸,5例合并心肺合并症,7例有胸部手术史.取两侧腋中线小切口,在胸腔镜的监视下,用穿通器将已塑形的钢板凸面朝下由左侧肋弓最高点经胸骨最低点拉至右侧肋弓最高点穿出,翻转钢板撑起凹陷的胸骨,固定钢板.结果 280例手术顺利,平均手术时间54 min(38～ 120 min).并发症发生率16.4％(46/280),其中早期并发症28例:心包穿孔3例,均退回并重置穿通器;肋间隙撕裂1例,重新选择肋间斜置钢板;心包炎1例,对症治疗好转;气胸12例,3例穿刺抽吸,3例闭式引流,6例未处理;胸腔积液7例,2例穿刺抽液,2例闭式引流,3例未处理;肺炎2例,予抗感染治疗后恢复;切口感染2例,换药处理后愈合.晚期并发症18例;切口无菌性囊肿3例,保守治疗好转;支架移位3例,均再手术纠正;疼痛造成获得性脊柱侧弯3例,理疗后1例恢复,2例未恢复;钢板金属过敏2例,分别提前取出固定片及支架;钢板压迫肋软骨3例,提前取出钢板;肋软骨过度增生4例,取钢板时加做肋骨截骨术.结论 早期诊断并及时处理是有效治疗Nuss手术相关并发症的关键.     

Coronary artery bypass via resternotomy after pectus excavatum repair

Pectus excavatum is a chest wall deformity that commonly warrants pediatric surgical correction for cosmesis or respiratory impairment via sternotomy. The repair typically consists of sternal wedge osteotomy and subsequent placement of a Steinman pin across the sternum with fixation to the ribs bilaterally. Coronary artery bypass grafting (CABG) after surgical repair of the sternum with a metal implant poses an intriguing surgical challenge. Literature review reveals only one such previously described case. We present a case of coronary revascularization in an adult who previously underwent pectus excavatum repair with ligation of the internal mammary arteries. Our coronary revascularization was accessed through a resternotomy after surgical removal of the metal implant previously placed during the pectus excavatum repair. Autologous greater saphenous vein was used as a conduit for bypass. The patient did well postoperatively and was discharged on postoperative day 4. The pectus repair remained intact even after the median sternotomy was performed. This was confirmed at the 1-year follow-up for the patient. Resternotomy after pectus excavatum repair with a prosthetic implant poses a challenge to cardiothoracic surgeons. Many such repairs have been described in the pediatric population. As our society ages and coronary artery disease becomes more prevalent, this unique situation may be more commonly encountered. We present an approach to coronary artery bypass grafting via median resternotomy after pectus excavatum repair.     

Anterior chest wall deformities and congenital heart disease

Pectus excavatum and pectus carinatum usually exist as isolated abnormalities. Only 19 cases of associated congenital heart defects have been reported. Significant complications related to uncorrected pectus excavatum have been described either during or after cardiac operations. Therefore we reviewed our experience with these coexisting lesions to assess the risk of surgical repair of chest wall deformities before and after correction of congenital cardiac anomalies. Among 20,860 infants and children with congenital heart disease seen at our institution, 36 (0.17%) had associated anterior thoracic deformities, 22 of whom underwent surgical correction of pectus excavatum or pectus carinatum. Ten of these 22 patients had pectus repair after a cardiac operation. Pleural or pericardial entry was avoided in all and none required a blood transfusion. Ten other patients had pectus repair either before cardiac repair (five patients) or without a subsequent cardiac operation. Another patient had a cardiac operation performed through a median sternotomy both before and after pectus repair, and the remaining patient, early in the series, had simultaneous banding of the main pulmonary artery and repair of pectus excavatum complicated by chest wall instability and a lethal intrathoracic hemorrhage. The experience indicates that congenital chest wall deformities can be safely and effectively repaired after early correction of congenital heart defects through a median sternotomy, although repair of the chest wall deformity after cardiac surgery also gives good results. However, in children who require an extracardiac conduit for repair of their congenital heart defect, we recommend initial repair of the pectus excavatum followed at 6 weeks or later by repair of the cardiac lesion to eliminate possible extrinsic compression of the conduit by the depressed sternum. We avoid simultaneous cardiac and pectus excavatum repair because of potential associated major complications.     

Simultaneous repair of pectus excavatum and congenital heart disease over the past 30 years

Objective: Pectus excavatum may be present in patient requiring operations for cardiac defects. The study was undertaken in order to assess our simultaneous repairs of pectus excavatum and congenital heart disease over past 30 years. Methods: Between 1970 and 2000, 12 patients underwent simultaneous repair of pectus excavatum and congenital heart disease. Six of 12 patients had ventricular septal defects as cardiac malformations (subgroup A). Operative technique, after the intracardiac procedure using cardiopulmonary bypass, consists of total subperichondrial resection of deformed costal cartilages, transection of deformed portion of the sternum in 2–3 points, and fixation of the sternum in elevated position using two Kirschner wires and a bridge external traction. Postoperative catheterization was performed in five of 12 patients (subgroup B). We evaluated the operative data, the improvement of pectus deformity and right ventricular performance retrospectively. The operative data in subgroup A were compared with those in recent random patients with ventricular septal defects only or with pectus excavatum only (control groups). Results: There was no operative death and non-serious complications were seen in nine patients (atelectasis in six, superficial wound infection in two, chylothorax in one). Pectus deformities improved with the drop of vertebral index postoperatively. The mean total operative time and postoperative drainage in subgroup A were 128.4% and 123.7%, respectively of those in the ventricular septal defect control group. The mean perioperative bleeding in subgroup A was more than the sum of those in control groups. Right ventricular end-diastolic (RVEDVI), end-systolic (RVESVI), stroke (RVSVI) volume indices and ejection fraction (RVEF) in subgroup B tended to increase after surgery. In particular, there were significant increases of RVEDVI (35%, P<0.05) and RVSVI (77%, P<0.01). Conclusion: Simultaneous cardiac and pectus repairs were performed successfully without serious complications. Moreover, simultaneous repair resulted in an improvement of right ventricular performance with significant increases of RVEDVI and RVSVI.     

Musculoskeletal deformities following repair of large congenital diaphragmatic hernias

Purpose

Large congenital diaphragmatic hernias (CDH) can be repaired with either a muscle flap or prosthetic patch. The purpose of this study was to assess the frequency and severity of scoliosis, chest wall, and abdominal wall deformities following these repairs.

Methods

Neonates who underwent CDH repair (1989–2012) were retrospectively reviewed. We then validated our retrospective review by comparing results of a focused radiologic evaluation and clinical examination of patients with large defects seen in prospective follow-up clinic. Tests for association were made using Fisher’s exact test.

Results

236 patients survived at least 1 year. Of these patients, 30 had a muscle flap, and 13 had a patch repair. Retrospectively, we identified pectus in 9% of primary repairs, 47% of flap repairs, and 54% of patch repairs. We identified scoliosis in 7% of primary repairs, 13% of flap repairs, and 15% of patch repairs. Prospectively, 75% of flap patients and 67% of patch patients had pectus and 13% of flap patients and 33% of patch patients had scoliosis. There was no significant difference between flap and patch patients.

Conclusions

Scoliosis and pectus deformity were common in children with large CDH. The operative technique did not appear to affect the incidence of subsequent skeletal deformity.     

Recent experiences with minimally invasive pectus excavatum repair "Nuss procedure".

Objective: To review the new technical modifications and results of 668 patients who have had pectus excavatum repair utilizing the minimally invasive technique. Methods: A retrospective chart review was conducted of 668 patients undergoing minimally invasive pectus repair from 1987 through July 2004. Since 1997, a standardized treatment pathway was implemented. Preoperative evaluation included computed tomography (CT) scan, pulmonary function tests, and cardiac evaluations with electrocardiogram and echocardiogram. Indications for operation included at least 2 of the following: progression of the deformity, Haller CT index greater than 3.25, mitral valve prolapse, cardiac compression or displacement, pulmonary function studies that indicate restrictive or obstructive airway disease, previous failed open or minimally invasive pectus repair. Technical and design modifications since 1998 have included routine thoracoscopy, the use of an introducer/dissector for creating the substernal tunnel, elevating the sternum, and routine use of a wired lateral stabilizer and polydioxanone suture (PDS) sutures around the bar and underlying rib to prevent bar displacement. The bar is removed as an outpatient procedure in 2 to 4 years. Results: In 668 patients undergoing minimally invasive pectus repairs, single bars were used in 78.1% and double in 21.7%. Lateral stabilizers were applied in 99.8% and were wired for further stability in 71%. Bar shifts before the use of stabilizers were 14.3%, which decreased to 4.6% after stabilizers were placed and 0.8% with a wired stabilizer and PDS sutures. Results were excellent in 78.5%, good in 13.1%, fair in 4.7% and failed in 3.7% after more than 1 year post bar removal. Conclusion: The minimally invasive technique has evolved into an effective method of pectus excavatum repair. Modifications of the technique have reduced complications. Long-term results continue to be excellent. Read at the Fifty-seventh Annual Meeting of the Japanese Association for Thoracic Surgery, Educational Lecture, Sapporo, October 20–22, 2004.     

鸡胸的微创外科治疗

目的 介绍微创治疗鸡胸的手术方法 、并发症和相关临床经验.方法 利用微创Nuss手术的原理行胸骨沉降术治疗6例鸡胸病儿,均为男性,年龄10.5～16岁,平均(13.6±1.94)岁.术前均行CT检查,测量Hailer指数.5例采用Nuss手术的钢支撑架及固定器作为同定架,1例采用国产钛同定架及专用固定器.结果 6例均顺利完成手术,无术中并发症.手术时间80～120 min,平均(104.17±15.63)min;术中出血3～10 ml,平均(5.17±2.56)ml;术后住院5～7天;随访1～11个月.1例术后3个月时同定架脱开,再次手术固定.余无并发症.结论 微创胸骨沉降术矫正鸡胸的手术方法 安全可行,并可以增加胸廓的容积.病儿手术修复的最佳时机为10～16岁.技术方法 的改进和远期效果的评价,还需进一步研究探讨.     

A 5-year experience with a minimally invasive technique for pectus carinatum repair

Purpose

This report describes a 5-year experience with a novel, minimally invasive surgical technique for treatment of pectus carinatum.

Methods

From June 2002 to August 2007, 40 patients underwent operation to correct pectus carinatum by pressure applied through a curved steel bar that was placed subcutaneously anterior to the sternum, via lateral thoracic incisions. The bar is inserted through a polyvinyl chloride tube with the convexity facing posteriorly. The polyvinyl chloride tube is positioned presternally by trocar.Subperiosteal wires attach small fixation plates to the ribs laterally, and the convex bar is secured to the small fixation plates with screws applying manual pressure to the anterior chest wall until the desired configuration is achieved. The compressive elongated bar is attached to the fixation plate with screws. The average age was 14.3 years (range, 10-21 years), and 90% were male. Both symmetric and asymmetric protrusions were treated. Patients whose chest was not malleable, and whose sternum could not be brought to a desirable position with pressure from the operator's hand, were treated by the open or “Ravitch” technique. After 2 or more years, the bar, wires stitches, screws, and fixation plates were removed.

Results

Of 40 patients treated with this procedure, 20 have undergone bar removal with the following results: 10 excellent, 4 good, 4 fair, and 2 poor. Average blood loss was 15 mL. Average length of hospital stay was as follows: implant, 3.8 days; removal, 1.4 days. Patients returned to routine activity 14 days after repair. Average follow-up since primary repair is 2.49 years. In those who have had bar removal, it is 1.53 years. Complications were pneumothorax in 1 patient, treated with chest tub e suction; skin adherence in 8 cases; seroma in 6; wire breakage in 3; persistence of pain in 1; and infection in 1. Technical modifications (selecting younger patients, excluding patients with a stiff thoracic wall, submuscular insertion of the bar, stronger pericostal wire) have been associated with no complications in the last 16 cases.

Conclusions

This experience with a new, minimally invasive technique for the treatment of pectus carinatum shows it to be safe and effective. The correction obtained was highly satisfactory with minimal complications. It should be considered in appropriate cases as an alternative to more invasive techniques.     

Recent experiences with minimally invasive pectus excavatum repair “nuss procedure”

Objective: To review the new technical modifications and results of 668 patients who have had pectus excavatum repair utilizing the minimally invasive technique. Methods: A retrospective chart review was conducted of 668 patients undergoing minimally invasive pectus repair from 1987 through July 2004. Since 1997, a standardized treatment pathway was implemented. Preoperative evaluation included computed tomography (CT) scan, pulmonary function tests, and cardiac evaluations with electrocardiogram and echocardiogram. Indications for operation included at least 2 of the following: progression of the deformity, Haller CT index greater than 3.25, mitral valve prolapse, cardiac compression or displacement, pulmonary function studies that indicate restrictive or obstructive airway disease, previous failed open or minimally invasive pectus repair. Technical and design modifications since 1998 have included routine thoracoscopy, the use of an introducer/dissector for creating the substernal tunnel, elevating the sternum, and routine use of a wired lateral stabilizer and polydioxanone suture (PDS) sutures around the bar and underlying rib to prevent bar displacement. The bar is removed as an outpatient procedure in 2 to 4 years. Results: In 668 patients undergoing minimally invasive pectus repairs, single bars were used in 78.1% and double in 21.7%. Lateral stabilizers were applied in 99.8% and were wired for further stability in 71%. Bar shifts before the use of stabilizers were 14.3%, which decreased to 4.6% after stabilizers were placed and 0.8% with a wired stabilizer and PDS sutures. Results were excellent in 78.5%, good in 13.1%, fair in 4.7% and failed in 3.7% after more than 1 year post bar removal. Conclusion: The minimally invasive technique has evolved into an effective method of pectus excavatum repair. Modifications of the technique have reduced complications. Long-term results continue to be excellent.