Surgical repair of pectus excavatum

From 1958 to March 1987 we corrected 704 patients with pectus excavatum. The condition occurred more frequently in boys (544 patients) than girls (160 patients). In the majority of patients (86%), the defect was evident at birth or within the first year of life. Musculoskeletal abnormalities were identified in 133 patients (scoliosis, 107; kyphosis, 4; myopathy, 3; Poland's syndrome, 3; Marfan's syndrome, 2; Pierre Robin syndrome, 2; prune belly syndrome, 2; neurofibromatosis, 3; cerebral palsy, 4; tuberous sclerosis, 1; and congenital diaphragmatic hernia, 2). Sixteen patients had associated congenital heart disease. A family history of chest wall deformity was present in 37% of the cases and a history of scoliosis in 11%. Surgical correction was performed using a uniform technique for bilateral subperichondrial resection of the deformed costal cartilages and sternal osteotomy resecting a wedge of the anterior cortex and fracturing the posterior cortex. Anterior displacement was maintained with silk sutures closing the osteotomy defect. In 28 early cases, the sternum was secured by intramedullary fixation with a Steinman pin. All repairs were completed with a low complication rate (4.4%; pneumothorax, 11; wound infection, 5; wound hematoma, 3; wound dehiscence, 5; pneumonia, 3; seroma, 1; hemoptysis, 1; hemopericardium, 1). Six complications were associated with Steinman pin fixation (hemoptysis, seroma, hemopericardium, pneumothorax, 3). Major recurrence occurred in 17 patients (2.7%) and led to revision in 12. Satisfactory long-term results were achieved in the remaining 687 patients, with follow-up ranging from 2 weeks to 27 years. Mean follow-up was 4.3 years.(ABSTRACT TRUNCATED AT 250 WORDS)     

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 treatment of pectus excavatum

In conclusion, the following points are reemphasized: 1) The abnormal (either depressed or protruding) cartilages should always be resected. This resection, especially in pectus excavatum abnormalities, should not be overdone because the highest point that the chest wall and sternum can be elevated to with these types of operations is only the level of the most anterior rib and the thickness of the sternum itself. 2) Marlex mesh is an ideal material to support the sternum in its corrected position. It is strong and holds well until the chest wall solidifies. Also, it is resistant to infection and it may be left in place permanently. The application of different metallic splints, rods, and so on, as well as costal allografts, was found to be absolutely unnecessary. 3) Intercostal strips detached from the sternum may be left in place. Also, the surgeon should not waste time in performing a meticulous "classic" subperichondrial resection of the cartilages and ribs but should just leave enough perichondrium and periosteum behind to ensure the regeneration of the ribs. For the same reason, a segment of the most lateral portion of the cartilage should be left in continuity with the ribs. 4) It is strongly recommended that in excavatum anomalies, one of the pleural cavities should be deliberately opened and wide communication established between the pleural and the retrosternal space; the entire operative area should be drained for a day or two using an intracostal water-sealed catheter. This will make the use of any other subcutaneous or mediastinal drainage devices unnecessary and will ensure appropriate drainage of blood or serum. It is also recommended that the resection of the cartilages should be done on the left side first, where inadvertent entering of the pleura is less likely because of the backing of the pericardium. If it happens, drainage of the right hemithorax is not necessary. Carinatum anomalies are handled with subcutaneous drainage. 5) To confirm appropriate results, the chest should be carefully inspected after closure of the skin, and flaws, if they exist, should be corrected right then. Also, surgical repair of all pectus anomalies, especially excavatum deformities, should be supplemented in due time with an appropriate exercise program. Swimming and weight lifting are especially useful. 6) We found that the age limit imposed on small children by some authors is unnecessary, and as a matter of fact it is preferable to operate on children at an early age, around 2 years, because of commonly existing psychologic problems at a later age. The author advises restraint in operating on individuals past the teenage years unless the deformity is physiologically restricting. 7) The jury is still out regarding procedures using limited exposure and that do not use transverse sternotomy to correct the depressed or elevated sternal axis. 8) The usage of cosmetic procedures, or in other words, operations that do not correct the anomaly of the bony chest wall but use various implants as camouflage, should be restricted to cases of moderate excavatum anomalies in late teenage patients and to adults without cardiorespiratory symptoms.     

Surgical treatment of a pectus excavatum deformity

The results of treatment of 114 patients, suffering pectus excavatum deformity (PED), in 42 of whom Marfan syndrome was diagnosed, were analyzed. Parasternal chondrotomy of a deformed cartilaginous parts of the ribs with subsequent fixation of their sternal ends towards sternum was used for the symmetric correction. The asymmetric PED correction on a convex side was performed similarly and on a concave one a mobilization effect was achieved, using a multiple notches putting on a cartilaginous parts of the deformed ribs. Good result in the treatment of a symmetric PED was achieved in 52 (81.2%) patients and satisfactory one--in 12 (18.7%), and in asymmetric PED--in 31 (62%) and 16 (32%) accordingly, poor result was noted in 3 (6%) patients. A sufficient efficacy of method of the deformity correction was confirmed by the analysis made on the applied surgical treatment results.     

Surgical correction of pectus excavatum and carinatum

The author presents three decades of experience in the management of anterior chest wall deformities. During this period more than 800 operations were performed on patients with pectus excavatum and carinatum. In this series, there was no death and serious complications were rare. The author believes that the principles on which surgical treatment of pectus excavatum should be based are as follows: (1) bilateral removal of the "culprit" costal cartilages, (2) adequate mobilization of the sternum and correction of the sternal positional deformity by transverse osteotomy, (3) stabilizing the corrected position of the sternum with a substernal "hammock" support. Using this technique the author developed new surgical techniques for the correction of different varieties of chest wall deformities: Pectus excavatum, asymmetric pectus excavatum, pectus carinatum with xiphoid angulation, horizontal pectus excavatum, asymmetric pectus carinatum, chondrosternal prominence with chondrogladiolar depression, and recurrent pectus excavatum. The present method applied for correction of pectus excavatum utilizes the above principles and a substernal Marlex mesh support with bilateral muscle coverage. For carinatum repair, the author routinely uses positional correction of the sternum and sternal shortening. Patients who have significant pectus deformities should undergo surgical repair, preferably between one and eight years of age.     

Cardiopulmonary effects of closed repair of pectus excavatum

Background/Purpose: Increasing numbers of patients with pectus excavatum defects are presenting for operative repair. Studies that follow-up with patients after open repair have found a decrease in pulmonary function with some improvement in cardiac output and exercise tolerance; however, these effects have not been examined systematically after closed or Nuss repair of pectus excavatum. This study examined the early postoperative effects of closed repair of pectus on pulmonary function, exercise tolerance, and cardiac function. Methods: Patients were followed up prospectively after initial evaluation for operation. All patients underwent preoperative computed tomography (CT) scan, and pre- and postoperative (3 months) pulmonary function studies, exercise tolerance, and echocardiographic evaluation of cardiac function. Results: Eleven patients underwent evaluation. Preoperative CT index was 4.1 [plusmn] 0.9. Patients reported an improvement in subjective postoperative exercise tolerance (4.1 [plusmn] 0.7; maximal, + 5). Pulmonary function studies (FVC and vital capacity) were significantly reduced at 3 months postsurgery: change in FVC, [minus ]0.67 [plusmn] 0.92 L and VC, [minus ]0.5 [plusmn] 0.72 L. Similarly, VO₂ max was reduced: preoperative, 35.6 [plusmn] 1.5 versus postoperative, 29.1 [plusmn] 11.9 L/kg/min. Cardiac function was significantly improved postoperation (stroke volume preoperative, 61.6 [plusmn] 25 versus 77.5 [plusmn] 23 mL postoperative). All comparisons had a P value less than .05 by Student's paired t test. Conclusions: These results show that closed repair of pectus excavatum is associated with a subjective improvement in exercise tolerance, which is paralleled by an increase in cardiac function and a decline in pulmonary function. These findings support the use of closed repair of pectus excavatum in patients who complain of subjective shortness of breath; further study is required to delineate the long-term cardiopulmonary implications after closed repair. J Pediatr Surg 38:380-385.     

Minimally invasive endoscopic repair of pectus excavatum.

OBJECTIVE: We report our initial 3 years 4 months' single institution experience in 31 consecutive patients with pectus excavatum treated with minimally invasive endoscopic pectus excavatum repair utilizing a modification of the 'Nuss' technique. METHODS: Under general anesthesia, a curved steel bar is individually shaped for each patient to match the ideal chest wall shape and is placed through an endoscopically created retrosternal tunnel between two bilateral midaxillary line 2-cm incisions. The tunnels initially go along the outside of the rib cage, under the pectoral muscles. At the level of the sternum, these tunnels go retrosternal and communicate with each other. The steel bar is passed with the convexity facing posteriorly, within a protective flat silastic drain. Under endoscopic guidance, the curved steel bar is passed through one tunnel, under the sternum, and out the other tunnel. Once positioned, the bar is turned over, thereby correcting the deformity. An epidural catheter provides perioperative pain relief. RESULTS: Minimally invasive endoscopic pectus excavatum repair has been performed on 31 patients (age: range 4.4-31.0 years, median 15.0 years, mean 14.5 years). Median hospital length of stay is 4 days (range 3-10 days, mean 4.6 days). Pneumothorax occurred in five patients requiring tube thoracostomy in three. One patient developed delayed bilateral pleural effusions requiring drainage. Two patients developed evidence of sterile seroma formation at the skin incision several months after minimally invasive repair of pectus excavatum. These seromas resolved with non-interventional conservative medical treatment. No other complications occurred. CONCLUSION: The minimally invasive endoscopic pectus repair is safe and effective and currently our procedure of choice for primary pectus excavatum in all ages. Endoscopic visualization facilitates the safe creation of the retrosternal tunnel. Short-term results have been excellent. Further follow-up will be necessary to determine long-term results.     

Surgical correction of pectus excavatum deformity and hypomastia

Female patients occasionally present with major pectus excavatum and hypomastia. The aim of this study was to investigate the clinical outcome of female patients who had combined surgical correction of both deformities. Since 1990, 12 young female patients underwent correction using a modelling sternochondroplasty with osteosynthesis using Borrelly’s slide fastener-handle. After 1 year, the material was removed, and the breast implants were placed in the subpectoral plane. Our investigation was based on functional, morphological, aesthetic and psychological criteria. Despite nonsignificant pulmonary function tests (p < 0.05), we noted a subjective improvement of physical capacity during exercise following pectus excavatum repair. Correction of thorax deformity increased the sternovertebral distance by a mean of 3.2 cm (range 1.5–5.5 cm) thus treating mediastinal compression. As for aesthetic results, all patients were satisfied or very satisfied. The psychological benefit was considered as phenomenal after surgical treatment. Repair of pectus excavatum by sternochondroplasty combined with correction of hypomastia for female patients suffering from a double deformity is possible with only two different operations.     

Surgical correction of pectus excavatum and carinatum.

This paper contains an analysis of the long-term results in 85 patients who had pectus excavatum or carinatum deformities repaired at the North Middlesex Hospital between 1951 and 1977. Seventy-seven patients had operations for correction of pectus excavatum and eight for pectus carinatum. A variety of surgical techniques was used. In the excavatum deformities the best results were obtained by the extensive resection of all deformed cartilages, the correction of the sternal deformity by a simple transverse wedge osteotomy, and by stabilising the chest with a stainless steel plate. For pectus carinatum, the involved cartilages were resected and an osteotomy of the sternum was performed. We preferred in most cases to stabilise the chest wall with a metal strut in this deformity as well. The best cosmetic results were achieved by the use of a stainless steel plate passed beneath the sternum and left for not more than six months.     

Surgical repair of pectus excavatum in young adults using the DualMesh 2-mm Gore-Tex

We present our surgical technique and clinical outcome of the surgical repair of pectus excavatum using the DualMesh 2-mm Gore-Tex, in 21 young adults. The main symptom was the exercise limitation in 15 patients. There were no postoperative complications and excellent cosmetic results were achieved. We can confirm that DualMesh seems to be the ideal material to support the sternum in its corrected position. Its advantages are the strength to stabilize well the chest wall, the quality to be detached easily from the pericardial surface even in the case of urgent median sternotomy due to its particular surfaces, the resistance to infection and the ability to be left in place permanently.     

Open repair of pectus excavatum with minimal cartilage resection

OBJECTIVE: To summarize the clinical experience with a new open repair for pectus excavatum (PE), with minimal cartilage resection. SUMMARY BACKGROUND DATA: A wide variety of modified techniques of the Ravitch repair for PE have been used over the past 5 decades, with the complications and results being inconsistent. Extensive subperiosteal costal cartilage resection and perichondrial sheath detachment from the sternum may not be necessary for optimal repair. METHODS: During a 12-month period, 75 consecutive patients with symptomatic PE underwent open repair using a new less invasive technique. After exposing the deformed costal cartilages, a short chip was resected medially adjacent to the sternum and laterally at the level where the chest had a near normal contour, allowing the cartilage to be elevated to the desired level with minimal force. A transverse anterior sternal osteotomy was used on most patients. A substernal support strut was used for 66 patients; the strut was placed anterior to the sternum in 9 patients under age 12 and over age 40 years. The strut was routinely removed within 6 months. RESULTS: With a mean follow-up of 8.2 months, all but 1 patient regarded the results as very good or excellent. Mean operating time was 174 minutes; mean hospitalization was 2.7 days. There were no major complications or deaths. CONCLUSIONS: The open repair using minimal cartilage resection is effective for all variations of PE in patients of all ages, uses short operating time, provides a stable early postoperative chest wall, causes only mild postoperative pain, and produces good physiologic and cosmetic results.