Surgical correction of pectus excavatum using a retrosternal bar.

Pectus excavatum is a progressive congenital deformity for which surgical correction is an established procedure. The method of correction using a stainless steel retrosternal bar to maintain the sternum elevated is, in our experience, the most successful procedure. Successful surgical correction usually requires resection of all deformed costal cartilages with transverse osteotomy of the anterior table of the sternum and internal fixation using a bar anterior to the rib cage but behind the sternum. In the last 13 years 118 patients with this deformity have been evaluated and 72 patients have been surgically corrected by the described procedure. Of these 72 patients, 65 (90 percent) have had excellent or good cosmetic and functional results. The best results were obtained when the child was operated on between the ages of 6 and 10 years, the poorest results in those operated on under the age of 3 or over the age of 20. For a satisfactory result the bar must be left in for at least six months; the best results were obtained in those patients in whom the bar was left in for at least one year. No serious complications have followed the use of this technique.     

Modified Ravitch procedure: using a pectus bar for posttraumatic pectus excavatum

Guidelines for surgical management of posttraumatic pectus excavatum have not been established due to the variable clinical manifestations and limited number of cases. A 34-year-old man who was involved in a truck-mixer vehicle crash 6 months previously complained of a depressed anterior chest wall deformity. The patient had successfully undergone subperichondral resection, sternal osteotomy, and pectus bar insertion placed under the depressed sternum, followed by bar rotation for elevation of the chest wall. This case illustrates that a modified Ravitch procedure, using a pectus bar, may be an alternative for posttraumatic pectus excavatum.     

Anesthetic management for the correction of pectus excavatum using pectus bar under video-assistance

We report anesthetic management for a child undergoing Nuss operation, a minimally invasive operation which requires neither cartilage incision nor its resection for correction of pectus excavatum. The patient was a 7-year-old boy with the funnel index 5 and the mediastinal shift to the left. General anesthesia with endotracheal intubation was induced and maintained with nitrous oxide, sevoflurane and fentanyl. Thoracic epidural anesthesia was used with 0.125% bupivacaine to supplement analgesia. When the curved bar was passed under the sternum with the aid of an endoscope, sinus tachycardia occurred and continued for 5 minutes but subsided without medication. Otherwise operative course was uneventful with negligible blood loss. After surgery, the patient was kept at bed rest for 2 days, receiving epidural patient-controlled analgesia combined with sedation with midazolam with good results. He was allowed to sit 3 days, to walk 5 days and discharged 10 days postoperatively.     

Experience with a simple technique for pectus bar removal

BackgroundThere have been numerous reports of techniques used for pectus bar removal after correction of pectus excavatum. We use 2 operating tables positioned perpendicular to each other in a T-shaped configuration with the patients thorax circumferentially exposed so the bar is removed in 1 motion without bending the bar. In this study, we report the results of this procedure.MethodsA retrospective chart review of patients undergoing bar removal after repair of pectus excavatum at our institution from August 2000 to March 2010 was performed.ResultsThere were 230 patients with a mean age of 16.7 years (range, 7.8-25.3 years) at bar removal. Mean operative time for bar removal was 28.6 minutes, and average estimated blood loss (EBL) was 9.5 mL (range, 5-400 mL). One patient demonstrated significant hemorrhage from the bar tract after bar removal, which was controlled with circumferential compression wrap. Calcification was noted in 11 patients, and chondroma, in 8 patients. Wound infection after bar removal occurred in 3% of patients. No patient required the bar to be bent into a straight configuration for removal.ConclusionsRemoval of pectus bars using this 2-table T-configuration technique is safe, is time efficient, and obviates the need for bending the bar.     

Life-threatening aortic hemorrhage during pectus bar removal

This report presents an unusual case of late, aortic hemorrhage that occurred during the removal of the stabilizing bar 3 years after a Nuss operation. The primary reason for this complication was a rotation of the sternum bar, which caused chronic damage to the aorta and development of an aortomediastinal fistula. Cardiopulmonary bypass and implantation of an aortic prosthesis were required for successful treatment of this complication.     

Bone-cartilage proportion in deformed ribs of male pectus excavatum patients

This study verifies the hypothesis that bone/cartilage proportion in deformed ribs of male pectus excavatum patients varies according to their ages. Anatomical evaluation of the thoraces was performed for 79 male pectus excavatum patients, referring to their three-dimensional computer-tomographic images. The patients were divided into Child Group (5–9 years old: n?=?35); Adolescent Group (12–15 years old: n?=?15) and Adult Group (18+ years old: n?=?29). For each patient, the most concave point of the sternum was identified and the pair of ribs closest to the point were defined as Key Ribs. On each Key Rib, the most ventral point was defined as Prominent Point (PP); the junction between the bone and cartilage was defined as Costo-Chondral Junction (CCJ). The distances of these points from the spine were defined as Distance of Prominent Point (DPP) and Distance of Costo-Chondral Junction (DCCJ), respectively. The horizontal length of the Key Rib was defined as Rib Length (RL). Inter- and intra-group comparisons were performed for DPP/RL and DCCJ/RL. Inter-Group Comparison: DCCJ/RL is significantly smaller and DPP/RL is significantly greater in Adult Group than in Child Group, meaning CCJs shift medially and PPs shift laterally as patients get older. Intra-Group Comparison: In Child Group, DCCJ/RL is significantly greater than DPP/RL, meaning CCJs exist lateral to PPs. Contrarily, in Adult Group, DCCJ/RL is significantly smaller than DPP/RL, meaning CCJs exists medial to PPs. Bone/cartilage proportion in the concave part of the chest shifts according to patients’ ages. To perform the Nuss procedure effectively, this age-related anatomical change must be taken into consideration.     

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.     

Evaluation of pectus bar position and osseous bone formation

Purpose

Minimally invasive repair has become a popular approach for pectus excavatum (PE). The bar is secured to the thoracic wall and left for approximately 2 years. The authors have noticed an intense bone formation (BF) around some of these bars at removal. A review of children undergoing bar removal was performed to better understand this BF in relation to bar placement.

Methods

A retrospective review of children undergoing bar removal after PE repair since January 1998 was performed. Chart review included age at bar insertion and removal, bar insertion position (subcutaneous [SC] v submuscular [SM]), BF on Chest x-ray and at bar removal, operating time, and estimated blood loss (EBL).

Results

Thirty-six patients underwent bar removal during the study period (16 SC and 20 SM). Chest x-ray evaluation was possible in 27 patients (16 SM, 11 SC). No difference existed for length of time the bar was in place or age at insertion/removal between groups. EBL was higher in the SM (18.3 v 8.8 mL, not significant). BF was seen radiographically in 15 SM and 3 SC patients (P < .001). BF was encountered at removal in 19 SM patients and a single SC patient (P < .001). Operating time was statistically longer (P < .01) for the SM group (30.2 v 15.6 min).

Conclusions

Bar position during repair of PE is important. SM positioning virtually always results in BF with increased EBL and statistically longer operating time at removal. Careful placement of the bar in the SC position without violating the fascia should be used to avoid these undesirable effects.     

Erosion of the Nuss bar into the internal mammary artery 4 months after minimally invasive repair of pectus excavatum

The minimally invasive repair of pectus excavatum has become increasingly popular. Life-threatening complications have included bleeding and cardiac perforation. There have been a number of delayed cases of bleeding, many of which never demonstrated a clear source. We present a case of a delayed acute bleed from the Nuss bar eroding into the internal mammary artery 4 months after bar placement.     

The measurement and designation of the pectus bar by computed tomography

Purpose

The length of the bar used for the Nuss procedure is typically determined by measuring the distance between the 2 midaxillary lines and subtracting 2.5 cm. However, this may not be accurate for all patients. Measurements of the chest using computed tomography (CT) were developed for better determination of bar length.

Methods

Seventy-five patients underwent the Nuss procedure between 2005 and 2008. The length and curve of the pectus bar were determined using both the traditional method (TM) and CT.

Results

Twelve patients (16%) had length differences (LD) with the methods. The LD and non-LD patients were 18.8 ± 2.4 and 11.3 ± 0.6 years old, respectively (P = .005). The proportion of females in the groups was 58.3% (7/12) and 28.6% (18/63), respectively (P = .046). The TM gave a longer bar estimation in all but one patient with a high sternal angulation. Slight bar protrusion was noted in 3 of the 12 patients with LD using TM and 0 of the 9 patients using CT.

Conclusions

Computed tomography measurement is a precise means for determining length, especially in older patients, females with developed breasts, or patients with high sternal angulation. It also allows for better curvature design, preventing multiple intraoperative adjustments.     

Removal of pectus bar fixed with absorbable vsmetallic stabilizers

Background/Purpose

The removal of a pectus bar fixed with a metallic stabilizer can be time consuming and tedious, because in some cases, fibrous or new bone tissue covers the metallic devices. Our study aims to evaluate bar removal in 2 groups of patients with metallic and absorbable stabilizers, respectively.

Methods

A total of 162 patients underwent mini-invasive repair of pectus excavatum. In all the cases, the bar was stabilized with at least 1 stabilizer on the left side. We used both metallic and absorbable stabilizers. Absorbable stabilizers were preferred when they were available in the market. The bar was removed in 30 patients. We compared removal of the bar in 17 absorbable stabilizers with those bars fixed with 18 metallic stabilizers. Length of incision, operative time, postoperative pain, and complications were studied.

Results

No differences between metallic and absorbable stabilizers were found in terms of postoperative pain and complications. However, removal of the bar fixed with an absorbable stabilizer required a significantly smaller incision and shorter operative time.

Conclusions

Removal of the pectus bar fixed with an absorbable stabilizer was simpler and faster.     

Intra-abdominal pectus bar migration – a rare clinical entity: case report

We present the case of a 20-year-old male who underwent successful surgical correction of pectus excavatum with the Highly Modified Ravitch Repair (HMRR). At 29 months the attempted operative removal of the Ravitch bar was unsuccessful despite the impression of adequate bar location on chest x-ray. Subsequent imaging with computed tomography was unclear in determining whether the bar was supra or infra-diaphragmatic due to the tissue distortion subsequent to initial surgery. Video assisted thoracoscopic surgery (VATS) successfully retrieved the bar and revealed that it was not in the thorax, but had migrated to the intra-abdominal bare area of the liver, with no evidence of associated diaphragmatic defect or hernia. Intra-abdominal pectus bar migration is a rare clinical entity, and safe removal can be facilitated by the use of the VATS technique.     

Minimally invasive bar repair for 'redo' correction of pectus excavatum

Background/Purpose: A small percentage of patients who have undergone traditional, [ldquo ]Ravitch-type[rdquo ] pectus excavatum repair present with unsatisfactory results and require a second procedure for correction. Reoperative open surgery for pectus excavatum has been associated with extensive dissection and substantial blood loss. The minimally invasive (MIS) bar repair for the correction of pectus excavatum has been gaining acceptance. This study evaluates the authors results with patients who have undergone the MIS bar repair for redo correction of their pectus excavatum. Methods: A retrospective chart review of all patients undergoing MIS bar repair between December 1997 and August 2001 was performed. Information about demographics, deformity, operative course, complications, and early outcome was recorded. Results: Ninety-two patients underwent MIS repair during this period. Ten patients had redo MIS bar repair for unsatisfactory prior open correction. Operating time was 52 minutes for standard patients and 70 minutes for the redo patients (P [lt ] .001). Blood loss and postoperative hospitalization were similar between groups. Conclusion: The minimally invasive pectus repair can be performed safely with minimal blood loss and short operating time in patients who have undergone prior unsatisfactory open repair of pectus excavatum and can be an alternative approach to reoperative open repair in these patients. J Pediatr Surg 37:1090-1092.     

Mechanism of bar displacement and corresponding bar fixation techniques in minimally invasive repair of pectus excavatum

Purpose

Bar displacement is a major complication in repair of pectus excavatum with the Nuss technique. Mechanisms of bar displacement have been elucidated by case-by-case analysis, and specific bar fixation techniques have been developed to deal with each mechanism. The efficacy of our bar fixation techniques is appraised.

Methods

Data from 725 consecutive patients between 1999 and 2006 who were repaired with our modifications to the Nuss procedure were retrospectively analyzed.

Results

The mechanism of bar displacement consisted of one or a combination of the following types: type 1, “bar flipping”—rotation of the bar along the axis of hinge; type 2, “lateral sliding”—horizontal slipping of the bar to one side in asymmetric pectus excavatum; and type 3, “hinge-point disruption”—a dorsal shift of the bar owing to tearing of the supporting intercostal musculature. Specific bar fixation techniques have been tailored to compensate for potential mechanisms of bar displacement according to pectus morphology: multipoint pericostal bar fixation (MPF) (n = 496) for type 1 displacement; incorporation of a stabilizer on the depressed side (n = 169) for type 2 displacement; and hinge point reinforcement and the crane technique (n = 122) for type 3 displacement. The bar displacement rate was decreased with our mechanism-based approach (4.6% before MPF vs 1.8% after MPF, P = .045). In addition, the major complication rates (6.8% before MPF vs 2.0% after MPF, P = .001) and reoperation rates (5.5% before MPF vs 1.6% after MPF, P = .019) decreased.

Conclusions

Mechanism-based bar fixation techniques, especially multipoint pericostal wire fixation, seems to be effective in preventing bar displacement following pectus excavatum repair.