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.     

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 correction of pectus carinatum

Pectus carinatum is an infrequent but eminently correctable chest wall deformity. It is encountered much less frequently than pectus excavatum. In 12 years, from 1973 to 1985, 152 pectus carinatum (16.7%) and 758 pectus excavatum deformities (83.3%) were corrected. It occurs more frequently in boys (119 patients) than girls (33 patients). The majority, 89 cases, were symmetric, while 49 were asymmetric, and 14 were mixed deformities (ipsilateral carinatum, contralateral excavatum). In almost half the patients the deformity was not identified until after the 11th birthday. A family history of chest wall deformities was present in 26%, and of scoliosis in 12%. Associated musculoskeletal abnormalities were identified in 34 patients (scoliosis 23, Poland's syndrome 4, neurofibromatosis 2, Morquio's disease 2, vertebral anomalies 1, hyperlordosis 1, and kyphosis 1). Surgical correction required bilateral resection of the third through seventh costal cartilages in 143 patients, and unilateral resection in nine patients with an isolated abnormality. A single osteotomy was used in 88 patients and a double osteotomy in 53 patients. In 11 cases no osteotomy was required. Mixed deformity with posterior angulation of the sternum was managed by osteotomy and anterior displacement. The remaining cases had sternal osteotomy and fracture of the posterior cortex to correct anterior angulation. The operation was completed with a low complication rate 3.9% (pneumothorax 4, wound infection 1, atelectasis 1, and local tissue necrosis 1). Three patients required revision with additional unilateral lower cartilage resection for persistent malformation of the costal arch. All patients ultimately had a satisfactory result.     

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.     

Surgical treatment of pectus carinatum

Pectus carinatum, just like its sister deformity pectus excavatum, is a condition with an undefined developmental mechanism and debated surgical techniques. Elongation of the costal cartilages and elongation and anterior displacement of the sternum characterize the different varieties of pectus carinatum. Repair of the anomaly involves positional correction as well as the shortening of the sternum and the maintenance of its corrected position by action of the rectus abdominis and pectoralis muscles.     

Reactive pectus carinatum in patients treated for pectus excavatum

Purpose

The Ravitch and minimally invasive Nuss procedures have brought widespread relief to children with pectus excavatum, chest wall deformities, over the last half century. Generally accepted long-term complications of pectus excavatum repair are typically limited to recurrence of the excavatum deformity or persistent pain. This study examines the authors' experience with patients who develop a subsequent carinatum deformity within 1 year of pectus excavatum repair.

Methods

The authors retrospectively assessed the charts of all patients diagnosed as having a carinatum deformity subsequent to treatment for pectus excavatum at a tertiary urban hospital. We noted age at original correction of pectus excavatum, time from original correction to diagnosis of carinatum deformity, age at correction of carinatum deformity, complaints before correction, methods of repair, postoperative complications, and we reviewed relevant radiography.

Results

Three patients who underwent pectus excavatum repair between January 2000 and August 2007 developed a subsequent carinatum deformity. Two patients initially underwent minimally invasive Nuss correction of pectus excavatum; 1 patient underwent the Ravitch procedure. Within 1 year of original correction and despite intraoperative achievement of neutral sternal position, a protruding anterior chest deformity resembling de novo pectus carinatum emerged in each patient; we term this condition reactive pectus carinatum. The mean age of patients undergoing initial pectus excavatum repair was 13 years (range, 11-16 years). The pathophysiology of this reactive lesion is not well understood but is thought to originate from reactive fibroblastic stimulation as a result of sternal manipulation and bar placement. Patients who underwent Nuss correction initially were managed with early bar removal. Two of the patients eventually required surgical resection of the carinatum deformity at a time interval of 3 to 6 years after initial excavatum repair. In one patient, the carinatum deformity resolved spontaneously. Neutral chest position and absence of dyspenic symptoms were achieved in all patients.

Conclusions

Reactive pectus carinatum is functionally encumbering and a poor cosmetic complication of either the Ravitch or minimally invasive Nuss procedures. Our experience with reactive pectus carinatum introduces the importance of postoperative vigilance even in patients without underlying fibroelastic disease. Examination of the chest with attention to the possibility of an emerging carinatum deformity, particularly in the first 6 postoperative months, is paramount. A telephone call to the patient at 3 months may be a useful adjunct to clinic visits. An optimal long-term result may be achieved through a combination of early Nuss bar removal or postpubertal pectus carinatum repair.     

Reconstruction of pectus excavatum with silicone implants.

The pectus excavatum deformity is characterised by a deep depression usually involving the lower one-half to two-thirds of the sternum. The indications for surgery are often aesthetic. Extensive procedures, requiring fracturing and remodelling of the chest wall skeleton are associated with high morbidity and high rate of complications. In this article we describe our renewed experience with reconstruction of mild and moderate pectus excavatum deformities with custom made prefabricated silicone implants. The fabrication of the implant and the surgical technique are described in detail. An excellent aesthetic correction of the deformity was achieved in all of the patients in our series, with high patient satisfaction rate. We conclude that with careful patient selection, artistic implant fabrication and meticulous surgical technique, this approach achieves excellent aesthetic correction with minimal morbidity and a low complication rate and therefore should maintain its place in the armamentarium of surgical techniques for reconstruction of pectus deformities.     

Marlex mesh support for the correction of very severe and recurrent pectus excavatum

A method for the correction of very severe and recurrent pectus excavatum is presented. The technique consists of mobilization of the sternum, transverse osteotomy, parasternal resection of the costal cartilages (modified Ravitch procedure), followed by placement of Marlex mesh behind the sternum and suturing the edge of the Marlex mesh to the peripheral stump of the resected ribs. This method has been used with good results in 6 patients, 2 of them with recurrent deformities.     

Reconstruction of congenital chest wall deformities using solid silicone onlay prostheses

Congenital chest wall deformities include five types: pectus excavatum (funnel chest), pectus carinatum (pigeon breast), Poland's syndrome, defects of sternal fusion, and miscellaneous dysplasias and skeletal disorders. Of these five types, two, pectus excavatum and Poland's syndrome, are defects of the skeletal chest wall. These two specific anomalies comprise the vast majority of congenital defects of the chest wall and, as depression deformities, are readily amenable to surgical correction.     

Surgical repair of pectus carinatum

Pectus carinatum represents a variety of protrusion deformities of the anterior chest wall. Although various non-operative methods of treatment have been employed, surgery has been widely accepted as the only effective method for the correction of pectus carinatum. We evaluate our 14 year single center experience of pectus carinatum correction on 111 patients using a uniform technique of internal stabilization employing stainless steel struts. Operative correction required double bilateral chondrotomy parasternally and at points of transition to normal ribs, followed by detorsion of the sternum, retrosternal mobilization and correction of the everted sternum as well as of the everted and inverted ribs. The mobilized sternum after incomplete wedge osteotomy was finally stabilized by one transternal and two bilateral parasternal metal struts. The corrections were completed with successful repair in 109 patients (98.2%). Major recurrences in 2 patients (1.8%) were corrected while mild recurrence were observed in 3 patients (2.7%).     

Simultaneous open-heart surgery and pectus deformity correction

PURPOSE: Pectus deformities and cardiac problems sometimes require simultaneous surgery. We report our experience of performing this surgery and review the relevant literature. METHODS: We performed simultaneous pectus deformity correction and open-heart surgery in six patients between 1999 and 2006. The pectus deformities were pectus carinatum in one patient and pectus excavatum in five patients. The cardiac problems were coronary artery disease in one patient, an atrioseptal defect (ASD) with a ventricular septal defect (VSD) in one, a VSD in one, mitral valve insufficiency with left atrial dilatation in one, and an ascending aortic aneurysm with aortic valve insufficiency caused by Marfan's syndrome in two. We corrected the pectus deformities using the modified Ravitch's sternoplasty in all patients. First, while the patient was supine, we resected the costal cartilage; then, after completing the cardiac surgery, the sternum was closed and the additional time required for the pectus operation was calculated for each patient. Patients were examined 1, 4, and 6 months postoperatively. RESULTS: The average operation time was 102 min, and there were no major complications. The pectus bars were removed 4-6 months postoperatively. Good cardiac and cosmetic results were achieved in all patients, who were followed up for 5 years. CONCLUSIONS: Concomitant pectus deformity correction and open-heart surgery can be performed safely, eliminating the risks of a second operation in a staged procedure.     

Repair of pectus excavatum and carinatum deformities in 116 adults

OBJECTIVE: To determine the feasibility of surgically correcting pectus excavatum and carinatum deformities in adult patients. SUMMARY BACKGROUND DATA: Although pectus chest deformities are common, many patients progress to adulthood without surgical repair and experience increasing symptoms. There are sparse published data regarding repair of pectus deformities in adults. METHODS: Since 1987, 116 patients over the age of 18 years with pectus excavatum (n = 104) or carinatum (n = 12) deformities underwent correction using a highly modified Ravitch repair, with a temporary internal support bar. The ages ranged from 19 to 53 years (mean 30.1). Eighty-six patients sought repair after reviewing information regarding pectus deformities available on the Internet. Each patient experienced dyspnea with mild exertion and decreased endurance; 84 had chest pain with activity; 75 had palpitations and/or tachycardia. Seven patients underwent repair for symptomatic recurrent deformities. The mean severity score (chest width divided by distance from sternum to spine) was 4.8. The sternal bar was removed from 101 patients 6 months after the repair without complications. RESULTS: Each of the patients with reduced endurance or dyspnea with mild exercise experienced marked improvement within 6 months. Chest discomfort was reduced in 82 of the 84 patients. Complications included pleural effusion (n = 7), pneumothorax (n = 2), pericarditis (n = 2), dislodged sternal bar (n = 3), and mildly hypertrophic scar (n = 12). Mean hospitalization was 2.9 days; mean blood loss was 122 mL. Pain was mild and of short duration (intravenous analgesics were used a mean of 2.1 days). There were no deaths. With a mean follow-up of 4.3 years, 109 of 113 respondents had a very good or excellent result. CONCLUSIONS: Although technically more difficult than in children, pectus deformities may be repaired in adults with low morbidity, short hospital stay, and very 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.     

Surgical management of pectus carinatum: 30 years' experience

Pectus carinatum is an uncommon malformation that is often more symptomatic than the appearance suggests, and one that physicians often do not refer for surgical correction. Hospital records of 90 patients who underwent repair of pectus carinatum deformities between 1970 and 2000 were reviewed. During the same period another 445 patients underwent repair of excavatum deformities. Minimal deformity was observed before the age of 10 years for 81 of 90 patients; only 7 of the 90 underwent repair before age 11 years. All patients were symptomatic; 84 had exertional dyspnea and exercise limitation, 52 had frequent respiratory infections, 24 had asthma, and 38 had chest discomfort. The mean pectus severity score (width of chest divided by the distance between the sternum and spine) was 1.73 (the normal chest is 2.56). The type of repair varied with the type of deformity, consisting of subperiosteal resection of the deformed cartilages, transverse osteotomy of the anterior sternum with insertion of a cartilage wedge, and support with a steel strut for 4 to 6 months in 76 of 90. There were no deaths within 1 year after the repair. Complications included hypertrophic scar (n= 13), wound seroma (n= 5), pleural effusion (n= 3), and pneumothorax (n= 2). The mean blood loss was 78 ml, and the mean hospital stay was 2.6 days. With a mean follow-up of 12.8 years, all patients experienced alleviation of respiratory symptoms and chest discomfort and diminished exercise limitation; 88 of 90 patients experienced a very good to excellent long-term result. One patient required reoperation. Pectus carinatum often causes more severe respiratory symptoms and exercise limitation than is generally recognized. Repair in 90 patients with carinatum deformities has resulted in marked clinical improvement in all patients, with low morbidity and short hospitalization.     

Scoliosis in children with pectus excavatum and pectus carinatum

Between 1974 and 1985, 461 patients with pectus excavatum and 135 patients with pectus carinatum underwent operative repair of their anterior chest wall deformities. Twenty-one percent of patients with anterior chest wall deformity had mild scoliosis by clinical and radiographic examination. The average lateral spinal deformity was 15 degrees (range 6-78 degrees) for pectus excavatum patients and 16 degrees (range 5-57 degrees) for pectus carinatum patients. Eighteen percent of the pectus excavatum patients with scoliosis and 14% of the pectus carinatum patients with scoliosis required therapeutic intervention of bracing and/or arthrodesis.     

Pectus carinatum.

In the mirror of the pertinent literature, we present our experiences gained in 161 operations for pectus carinatum. The Type I (keel chest) deformity is corrected by bilateral resection of the costal cartilages, transverse osteotomy of the sternum, detachment of the xiphoid process, and resection of the lower end of the body of the sternum. The sternum is maintained in its corrected position by utilizing the pulling force of the rectus muscles through the reattached xiphoid and by tacking the pectoralis muscles together in front of the breast bone. Type II (pouter pigeon breast) is handled by double transverse osteotomy, chiseling off the protuberant portion of the strernomanuberial junction, and by supporting the lower sternal body with either the suspended xiphoid process or with Marlex mesh. Limited forms of Type III (asymmetrical or lateral pectus carinatum) are managed with simple resection of the involved cartilages only. If the anomaly is more extensive, bilateral resection of the cartilages and correction of the sternal axis is carried out.     

Coronary revascularization without cardiopulmonary bypass in patients with pectus excavatum.

BACKGROUND: Coronary revascularization in patients with pectus excavatum is technically difficult through a median sternotomy secondary to the posterior displacement of the sternum and the asymmetric angulation that it produces. The role of minimally invasive coronary artery bypass grafting (MIDCABG) in this subset of patients was evaluated. METHODS: In 1998, four patients with pectus excavatum underwent revascularization of the left anterior descending artery without cardiopulmonary bypass through a left anterior minithoracotomy. RESULTS: All patients underwent the procedure without intraoperative complications and postoperative angiography demonstrated adequate graft patency. CONCLUSIONS: The advantages of MIDCABG in patients with pectus excavatum is the superior exposure to the LAD and LIMA and avoidance of a median sternotomy and cardiopulmonary bypass. This procedure is deemed safe and effective in patients with such deformities of the chest wall.     

Repair of pectus excavatum and carinatum in adults

BACKGROUND: There is sparse published information regarding the repair of pectus chest deformities in adults. This report summarizes our clinical experience with the surgical repair of pectus excavatum and carinatum deformities in 25 adults. METHODS: During the past 11 years, 25 patients 20 years of age or older (mean 31) with symptomatic pectus excavatum (23) or carinatum (2) deformities underwent surgical repair using a temporary internal sternal support bar. RESULTS: Each of the patients with decreased stamina and endurance or dyspnea with exercise experienced marked clinical improvement within 4 months postoperation. Exercise-induced asthma was improved in 6 of 7 patients; chest pain was reduced in each of 9 patients. Postoperative complications included pneumothorax (1), keloid (2), and discomfort from sternal bar (2). The sternal bar was removed 7 to 10 months postoperation in 19 patients; there has been no return of preoperative symptoms or recurrent depression in any patient with a mean follow-up of 4.8 years. CONCLUSIONS: For adults who have symptoms and activity limitations related to uncorrected pectus chest deformities, surgical repair can be performed with low morbidity, low cost, minimal limitation in activity, and a high frequency of symptomatic improvement. The operation in adults is more difficult than in children, although the results are similar.     

Etiology of chest wall deformities—a genetic review for the treating physician

Chest wall deformities such as pectus excavatum, pectus carinatum, and cleft sternum can be isolated malformations or dysmorphic features of genetic associations, monogenic disorders, and various numeric and structural chromosomal aberrations. In contrast to the most important syndromes such as Marfan syndrome or Noonan syndrome that can be associated with a chest wall deformity and for which the causative genes are known, etiology of isolated chest wall deformities is still a matter of research. Therefore, an interdisciplinary approach, particularly in patients with additional symptoms is strongly recommended to choose the best therapeutic approach for each patient and its family.     

Chest wall deformities

BACKGROUND: Pectus deformities and atypical costal anomalies are congenital thoracic wall defects that can cause a marked cosmetic defect with attendant psychological trauma and limited physical performance. PATIENTS AND METHODS: We reviewed 43 patients with chest wall deformities, 24 (55.8%) were pectus excavatum, 13 (30.2%) pectus carinatum and 6 (14%) atypical costal anomalies, in the last sixteen years. There were nine female and 34 (79.1%) male patients. The mean age of the patients was 14.4 years (range, 5 to 23). Scoliosis (13.5%), Poland's syndrome (5.4%), Marfan's syndrome (5.4%), neurofibromatosis (2.7%), atrial septal defect (2.7%) and mitral valve prolapse (13.5%) were associated with pectus deformities. The modified Ravitch's technique was used in pectus cases. Concomitant surgery was performed in two patients with pectus carinatum. RESULTS: The complications of pectus deformity repair were pneumothorax (24.3%), wound infection (8.1%), and local tissue necrosis (2.7%). There was no major recurrence, while minor recurrence rate was 10.8%. There was no mortality. CONCLUSION: Timely surgical procedures for the treatment of pectus deformities result in an excellent cosmetic outcome and improve cardiorespiratory function, providing both physical and psychological benefits.