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.     

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.     

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.     

Technical considerations in the surgical management of pectus excavatum and carinatum

During the past 25 years, 650 operations have been performed on 608 patients for anatomically significant pectus excavatum or carinatum deformities of the anterior chest wall. There were no deaths in this series, and serious complications were very rare.We conclude that repair of pectus excavatum and carinatum deformities should include the following operative steps: (1) adequate mobilization of the sternum and correction of its abnormal angulation by transverse osteotomy; (2) adequate bilateral removal of the involved costal cartilage; and (3) securing the corrected position of the sternum with the patient's own living tissue, retaining its blood supply and using it as an internal support.Using these principles, new surgical procedures were developed for the correction of: symmetrical pectus excavatum, asymmetrical pectus excavatum, pectus carinatum with xiphoid angulation, pectus carinatum without xiphoid angulation, asymmetrical pectus carinatum, chondromanubrial prominence with chondrogladiolar depression, and recurrent pectus excavatum.We recommend surgical correction for patients in whom the deformity is significant and no contraindication exists. The ill effects of this condition should not be underestimated.     

Nuss miniinvasive procedure for pectus excavatum in adolescents and adults

Pectus excavatum is a congenital chest wall deformity with depression of the sternum and adjacent costal cartilages. Severe forms of this deformity lead not only to psychosocial deprivation but also limit physical performance due to lung volume reduction and cardiac compression. Open surgical correction using stemochondroplasty represented the gold standard of surgical treatment of pectus excavatum. Miniinvasive technique of corrective steel bar insertion was published in 1998. Since then, so called Nuss operation has become widely accepted. Good experience with this type of the pectus excavatum correction have encouraged us to adopt this procedure. We use this technique not only in children and adolescencents but also in adults suffering from depressed anterior chest wall. We present our initial experience with the treatment of nine patients. We describe the benefits and pitfalls of the method which are known to us.     

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.     

An innovative single-stage repair of severe asymmetric pectus excavatum defects using substernal mesh bands

An internally supported technique employing selective subperichondral cartilage resection and wedge sternal osteotomy reinforced with multiple transverse nonabsorbable mesh bands was performed in 52 patients undergoing surgical repair of severe asymmetric pectus excavatum chest wall deformity. The short-term structural and cosmetic results were excellent, the length of hospital stay was short (3.1 days), and complications were few. The long-term results were also excellent at 5 to 161 months (mean, 79 months) after repair. The procedure is well accepted by patients and families as a treatment for the severe variants of this chest wall lesion and as such is recommended as a satisfactory alternative to current techniques.     

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.     

Difficulties and limitations in minimally invasive repair of pectus excavatum--6 years experiences with Nuss technique.

OBJECTIVE: In 1998, Dr Donald Nuss proposed minimally invasive repair of pectus excavatum (MIRPE) which did not require the osteochondrous parts of the anterior chest wall to be resected. The paper aims at presenting the authors' own 6 years of experience in funnel chest repair with MIRPE technique. Also, many technical problems of this method are discussed. MATERIALS AND METHODS: Between 1999 and 2005, 461 patients (99 female and 362 male, aged 3-31 years, mean age 15.2 years) with pectus excavatum were operated with the Nuss technique. All patients were operated-on according to the original operative protocol proposed by Donald Nuss. With growing experience, own modifications were introduced. Insertion of two bars was done in 17.4%, transverse sternotomy in adolescents with rigid anterior chest wall in 7.8%, limited excision of the rib cartilages in 5.9%, and parasternal fixation of the bar to prevent it from rotating in 59.7% of patients. RESULTS: There were no deaths. Intraoperative complications were noted in 19 (4.1%) patients and postoperative ones were observed in 43 (9.3%) patients. The operative time ranged from 25 to 130 min (52 min on average). In 192 (41.6%) patients, an epidural block was used. The hospital stay ranged from 4 to 12 days with the mean of 5.3 days. A redo procedure for the bar rotation was necessary in 13 (2.8%) patients. The support bar has been removed in 260 (56.4%) patients so far. In all the patients, an adequate contour of the anterior chest wall has been maintained. CONCLUSIONS: MIRPE proposed by Nuss has all the features of a minimally invasive procedure and is straightforward. Better clinical results are achievable in patients under 12 years of age with a symmetric deformity. In older patients (over 15 years of age) with a rigid chest or with an asymmetric deformity, additional procedures are required to achieve a comprehensive correction of the deformity. Recent results and forward clinical observations may give proof to establish MIRPE as a method of choice in funnel chest correction.     

Simultaneous pectus and open heart surgery

Various surgical approaches to pectus excavatum repair concomitant with surgery have been recommended. In this article the authors describe their approach to the problem that they applied in 1989 and onward, successfully, in six consecutive patients. The favorable early and long-term results of these cases illustrate that the simultaneous correction of pectus excavatum and the underlying diseases of the ascending aorta, aortic arch, and the heart can be performed successfully even in emergency situations. The technique recommended provides good cosmetic results and a stable chest wall. It is well applicable in patients of adult age.     

Pectus Excavatum Breast and Chest Deformity: Indications for Aesthetic Plastic Surgery Versus Thoracic Surgery in a Multicenter Experience

Background Breast and chest wall disfiguration attributable to a funnel chest is an aesthetically and sometimes functionally debilitating deformity requiring surgical correction. Whereas extensive and combined deformities of the ventral chest wall are classically corrected using a so-called minimally invasive repair of the pectus excavatum, a modified Ravitch repair, or the minimized Erlangen repair, plastic surgeons are mostly challenged with alloplastic implant corrections of mild funnel chests. The authors have introduced an endoscopic method for placement of customized implants to restore the visible and nonfunctionally disturbing deformation of mild funnel chests when only the sternal plate is involved. This study compared these different plastic surgical and thoracic surgical approaches in a multicenter experience to develop a clinical algorithm and to identify those patients not requiring bony correction but rather alloplastic endoscopic implant correction alone. Methods Patients with deformed rib cages and sternal plates were treated with the Erlangen minimally invasive procedure or a modified Ravitch procedure. For deformities involving the sternal bones only, endoscopically assisted minimally invasive implantation of silastic implants was performed. Results Between 1987 and 2003, 599 patients with a pectus excavatum deformity were treated surgically by the authors’ group. Between 1999 and 2003, 515 patients underwent surgery using the Erlangen minimally invasive repair technique at Friedrich–Alexander University–Erlangen. In addition, 84 patients underwent surgery at the Freiburg University Medical Center. In the current series, 79 patients underwent surgery using the modified Ravitch method. The mean patient age was 20.5 years (range, 3–54 years), and the rate of postoperative relapses was 5%. The findings showed that 73% of the patients judged the aesthetic result as excellent to good, and 20% were satisfied. In contrast, only five patients were suitable for soft tissue augmentation only. Two of these patients in the initial period received custom implants presternally via classical transverse skin incisions, whereas three patients were treated with endoscopic customized implant tissue augmentation. Conclusion Whereas with combined deformity of the sternal plate and the rib cage, a modified Ravitch repair yields good results, the endoscopic soft tissue correction with customized implants helps to avoid unsightly scars, allows for safe hemostasis in the dissection pocket, and leads to enhanced patient satisfaction. In the case of major chest wall deformity with orthopedic and functional relevance, a combination of the minimally invasive procedures (e.g., endoscopic correction and Erlangen repair) seems to show both optimized cosmetic results and maximized functionality.     

Improved chest wall fixation for correction of pectus excavatum.

Pectus excavatum, the most common congenital chest wall abnormality, is manifested by deformity of the costal cartilages resulting in a depressed and often rotated sternum. Although there are conflicting data to support and reject the concept that physiologic improvement can be a consequence of surgical repair, correction is frequently indicated for aesthetic improvement alone. The most popular current repair involves resection of abnormal costal cartilages, sternal osteotomy and mobilisation, followed by fixation of the sternum in the corrected position. Improved fixation techniques have evolved, but generally have not employed current concepts of rigid fixation. The correction of pectus excavatum using reconstruction plates incorporates the benefits of rigid fixation, while allowing custom chest wall contouring and sternal reorientation. Reconstruction plate fixation of the sternum should be considered during correction of pectus excavatum in adult and adolescent patients.     

The Nuss Procedure After Breast Augmentation for Female Pectus Excavatum

Pectus excavatum, the most common congenital chest wall malformation, has a higher incidence among men. Since 1987, when Donald Nuss performed his technique for the first time, the minimally invasive approach has become the most widely used technique for treating pectus excavatum. Few reported studies have focused on the repair of female pectus excavatum. Women with pectus excavatum often present with breast asymmetry that may require breast augmentation, either before or after pectus excavatum repair. To the authors’ knowledge, no reports on the Nuss procedure after breast implant surgery have been published. This report describes the case of a 26-year-old woman who underwent minimally invasive repair after breast implant surgery. The authors believe that for women with severe pectus excavatum, the Nuss procedure should be the first choice for surgical correction. Moreover, for breast implant patients, this technique is absolutely feasible without major complications.     

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.     

Repair of pectus excavatum deformities: 30 years of experience with 375 patients

OBJECTIVE: To review the surgical experience with pectus excavatum chest deformities at UCLA Medical Center during a 30-year period. BACKGROUND: Pectus excavatum is a relatively common malformation that is often symptomatic; however, children's physicians often do not refer patients for surgical correction. METHODS: Hospital records from 375 patients who underwent repair of pectus excavatum deformities between 1969 and 1999 were reviewed. Decrease in stamina and endurance during exercise was reported by 67%; 32% had frequent respiratory infections, 8% had chest pain, and 7% had asthma. The mean pectus severity score (width of chest divided by distance between posterior surface of sternum and anterior surface of spine) was 4.65 (normal chest = 2.56). All patients had marked cardiac deviation into the left chest. Repair was performed with subperiosteal resection of the abnormal cartilages, transverse wedge osteotomy of the anterior sternum, and internal support with a steel strut for 6 months. Repair was performed on 177 children before age 11 years; 38 adults with severe symptoms underwent repair. RESULTS: The mean hospital stay was 3.1 days. With a mean follow-up of 12.6 years, all patients with preoperative respiratory symptoms, exercise limitation, and chest pain experienced improvement. Vital capacity increased 11% (mean) within 9 months in 35 patients evaluated. There were no deaths. Complications included hypertrophic scar formation (35), atelectasis (12), pleural effusion (13), recurrent sternal depression (5), and pericarditis (3). More than 97% had a very good or excellent result. CONCLUSION: Pectus excavatum deformities can be repaired with a low rate of complications, a short hospital stay, and excellent long-term physiologic and cosmetic results.     

Satisfaction levels and radiological improvement in patients with chest deformity after reconstructive surgery

Many methods for surgical correction of anterior chest deformities has been described; the modified Ravitch's technique is the most performed. We reviewed the clinical reports of 15 patients who had corrected chest deformity from 1991 to 1999. We compared the photographies, CT images and Haller's pre and postsurgery indexes. The modified Ravitch's technique was performed in 14 cases and the Nuss's technique in one. A postoperative questionnaire was done to know the grade of satisfaction that the patients reported after surgery. Of 15 patients, 14 were male. The mean age at the moment of surgery was 11 year old (range: 4-17). Nine patients (60%) had pectus excavatum and six (40%) pectus carinatum. In all cases, the postsurgery photographies and CT images showed neither chest depression nor protrussion. The mean of Haller's pre and postsurgery indexes changed from 4.75 (range: 2.8-7.7) to 3.12 (range: 2.4-3.7). The grade of satisfaction after surgery was high in the 80% of the patients. In our limited experience, the most of the patients with anterior chest deformities are satisfied with the results of the surgical management.     

A straightforward technique for removal of the substernal bar after the Nuss operation

Pectus excavatum is the most common chest wall deformity seen in the pediatric population. There have been a number of reports describing the operative correction of pectus excavatum, but scant literature is available describing removal of the substernal bar.This report describes a straightforward technique for removal of the substernal bar after the Nuss operation. This technique has been used in more than 110 patients without complications.     

Repair of Pectus Excavatum by Sternal Eversion

Pectus excavatum was repaired by the sternal eversion (turnover) technique in 26 patients over a 7-year period. Vascular supply to the sternal graft was maintained by preservation of one internal mammary vascular pedicle. Good results were obtained in 21 (81%) patients followed for periods ranging from 2 to 76 months (mean, 32 months) postoperatively. Four patients (15%) had fair results; 2 patients with Marfan's syndrome had partial recurrence, as did 1 patient with skin necrosis and 1 with hypertrophic scar. One patient (4%) had a poor early result due to wound infection and distal sternal necrosis requiring reoperation. Other complications were minor: superficial wound seroma in 2 patients and pneumothorax in 1.The sternal eversion technique for repair of pectus excavatum utilizes the concave shape of the sternum when turned over to create a cosmetically acceptable convex anterior chest wall contour. Judicious tailoring of the costal cartilages and shaping of the anterior sternum corrects asymmetrical deformities. The chest wall is very stable after repair. Since no prosthetic struts or pins are used, a second operation for removal is avoided. Preservation of the vascular supply to the sternum should allow normal growth of the anterior chest wall. The results have been sufficiently encouraging for us to recommend sternal eversion as the primary method for repair of pectus excavatum.     

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.     

Antioxidant vitamins C, E and coenzyme Q10 vs Dexamethasone: comparisons of their effects in pulmonary contusion model

Background

Pectus excavatum (PE) is a common chest wall malformation, with surgery being the only method known to correct the defect. Although the Nuss and Ravitch procedures are commonly used, there is no consensus as to whether surgical repair improves pulmonary function. We therefore investigated whether pulmonary function recovers after surgical repair, and if recovery is dependent on the type of procedure or time after surgery.

Methods

Literature searches were performed using PubMed, EMBASE, Health Periodicals Database, and CNKI (Chinese National Knowledge Index) from January 1990 to December 2007. The following keywords were used: pectus excavatum, chest wall deformity, funnel chest, pulmonary function, respiratory, lung function, and pectus severity index. The primary outcome of interest was possible changes in pulmonary function following surgical repair.

Results

Meta-analysis of 23 studies showed that, although there was evidence of statistically significant heterogeneity among studies (Chi-square, 17.11, p?<?0.05), changes in pulmonary functional indices, including forced expiratory volume over 1 s (FEV1), forced vital capacity (FVC), vital capacity (VC), and total lung capacity (TLC), were similar 1 year after the Ravitch and Nuss procedures. Several years after surgery and bar removal, however, the changes in pulmonary functional indices significantly favored the Nuss procedure.

Conclusions

Pulmonary function tends to improve after the surgical correction of pectus excavatum. Although the Nuss procedure was not significantly better 1 year after surgery, long-term postoperative pulmonary function improvement was significantly better after bar removal.