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.     

Pectus bar repair of pectus excavatum in patients with connective tissue disease

Purpose

Few studies address the surgical correction of pectus excavatum (PE) in patients with connective tissue disease (CTD). We have identified the preoperative characteristics, postoperative complications, and outcomes of patients with CTD undergoing bar repair of PE and compared these outcomes to a control group without CTD.

Methods

A retrospective review of patients undergoing primary repair of PE with a bar procedure from 1997 to 2006 identified 22 patients with CTD. Of those, 20 (90.9%) had their bars removed. We identified 223 patients of similar age without CTD whose bars were removed. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes.

Results

Among those with CTD, the median age at repair was 15.5 years, with a mean pectus index of 4.0 ± 1.4. Three patients (13.6%) experienced bar displacement or upper sternal depression requiring surgical revision. Only 1 patient recurred after bar removal. Rates of bar displacement, upper sternal depression, and recurrence were not statistically different than those in the comparison group.

Conclusions

Patients with CTD benefit from primary bar repair of PE and experience excellent operative outcomes after repair, with complication rates being no different than those found in similarly aged control patients.     

Minimally invasive repair of pectus excavatum in patients with Marfan syndrome and marfanoid features

Purpose

The presence of a pectus excavatum (PE) requiring surgical repair is a major skeletal feature of Marfan syndrome. Marfanoid patients have phenotypic findings but do not meet all diagnostic criteria. We sought to examine the clinical and management differences between Marfan syndrome patients and those who are marfanoid compared with all other patients undergoing minimally invasive PE repair.

Methods

A retrospective institutional review board-approved review was conducted of a prospectively gathered database of all patients who underwent minimally invasive repair of PE. Patients were grouped according to diagnosis of Marfan syndrome (MAR), Marfanoid appearance (OID), and all others (ALL). Patient demographics, preoperative imaging and testing, operative strategy, complications, and postoperative surveys were evaluated. Fisher's Exact test and χ² were applied for statistical analysis.

Results

From June 1987 to September 2008, 1192 patients underwent minimally invasive PE repair (MAR = 33, OID = 212, ALL = 947). There was a significantly higher proportion of females with either MAR or OID who underwent repair (21.5%vs 15.5%, P = .04). The MAR patients had significantly more severe PE determined by computed tomography index (MAR = 8.75, OID = 5.82, ALL = 4.94, P < .0001) and required multiple pectus bars (≥2) to be placed during operation (MAR = 58%, OID = 36%, ALL = 29%, P = .001). There was a trend toward higher wound infection rates in MAR patients (MAR = 6%, OID = 1.4%, ALL = 1.3%, P = .07). The recurrence rate was similar among all groups (MAR = 0%, OID = 2%, ALL = 0.7%, P = .12). Successful outcome from surgeon perspective in either MAR or OID patients was similar to ALL (98%vs 98%, P = .88) and correlated well with patient satisfaction after repair (96%vs 95%, P = .43).

Conclusions

Minimally invasive PE repair is safe in patients with Marfan syndrome or marfanoid features with equally good results. Patients with Marfan syndrome have clinically more severe PE requiring multiple bars for chest repair and may have slightly higher wound infection rates. Patients are satisfied with minimally invasive repair despite a phenotypically more severe chest wall defect.     

改良胸骨上举术治疗漏斗胸

目的探讨改良胸骨上举术治疗漏斗胸以取得操作简便、创伤小、不易复发的手术方法。方法通过松解剑突后牵拉纤维束、矫正胸肋软骨反向关节畸形、胸骨前板V形截骨钢丝固定、斜形切除部分软骨牵拉固定等改进胸骨上举术方法治疗漏斗胸。结果1997年3月以来，治疗8例漏斗胸患儿，其中4例术前心率快者术中解除胸骨压迫后心率立即减缓。术中出血少，术后胸部形态恢复正常，活动能力明显改善。未出现气胸、感染等并发症。随访6个月～1年，未见畸形复发。结论改良胸骨上举术治疗漏斗胸畸形是安全有效的治疗方法。     

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.     

Classification of the dysmorphology of pectus excavatum

Background/Purpose

To describe the dysmorphology of pectus excavatum, the most common congenital chest wall anomaly.

Methods

A stratified sample of 64 patients, representative of a patient population with pectus excavatum of the Children's Hospital of King's Daughters in Norfolk, Va, was described and classified. The sample was stratified by sex to represent a 4:1 male-to-female ratio. The sample was further stratified to represent categories of age (3-10, 11-16, and 17 years and older). Preoperative photos and baseline chest computed tomography scans were examined and categorized according to the chief criteria, including asymmetry/symmetry of the depression, localized vs diffuse morphology, sternal torsion, cause of asymmetric appearance, and the length of the depression.

Results

Useful morphologic distinctions in pectus excavatum are localized depressions vs diffuse depressions, short and long length, symmetry, sternal torsion, slope/position of absolute depth, and unique patterns such as the horns of steer depression.

Conclusions

These classifications simplify the diagnosis of pectus excavatum, aid in corrective surgery, and should improve correlation of phenotype and genotype in future genetic analysis.     

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.     

胸腔镜微创Nuss手术治疗小儿漏斗胸

目的:探讨胸腔镜辅助下漏斗胸矫形术(Nuss手术)的优越性。方法:在胸腔镜辅助下实施漏斗胸矫形术2例。结果:手术过程顺利,手术时间分别为35、30m in,术中出血1~2m l,均恢复顺利,分别于术后第4天和第5天出院,分别随诊1年和10个月无任何并发症出现。结论:Nuss手术具有切口小而隐蔽、手术时间短、出血少、活动早、手术创伤小、无手术瘢痕、矫形效果好等优点,手术方法安全可行,值得推广。     

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.     

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     

Nuss手术矫治复杂漏斗胸

目的 总结Nuss手术治疗复杂漏斗胸的临床经验.方法 2006年9月至2009年10月,采用Nuss于术治疗169例漏斗胸病儿,其中复杂漏斗胸45例,术前常规行胸部CT和心脏B超等检查.有合并症者同时行合并症矫治,极重度和严重不对称漏斗胸分别采用剑突下小切口辅助、个性化钢板、多钢板放置、斜行放置钢板等方法完成矫治.结果 45例均顺利完成手术,平均手术时间54 min,术后4例出现少量气胸或皮下气肿,术后平均住院7天.矫形效果为优秀30例,良好13例,中等2例.所有病儿均获得随访,效果满意.结论 对复杂漏斗胸术前必须完善诊断,并分别和综合采用多种改良的Nuss手术方法,可以达到较好的矫治效果.     

A novel measure for pectus excavatum: the correction index

Objective

The Haller Index (HI), the standard metric for the severity of pectus excavatum, is dependent on width and does not assess the depth of the defect. Therefore, we performed a diagnostic analysis to assess the ability of HI to separate patients with pectus excavatum from healthy controls compared to a novel index.

Methods

After institutional review board approval, computed tomography scans were evaluated from patients who have undergone pectus excavatum repair and controls. The correction index (CI) used the minimum distance between posterior sternum and anterior spine and the maximum distance between anterior spine most anterior portion of the chest. The difference between the two is divided by the latter (×100) to give the percentage of chest depth the defect represents.

Results

There were 220 controls and 252 patients with pectus. Mean HI was 2.35, and the mean CI was 0.92 for the controls. The mean HI was 4.06, and the mean CI was 31.75 in the patients with pectus. In the patients with pectus, HI demonstrated a 47.8% overlap with the controls, while there was no overlap for CI.

Conclusions

The Haller index demonstrates 48% overlap between normal patients and those with pectus excavatum. However, the proposed correction index perfectly separates the normal and diseased populations.     

胸腔镜下Nuss手术治疗小儿漏斗胸38例报告

目的探讨胸腔镜下Nuss手术治疗小儿漏斗胸的疗效和安全性。方法胸腔镜监视下用穿通器在胸骨凹陷最低点水平，两腋中线之间，于胸膜外经胸骨后穿通一遂道，放置支撑板将凹陷胸骨抬起，支撑板两端安装固定器。5例使用进口器械，33例使用国产器械。结果38例均在胸腔镜辅助下顺利完成手术，手术时间40～80min，平均50min。术中出血量5～30ml，平均16ml。36例放置1根钢板支撑，2例放置2根钢板支撑。术后气胸4例，皮下气肿16例，右侧固定器滑脱1例，钢板轻度翻转1例。术后住院7～21d，平均8d。38例随访3～22个月，平均11个月，优36例，良2例，优良率100％。结论胸腔镜辅助下Nuss手术治疗小儿漏斗胸方法安全可靠，疗效好，手术最佳时机3～12岁。     

微创漏斗胸矫形术治疗漏斗胸53例报告

目的探讨微创漏斗胸矫形术（minimally invasive repair of pectus excavatum或Nuss手术）的近期效果。方法53例均在气管插管全麻下手术。双侧胸壁做横行切口，在胸腔镜下将塑形之矫形板由右胸腔经胸骨后穿至左胸腔，翻转矫形板，将胸骨抬起矫正胸骨凹陷，矫形板两侧用固定片固定于肋骨。矫形板放置2年后取出。结果53例均顺利完成手术，手术时间30-240min，平均47min，无术中并发症。术后住院2～14d，平均6．1d。术后疼痛超过1周1例；气胸7例；皮下气肿11例；矫形板旋转3例；单侧固定片滑脱4例；切口感染3例，其中2例被迫将矫形板取出，1例经清创换药伤口愈合。53例随访3-28个月，平均15．6月，优42例，良4例，一般3例，差4例。结论Nuss手术治疗小儿漏斗胸近期效果满意。     

Reducing cardiac injury during minimally invasive repair of pectus excavatum

Minimally invasive repair of pectus excavatum (MIRPE) provides a minimal access approach to correct pectus excavatum deformities. Cardiovascular complications represent a rare but catastrophic complication of this cosmetic operation. We describe a modification to the technique following a case of cardiac puncture.     

双支架Nuss手术治疗青少年漏斗胸

目的 探讨使用双支架治疗青少年大范围漏斗胸微创Nuss手术的适应证、可行性和手术方法及效果.方法 31例中男24例,女7例;年龄14～18岁,平均(15.32±3.12)岁.根据Hallar指数均评价为中到重度,凹陷范围为4个肋间以上.选择胸腔镜辅助Nuss手术两点或者多点双支架支撑固定法手术.结果 均采用双支架在胸腔镜辅助下顺利完成Nuss手术.术后住院5～10天,平均(7.48±1.95)天;随访4个月到5年.术中发生出血2例,支架滑动移位和间断疼痛2个月各1例,均治愈.结论 胸腔镜辅助双支架矫正大面积、不对称漏斗胸的Nuss手术对青少年是一种安全、有效的方法.

Abstract：

Objective To investigate the indication, feasibility and technique of minimally invasive nuss procedure with thoracoscope by using double braces in the treatment of wide-scope pectus excavatum repairing in adolescence. Methods 31 patients including 24 boys and 7 girls, suffered from pectus excavtum were corrected by nuss procedure under thoracoscope.The average age was (15.32 ± 3.89)years (ranged, 14 years and 18 years). All cases were moderate to severe degree according to Hallar index with depression scope of 4 ribs or more. A couple of braces of two-point or multipoint fixation for thoracoscopic-assisted nuss procedure were used. Results The procedure was successfully completed under thoracoscopy in all patients. Double braces were utilized in 27 cases, double are bars were required in 4 cases, and multipoint fixations were in 6 patients. The postoperative hospital stay was 5-11 days [average, ( 7.48 ± 1.95 ) days]. The duration of following up was one month to three years. The perioperative complications included intraoperative hemorrhage in 2 patients, bar invertion with displacement in 1, and interrupted pain for two months in 1. All patients recovered after expectant treatment. Conclusion Nuss procedure with double braces for the correction of a large area of asymmetric pectus excavatum under thoracoscopy is safe and effective technique for adolescence.     

Chest x-ray as a primary modality for preoperative imaging of pectus excavatum

Background

Adolescents with a pectus excavatum mostly present with cosmetic complaints and rarely have significant physical limitations. The preoperative evaluation includes pulmonary functions tests, echocardiography, and chest computed tomography (CT) scan to measure the Haller index. In most patients, the chest CT is performed only to measure the Haller index. The purpose of this study was to evaluate whether indices measured on chest radiograph (CXR) and CT scan are comparable.

Methods

Cases of pectus excavatum treated with the minimally invasive approach in the last year were prospectively collected. In patients for whom a preoperative CXR and CT scan were available, an index was measured using both imaging modalities and compared.

Results

Both preoperative imaging studies were available in 12 patients. The mean Haller indices on CT scan and CXR were 3.97 and 4.08, respectively. The Pearson correlation score between the 2 groups was 0.984.

Conclusions

We propose that the Haller index measured on CT scan be replaced by CXR measurement in asymptomatic patients in whom a chest CT scan is otherwise not necessary. This will limit radiation exposure to children. When in doubt, a CT scan of the chest can be used for the preoperative evaluation.