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Ann Thorac Surg 1996;62:1242-1243
© 1996 The Society of Thoracic Surgeons

Correspondence

Too Large Resection of Pectus Excavatum in Young Patients: A Reason to Worry?

Guglielmo M. Actis Dato, MD, Marco Cavaglià, MD, Alberto Actis Dato, MD, Paolo Centofanti, MD, Michele di Summa, MD

Italian Institution of Cardiac Surgery, Via Genova, 4, 10126 Torino, Italy

To the Editor:

We read with great interest the report by Dr Haller regarding the repair of chest deformity as pectus excavatum (PE) at an early age [1], and we desire to contribute to this subject our experience.

In a recent review of our patients, operated on for PE with one surgical technique (Fig 1Go) during a long period (1958 to 1991), we found results worthy of consideration regarding the indications and the correct timing for operation [2]. The patient population features and clinical operative and postoperative conditions are reported in Table 1Go.



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  		Fig 1. . Surgical technique: a double transverse sternotomy and an incomplete wedge resection of ribs is made. Sternal fragments are easily displaced anteriorly, and the Seagull Wing prosthesis (Sorin Biomedica, Vercelli, Italy) is positioned to sustain the chest wall. A few steel wires complete the sternum stabilization. The prosthesis can be easily removed 12 months later through a small skin incision.

 

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  		Table 1. . Clinical Features and Preoperative and Postoperative Status of 315 Patients Operated on for Pectus Excavatum, 1958 to 1991
 
Surgical correction of PE is often required because of psychological reasons that generally appear during adolescence; for this reason, most of the patients who received operation in our series were between 10 and 30 years old. The mean age was 17.8 ± 5.5 years. Surgical correction at an earlier age can be justified only if respiratory and hemodynamic symptoms are present. In fact, preoperative reduced pulmonary function can improve after the correction of PE only in cases of severe respiratory insufficiency, but in mild or moderate forms there is no improvement [2]. Moreover, during pediatric age, an important tract of the parasternal ribs is constituted by cartilages essential for growth of the chest cage.

In our experience, we never found cases in which surgical correction of PE was mandatory before 7.5 years of age.

Operation-related mortality in patients operated on for PE is virtually absent, but complications such as infections or the need of a redo operation are always present, with a variable incidence in the different experiences. The overall complications after surgical correction of PE in our series was very low (3.7% at a mean follow-up of 15.8 years), but it can be higher depending on the age at operation and the surgical techniques used. We believe unjustified an aesthetic operation when the relation between risk and benefit is unfavorable.

Surgical techniques that require extensive rib cartilage removal or a sternal turnover are more likely to lead to infections in the early postoperative period because of the scarce sternal vascularization, resulting in tissue necrosis. Moreover, recurrence of chest deformity at follow-up can be produced by the retraction of soft tissues surrounding the sternum and by the respiratory movements if a rigid support is not positioned during the consolidation of the bone after surgical resection. We believe that a surgical technique with the use of internal fixation with mild sternal rib mobilization, as proposed in our technique, can be effective in reducing the recurrence of PE.

In conclusion, we agree with the alert of Dr Haller that one should delay primary operative repair and avoid extensive resections. A younger age at operation and a more destructive surgical technique, in our opinion, are expected to produce more problems than satisfaction.

"Primum non nocere" ...

References

  1. Haller JA. Severe chest wall constriction from growth retardation after too extensive and too early (<4 years) pectus excavatum repair: an alert. Ann Thorac Surg 1995;60:1857–8.
  2. Actis Dato GM, De Paulis R, Actis Dato A, et al. Correction of pectus excavatum with a self-retaining Seagull Wing prosthesis. Long-term follow-up. Chest 1995;107:303–6.



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[Abstract] [Full Text] [PDF]

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