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Ann Thorac Surg 1999;67:511-518
© 1999 The Society of Thoracic Surgeons

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Original Articles

A 26-year review of pectus deformity repairs, including simultaneous intracardiac repair

^a Division of Cardiovascular-Thoracic Surgery, Department of Surgery, Children’s Memorial Hospital, Northwestern University Medical School, Chicago, Illinois, USA

Address reprint requests to Dr Backer, Children’s Memorial Hospital, 2300 Children’s Plaza, MC22, Chicago, IL 60614
e-mail: c-backer{at}nwu.edu

Presented at the Forty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 12–14, 1998.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. We reviewed our operative experience and long-term results with repair of pectus excavatum and carinatum deformities through a vertical midline approach, including those cases with simultaneous intracardiac repair.

Methods. From 1972 through 1998, 120 children underwent pectus deformity repair. Operative technique used a vertical midline incision with subperichondrial resection of deformed cartilages and an anterior sternal osteotomy. Thirty-five patients had a temporary metal bar for retrosternal support for 6 months; 85 underwent repair without a bar. Patients and parents were asked to assess the outcome after pectus repair as poor, fair, good, or excellent.

Results. There were 94 male and 26 female patients (mean age, 8.4 years; range, 3 to 21 years). There were 111 cases of pectus excavatum and 9 of pectus carinatum. Fourteen children (11.5%) had an associated congenital heart defect; 9 patients had simultaneous pectus and intracardiac repair. One patient was referred for emergent open heart repair and pectus repair after attempted "Nuss" repair resulted in a perforated right atrium, perforated right ventricle, and partially disrupted tricuspid valve apparatus. There were no deaths and only one significant complication, which required a return to the operating room for bleeding. Morbidity was not higher in patients with simultaneous intracardiac repair. Long-term follow-up was established in 83% of patients. Results were classified as excellent in 64 patients (64%), good in 25 (25%), fair in 8 (8%), and poor in 3 (3%). Thirty (86%) of 35 patients with a sternal bar had excellent results versus 34 (52%) of 65 without a bar (p = 0.004); 97% of patients who underwent repair with a sternal bar classified the result as excellent or good.

Conclusions. Long-term results of pectus excavatum and carinatum repair through a vertical midline approach are excellent. Outcome with a temporary sternal bar is superior to outcome without a bar. Concomitant repair of congenital heart defects and pectus deformity may be performed successfully without additional morbidity.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Pectus excavatum and, less commonly, pectus carinatum are chest wall deformities found in children. There are many surgical series with excellent results that support the routine repair of severe pectus deformities [1–4]. Among surgeons, controversy remains regarding the need for an internal prosthetic sternal support and whether to use it routinely, selectively, or not at all. Also controversial is the ideal age for repair, vertical versus horizontal incision, and the timing of intervention (simultaneous or separate procedures) for patients who have congenital heart defects. There are scattered case reports among the English-language published reports documenting the efficacy of simultaneous repair of pectus deformities and congenital heart defects [5–8]. The techniques range from sternal turnover to a variety of sternal splits, and long-term follow-up is limited [6–9]. We review our experience with pectus deformity repairs over the past 26 years and compare those procedures done without a sternal bar with procedures done with a sternal bar. We add to this review our technique and experience with concomitant repair of pectus deformities and intracardiac lesions, along with their long-term follow up. Other variables examined in our review include medical evaluation before repair, postoperative complications, length of stay, and long-term results, as determined by telephone interviews with parents or the child.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
From January 1972 through August 1998, 120 children underwent repair of a pectus deformity. One hundred eleven pectus excavatum and nine pectus carinatum deformities were repaired. There were 94 male and 26 female patients (mean age, 8.4 years; range, 3 to 21 years). In the past 10 years all children have had preoperative cardiac echocardiographic screening, along with posteroanterior and lateral chest radiography. All patients with pectus excavatum deformities had marked displacement of the heart into the left chest. Indication for operation was primarily the depth of the deformity as assessed with two tongue blades, one lying across the deformity and one perpendicular into the deformity. Patients with a defect between 1.5 and 2.5 cm were observed yearly. Patients with a deformity greater than 2.5 to 3.0 cm were recommended for surgical repair. Other factors taken into account in recommending surgical repair included unwillingness to expose the chest while taking part in athletic or social activities, easy fatigability, and decreased stamina compared with one’s peers. Patients did not routinely have computed tomographic scans or pulmonary function testing.

Operative technique
Operative technique used a limited vertical midline incision directly over the defect (Fig 1a). Use of a vertical (rather than horizontal) incision has been used in our division since the time of Willis Potts [10]. Bilateral skin, pectoralis, and rectus muscle flaps are mobilized (Figs 1b, 1c). Bilateral subperichondrial resection of all deformed cartilages (usually cartilages 3 to 6 or 3 to 7) is then performed with a Freer elevator (Fig 2). The xyphoid is freed from the rectus attachments. The intercostal muscle bundles and perichondrial sheaths are dissected free of the sternum with electrocautery (Fig 3). The cephalad extension of the sternal dissection is usually to a point just inferior to the second cartilage, at the sternal–manubrial junction. For pectus excavatum deformities, an anterior sternal osteotomy is performed with resection of a triangular wedge of sternum just inferior to the last normal costal cartilage, leaving the posterior cortex intact (Fig 4a). The posterior table is fractured and angulated anteriorly, without displacement, to maintain an adequate blood supply (Fig 4b). Two heavy Ticron (Davis & Geck, Manati, PR) sutures are placed to close the wedge after the sternum has been elevated to the desired position (Fig 5a). A substernal bar (V. Mueller Co, Allegiance Healthcare Corp, Deerfield, IL) is now used in all cases of pectus excavatum and is placed at the fourth or fifth intercostal space. The bar extends from the right anterior axillary line to the left anterior axillary line anterior to the ribs and posterior to the sternum (Fig 5a). The ends are bent to conform to the contour of the ribs and are transfixed with absorbable sutures (0 Maxon [Davis & Geck]) to the rib in two sites. In pectus carinatum deformities, a bar is not routinely used, and a posterior sternal osteotomy is performed. After resection of a triangular wedge of the sternum, the sternum is fractured and angulated posteriorly without displacement to the desired position. Reattachment of the perichondrial sheaths to the sternal edges (Fig 5b), followed by reapproximation of the rectus and pectoralis muscles and skin flaps completes the operation (Fig 6). Pliable, closed suction drains (Hemovacs) are left beneath the pectoralis and skin flaps. The drains are removed when the output is 20 to 30 mL/day or less (usually postoperative day 3 or 4). A small chest tube is routinely placed in the right pleural space and removed on postoperative day 2. The sternal bar is removed as an outpatient procedure in the operating room 6 months later, except in children with Marfan’s syndrome, when it is removed 12 months later.

View larger version (72K): [in this window] [in a new window]   Fig 1. (a) Incision is a vertical midline incision directly over the deformity. (b) Skin flaps are elevated bilaterally using skin hooks and electrocautery. (c) Pectoralis muscle flaps are elevated off the cartilages with electrocautery.

View larger version (70K): [in this window] [in a new window]   Fig 2. Subperichondrial resection of deformed cartilages, usually cartilages 3, 4, 5, and 6. (a) Perichondrium is scored with electrocautery. (b) Freer elevator is used to dissect the perichondrium away from the cartilage. (c) The cartilage is sharply divided in the middle to facilitate removal. (d) Towel clip is used to grasp and remove cartilage.

View larger version (63K): [in this window] [in a new window]   Fig 3. The perichondrial sheaths and intercostal muscle bundles are dissected free of the sternum bilaterally.

View larger version (57K): [in this window] [in a new window]   Fig 4. (a) Chisel and hammer are used to resect an anterior triangular wedge of the sternum, preserving the posterior table. (b) The posterior table is fractured and angulated anteriorly without displacement.

View larger version (52K): [in this window] [in a new window]   Fig 5. (a) A substernal bar is fixed to the ribs laterally and to the sternum. The anterior sternal wedge has been closed with two sutures. (b) The perichondrial sheaths are attached to the sternal edges with interrupted sutures.

View larger version (55K): [in this window] [in a new window]   Fig 6. The repair is completed by suturing the pectoralis and rectus abdominis muscle flaps together in the midline. Closed suction drains are placed beneath the pectoralis flaps and beneath the skin flaps.

After 1 year, patients are not routinely followed up; thus, long-term follow-up was established through telephone conversation with the patient or parents, or both. A rating scale similar to that published by Humphreys and Jaretzki [11] was used to judge the surgical outcomes. Results were deemed excellent when the chest contour was perceived as perfectly normal, with no postoperative sequelae (ie, an inconspicuous scar, no persistent pain or clicks, and no bony "bumps"). Results were coded as good if the chest contour was comparable to one’s peers but maybe not quite normal and with only minor postoperative sequelae occurring. Results were regarded as fair if the chest had partially sunk back or remained somewhat protuberant (carinatum defect). Also termed fair were prominent scar, persistent pain or clicks, or bony "bumps." Results were classified as poor if the chest appeared as it had preoperatively or if the patient had had a revision operation. Of note, we did not do any reoperative pectus repairs in any of our own patients or in any patient operated on by other surgeons. One 21-year-old patient had been previously operated on by a plastic surgeon and had had subcutaneous placement of a silicone prosthesis at age 18 years to relieve the cosmetic deformity. This prosthesis was uncomfortable (felt "heavy"), and he had respiratory symptoms with exercise. The prosthesis (19 x 15 x 3 cm, 0.55 kg) was removed; standard pectus repair was performed; and his respiratory symptoms disappeared. One patient underwent reoperation to remove several prominent cartilage "tags," which were noticeable through the skin.

One child was emergently referred when an attempted noninvasive "Nuss" procedure [12] was complicated by perforation of the right atrium and right ventricle by the sternal bar, with both resultant hemorrhage and disruption of the tricuspid valve apparatus. Emergent standard median sternotomy incision was performed, and the right atrial and right ventricular perforations were repaired. Transesophageal echocardiography demonstrated severe tricuspid valve insufficiency secondary to the bar passing through the tricuspid valve, and cardiopulmonary bypass was initiated. The heart was arrested with cardioplegia, and the tricuspid valve, which was partially disrupted anteriorly, was repaired. The sternotomy incision was closed, and standard pectus repair was performed with subperichondrial cartilage resection and substernal bar.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The mean hospital stay was 4 days for isolated pectus repair and 5 days for simultaneous intracardiac repair. There were no early or late deaths. Only 1 patient undergoing repair of an isolated pectus excavatum received a blood transfusion. All patients undergoing cardiopulmonary bypass received a transfusion. Postoperative complications were as follows: atelectasis in 7 patients, pleural effusion in 4, postoperative bleeding in 1, pneumothorax in 2, wound infection in 1, seroma in 6, arrhythmia and atelectasis in 1, sternal bar migration in 2. The 1 patient with bleeding required a return to the operating room for control of a lacerated left internal thoracic artery. The pleural effusions and the pneumothoraces resolved spontaneously without tube thoracostomy. The single wound infection was superficial and responded to oral antibiotics. All seromas required needle aspiration in the office. One sternal bar migrated laterally and had to be removed 1 month postoperatively because of discomfort to the patient. One sternal bar migrated and punctured the skin and required premature urgent removal 5 months postoperatively. Only one complication (left lower lobe atelectasis) occurred in the subgroup of patients who had a congenital heart defect repaired simultaneously.

One hundred of 120 patients were contacted, for a total follow-up of 83%. The results, as shown in Table 2, are grouped into 5-year intervals. Results were classified as excellent or good in 89 patients (89%). Results were described as poor in only 3 patients (3%). Selective use of a sternal support bar began in 1981, and the bar has been routinely used since 1994. These results were compared with those for repairs done without a sternal bar, which have follow-up data since 1972 (Table 3). Of patients undergoing repair with a sternal bar, 30 (86%) of 35 had an excellent outcome versus 34 (52%) of 65 undergoing repair without a sternal bar (p = 0.004, ² analysis). No poor results were reported for patients who had a temporary sternal support, and only 1 patient had a fair result.

Four male patients with Marfan’s syndrome (age range, 8 to 17 years) had repair with a sternal bar. Three had pectus excavatum, and 1 had pectus carinatum. The follow-up period ranges from 3 to 16 years, with excellent outcomes in 2 patients and good outcomes in the other 2. One patient with a good outcome was previously described. The second good outcome was in one of the patients who had migration of his sternal bar, requiring early removal at 1 month.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Excellent or good results from pectus deformity repair were found in 89% of our patients. Use of a retrosternal metal bar for 6 months improved the outcome to excellent or good in 97% of patients. In these patients the sternum healed in a normal contour, with essentially a normal cosmetic appearance. Although ours was a retrospective clinical study, based on patient satisfaction, it shows that the long-term outcome of pectus deformity repair using standard surgical techniques is durable. With the use of a temporary sternal bar, the results were superior to pectus repair done without a sternal bar. In addition to improved long-term outcome, we believe that a sternal bar provides immediate postoperative stabilization and that the patients have less pain. Other studies have documented similar findings with the use of a metal bar [13–15].

Fonkalsrud and colleagues [14] described a 25-year experience with 252 children having repair of pectus deformities. Their technique is essentially identical to ours, except for the use of a transverse skin incision. The substernal bar was used chiefly for patients older than 5 years (136 patients [54%]). They reported no deaths and no significant complications, except for recurrent chest depression in 3 patients (1.2%). More than 98% of patients had improvements in exercise tolerance, endurance, respiratory symptoms, and cosmetic appearance; these improvements were considered excellent results.

The excellent outcomes in the clinically complex children with Marfan’s syndrome further support use of a sternal bar. A previous report recommended delaying the repair of an anterior chest wall deformity in children with Marfan’s syndrome until skeletal maturity was reached [16]. We believe that pectus repair can be done safely with a sternal bar, with a good cosmetic outcome, at a young age, preferably between 4 and 8 years old, before skeletal maturity is reached. One variation of our treatment in these patients is to allow the bar to remain in place a full 12 months.

Abnormal cardiac findings associated with pectus deformities range from benign functional murmurs to single-ventricle physiology. The flow murmurs may be innocent or may possibly be related to compression of the right ventricular outflow tract [17]. When the children with connective tissue disorders were excluded, the incidence of mitral valve prolapse in our study was 5%. In a larger study by Shamberger and Welch [18], mitral valve prolapse was found in 7.7% of 426 patients. The incidence of mitral valve prolapse in the general population is approximately 5% [19]. After repair of the pectus deformity, approximately in 40% of cases the mitral valve prolapse resolves [18]. The incidence of congenital heart disease was 11.6% in our review. However, we believe that this incidence is unusually high and is probably related to our referral pattern, which is that of a pediatric heart surgical center in a large urban setting. A review from Children’s Hospital in Boston documented a 0.17% incidence of pectus deformities in children with congenital heart defects [20]. Probably because this association is uncommon, there are only scattered case reports documenting the efficacy of doing combined repairs. Some surgeons suggest doing staged procedures [1, 20]. Historically, there have been concerns for complications, such as increased bleeding, increased sternal infections, or very extended operative times. We agree that operating time is prolonged, and if the heart defect is very complex and has high associated morbidity, for instance, a Fontan procedure, we will stage the procedure. In particular, for the Fontan operation, it is advantageous to have no compression whatsoever of the highly compressible lateral venous tunnel. Our incidence of complications in 9 patients with simultaneous combined pectus and congenital heart defect repairs was very low and was limited to atelectasis in 1 patient. Combined repairs may be safely accomplished without increased bleeding or sternal wound problems. Furthermore, chest wall instability, which could lead to pulmonary difficulties compounded by the cardiac procedure, is not a problem because we now use a sternal support bar in all cases.

Another problem frequently cited with simultaneous pectus and intracardiac repair is lack of exposure and inability to place a sternal retractor. Various techniques, including sternal turnover or horizontal or vertical sternal splits, have been proposed. Our technique is simple and provides adequate exposure for intracardiac defects. The midline incision provides the same access that cardiac surgeons are familiar with using a median sternotomy. If improved exposure is necessary for repair of the aortic arch or distal pulmonary arteries, we will perform a sternotomy after resecting the deformed cartilages, leaving the intercostal muscle bundles attached to the sternum. The long-term outcomes are excellent and similar to that of isolated pectus repairs. Further benefits are that two operations are performed under a single anesthetic, and only one hospital stay is required. Patients with connective tissue disorders such as Marfan’s syndrome are a special group. There is a definite association of cardiovascular anomalies with thoracic skeletal deformities in these patients [21]. Up to 60% of patients with Marfan’s syndrome may have mitral or aortic regurgitation. Again, if necessary, we believe a combined repair may be done without added morbidity.

The ideal age for pectus repair remains controversial. Our patients ranged in age from 3 to 21 years, with a mean age at operation of 8.4 years. Randolph and associates [22] reported on 50 children undergoing pectus excavatum repair at under 36 months of age and concluded that 90% had excellent results. A potential problem with this young age at repair has been raised independently by Haller [23] and Weber and Kurkchubasche [24]. Weber and Kurkchubasche [24] described 1 patient who had pectus repair at age 4 and required reoperation at age 14 because of restrictive thoracic dystrophy secondary to the extensive and early pectus repair. Haller [23] discussed 3 patients with severe chest wall restriction after pectus repair at ages 2, 3, and 4 years. He recommended not repairing pectus excavatum before 4 years of age, not removing the second cartilage, limiting the number of cartilages removed, and not suturing the perichondrial sheaths behind the sternum [23]. Use of a substernal bar avoids the need for suturing the perichondrial sheaths behind the sternum. We have not seen this complication in the relatively few patients less than 4 years old (6 patients) operated on in our series.

As noted earlier, one of the patients in our series was referred emergently when the right atrium, right ventricle, and tricuspid valve were perforated during an attempted "Nuss" repair [12]. The Nuss technique involves placement of a convex steel bar under the sternum through bilateral thoracic incisions. Cartilage resection is not performed. The steel bar is inserted with the convexity facing posteriorly, and when the bar is turned over, the deformity is "corrected." Average hospital stay was 4.3 days. The bar is left in place for 2 years, at which time remolding of the chest has occurred. Nuss and colleagues [12] reported on follow-up in 30 patients, with results classified as excellent in 22 patients (73%), good in 4 (13%), fair in 2 (7%), and poor in 2 (7%). Obviously it is difficult to compare two different series, but on superficial analysis, our technique using a bar was superior and resulted in excellent or good results in 97% of patients. The risk of cardiac perforation requiring emergent sternotomy and cardiopulmonary bypass needs to be considered in light of the patient emergently referred to our service.

In conclusion, our clinical review documents that there is long-term patient satisfaction with our described standard surgical pectus excavatum and carinatum repair. The technique uses a vertical midline incision with subperichondrial cartilage resection, anterior sternal osteotomy, and placement of a temporary metal bar for retrosternal support. There were no deaths, and the operative morbidity was minimal. The chest wall contour is maintained over time. The metal sternal support bar improves the long-term outcome and should be used routinely. Patients with congenital heart defects can undergo simultaneous cardiac and pectus deformity repair, with no added morbidity and excellent long-term results with regard to chest wall contour.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Haller J.A., Scherer L.R., Turner C.S., Colombani P.M. Evolving management of pectus excavatum based on a single institutional experience of 664 patients. Ann Surg 1989;209:578-583.[Medline]
2. Shamberger R.C., Welch K.J. Surgical repair of pectus excavatum. J Pediatr Surg 1988;23:615-622.[Medline]
3. Shamberger R.C., Welch K.J. Surgical repair of pectus carinatum. J Pediatr Surg 1987;22:48-53.[Medline]
4. Golladay E.S., Wagner C.W. Pectus excavatum: a 15-year perspective. South Med J 1991;84:1099-1102.[Medline]
5. DeLeon M.M., Magliato K.E., Roughneen P.T., et al. Simultaneous repair of pectus excavatum and congenital heart disease. Ann Thorac Surg 1997;64:557-559.[Abstract/Free Full Text]
6. Doty D.B., Hawkins J.A. A Turnover operation for pectus excavatum at the time of correction of intracardiac defects. J Thorac Cardiovasc Surg 1983;86:787-790.[Abstract]
7. Jones W.G., Hoffman L., Devereux R.B., Isom O.W., Gold J.P. Staged approach to combined repair of pectus excavatum and lesions of the heart. Ann Thorac Surg 1994;57:212-214.[Abstract]
8. Tschirkov A., Natschev G., Mishev B., Savoya A. An easy and safe approach for simultaneous repair of severe pectus excavatum and the underlying lesions of the heart and aorta. J Thorac Cardiovasc Surg 1989;98:305-306.[Medline]
9. Karl T.R. A technique for concurrent repair of pectus excavatum and intracardiac defects. J Cardiac Surg 1988;3:487-489.[Medline]
10. Potts W.J. The surgeon and the child. Philadelphia: WB Saunders, 1959:78-81.
11. Humphreys G.H., Jaretzki A. Pectus excavatum: late results with and without operation. J Thorac Cardiovasc Surg 1980;80:686-695.[Abstract]
12. Nuss D., Kelly R.E., Jr, Croitoru D.P., Katz M.E. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-552.[Medline]
13. Ravitch M.M. The operative treatment of pectus excavatum. Ann Surg 1949;129:429-444.[Medline]
14. Fonkalsrud E.W., Salman T., Guo W., Gregg J.P. Repair of pectus deformities with sternal support. J Thorac Cardiovasc Surg 1994;107:37-42.[Abstract/Free Full Text]
15. Golladay E.S., Wagner C.W. Pectus excavatum: a 15-year perspective. South Med J 1991;84:1099-1102.
16. Arn P.H., Scherer L.R., Haller J.A., Pyeritz R.E. Outcome of pectus excavatum in patients with Marfan syndrome and in the general population. J Pediatr 1989;115:954-958.[Medline]
17. Guller B., Hable K. Cardiac finding in pectus excavatum in children: review and differential diagnosis. Chest 1974;66:165-171.[Abstract/Free Full Text]
18. Shamberger R.C., Welch K.J. Mitral valve prolapse associated with pectus excavatum. J Pediatr 1987;111:404-406.[Medline]
19. Kirklin J.W., Barratt-Boyes B.G. Mitral valve disease with or without tricuspid valve disease. In: Kirklin J.W., Barratt-Boyes B.G., eds. Cardiac surgery, 2nd ed. New York: Churchill Livingstone, 1993:425-489.
20. Shamberger R.C., Welch K.J., Castaneda A.R., Keune J.F., Fyler D.C. Anterior chest wall deformities and congenital heart disease. J Thorac Cardiovasc Surg 1988;96:427-432.[Abstract]
21. Pyeritz R.E., McKusick V.A. The Marfan syndrome: diagnosis and management. N Engl J Med 1979;300:772-777.[Medline]
22. Randolph J.G., Tunell W.P., Morton D., Jr Repair of pectus excavatum in children under 3 years of age: a twelve-year experience. Ann Thor Surg 1977;23:364-366.[Abstract]
23. Haller J.A., Jr Severe chest wall constriction from growth retardation after too extensive and too early (<4 years) pectus excavatum repair: an alert [Letter]. Ann Thorac Surg 1995;60:1857-1858.[Free Full Text]
24. Weber T.R., Kurkchubasche A.G. Operative management of asphyxiating thoracic dystrophy after pectus repair. J Pediatr Surg 1998;33:262-265.[Medline]

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