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Ann Thorac Surg 1999;67:821-824
© 1999 The Society of Thoracic Surgeons

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Original Articles

Long-term observation in 68 patients operated on for pectus excavatum: surgical repair of funnel chest

Janusz Kowalewski, MD^a, Marian Brocki, PhD^a, Krystian Zolyski, PhD^b

^a First Surgical Department, Military Medical Academy, Lodz, Poland
^b Department of Orthopedic and Trauma Surgery, Military Medical Academy, Lodz, Poland

Accepted for publication August 24, 1998.

Address reprint requests to Dr Kowalewski, SK WAM, ul Zeromskiego 113, 90-549 Lodz, Poland
e-mail: wam1klch{at}polbox.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Recurrence after correction of pectus excavatum may sometimes occur, but its origin is not clear. The type of deformity, surgical technique, and patient lifestyle after operation can all affect the final shape of the thorax. The purpose of the present study was to compare the short-, medium-, and long-term cosmetic results of funnel chest repair.

Methods. Sixty-eight patients (mean age, 12.1 ± 5.4 years; 48 male) were operated on for pectus excavatum using the same surgical technique: subperichondrial resection of the abnormal costal cartilages and stabilization of the elevated anterior chest wall with Kirschner’s wires. The patients were followed up every year (1 to 10 years) after operation, and the anterior chest wall contour was checked by physical examination and x-ray film.

Results. Excellent to good cosmetic results 1 year after operation were achieved in 66 patients (97.1%). During the later follow-up period, a mild or moderate degree of recurrent sternal depression was noted in 6 patients (8.8%), teenagers only, 3 to 9 years after primary repair.

Conclusions. Our technique for correction of pectus excavatum yields good short-term cosmetic results. Late recurrence of the deformity occurs during pubertal growth and does not appear to depend on surgical technique or length of follow-up.

	Introduction

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Pectus excavatum is a growth abnormality of the chest that is disturbing for many children and young adults [1–4]. Surgical repair of the deformity may be indicated at different ages and for different reasons: to relieve cosmetic and psychological problems [3–5] and cardiorespiratory difficulties [6] and to promote normal growth of the thorax [2].

A wide variety of surgical techniques for correction of pectus excavatum have been described, usually with good short-term cosmetic and functional results [5–12]. However, it is necessary to follow up a patient (especially a child) for many years after operation because other late factors (eg, lack of physical activity, pubertal growth spurt, presence of postural abnormalities [scoliosis, rounded shoulders]) may diminish the good cosmetic result obtained at operation [2, 3, 13–15]. The purpose of the present study was to compare the short-, medium-, and long-term results of surgical repair in 68 patients with pectus excavatum.

	Material and methods

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Patients
Between 1986 and 1996, 68 patients underwent operation for pectus excavatum. Mean age at operation was 12.1 ± 5.4 (range, 5 to 33 years); 36 patients (52.9%) were younger than 12 years. Of the 68 patients, 48 were male (70.6%).

Before operation and at follow-up, a subjective assessment of psychological state and self-evaluation regarding cosmetic appearance and exercise tolerance were recorded, physical examination was performed, chest x-ray film was obtained, and an electrocardiogram was recorded. To assess the severity of the deformity, a pectus index (PI) was used: the distance between the vertebral body and the sternum at the angle of Louis divided by the shortest sternovertebral distance. The distances were measured on the lateral chest x-ray films. The deformity was found to be mild if the PI was less than 1.2, moderate if 1.2 to 1.3, and severe if greater than 1.3.

Operative technique
The operation was performed under general anesthesia. Since 1993 (22 patients), before induction of anesthesia a catheter was routinely placed by the anesthesiologist at the T4 to T6 level for postoperative continuous thoracic epidural analgesia. Since 1990 (33 patients), a wide-spectrum antibiotic (cephalosporine) was administrated prophylactically.

Access to the sternum was achieved through a transverse skin incision, usually centered over the deepest part of the deformity. Then, the skin flaps were elevated to expose the whole concavity. The fragments of the abnormal cartilages (0.5 to 1.0 cm long) were excised subperichondrially and bilaterally (usually ribs 4 to 7). The pectoralis muscles were not reflected as a whole but only incised over the place of the cartilage excision. The sternum was cut transversally above the deformity and longitudinally across it. The costal cartilage resection allowed easier displacement of the anterior chest wall, which was elevated and stabilized in the proper position with three or four Kirschner’s wires. The wires were passed through the sternum and were attached laterally to the ribs with absorbable sutures. Two catheters (one of a soft plastic in the substernal space and a small one of silicone elastomer beneath the skin flaps) were placed and connected with suction. The incisions in the pectoralis muscles were sutured, and the skin was closed with interrupted sutures. The operations were generally performed by the same surgical team.

The patients were asked to avoid physical contact activity for 2 months, but after this period of time they were encouraged to participate in sports and games.

The struts were removed 12 to 15 months after the primary repair. The patients were followed up at the outpatient department every year by the same surgeon (J.K.). Physical examination was performed, and the electrocardiogram and chest x-ray film (if necessary) were obtained. In addition, body surface area (BSA) was calculated to indicate the degree of pubertal growth.

The results were judged as excellent in patients with normal morphologic features of the chest, unapparent scar, and patient satisfaction; good if a small deformity was still present or the scar was bothersome but the patient was satisfied; and poor if the patient was not satisfied because of residual chest depression.

Statistical analysis
Preoperative and postoperative PIs were compared by a two-tailed t test to identify statistically significant differences. A p value less than 0.05 was considered statistically significant.

	Results

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Preoperative clinical characteristics of the patients are presented in Table 1. Twenty-one patients (30.9%) were asymptomatic; 43 patients (63.2%) were psychologically disturbed by the abnormal shape of the chest (feelings of shame, persistent efforts to hide the deformity); 37 patients (54.4%) had exercise limitations; 24 patients (35.3%) had electrocardiographic changes (incomplete right bundle branch block, right-axis deviation).

Short-term follow-up (between 12 and 15 months after primary operation) included all patients. Psychological disturbances were reported in 2 patients (2.9%) and exercise limitations in 5 (7.2%). There were no changes in electrocardiographic abnormalities at 1 year after repair. The cosmetic result was excellent in 48 patients (70.6%), good in 19 (27.9%), and poor in 2 (2.9%). The PI was significantly lower after operation (p = 0.0014).

Medium- and long-term follow-up included 60 patients (88.3%). The cosmetic results at each year of follow-up are presented in Table 2. The final follow-up results, obtained in 1997, are presented in Table 3.

Although the patients were still satisfied with the results of the repair, the previous excellent result (noted 1 year after operation) had to be modified to a good result in 4 patients because of mild recurrent sternal depression: a 13-year-old female patient 3 years after repair of severe symmetric diffuse deformity (PI, 1.18; BSA, 6.58%; 'BSA, 6.21%; n = 8); a 13-year-old female patient 6 years after operation for severe symmetric deformity (PI, 1.15; BSA, 6.47%; 'BSA, 6.21%; n = 8); a 14-year-old male patient 5 years after repair of moderate diffuse asymmetric deformity with scoliosis (PI, 1.14; BSA, 8.12%; 'BSA, 7.82%; n = 20); and a 15-year-old female patient 7 years after operation for severe diffuse asymmetric deformity with scoliosis (PI, 1.11; BSA, 10.71%; 'BSA, 10.37%; n = 9).

In 2 patients the results were modified to poor during follow-up because of moderate recurrence and patient dissatisfaction in a 14-year-old male patient 9 years after operation for severe diffuse asymmetric deformity with a formerly good result (PI, 1.25; BSA, 8.17%; 'BSA, 7.82%; n = 20); and a 15-year-old male patient 8 years after repair of severe diffuse symmetric deformity with a formerly excellent result (PI, 1.22; BSA, 8.03%; 'BSA, 7.81%; n = 21).

Statistical analysis of the comparison between particular BSA and 'BSA was not performed because there were too few patients with recurrence in the particular age groups.

No recurrence required reoperation. During the follow-up period, there were no changes in the primary cosmetic results in patients operated on after 13 years of age (n = 28). In these patients the PI 1 year after operation was not significantly different from that at the last follow-up visit (p = 0.094). No changes in anterior chest wall configuration were seen in patients examined after 15 years of age, and the PI in these patients also did not change significantly (p = 0.174). However, recurrent sternal depression had been found earlier in 6 of them.

	Comment

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Although the first report of pectus excavatum was in 1494 by Bauhinus, it is only since the beginning of this century that a number of methods for surgical correction of this deformity have been introduced [5]. More mild deformities without symptoms of cardiopulmonary compromise may be reconstructed with solid silicone implants for cosmetic reasons only [16], but most investigators believe that sternal and rib reconstruction in patients with pectus excavatum relieves structural compression of the chest, allows normal growth of the thorax, and prevents pulmonary and cardiac dysfunction in teenagers and adults [2, 5, 8, 13]. These methods may be classified into two types: sternal elevation and sternal turnover.

To hold the mobilized and elevated sternum in position during healing and to avoid recurrence of the sternal depression after the repair, most surgeons currently favor some methods of postoperative sternal fixation [2, 5, 6, 11, 12]. Operations that refrain from the use of traction or internal support are modifications of the basic Ravitch procedure [7]. Despite excellent results described by Wada and colleagues [8] in 1970, sternal turnover operations outside Japan are not very popular [3].

Although the importance of removing all deformed cartilages has been stressed [3, 4, 12], recent research in animals [17] has suggested abnormal development of the thoracic cage after resection of rib cartilages. Such extensive pectus excavatum operations (the whole cartilage excision of six ribs), especially at a very early age (<4 years), may cause development of severe cardiorespiratory symptoms because of failure of chest wall growth [18]. Another problem related to the extensive resection of costal cartilages is that of infection or necrosis because of insufficient sternal vascularization [5].

Preservation of the perichondrium is essential to allow costal cartilages to regenerate to achieve support for the elevated sternum [3].

The technique used in our patients appears to be safe and simple. We avoid total removal of costal cartilages that are deformed and limit the resection to 1-cm fragments only. It is sufficient to elevate the sternum and thereby achieve an improved anterior chest wall contour.

The use of Kirschner’s wires provides rigid fixation of the sternum, resulting in earlier union with primary osseous healing [19] and ensures long-term stability of the repair, which is particularly important in older patients with severe deformities [2]. This approach allowed us to be more aggressive in the management of patients older than 15 years because, chiefly as a consequence of this rigid stabilization, we were able to achieve and preserve good cosmetic results in these patients.

Although the procedure described by Ravitch [7] does not require any internal or external fixation, its drawback is the incidence of recurrence caused by the retraction of soft tissues by which the sternum is held after the repair (pericardium, muscles, and endothoracic fascia) [5].

Opinions differ about the optimal age for operation. Some surgeons advocate early operation [2, 3], which allows normal structural development of the chest. Others prefer operation after completion of growth because they find results to be worse and recurrence more common in children [14]. In our experience, patient age was not a determinant of the short-term results.

Insofar as the indications for operation are concerned, we followed the principle of Ravitch [1], and we operated whenever we recognized a marked deformity and the patient was older than 4 years. In addition, we were reluctant to operate in patients who did not ask for the operation themselves. We based the indications for surgical treatment on the physical examination results and chest x-ray film that were obtained before operation. In our opinion computed tomographic scans are costly, and they seldom influence the decision to operate.

The problem of pectus excavatum repair is always twofold: repair of the deformity and maintenance of the repair [1]. Early results of such repairs are usually satisfactory, with more than 90% of patients having good to excellent results [2–5], mainly depending on the technique used, in our opinion. Sometimes early recurrence may occur because of too early removal of the internal support [4]. After 1 year, excellent and good cosmetic results were achieved in 97% of our patients, which indicates that the technique itself is good. Long-term results depend on many other factors, such as patient age at operation, physical activity after pectus repair, posture, and the presence of scoliosis. Our patients were encouraged to participate in sports or games at 2 months after chest wall reconstruction because we consider physical activity an important adjuvant of operation. Physical activity helps to develop not only the latissimus dorsi, trapezius, and abdominal muscles, thus improving posture and scoliosis, but also the pectoral muscles, thus helping to mask any possible residual deformity.

In those of our patients who were operated on during childhood, the results did not change until teenage growth. During the pubertal growth spurt, the results were diminished in 6 (16.7%) of 36 patients. After that time there were no changes in the shape of the chest wall. Mild or moderate sternal depression, which occurred from 3 to 9 years after primary repair, was probably due to an intensive growth spurt in some patients and does not necessarily mean that the indication for operation was unnecessary or that the technique was wrong. In older patients (operated on after 13 years of age), the results did not change at all during medium- and long-term follow-up.

Our data confirm the necessity of long-term follow-up after pectus excavatum repair (especially in children) to evaluate the final result of chest wall reconstruction and indicate that recurrence after such repair may occur because of an intensive growth spurt in some patients [20].

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Ravitch M.M. Depression deformities. In: Welch K.J., Randolph J.G., Ravitch M.M., O’Neill J.A., Rowe M.I., eds. Pediatric surgery, 4th ed. Chicago: Year Book Medical Publishers, 1986:568-578.
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