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Ann Thorac Surg 2004;78:e19-e21
© 2004 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Einstein College of Medicine, New York, New York, USA
b Department of Anesthesiology, Albert Einstein College of Medicine, New York, New York, USA
Accepted for publication February 10, 2004.
* Address reprint requests to Dr Gold, Department of Cardiothoracic Surgery, Montefiore Medical Center, 111 E 210 St, Bronx, NY 10467, USA
e-mail: jgold{at}montefiore.org
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Abstract |
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Introduction |
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The evolution of these techniques to a permanent nonmetallic semirigid stabilizing system and the 6-year follow-up are described here.
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Technique |
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(1) A short vertical (44 patients) or small inframammary chevron incision (8 patients) is performed. Both pectoralis major muscles are mobilized extensively from the skin and from the chest wall to the anterior axillary line.
(2) The cartilaginous component of ribs 3 to 8 is mobilized including central elements of the arch. The cartilage of rib 4 to 8 is resected subperichondrally, from the costosternal joint to the osseous joint. The dissection remains extrapleural, and the perichondrium of each anterior costal arch is preserved intact.
(3) A full-thickness transverse "V" wedge osteotomy incision of the sternum is performed at the second intercostal level. This was shaped such that when the upper and lower edges were completely brought together, the lateral, twisting, and posterior sternal displacement was eliminated or minimized. The osteotomy is closed with interrupted polypropylene (Prolene; Ethicon-J&J, Cincinnati, OH) suture elevating the lower sternal segment and stabilizing any degree of sternal rotation and deviation.
(4) An anterior oblique shingle of the third costal segments bilaterally is performed, allowing the medial components of the cartilage to rest anteriorly upon the lateral components, thus further anteriorly displacing and stabilizing the lower sternum.
(5) Five intercostal transverse polypropylene mesh bands (Marlex Mesh; Davol Inc., Bard Cardiosurgery, Cranston, RI) 12 cm x 1 cm are placed posterior to the sternum and anterior to the pleura and pericardium. The mesh bands are anchored under tension to the ribs with 2-0 polypropylene sutures (Fig 1).
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(7) Two flat section drains are placed laterally anterior to the muscle flaps, and one more is then placed centrally, posterior to the pectoral muscle flaps. The drains are removed when drainage is less than 30 mL/24 h.
(8) The wound is lavaged with anesthetic (Marcaine, 0.25%/25 mL) and broad-spectrum antibiotic solutions. The subdermal layer is closed with absorbable suture, followed by skin closure with intradermal removable polypropylene suture.
The patients were typically extubated in the operating room with minimal discomfort and no respiratory difficulties. No patient required reintubation. On postoperative day 2, the light dressing and flat drains were typically removed. No external support or protection was necessary. Patients were advised to begin physical therapy in 2 to 3 months. Competitive sports should be delayed for 9 to 12 months and contact sports delayed 12 months.
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Results |
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Our technique uses as internal support multiple transverse flexible mesh bands, which become permanently incorporated with the fibrous tissue, thus avoiding the need for a second operation. The combination of subperichondral costal cartilage resection and nonabsorbable transverse posterior sternal support produces immediate chest wall stability and holds the sternum, osseous rib ends, and perichondral sheaths in an optimal position for permanent cartilage regeneration and subsequent chest wall healing.
We used this technique in 52 consecutive patients from 1990 to 2003 with pectus excavatum deformities as our technique of choice. Before this period, more classic repairs with indwelling metal struts were performed. Associated operable cardiac pathology was found in 6 patients (one atrial septal defect, two partial atrioventricular septal defects, one ventricular septal defect, one ascending aortic aneurysm, and one mitral regurgitation). Pulmonary pathology characterized as asthma was diagnosed preoperatively in 22 patients. The pectus lesion was judged to be severely asymmetric in 24 patients.
Patient characteristics included a mean age of 19.3 years (range, 4 to 39 years); there were 32 females and 20 males. The average hospital length of stay was 3.1 days (range, 2 to 11 days). There were no hospital readmissions or perioperative deaths and only two perioperative complications consisting of prolonged drainage [1] and placement of a thoracostomy tube for a moderate asymptomatic pneumothorax [1]. There were no wound infections, instances of chest wall instability, or need for transfusion. There were no early reoperations, and a satisfactory early structural result was achieved in all 52 patients as judged by the patients, families, and surgical team.
There were no late deaths, and one late complication of pain secondary to a chest wall hockey injury 6 months postoperatively with no radiographic lesion noted. There were no late reoperations for revision of the chest wall reconstruction or removal of any of the mesh bands. All the preexisting cardiac defects were successfully repaired at a subsequent setting using a standard sternotomy approach. The transverse mesh bands presented no difficulty at the time of sternal incision, closure, or to late sternal healing and chest wall stability.
The mean follow-up was 79 months (range, 5 to 161 months) from the date of the surgical pectus repair. A satisfactory late result in terms of sternal stability was achieved in all patients on outpatient examination and on careful patient/family questioning. In the preadolescent patients, chest wall growth maintained symmetry and the early improvements in the chest wall appearance were sustained or appeared to improve throughout adolescence. All the patients enjoy unrestricted physical activity, with many involved in competitive sports. There was no instance of repeat surgery of any type to further modify the original chest wall repair.
An internally supported single-stage technique employing selective cartilage resection and anterior wedge sternal osteotomy stabilized with multiple transverse nonabsorbable flexible mesh bands is a safe and reliable surgical repair for severe asymmetric pectus excavatum chest wall deformities. The short-term structural and cosmetic results are excellent, length of hospital stay is short, and complications are few. The long-term stability and cosmetic results are also excellent. No revisions are necessary, and subsequent transsternal cardiac surgery is safe and does not compromise the previous chest wall 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.
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This article has been cited by other articles:
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  E. W. Fonkalsrud, J. Mendoza, P. J. Finn, and C. B. Cooper Recent Experience With Open Repair of Pectus Excavatum With Minimal Cartilage Resection Arch Surg, August 1, 2006; 141(8): 823 - 829. [Abstract] [Full Text] [PDF]
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