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Ann Thorac Surg 2004;78:421-426
© 2004 The Society of Thoracic Surgeons

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Original article: general thoracic

Repair of the pectus deformity: Results of the Ravitch approach in the current era

^a Department of Cardiothoracic Surgery, Columbus Children's Hospital, Columbus, Ohio, USA
^b Department of Surgery, The Ohio State University School of Medicine and Public Health, Columbus, Ohio, USA

Accepted for publication January 9, 2004.

^* Address reprint requests to Dr Davis, ED 620, Education Building, Columbus Children's Hospital, 700 Children's Dr, Columbus, OH 43221, USA
e-mail: tdavis{at}chi.osu.edu

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
BACKGROUND: Recent publications have advocated a minimally invasive approach to repair of the pectus deformity. Efforts to evaluate this new approach have been hampered by lack of comparative information regarding outcomes of the standard Ravitch approach. We use a modified Ravitch procedure, and present our series as a basis for comparison.

METHODS: Records of 69 consecutive patients undergoing repair of the pectus deformity were retrospectively reviewed. Modifications included a minimal incision and a new technique to address sternal angulation. A patient satisfaction survey evaluated the patients' perception of the outcome.

RESULTS: We found one wound infection (1.4%). Five patients (7.2%) had a seroma, and were treated as outpatients. Because the minimally invasive approach is used for pectus excavatum, we divided our series into excavatum and carinatum subsets. The subset of 44 pectus excavatum patients had a mean postoperative length of stay (LOS) of 2.9 days. The median patient satisfaction score was 4 on a scale of 1 to 5, at an average of 4.75 years after repair. The subset of 25 pectus carinatum patients had a mean LOS of 2.4 days and a median patient satisfaction score of 5.

CONCLUSIONS: The modified Ravitch procedure yields excellent results with low morbidity, hospital LOS, and cost, combined with high patient satisfaction. These current data will be useful for comparison as newer techniques for pectus repair continue to evolve.

	Introduction

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The pectus deformity, including both pectus excavatum and pectus carinatum, is common in the pediatric age group. The underlying pathology is overgrowth of the costal cartilage that displaces the sternum either dorsally or ventrally. The deformity appears initially or becomes more prominent during growth spurts. Repair is undertaken to alleviate symptoms of pain, cardiac or respiratory compromise [1], as well as to diminish significant psychosocial consequences to a child or adolescent.

For the last half century the standard surgical approach to the pectus repair has been based on the techniques described by Ravitch [2]. The basic principles include subperichondrial removal of the offending costal cartilage, remodeling of the sternum, and stabilization [3]. Several reports have documented the results of the Ravitch approach [4–6], but none have appeared in the last 5 years.

Recently, a two-stage, minimally invasive approach ("the Nuss procedure") has been described that avoids resection of the costal cartilage [7, 8]. The first stage involves small bilateral incisions through which a convex metal plate is placed behind the sternum and then rotated 180 degrees to move the sternum ventrally. The second stage consists of removal of the bar, which is recommended at 2 to 4 years after the first stage procedure. Advantages of this approach include the absence of an anterior scar and the avoidance of cartilage resection. As a relatively new technique, the Nuss procedure is still in evolution. Technical modifications have been made to minimize some of the reported complications including cardiac perforation and loss of bar position [9–13]. As with all innovative surgical procedures, the results of this new technique are reported and are compared with the standard Ravitch procedure in terms of outcomes [14, 15]. Surgical results can be scientifically documented by computed tomography (CT) measurements [16, 17] or subjectively evaluated by some measurement of patient satisfaction. As the Nuss procedure continues to evolve, comparisons of rates of complications, recurrences, lengths of stay, and cost will be necessary. Although in two recent series the Ravitch and the Nuss approaches were compared at the same institution [11, 18], lack of data about the criteria for procedure selection make the data difficult to interpret.

During the last decade we have continued to use the Ravitch approach and have made several technical modifications in the operative procedure and perioperative management strategy. We present a series of 69 consecutive patients with the pectus deformity who have undergone repair from 1991 to the present. We believe that these updated data regarding the efficacy, safety, and resource utilization of the Ravitch approach will be useful for comparison as more results from the Nuss procedure become available.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Office records of the Department of Cardiothoracic Surgery at Children's Hospital in Columbus, Ohio were retrospectively reviewed for all patients undergoing repair of the pectus deformity from July 1991 through July 1, 2003. Operative notes and clinical data were reviewed for each patient including severity grading of the deformity. For reasons discussed below, we did not use preoperative CT scanning as an evaluation tool. The severity was expressed as a numerical expression of one observer's subjective impression of severity: a scale of 1 to 10, with 1 being barely noticeable and 10 being the most severe. We also recorded operative technique, hospital length of stay, complications, and immediate patient satisfaction. Hospital charges and total direct costs were determined for patients during the last 3 years of the study.

To assess long-term patient satisfaction, an Institutional Review Board-approved questionnaire was sent to all patients in the study. Patients were asked to rate their satisfaction with the results of the operation on a scale of 1 to 5 (Table 1). At all times, patient confidentiality was maintained, and no reports were generated that contained information identifiable by patient.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

View larger version (19K): [in this window] [in a new window]   Fig 1. Distribution of patient age at the time of pectus repair.

View larger version (26K): [in this window] [in a new window]   Fig 2. Indications for surgery.

Surgical technique
We continue to employ the fundamental concepts outlined by Ravitch [3] of subperichondrial resection of the offending pairs of costal cartilage, separation of the perichondrium from the sternal edge, sternal remodeling, and stabilization. However, we have evolved our technique over the years to make the procedure less invasive. By developing a generous subcutaneous flap over the muscle fascia, the procedure can be accomplished through a limited skin incision (Fig 3) for both excavatum and carinatum procedures. A median of four sets of costal cartilage were removed in both subgroups.

View larger version (116K): [in this window] [in a new window]   Fig 3. Appearance of scar 2 weeks after repair of pectus excavatum.

Asymmetry can be easily dealt with by adjusting the angle of the posterior osteotomy (Fig 4). When the right side is most severely depressed, the right side of the osteotomy should be more cranial and the left side more caudal (Fig 4A), with the angle roughly approximating the degree of twist. This maneuver changes the axis of elevation so that when the distal sternum is then brought forward and stabilized with a bone wedge (Fig 4B) the "twist" in the sternum is straightened out (Fig 4C). Flattening of the sternum results in mild lateral deviation to the right. However, once covered with muscle, subcutaneous tissue, and skin, this degree of deviation cannot be noticed and only the flatness of the chest wall is apparent. We have found this technique yields a stable repair; a pectus strut for stabilization was required in only 10 of 44 patients (23%). A strut was employed in the more severe pectus patients if the amount of anterior deviation created by the repair was so great that additional stabilization during the time of bone healing was deemed to be desirable. Struts were easily removed at 6 to 8 months as an outpatient procedure.

View larger version (24K): [in this window] [in a new window]   Fig 4. Use of oblique posterior osteotomy to compensate for sternal asymmetry (see text). (A) Before, showing sternal twist. (B) Bone wedge to hold anterior position. (C) After, showing anterior displacement of sternum and elimination of the twist.

Postoperative management has been enhanced recently by the routine use of indwelling epidural catheters placed at the time of surgery. This strategy has greatly reduced the amount of narcotics required and allowed for more rapid mobilization.

Complications
No deaths or significant intraoperative morbidities were found. Blood loss was minimal and no transfusion was required. Six early complications were noted. One patient (1.4%) had a wound infection that required incision and drainage, with sternal debridement and an additional hospitalization. The cosmetic result for this patient was unsatisfactory.

Seromas developed after discharge in 5 patients (7.2%), requiring aspiration in the office. Three of the 5 patients were large adolescents. We believe the seromas were related to larger flaps that attend the smaller skin incision, and we have modified our postoperative drainage regimen as a result. Now, Jackson-Pratt drains are left until drainage fully ceases. If the drainage persists for more than 3 days, we discharge the patient with the drains to be removed in the office. Early results suggest this procedure may reduce the problem. No patient required a chest tube for pneumothorax.

Of late complications, 3 patients returned with pain. In 1 of these patients, CT scan demonstrated considerable ossification of the perichondrial beds. The other 2 patients had CT evidence of subluxation of regenerated perichondrium underneath the sternum. In 2 of the 3 patients the pain was mild and did not require therapy. In the third, re-resection of the cartilage eliminated the pain. Two patients had recurrence of sternal depression: 1 was mild and the other patient thought the deformity ended up unchanged after several years. One patient had an area of nonregenerated cartilage that resulted in a small soft space anterolaterally.

Hospital charges, cost, and length of stay
Lengths of stay and hospital financial information were gathered for the last 3 years of the study. This period of time was chosen to be most relevant to the current data on the Nuss procedure for comparison purposes, and avoided the need to adjust for inflation and pricing changes. Additionally we had accurate cost accounting data for this time frame. Table 2 lists the results. Length of stay is mean postoperative length of stay. Hospital charges are the overall hospital bill and hospital costs are the total (fixed plus variable) direct costs identified by the Eclipsys Financial Support System. The postoperative length of stay and costs were both slightly lower for the carinatum subset compared with the excavatum subset, reflecting the slightly lower complexity of the operative procedure.

View larger version (17K): [in this window] [in a new window]   Fig 5. Patient satisfaction scores for all responders. See Table 1 for descriptors of score.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

Our policy is to avoid CT scans to routinely quantify the severity of the deformity or the efficacy of the surgery [16, 17]. The primary reason to avoid CT scanning is that the findings are of no particular value in planning the operation. The scan offers no information that is not immediately available to the experienced surgeon from a routine physical evaluation. Although CT scanning does precisely quantitate the degree of pectus, even Haller and coworkers, in their original description [16], stated that the study "simply documents our selection bias." No actual pathophysiologic consequences have been attached to specific Haller indices, nor have they correlated with the degree of psychosocial impairment that can occur with the deformity.

Recent concern about the potential long-term effects of the radiation from CT scanning in children, including cancer, has also colored our thinking [19]. Therefore, in our view, routine use of the Haller index as an indication for surgery gives no real information about medical necessity, and only adds significant cost and a possible risk that we cannot justify. A follow-up study to document surgical results would only compound these problems. The downside of this approach is that we are limited to a less scientific assessment of the degree of severity.

Assessment of the outcome of surgery is also a challenge with the pectus deformity. Because self-image is a major concern in many patients, we thought it was important to find a mechanism to assess how they felt about the outcome, not their surgeon.

The results of the patient survey indicated that patients were satisfied with the results. We considered a 42% response rate satisfactory given the mobility of the population and the 10-year time span. We are encouraged that more than 4 of 5 considered their outcome very good or excellent. Three patients were dissatisfied with their result. One was the patient with the infection. The other 2 had recurrences, although one recurrence was mild. It is too early in the development of the Nuss procedure to make comparisons about recurrence rates, because most of the Nuss bars have yet to be removed and the cartilage remains. Assessing whether recurrence will be a problem will take years after the bar is removed.

Comparison of the two approaches regarding length of stay is problematic. Current information published on the Nuss procedure report postoperative lengths of stay from 3.7 days to 5.5 days [7, 11, 13, 18]. We recognize that these series included earlier data and that, with experience, lengths of stay may diminish. Nonetheless, it must be remembered that these lengths of stay are for the first stage only. Because comprehensive reports are not yet available on the second stage (bar removal), calculating the total length of stay for this approach is not possible. Our mean postoperative length of stay for the excavatum subset was 2.9 days. The 23% of patients who had a pectus strut removed as part of the repair underwent that part of the procedure as an outpatient and none required hospitalization; therefore the length of stay for the entire event remains at 2.9 days.

Comparison of morbidity rates reported is also difficult. Most series [7, 11 13, 18, 20] include an early learning curve, which may explain the higher morbidities. In the most recent large series [13], Nuss reported on 303 patients; morbidities listed include a 2.1% wound infection rate, 2.4% rate of pericarditis (2 patients requiring drainage), and an 8.8% rate of bar shifting requiring repositioning.

We are unaware of any reported financial data on the Nuss procedure. However, the longer length of stay for the first stage as well as the higher cost of the required supplies suggests that the charges and costs are likely to be higher. In addition, to compare the two approaches fairly, the cost must be evaluated for the entire therapeutic intervention. Because only 23% of the bars as described by Nuss have actually been removed [13, 20] and 100% of these patients will presumably require bar removal, the total cost, length of stay, and complication rate for the completed repair will need to be accounted for in the final analysis. With the recent trends toward utilization of lateral stabilizing bars and other methods to prevent loss of bar position, as well as the use of two bars for more complex cases, it remains to be seen what resources will be necessary for their removal and how many patients will require hospitalization after bar removal.

These data support the conclusion that the Ravitch procedure remains a safe and effective approach to the repair of the pectus deformity in all of its presentations. Technical modifications that limit the size of the incision and allow the surgeon the flexibility of dealing with all types of severity and obliquity contribute to consistent outcomes. A low morbidity with excellent short- and long-term results combined with a high level of patient satisfaction are achieved and should be the standard against which the Nuss procedure is compared.

The ultimate role of the Nuss procedure will be based on the scientific comparison of safety, efficacy, and resource utilization for the two approaches. The Nuss procedure offers repair of the deformity without an anterior scar, but questions remain as to whether that advantage warrants changing the current standard of care. The Ravitch approach offers proven results over a long period of time, but requires a small anterior scar. It is likely that the Nuss procedure will emerge as a useful technique in the armamentarium of the surgeon dealing with certain subsets of patients with pectus excavatum. These updated data from the Ravitch approach should form a useful basis for comparison to make that determination.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The authors acknowledge the invaluable assistance of Mary Lou Naftzger for database analysis as well as Georgiana Roberts and Silva Gramlich for financial analysis and assistance. Anthony Baker provided Figure 4.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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