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Ann Thorac Surg 2006;82:451-456
© 2006 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, Kimitsu Central Hospital, Sakurai Kisarazu, Japan
b Department of Cardiothoracic Surgery, Dokkyo University School of Medicine, Mibu, Tochigi, Japan
Accepted for publication March 20, 2006.
* Address correspondence to Dr Iida, Department of Cardiovascular Surgery, Narita Red-Cross Hospital, Iidachou Narita, Chiba 2868523, Japan (Email: iidahomburg{at}hotmail.com).
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Abstract |
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METHODS: From 1993 through 2004, 62 patients underwent repair of pectus excavatum. Sternocostal elevation was adopted for 54 patients (11.7 ± 8.3 years old). A part of the third or fourth to the seventh costal cartilages was resected. All of the stumps were pulled to generate tension and resutured with the sternum. Cortical osteotomy of upper sternum and introduction of exogenous material were not employed. Sternal turnover and overlap was adopted for 8 adults (24.1 ± 9.0 years old) with severe asymmetric deformities. The sternum was cut at the level of the second or third intercostal space. The lower part of the sternum was turned over and secured in a position so that it overlapped with the upper sternum, and the stumps of cartilages were reattached to the plastron. In these procedures, the natural tension exerted by the patient's ribs is sufficient to elevate and fix the sternum.
RESULTS: Mechanical ventilation was not required after emergence from anesthesia. None of the patients experienced threatening complications or required reoperation. Fifty patients (81%) were graded as excellent, and 12 patients (19%) were graded as good at 1 month after surgery.
CONCLUSIONS: The procedures described here yielded excellent results with low morbidity and no mortality, and produced high patient satisfaction.
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Introduction |
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Patients and Methods |
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Operative Technique
We adopted two types of techniques, both of which were modified from the method described by Wada and coworkers [19] and Kasagi and Hino [20]. Sternocostal elevation was used for 54 patients (11.7 ± 8.3 years old), a group that included all of pediatric patients and adult patients with relatively symmetric deformities. The second technique used was sternal turnover and overlap, which was employed for 8 adult patients (24.1 ± 9.0 years old) with severe asymmetric deformities, such as those characteristic of Marfan syndrome.
Sternocostal Elevation
In males, a median vertical incision was made superficial to the defect, whereas in female patients, an inframammary incision with upward curvature in the middle was used to reduce scar visibility. Diluted epinephrine (0.005 mg/mL) was injected subdermally to reduce bleeding and burns caused by the use of electrocautery.
The median section of the bilateral pectoralis muscles was exfoliated from the sternum and associated cartilages. The rectus muscle and xiphoid were freed from the sternum at the xiphosternal junction. A part of the third or fourth to the seventh costal cartilages was resected using a periosteal knife. The mediastinal aspect of the pericartilage was preserved from cutting and resection to prevent injury to mammary vessels and pleura. All of the stumps of cartilages were reattached to the sternum using 1 (for pediatric patients) or 3 (for adult) braided polyester sutures (Fig 1). The number and length of cartilages resected was determined by the degree of deformity. In the case of asymmetric deformity, different lengths and different numbers of cartilages were resected on each side. Adequate lengths of cartilages, 5 to 60 mm, generally longer lengths in the lower cartilage, were resected so that the resected and reshaped cartilages and ribs generated 0.5 to 7 kg of tension on reattachment to the sternum.
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Two small-gauge tubes less than 5 mm connecting to closed portable evacuating drainage system (Relia Vac; DAVOL, Cranston, Rhode Island; or SB Vac; Sumitomo Bakelite, Tokyo, Japan) were placed around the sternum and cartilages. The rectus muscle and xiphoid was attached to anterior face of the lower sternum by braided polyester suture. The inner layer of the pectoralis muscle was secured to the edge of the sternum. Both sides of the outer layer of pectoralis muscle were sutured together at the midline, and the lower edges of the pectoralis and rectus muscles were sutured together, so that the muscle layer covered the corrected costal cartilage and sternum. The repair was completed by suturing the overlying skin. Drains were removed in 3 to 5 days, after the discharge declined to less than 20 mL per day.
Sternal Turnover and Overlap
The sternal turnover and overlap technique was employed for adult patients whose sterna were both severely distorted and sufficiently ossified. Incisions of slightly greater length were made in essentially in the same sites as in sternocostal elevation. The muscles were exfoliated, and the xiphoid was cut in the same manner as in the sternocostal elevation procedure. Costal cartilages were cut at the middle of the cartilage, and the sternum was also cut at the height of the second or third intercostal space. The lower part of the sternum with costal cartilages was then removed from the wound, and the distortion was corrected, if necessary by tearing the cortex. The lower sternum was turned over and fixed on the upper sternum with an overlap of 1 to 1.5 cm using two metal wires. An adequate length of each cartilage was resected, and all of the stumps of cartilages were attached to the plastron with sufficient tension to achieve good correction of defects and to prevent flail chest in the same manner as achieved in sternocostal elevation. Methods of repairing muscles and skin were as described for sternocostal elevation, above.
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Results |
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in some cases scoliosis was improved, and cardiac shadows observed in thoracic roentgenogram returned to near midline in pediatric patients. Fifty patients (81%) were graded as "excellent," and the remaining 12 (19%) patients were graded "good," with marked improvement in appearance at 1 month after surgery. None of the patients have had "fair" or "poor" results. The wound was inconspicuous, and most of patients reported satisfaction with the wound and the shape of the corrected chest. The median length of incision was 6.0 ± 1.9 cm in patients undergoing sternocostal elevation, and 11.7 ± 2.9 cm in patients undergoing sternal turnover and overlap. All of the patients under 16 years old (n = 39) underwent sternocostal elevation; the median length of the vertical wound of males in this age group was 5.4 ± 1.8 cm. In the most recent 10 patients less than 7 years old, the length of the anterior chest wound was 3.9 ± 0.5 cm.
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Preadolescent patients were able to return to their preoperative daily activities within a week of surgery, whereas adult patients took little bit longer. We advise our patients to avoid contact sports for 3 months as a precaution, but in general these patients experience no restrictions on normal activities and do not need to undergo any subsequent surgery.
All of the patients were followed up for at least 1 year. The rating of a single patient who had undergone sternocostal elevation and been classified as excellent at 1 month after surgery was later revised to good at 1 year after surgery. Three adult patients with tall, thin Marfan-like physiques who underwent sternal turnover and overlap exhibited slight chest depression and were classified as fair at 1 year after surgery, but even these patients exhibited marked improvement in chest shape compared with that before the operation. No other patient has experienced deterioration of chest contour.
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Comment |
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We did not use CT for determination of surgical indication. We chose not to use this technology as it involves relatively high-dose radiologic exposure for children. The position of the apex of the depression, the ratio of sagittal to lateral diameter, and the protrusion of the costal arches were different in each case. We relied on physical examinations and interview to determine indication for surgical correction. We note that the indicative criteria have been empiric in most other series reported to date as well [9].
Most conventional techniques for the repair of pectus excavatum were based on methods first described by Ravitch [8], including a long incision in the anterior chest wall, resection of deformed rib cartilages, and the tearing of the sternal cortex in order to remodel it. Others have made several modifications in the operative procedures, such as the introduction of a metal bar that used to stabilize the lower part of sternum [1–3, 9–11]. Such procedures can be employed in any age group, but are considered to be invasive because of the large wound opened in the anterior chest wall and the resection or tear that must be made in cartilages and sternum.
A revolutionary procedure first reported by Nuss and colleagues [12] has been described as minimally invasive repair for pediatric patients, because this approach does not require either an anterior wound or the cut of cartilage or sternum. In this procedure, a metal bar is placed behind the sternum through pleural spaces, and is secured to the ribs. The Nuss procedure has gained substantial popularity [13–17], but has also involved a relatively high morbidity rate [12, 15–17], especially during the learning curve [13, 14]. Migration of the bar has been reported in 3.6% to 8.8% of patients [12–14]. Perioperative and late complications including infection of the bar, pneumonia, pleural effusion, hemothorax, wound seroma, skin necrosis, pericarditis, and even cardiac perforation have been reported [12–17]. Reoperation for complications was needed in 4.1% to 11% [13, 15–17]. Severe pain is one of the unpleasant complications of the Nuss procedure [12, 15, 16]. Sedation and thoracic epidural analgesia is often utilized for several days after the Nuss procedure [12], and Croitoru and associates [14] reported that transient Horner's syndrome occurred in 74.8% of patients who received epidural analgesia. Some patients suffered from residual pain and required analgesia for extended periods [16].
We believe that the complications associated with the Nuss procedure may be caused, at least in part, by the introduction of the metal bar, as the chest wall moves with respiration and body movements, and grows for years, and the ribs are sensitive to the stress of being subjected to stabilization with a metal bar. In addition, the extent of the physical and mental burden that may be associated with the introduction of a foreign body into the chest of a growing, preadult patient remains unknown. Because the majority of pectus excavatum corrections are performed in young patients, and candidates for surgical correction rarely exhibit life-threatening complaints and are able to maintain acceptable quality of life preoperatively, surgeons have a strong obligation to avoid the risk of complications requiring long-term medical treatment or reoperation.
Wada and colleagues [19] described sternal turnover for pectus excavatum in 1970. We have adapted this technique to make it less invasive. We realized that, especially for preadolescent patients, the sternum is quite pliable, and could be corrected without the requirement of turnover, wedge osteotomy on the cortex, or the insertion of a foreign body [20]. It has been shown in the Nuss procedure that the sternum can be corrected without the resection of cartilages or sternal osteotomy, and indeed, in our method, the deformed sternum is easily corrected by the shortening of cartilages. The sternum is pulled laterally by shortened and resutured costal cartilages, and the resultant force raises the sternum ventrally. The same force prevents flail chest and allows patients to breathe on their own in the operating room immediately after surgery. Because we secure the stumps of all cartilages, while only a subset of the lower cartilages are secured in the Ravitch method, the resilience of each rib and the chest wall as a whole helps to correct chest wall deformity, and even asymmetric deformities and projecting costal arches can be corrected.
For some patients, asymmetry of the thorax and projection of costal arch may be the chief aesthetic complaints. In adult patients with Marfan syndrome or severe asymmetrical deformity, the sternum is so twisted and resistant to reconformation that it must be cut and turned over. However, even in these cases, the chest wall is moderately stabilized by the tension exerted by the ribs, and the patients can breathe independently immediately after surgery. None of our patients experienced major complications resulting in an extended hospital stay, needed extensive outpatient treatment, or required reoperation for any reason. In this procedure, no exogenous material is left within the chest wall, and cartilages and sternum are covered with a muscle layer having a rich blood supply, making it possible to expect prompt wound healing and tolerance to infection. None of our patients suffered from residual pain that disturbed the resumption of their normal participation in society. Subsequent surgery to remove foreign bodies was also unnecessary. In these procedures, as sections of cartilage longer than those in the normal chest were partially resected and were secured to the sternum, relapse was rare [20]. Haller and coworkers [21] have cautioned against extensive cartilage resection in children, because of the occasional occurrence of constricting asphyxiation thoracic dystrophy. Because only a part of the cartilages are resected, and all of the stumps are secured with the sternum in our methods, the growth of the remaining cartilages and chest wall after surgery is not affected.
We employed sternocostal elevation or sternal turnover and overlap in patients of all age groups and achieved satisfactory surgical correction; but we believe, for several reasons, that the most appropriate age for this procedure is before puberty, with 4 to 6 years of age being the optimal range [10]. Before the onset of puberty, the chest is more malleable, sternocostal elevation for children usually takes less than 2 hours to perform, but corrections may take more than twice as long in adults. The surgical wound in sternocostal elevation is shorter than that in sternal turnover and overlap. In addition, after the age of 30, cartilage becomes more rigid and brittle. Because adult patients may present with a greater number of complaints than children before surgery [1, 11], we believe that it is important to relieve structural compression of the chest and allow normal growth of the thorax, and do surgical repair to reduce potential physical and psychological impact. Children in our recommended age range are sufficiently emotionally mature and are more likely to expect a positive experience from their hospital stay. Children at this age are also generally young enough not to have suffered psychological impairment secondary to the perception of abnormal body image [10].
In conclusion, an excellent postoperative chest contour was achieved in most of the patients, and none of our patients had major complications requiring long-term hospitalization. We believe that the risk of complications is one of the most important factors in determining the appropriateness of major surgical invasion, especially in pediatric patients. The procedures described here include the resection of cartilage, but we believe that our technique represents a less invasive and lower risk procedure for the repair of pectus excavatum.
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Notice From the American Board of Thoracic Surgery Regarding Trainees and Candidates for Certification Who Are Called to Military Service Related to the War on Terrorism |
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If you have any questions about how this might affect you, please call the Board office at (312) 202-5900.
Carolyn E. Reed, MD
Chair
The American Board of Thoracic Surgery
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This article has been cited by other articles:
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  H. K. Pilegaard and P. B. Licht Routine Use of Minimally Invasive Surgery for Pectus Excavatum in Adults Ann. Thorac. Surg., September 1, 2008; 86(3): 952 - 956. [Abstract] [Full Text] [PDF]
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