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Ann Thorac Surg 1996;61:1625
© 1996 The Society of Thoracic Surgeons
DR HAROLD C. URSCHEL, JR (Dallas, TX): This is a landmark paper and I think probably one of the most important on the program. There is virtually no literature about this disease, and I have never seen a case personally. I would be interested to poll the audience to see if anybody has seen a personal case. I have seen one referred to me for medical-legal reasons that was operated on before the age of 4 years in which this developed, and then subsequently another case that never healed and had a total flail chest with excessive use of the cautery. These cases represent the two ends of the spectrum.
This is like volume reduction in reverse. When I came to Texas 35 years ago, Shaw and Paulson had operated on many of the young kids with tracheoesophageal fistulas, pectuses, and so on. I found 38 cases that were operated on at age 4 years or younger, and there were no cases in which this complication subsequently developed. Doctor Haller sent me this manuscript to review.
The possible explanations are, as he pointed out, you either injure the rib or sternal growth centers someplace, wherever they are, or the resection of the perichondrium totally could fail to regenerate any perichondrium and the patient would heal by fibrous tissue that was solid not flail. I think that this is an excellent report and an excellent solution.
Spiral computed tomography and three-dimensional magnetic resonance imaging are extremely valuable in these cases. I think this is an ingenious therapeutic operation and should be called the Haller procedure.
DR FRANCIS ROBICSEK (Charlotte, NC): Doctor Haller, as usual, presented a very interesting paper. However, I can agree only with part of it; namely, that you have to do the operation well. If you do it well, ie, not too radically, and you do not extirpate radically the costal cartilages with the perichondrum on both sides, this complication will not occur.
I especially disagree, that age creates even a relative contraindication. Naturally, if you make a mistake in a small person, your mistake becomes a "big" mistake! With my late partner, Paul Sanger, we did approximately 850 pectus repairs, close to 300 of them were in children less than 3
years of age. We have not seen this complication once! My preferred time is still around 3 years. But you have to do it well!
And as far as the technique is concerned, in the early 1970s we developed a method that consists of sternal osteotomy, bilateral costal cartilage resection, detachment of the xyphoid process, substernal Marlex mesh support, and presternal approximation of the pectoralis muscles. Our long-term results remain consistently very good.
DR HALLER: Doctor Robicsek, I think you asked me something about the age, and I would only say that you are correct, a good operative procedure done delicately in a small child is probably all right. But because we do not know why these few children have had this growth retardation-and certainly it's true that the younger the patient's chest, the more likely you could interfere with growth-my point is why operate on them at 3 years of age? (unless you're just afraid they will get out of town to some other thoracic surgeon if they are allowed to be followed up!) I think you can follow them up until they are school age; they handle their operative procedure better and also their hospitalization. But your point is a good one; the procedure needs to be done properly.
DR CONSTANTINE MAVROUDIS (Chicago, IL): I would like to follow up on one of the issues that Dr Urschel touched upon. Where do you think the growth center is in the rib? We know that if you do an above-the-knee amputation in a little child, the femur will stop growing. Do you think that is what happens here? Should we leave a little piece of that cartilage behind where the rib is? I would be interested to hear what you have to say.
DR HALLER: I tried to find out where the growth centers of the costal cartilages lie, and there are not very good data on that, Dr Mavroudis. I think that it is likely to be at the cartilaginous bony junction laterally, because that certainly is the most active growth center in the chest wall. We have just luckily, by the grace of God, stayed away from it by removing a short segment next to the sternum. You certainly do not need to remove all of the cartilage; that may be one of the reasons we have been lucky in not having this complication.
DR JOEL D. COOPER (St. Louis, MO): I was excited when I saw this paper on the program, because it explained a patient I saw recently, and I previously had no knowledge of this entity. The patient was a 35-year-old man sent to me with a severe restrictive deficit. I had my secretary fax me my record today. His vital capacity was 19% of predicted, his first-second vital capacity was 17% of predicted, and his total lung capacity was 33% of predicted. At the age of 4 years this patient had had a pectus deformity repaired. When I examined him I said I had never seen anything like this; he seemed to have a hypoplastic chest. We did dynamic magnetic resonance imaging and there was nothing that moved other than his diaphragm. In this particular case his ribs were very horizontal, and so moving the sternum forward would not help him. On the roentgenogram, the entire ribcage looked like that of a dog. The ribs from their posterior joint to the front were very horizontal and fixed, with a 4-cm distance between the front and back of his chest. I do not think for him just moving the sternum forward would do anything. We decided there was nothing that we could possibly offer him. If you come up with something, I would love to send him to you. My question is: Have you seen any of these patients in whom the entire ribcage was involved, not just the front plate? Thank you for the opportunity of commenting on this interesting report.
DR HALLER: Doctor Cooper, you were kind enough to mention that in the hall to me before the meeting. I think each surgeon who does a number of pectus repairs may have one or two such complications. I believe that the whole anterior chest wall is failing to grow, which may extend out to the midaxillary line.
Your point about diaphragmatic function is an important one. If this operative procedure we are proposing does help, it can only help by relieving the diaphragm to function better, because we are only expanding the volume of the chest cavity. We are obviously not increasing lung growth; these patients have already passed the lung growth stage. So I think this is like a box that you make bigger; the diaphragms are pushed far down before; they may function better if they have more volume in which to expand. Whether in a 35-year-old man you could expect to do that or not, I am not sure.
Related Article
Ann. Thorac. Surg. 1996 61: 1618-1624.
This article has been cited by other articles:
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  F. Robicsek and A. A. Fokin How not to do it: restrictive thoracic dystrophy after pectus excavatum repair Interactive CardioVascular and Thoracic Surgery, December 1, 2004; 3(4): 566 - 568. [Abstract] [Full Text] [PDF]
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