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Ann Thorac Surg 2003;76:391-395
© 2003 The Society of Thoracic Surgeons
a Joseph B. Whitehead Department of Surgery, Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
* Address reprint requests to Dr Mansour, 1365 Clifton Road, The Emory Clinic, Atlanta, GA 30322, USA.
e-mail: kamal_mansour{at}emory.org
Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, FL, Nov 7–9, 2002.
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Abstract |
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METHODS: A retrospective review of all adult patients (> 16 years old) who underwent repair of congenital pectus deformities from 1971 through 2001.
RESULTS: There were 77 patients, 64 men and 13 women. Sixty-eight patients underwent surgery for pectus excavatum and 9 for pectus carinatum; median age was 22 years old (range, 16 to 68 years old). Indication for repair was medical concerns in all patients. Preoperative symptoms were dyspnea on exertion in 43 patients, shortness of breath at rest in 22 patients, chest pain in 8 patients, and palpitations in 8 patients. Preoperative electrocardiogram findings included right bundle branch block in 9 patients, sinus bradycardia in 8 patients, left atrial enlargement in 6 patients, and right atrial dilatation in 5 patients. Patterns of the pectus defect were symmetric and localized in 29 patients, symmetric and diffuse in 21, asymmetric and localized in 18, and asymmetric and diffuse in 9 patients. Intraoperative classifications were severe in 38 patients, moderate in 33 patients, and mild in 6 patients. There were no operative deaths. Complications occurred in 11 patients (14.3%). Mean hospital stay was 4 days (range, 2 to 8 days). Mean follow-up was 12 ± 7 years (range, 4 months old to 24 years old); 1 patient (1.3%) required reoperation for recurrent pectus excavatum. Patient satisfaction and relief of medical symptoms was excellent in 70 patients (90.9%), good in 6 patients, and fair in 1 patient.
CONCLUSIONS: Repair of congenital defects of the sternum in adults can be performed safely with low morbidity and no mortality. Long-term results are excellent with requirement for reoperation rare.
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Introduction |
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The etiology of pectus deformities has not been clearly elucidated, genetic predisposition may be possibly seen. Surgical correction is often necessary for moderate or severe deformities, because spontaneous regression is rare. Although a myriad of literature has been published on the outcomes following repair of pectus deformities in the pediatric population [1–4], little data have been published in adults requiring pectus repair [5–7]. Therefore, we retrospectively reviewed our experience with repair of pectus deformities in adults.
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Material and methods |
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Evaluation before surgical repair included conventional chest roentgenography in all patients and electrocardiogram and pulmonary function tests on a per needed basis. Computed tomography (CT) scan of the chest was performed to evaluate the extent and nature of the deformity (Fig 1). More recently, several insurance carriers have required calculation of the pectus index (calculated by a chest CT) and pulmonary function tests with and without exercise. In those patients with associated chest pain, noninvasive cardiac evaluation was performed to rule out significant coronary artery disease. Patient’s medical records were reviewed for patient age, gender, surgical history, symptoms, electrocardiographic changes, anatomic defect identified at the time of the surgical repair, the type of surgical reconstruction, and hospital course. Patients were contacted for satisfaction of repair and presence of postoperative symptoms.
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The pattern of sternal defect was symmetric and localized in 29 patients (37.7%), symmetric and diffuse in 21 patients, asymmetric and localized in 18 patients, and asymmetric and diffuse in 9 patients. Intraoperatively, the severity of the pectus deformity was classified as severe in 38 patients (50.6%), moderate in 33 patients, and mild in 6 patients. In those patients with mild or moderate pectus deformities, coexisting esthetics and psychologic reasons played a larger part in the decision to proceed with surgery.
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Results |
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Sixty-one patients (79%) underwent long-term follow-up with telephone calls (mean 12 ± 6 years; range, 4 months to 24 years), the remaining 16 patients (21%) had follow-up as performed by clinic chart reviews during visits at our institution (mean 10 ± 6 years; range, 2 to 23 years). One patient (1.3%) required reoperation for recurrent pectus excavatum 3-years after the initial operation, reconstruction was performed using methylmethacrylate sandwich Prolene mesh repair. The 3 patients who underwent simultaneous bar placement required bar removal at 6, 12, and 13 months for pain or bar protrusion, respectively. Relief of symptoms and patient satisfaction was excellent in 70 patients (90.9%), good in 6 patients, and fair in 1 patient. No patient experienced worse symptoms after repair.
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Comment |
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A variety of techniques have been described for repair of pectus defects, including the classic and the consequently modified repairs by Ravitch [8, 9], the sternal turnover technique, the unilateral costoplasty technique, the reconstruction with silicone implants, and the minimally invasive (Nuss) procedure [11]. In the current series, the majority of patients were repaired using modifications outlined by Ravitch, based on subperichondrial resection of deformed costal cartilages, sternal osteotomy, xiphoid detachment and translocation underneath the sternum, and anterior fixation of the sternum without a prosthesis [8, 9]. In contrast to Fonkalsrud and associates [6], we do not routinely place a sternal support bar, except in reoperative patients or those with connective tissue disorders. The use of Kirschner wires for substernal support to accelerate primary osseous healing in the short-term and in the long-term, to stabilize the results of early healing [12], has largely been abandoned secondary to migration of the wires.
Popularization of the Nuss procedure (minimally invasive pectus excavatum repair) has revolutionized the care of children with congenital sternal defects [13]. This repair avoids cartilage resection and sternal osteotomy, with the tenets of repair relying on a steel bar placement under the sternum to elevate the aberrant sternum and costal cartilages. In an eloquent series from Nuss and colleagues [11] in more than 300 patients, 257 patients (84.5%) had excellent initial results with minimal morbidity and no mortality; mean age of these patients was 12.4 years. In 71 patients with long-term follow-up, 71.8% had excellent results, 19.7% good results, and 8.5% failed correction. When comparing the results in younger patients with older patients, the authors noted that in the latter group, recovery time was longer, frequently required two bars for complete correction, and bar displacement was more common.
In a comparative study, Fonkalsrud and colleagues [14] noted that patients undergoing minimally invasive pectus excavatum repair (MIPER; average age 12 years old) or modified Ravitch repair (MRR; average age 17 years old) had excellent clinical results. Patients undergoing MRR had longer operating times, but decreased hospital stay, complication rates, and use of pain medications. Because measurement of the amount of force in pounds required to correct a sternal deformity has been demonstrated to be predictive of surgical success, Fonkalsrud and coworkers [6] noted that children less than 11 years old required a mean of 15.3 pounds for correction of the sternal defect, whereas adults 19 years old and older required a mean of 41.2 pounds. Patients undergoing a modified Ravitch procedure required only 1.5 pounds of force, regardless of pectus severity.
To date, only Coln and colleagues [7] have specifically addressed implementation of the Nuss minimally invasive correction of pectus excavatum in 8 symptomatic adults with cardiac compression. They noted relief of symptoms, increase in energy levels, improvement in appearance, and demonstrable relief of cardiac compression at a mean follow-up of 22 months in all patients. Although these results are encouraging, a larger cohort of patients with longer follow-up is necessary for widespread use of minimally invasive repair of pectus deficits in adults. In the current series, we did not utilize the minimally invasive technology.
There exist conflicting reports as to the physiologic deficits associated with carinatum deformities. Some have described that cardiopulmonary compromise and postoperative improvement are nearly equivalent to that in pectus excavatum, suggesting underlying pathology in both conditions [15]. Others report no correlation of pectus carinatum with any functional deficits, and propose that the only indication for surgical correction is cosmetic [16]. The operative technique, similar to that of pectus excavatum, consists of removal of deformed costal cartilages and correction of the sternal angle with anterior transverse osteotomies [6, 16, 17]. In the current series, we have accumulated 9 patients who required surgical intervention for pectus carinatum. All patients exhibited marked clinical improvement, with associated low morbidity. All patients underwent correction for medical reasons.
Thus far, no consensus regarding the constellation of physiologic impairments required for pectus repair has been ascertained. The compression of thoracic contents results in either reduction in right ventricular volume [18] or mild restrictive lung disease [19]. Patients with pectus most often complain of reduced exercise tolerance, though the clinical importance of this symptom remains a source of controversy. Some believe that functional impairment is so minimal that psychologic problems are the only indication for surgical repair. In the surgical repair of pectus defects in adults, we have found that patient symptomology is the most important preoperative decision factor.
More important is the debate as to whether surgery is an effective means of improving exercise tolerance in patients with pectus excavatum. One study concluded that although patients anecdotally reported symptomatic improvement postoperatively, there was no objective correlation between right ventricular function and the degree of sternocostal elevation [20]. Another study, however, revealed evidence of marked improvement in postoperative exercise tolerance at 6 months [6]. These conclusions suggest underlying cardiopulmonary dysfunction that is likely additive to a compression-related deficit.
Although repair of pectus deformities is most commonly performed in children, in those adult patients with symptomatic pectus defects, we have indicated in the current series that effective repair utilizing the modified Ravitch techniques can be performed with low morbidity, no mortality, and marked long-term improvement in symptomatic limitations.
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Discussion |
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DR THOURANI: Doctor Jones, thank you for those comments and questions. The stabilization bar was used very infrequently in our series; in fact, only three patients had stabilization bars placed. In those patients, the bars were removed at 6 months, 12 months, and 13 months postoperatively.
The bar, popularized by Dr Nuss, has been used primarily in repair of pectus examination in the pediatric population.
In the few adult series of pectus excavatum repair, the bar has been sparingly used. More recently, in the World Journal of Surgery in 2002, Dr Coln has described the use of the bar in repair of pectus deformities in 8 adults. He had excellent outcomes with that, but it is a preliminary study with only eight patients and approximately 12- to 20-month follow-up.
Although we do not use the stabilization bar frequently, some surgeons feel that the bar may be useful in those patients with extremely broad deformities in which unusually long segments of ribs have been resected, in Marfanoid patients in whom the length of the sternum would impose excessive leverage on the repair, and in recurrence pectus patients requiring a major reconstruction.
DR GEOFFREY M. GRAEBER (Morgantown, WV): I very much enjoyed your presentation. It is excellent work. I wanted to ask you one question about one problem that sometimes we face. In doing that extensive a dissection sometimes there is a fair amount of drainage from the wound. What type of drainage system do you use, how do you handle persistent drainage? I notice your incidence of seroma was low, but I would be interested to hear how you handle the drainage and how you minimize it. Thank you.
DR THOURANI: Doctor Graeber, thank you for your eloquent comments and questions. In the majority of patients, we intentionally open the right pleural space and place a chest tube. We also place two 10-mm J-P drains underneath the pectoralis muscle closure over the corrected pectus defect. In the majority of cases, all drains are removed between postoperative days 3 to 5. If the J-P drainage is excessive, the patient is discharged and is monitored until the drainage is minimal (< 50 cc/day), when the drains are removed on an outpatient basis.
DR W. STEVES RING (Dallas, TX): Frequently in adult pectus deformity you have associated rib abnormalities that have developed over time because of the prolonged costal abnormalities. Do you handle these any differently?
DR THOURANI: In addition to subperichondrial removal of the deformed cartilages, we remove the portion of the abnormal rib. We do not remove the entire rib.
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References |
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TopAbstractIntroductionMaterial and methodsResultsCommentDiscussionReferences |
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an A., Ayten A., Öz N., Demircan A. Early and long-term results of surgical repair of pectus excavatum. Asian Cardiovasc Thorac Ann 2002;10:39-42.
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