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Surgical Correction for Chest Deformity

Surgical Correction for Chest Deformity (Funnel Chest; Pectus Excavatum and Pigeon Chest; Pectus Carinatum)

Hiroshi Iida MD, PhD
Department of Chest Wall Surgery, Shonan Kamakura General Hospital, Japan

Funnel chest (pectus excavatum) is the most common congenital chest deformity, occurring in approximately 0.13 to 0.7% of births. Patients of pectus excavatum sometimes complain symptoms such as dyspnea on effort, diminished endurance, palpitation and chest pain, as well as cosmetic or psychological impairment. Adult patients tend to have more complaints than pediatric patients. Improvement of physiological data and symptoms after surgical correction of pectus excavatum has been reported for years. The methods for correcting pectus excavatum are the subject of some controversy. Conventional techniques, which were originally described by Ravitch included potentially major invasive procedures. Since Nuss et al. described a new method for repair of pectus excavatum for pediatric patients using a pectus bar, the popularity of this operation has increased. However, a high incidence of complications associated with this method has been reported. We introduce our methods of pectus excavatum repair in which the introduction of exogenous material is not a requirement.

About our patients

From July 1993 to March 2014, 294 patients underwent repair of chest deformity; all of the procedures were performed by a single surgeon. Mean age was 14.6+/-9.0, ranging from 3 to 44 years of age. Three of the patients simultaneously underwent cardiac procedures. The indication for surgery was decided by a visual comparison of the depth and volume of the excavation with the patient's clenched fist. If the depth and volume of the excavation were observed to exceed that of patient's fist, the patient was recommended for surgical repair.

Operative technique

We adopted two types of techniques, both of which were modified from the method described by Wada et al. Sterno-costal elevation (SCE) was used for 283 patients, a group that included all of pediatric patients and adult patients with relatively symmetric deformities. The second technique used was sternal turnover (STO), which was employed for 11 adult patients with severe asymmetric deformities. We have made several modification for SCE, and STO is not performed now.

Sterno-costal elevation (SCE)

In males, a median vertical incision was made superficial to the defect, while in female patients an inframammary incision with upward curvature in the middle was used to reduce scar visibility. A part of the third or fourth to the seventh costal cartilages was resected. All of the stumps of cartilages were reattached to the sternum using surgical 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. The secured ribs pulled the sternum toward both sides, such that the resultant force caused the sternum to raise anteriorly. A triangular resection of the upper anterior sternal cortex, which was made by Ravitch method, was not performed. The sternum exhibits pliability without cortical tearing, especially in pediatric patients. The lower part of the sternum below sixth cartilage junction was resected. In most cases, this part of the sternum was not completely ossified and tilted back toward the vertebrae. This modification made it possible to secure the sixth and seventh costal cartilages to the lower cutting face of the sternum, causing these cartilages to pull the sternum caudally. The resultant force pulled the sternum up ventrally, while protruding costal arches, which were frequently observed in patients with funnel chest, was pulled down and corrected. Since all of the cartilage stumps were secured, the tension exerted by the patient's ribs was enough to flatten and fix the sternum without exogenous materials and cortical osteotomy of upper sternum, but did not disturb respiration. In adult patients with severe asymmetric deformity, oblique groove in sternal cortex was made to correct distorted sternum. The muscles were secured to the position where they were. The repair was completed by suturing the overlying skin.

Fig. 1
Basic surgical technique of sterno-costal elevation (SCE). An area of the fourth to seventh costal cartilages was resected. (marked in blue). The lower part of sternum below sixth cartilage junction was also resected. All of the cartilage stumps were then affixed to the sternum with braided polyester sutures.

Sternal turnover (STO)

STO was employed for adult patients whose sterna were both severely distorted and sufficiently ossified. Incisions of slightly greater length were made essentially in the same sites as in SCE. 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. The lower sternum was turned over and fixed on the upper sternum with an overlap of 1 to 1.5cm. An adequate length of each cartilage was resected, and all of the stumps of cartilages were attached to the plastron in the same manner as achieved in SCE. STO was not performed for more than resent 200 patients including adults. It have been replaced by modified SCE.

Results of the surgery

Mechanical ventilation was not needed after emergence from anesthesia, and all of the patients were returned immediately from the operating room to an ordinary ward, and none of them needed blood transfusion with the exception of two cases who underwent simultaneous cardiac repair. The depression of the anterior chest wall was corrected (Fig. 2-3), asymmetric chest walls reshaped to symmetric (Fig. 4), protruding costal arches were corrected (Fig. 5), in some cases scoliosis was improved, and cardiac shadows observed in chest X-ray returned to near midline (Fig. 6). Chest deformity was remarkably improved in all patients. None of the patients have had fair or poor results. Post operative chest appearance of pediatric patients tend to be better than that of adult patients. The wound was inconspicuous, and most of the patients reported satisfaction with the wound and the shape of the corrected chest. The length of incision was 3.6+/-0.5 cm in patients under seven years old, and 5.2+/-1.2 cm in patients 7 to 14 years old, and 7.2+/-1.7 cm in over 14 years old.

None of the patients developed pneumonia or any life-threatening postoperative complications. One adult female patient developed superficial wound infection at the apical point of the convex inframammary incision. Two patients developed pneumothorax and required tube drainage. No other postoperative complications were seen and no reoperations were required in any of the patients for any reasons. Epidural analgesia was not needed in pediatric patients. Orally-administered analgesia was provided for up to 7 postoperative days in adult patients, as needed. In pediatric patients, analgesia was needed for only 2-3 days following surgery. We believe that none of the patients experienced residual pain.

Pre-adolescent patients were able to return to their preoperative daily activities within a week of surgery, while adult patients took a little bit longer. Our patients need not to use protective or corrective brace. Our patients went back to school or job within one month. We advise our patients to avoid contact sports for three months as a precaution, but in general these patients experience no restrictions on normal activities and do not need to undergo any subsequent surgery. No patient has experienced severe deterioration of chest contour in follow up period.

Fig.2A
Chest of 5 year-old boy with pectus excavatum before surgery.
Fig. 2B
Six month after sterno-costal elevation (SCE). The length of the wound was 3.5 cm. Normal chest contour was seen.

Fig.2C, D
Chest CT scan of the patient fig. 3 before (C) and after (D) SCE.

Fig.3A
Chest of 22 year-old male with Marfan syndrome like figure before surgery.
Fig.3B
Six month after sternal turnover (STO).

Fig.4AB
Chest CT scan of 4 year-old boy before (A) and after (B) SCE. Asymmetric chest walls reshaped to symmetric.

Fig.5A
Chest of 16 year-old male. Protruding costal arches were seen.
Fig.5B
Two weeks after SEC. Protruding costal arches were corrected.

Fig.6
Chest X-ray of the patient of Fig. 2, before (A) and after (B) SCE. Cardiac shadow returned to near midline and scoliosis was improved.

Theories and merits of our methods

We realized that, especially for preadolescent patients, the sternum is quite pliable, and could be corrected without the requirement of turnover, or the insertion of a foreign body. The sternum is pulled laterally by shortened and resutured costal cartilages, and the resultant force raises the sternum ventrally (Fig. 7). 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. None of our patients experienced major complications resulting in an extended hospital stay, needed extensive outpatient treatment or required reoperation for any reason. 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. Because 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 SCE or STO 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 four to seven years of age being the optimal range. Before the onset of puberty, the chest is more malleable, SCE for children usually takes less than two hours to perform, but corrections may take more than twice as long in adults. In addition, after the age of thirty, cartilage becomes more rigid and brittle. Because adult patients may present with a greater number of complaints than children before surgery, we believe that it is important to relieve structural compression of the chest and allow normal growth of the thorax, and 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.

Fig.7
The sternum is pulled laterally by shortened and resutured costal cartilages (green vector), and the resultant force raises the sternum ventrally (red vector).

Histories of funnel chest correction

After Myer et al. reported the correction for pectus excavatum in 1911, various methods have been reported. Most conventional techniques for the repair of pectus excavatum were based on methods described by Ravitch, including a long incision in the anterior chest wall, resection of deformed rib cartilages and the tearing of the sternal cortex. 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. Such procedures can be employed in any age group, but are considered to be invasive.

Wada et al described sternal turnover for pectus excavatum in 1970. We have adapted this technique to make it less invasive.

A revolutionary procedure first reported by Nuss in 1998 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, but has also involved a relatively high morbidity rate. Migration of the bar has been reported in 3.6-8.8% of patients. 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. Reoperation for complications was needed in 4.1-11%. Severe pain is one of the unpleasant complications of Nuss procedure. Sedation and thoracic epidural analgesia is often utilized for several days following the Nuss procedure, and transient Horner's syndrome occurred in 2/3 of patients who received epidural analgesia. Some patients suffered from residual pain and required analgesia for extended periods. We believe that the complications associated with the Nuss procedure may be caused 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, pre-adult patient remains unknown. Because the majority of pectus excavatum corrections are performed in young patients, and candidate 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.

Conclusions

An excellent postoperative chest contour was achieved in most of the patients, and none of our patients developed major complications requiring long-term hospitalization or restriction of normal life. 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.

About Shonan Kamakura General Hospital

Shonan Kamakura Gneral Hospital is located 50km south from Tokyo. All of the hospital costs and surgical cost for the operation of funnel chest are estimated ten thousand US dollar, covered with Japanese health care insurance for Japanese residents.

We are also open for foreigners. We have accredited by Joint Commission International.

If there are further questions, please feel free to ask us. (funnel@shonankamakura.or.jp)

References

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  2. Mansour KA, Thourani VH, Odessey EA, Durham MM, Miller JI Jr, Miller DL. Thirty-year experience with repair of pectus deformities in adults. Ann Thorac Surg 2003;76:391-5.
  3. Fonkalsrud EW, Dunn JCY, Atkinson JB. Repair of pectus excavatum deformities: 30 years of experience with 375 patients. Ann Surg 2000;231:443-8.
  4. Lacquet LK, Morshuis WJ, Folgering HT. Long-term result after correction of anterior chest wall deformities. J Cardiovasc Surg 1998;39:683-8.
  5. Morshuis WJ, Folgering HT, Barentsz JO, Cox AL, van Lier HJ, Lacquet LK. Exercise cardiorespiratory function before and one year after operation for pectus excavatum. J Thorac Cardiovasc Surg 1994;107:1403-9.
  6. Kowalewski J, Brocki M, Dryjanski T, Zolynski K, Koktysz R. Pectus excavatum: increase of right ventricular systolic, diastolic, and stroke volumes after surgical repair. J Thorac Cardiovasc Surg 1999;118:87-93.
  7. Zhao L, Feinberg MS, Gaides M, Ben-Dov I. Why is exercise capacity reduced in subjects with pectus excavatum? J Pediatr 2000;136:163-7.
  8. Ravitch MM. The operative treatment of pectus excavatum. Ann Thorac Surg 1949;129:429-44.
  9. Davis JT, Weinstein S. Repair of pectus deformity: results of the Ravitch approach in the current era. Ann Thorac Surg 2004;78:421-6.
  10. Heller JA Jr, Scherer LR, Turner CS, Colombani PM. Evolving management of pectus excavatum based on a single institutional experience of 664 patients. Ann Surg 1989;209:578-83.
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  12. Park HJ, Lee SY, Lee CS. Complications associated with the Nuss procedure: analysis of risk factors and suggested measures for prevention of complications. J Pediatr Surg 2004;39:391-5.
  13. Croitoru DP, Kelly RE Jr, Goretsky MJ, Lawson ML, Swoveland B, Nuss D. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37:437-45.
  14. Wada J, Ikeda K, Ishida T, Hasegawa T. Results of 271 funnel chest operation. Ann Thorac Surg 1970;10:526-32.
  15. Kasagi Y, Hino T. Operative method of funnel chest. In Wada J, ed. Chest deformities. Tokyo, Japan: Nankodo, 1987:96-105
  16. Iida H, T Sunazawa, Ishida K, et al: Surgical repair of pectus excavatum not requiring exogenous implants in 113 patients. Eur J Cardiothorac Surg. 37: 316-321 2010
  17. Iida H: Surgical repair of pectus excavatum. Gen Thorac Cardiovasc Surg 58: 55-61, 2010

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