The 're-do' chest wall deformity correction

Pectus Excavatum in Cardiac Surgery Patients

BACKGROUND

Pectus excavatum frequently accompanies congenital heart disease and connective tissue diseases requiring cardiac surgery. Sometimes the indication is cardiac repair, with the pectus being incidentally noticed; other times, the pectus subsequently develops or becomes more significant after cardiac surgery. This review arms cardiac and congenital surgeons with background about the physiologic impact of pectus, indications for repair and repair strategies, and outcomes for cardiac surgery patients requiring pectus repair.

METHODS

A comprehensive literature review was performed using keywords related to pectus excavatum, pectus repair, and cardiac/congenital heart surgery within the PubMed database.

RESULTS

The risks of complications related to pectus repair, including in the setting of cardiac surgery or after cardiac surgery, are low in experienced hands, and patients demonstrate cardiopulmonary benefits and symptom relief. Concomitant pectus and cardiac surgery should be considered if it is performed in conjunction with those experienced in pectus repair, particularly given the increased cardiopulmonary impact of pectus after bypass. In the setting of potential bleeding or hemodynamic instability, delayed sternal closure is recommended. For those with anticipated pectus repair after cardiac surgery, the pericardium should be reconstructed for cardiac protection. For those undergoing pectus repair after cardiac surgery without a membrane placed, a "hybrid" approach is safe and effective.

CONCLUSIONS

Patients undergoing cardiac surgery noted to have pectus should be considered for possible concomitant or staged pectus repair. For those who will undergo a staged procedure, a barrier membrane should be placed before chest closure.

Reoperative Pectus Repair Using Biomaterials

BACKGROUND

Reoperation after failed pectus repair, Open or Nuss, is complex. In the majority of patients, metal bars or plates are used. Recently, an absorbable bar (poly-L-lactide [PLA]) was introduced for rib fixation. This series is my experience of using this biomaterial for reoperative pectus surgery.

METHODS

We respectively reviewed the medical records of all patients who were referred to our institution for pectus abnormalities; 180 patients were evaluated, 62 patients (34%) underwent reoperation.

RESULTS

Sixty-two patients underwent reoperative Open repair. Median age was 38 years (range 18-, 72 years); 39 (63%) were men. Thirty-two patients had Open repair for recurrent pectus using posterior sternal support with PLA bars, and 30 patients with acquired restrictive thoracic dystrophy had expansion surgery with multiple PLA bars. Median hospital stay was 7 days (4-21 days). Postoperative complications occurred in 22 patients (35%); late complications in 10 patients (16%); all required reoperation for incisional or soft tissue issues. No patient required reoperation for a pectus or acquired restrictive thoracic dystrophy recurrence. Patient satisfaction was excellent in 85%, good in 8%, fair in 4%, and poor in 3%.

CONCLUSIONS

Reoperative pectus surgery is complex and requires a detailed preoperative evaluation and individualized plan for correction. Use of PLA absorbable bars for sternal support and chest cavity expansion provides a safe alternative. Soft tissue complications are common and reversible; early results are promising in these challenging patients.

Complex corrective procedure in surgical treatment of asymmetrical pectus excavatum

Aim

In this study we analysed the early and late results of surgical treatment of asymmetrical pectus excavatum using complex surgery combining the Ravitch procedure and the Nuss procedure in the same general anaesthesia.

Material and methods

Eighty out of 938 patients with pectus excavatum operated on between 2002 and 2013, 67 males and 13 females aged 11 to 49 years (mean: 19.2), underwent a complex surgical procedure. During surgery the Nuss procedure was usually performed first (one corrective bar was implanted in 35 patients and two bars were inserted in 45 patients). Because of the unsatisfactory cosmetic effect, additionally the Ravitch procedure was started. The bars were electively removed 3 years after the primary operation.

Results

No mortality was observed in the early postoperative period. Non-life-threatening and transient postoperative complications occurred in 44 (55%) patients. The most common was pleural effusion (21%), which in 50% of patients required pleural drainage. A satisfactory and stable correction effect was achieved in 88% of cases. Six of those patients required repeat surgery due to recurrence of deformity.

Conclusions

A complex corrective procedure is a successful method of surgical treatment in patients with asymmetrical pectus excavatum and is characterized by satisfactory postoperative results. The use of corrective bars enhances the cosmetic effect. The frequency of early, mostly non-life-threatening postoperative complications after a complex procedure is insignificantly higher than that after the Nuss procedure.

Effects of platelet-rich plasma on cartilage regeneration after costal cartilage resection: a stereological and histopathological study

BACKGROUND

In cases of congenital chest wall deformities, it is important to maintain the flexibility of the chest wall after rib cartilage resection. In this study, we aimed to determine the regeneration capability of cartilage and the effects of platelet-rich plasma (PRP) on the regeneration process.

METHODS

A total of 16 four-week-old New Zealand rabbits were used in this study. In the 4th-5th right costal cartilages, the perichondrial sheaths were dissected and costal cartilages were excised. Then, the perichondrial sheaths were closed with absorbable material in the sham group (n = 8), and this was done after replacing PRP in the PRP group (n = 8). The left costal cartilages of the animals were used as controls. The volumes of the costal cartilages and their perichondrial sheaths were estimated using Cavalieri's principle. In addition, the mean numerical densities of the chondroblasts and chondrocytes per square millimetre were estimated using unbiased counting frames.

RESULTS

In the PRP and sham groups, the volumes of the cartilages and perichondrial sheaths were higher than those of the control group (p < 0.05). The numerical densities of the chondroblasts and chondrocytes increased more in the PRP group than in the sham group (p < 0.05).

CONCLUSIONS

Applying PRP after resection may provide better healing and faster regeneration of cartilage.

Nuss procedure for repair of pectus excavatum after failed Ravitch procedure in adults: indications and caveats

BACKGROUND

Recurrence of pectus excavatum (PE) is not an uncommon problem after open repair using the Ravitch technique. The optimal approach for redo surgery is still under debate, especially in adults with less chest wall pliability. Aim of this study was to investigate the usefulness and efficacy of the minimally invasive Nuss technique for repair of recurrent PE after conventional open repair.

METHODS

We performed a retrospective multicentre review of 20 adult patients from University Hospital Bern (n=6) and the US Mayo Clinic (n=14) who underwent minimally invasive repair of recurrent PE after unsuccessful prior Ravitch procedure.

RESULTS

Mean patient age at primary open correction was 21 years, with recurrence being evident after a mean duration of 10.5 years (range, 0.25-47 years). Mean age at redo surgery using the Nuss technique was 31 years, with a mean Haller index of 4.7 before and 2.5 after final correction. Main reason for redo surgery was recurrent or persistent deformity (100%), followed by chest pain (75%) and exercise intolerance (75%). No major intraoperative or postoperative complications occurred and successful correction was possible in all patients.

CONCLUSIONS

Although the procedure itself is more challenging, the minimally invasive Nuss technique can be safely and successfully used for repair of recurrent PE after failed open surgery. In our series final results were good to excellent in the majority of patients without major complications or recurrence.

Revision of failed, recurrent or complicated pectus excavatum after Nuss, Ravitch or cardiac surgery

Pectus excavatum (PE) can recur after both open and minimally invasive repair of pectus excavatum (MIRPE) techniques. The cause of recurrence may differ based on the initial repair procedure performed. Recurrence risks for the open repair are due to factors which include incomplete previous repair, repair at too young of age, excessive dissection, early removal or lack of support structures, and incomplete healing of the chest wall. For patients presenting after failed or recurrent primary MIRPE repair, issues with support bars including placement, number, migration, and premature removal can all be associated with failure. Connective tissue disorders can complicate and increase recurrence risk in both types of PE repairs. Identifying the factors that contributed to the previous procedure's failure is critical for prevention of another recurrence. A combination of surgical techniques may be necessary to successfully repair some patients.

Contemporary management of recurrent pectus excavatum

BACKGROUND

Optimal management of recurrent pectus excavatum (PE) has not been established. Here, we review our institutional experience in managing recurrent PE to evaluate long-term outcomes and propose an anatomic classification of recurrences, and a decision-making algorithm.

METHODS

Clinical records of patients undergoing repair of recurrent PE (1996-2011) were reviewed. Univariate and multivariate logistic regression analyses were employed to examine patient characteristics as potential predictors for re-recurrence.

RESULTS

Eighty-five patients with recurrent PE were identified during the study period. The initial operation was a Ravitch procedure in 85% of cases. Revision procedures were most frequently Nuss repairs (N=73, 86%), with remaining cases managed via open approach. Overall cosmetic and functional results were satisfactory in 67 patients (91.8%) managed with Nuss and in 7 (58%) patients managed with other techniques. Seven (8%) patients required additional surgical revision. Multivariate analysis identified no statistically significant patient or procedural factors predictive of re-recurrence.

CONCLUSION

This study demonstrates that the Nuss procedure can be an effective intervention for recurrent pectus excavatum, regardless of the initial repair technique. However, open repair remains valuable when managing severe cases with abnormalities of the sternocostal junction and cartilage regrowth under the sternum.

Anesthesia and analgesia for pectus excavatum surgery

The technique of choice for surgical correction of pectus excavatum is the Nuss procedure, a minimally invasive technique in which rigid metal bars are placed transthoracically beneath the sternum and costal cartilages until permanent remodeling of the chest wall has occurred. Intraoperatively, anesthesia focuses on three areas: the potential for catastrophic blood loss caused by perforation of large capacitance vessels and the heart, the potential for malignant arrhythmias, and the consequences of bilateral iatrogenic pneumothoraces. Postoperatively, analgesia is institutionally dependent and controversial, based on usage and type of regional anesthesia. The necessity of multimodal analgesic techniques creates a common ground across different hospital systems.

Modified Nuss procedure is a safe choice for recurrent pectus excavatum after previous open repair experience of 26 cases

PURPOSE

This study is aiming to investigate the feasibility and effect of applying modified Nuss procedure on recurrent pectus excavatum following previous open repair.

METHODS

By retrospectively reviewing patients of pectus excavatum enrolled in our department from July 2007 to August 2012, we find 27 cases of recurrent PE who received open repair previously. Twenty-six patients received Nuss repair, while one patient refused. Relevant data are collected and processed. A 3-month follow-up after operation is also reviewed. Analysis of data is conducted.

RESULTS

Twenty-six recurrent patients underwent modified Nuss procedure safely. Pneumothorax after operation occurred in one case. Pleural effusion occurred for every case, most were mild in quantity except two cases whose pleural effusion were moderate. All patients left hospital within 2 weeks after operation except one patient who died of respiration failure. Mean postoperative Haller Index is significantly different from the preoperative one. Cosmetic effect was excellent for 5 cases, good for 15 cases, moderate for 6 cases. In a 3-month follow-up, no bar displacement or rejection happened and pleural effusion was completely absorbed.

CONCLUSION

Although technically challenging, Nuss procedure is feasible and good for recurrent PE after open repair.

Modified Nuss procedure in the treatment of recurrent pectus excavatum after open repair

OBJECTIVES

The purpose of this study was to evaluate the efficacy of the modified Nuss procedure with a subxiphoid incision in correcting recurrent pectus excavatum.

METHODS

From August 2006 to July 2010, 28 patients with recurrent pectus excavatum underwent a secondary repair using the modified Nuss procedure with a subxiphoid incision and bilateral thoracoscopy. Data concerning symptoms, operative course, complications, pulmonary function and early outcome were recorded.

RESULTS

Prior repairs of the reoperation patients included 16 Ravitch, 9 modified Ravitch and 3 sterno-turnover procedures. The median Haller index was 4.52 for the redo patients. Presenting symptoms included decreased endurance, dyspnoea on exertion, chest pain, frequent respiratory infections and palpitations. The median duration of reoperation was slightly longer than that of the primary surgeries. Blood loss and postoperative hospitalization were similar between groups. Complications from pectus reoperations included pneumothorax, pleural effusion, postoperative pain and wound infection in the lateral incision. There were no perioperative deaths or cardiac perforations. Initial postoperative results varied from excellent to good. The patients were followed up for 24-74 months. No steel bar malposition or stabilizer displacement was found in any case.

CONCLUSIONS

The modified Nuss procedure with subxiphoid incision and bilateral thoracoscopy can avoid cardiac injury to the greatest degree. It would be a minimally invasive and safe approach for patients with recurrent pectus excavatum after failed open repair.

Pectus excavatum and MASS phenotype: an unknown association

INTRODUCTION

Severe pectus excavatum (PE) is a deep chest wall deformity that generates both a cosmetic damage and a cardiac/respiratory function impairment. Excluding the scarce reports on Marfan's syndrome (MFS) and Ehlers-Danlos's syndrome (EDS), few studies have examined the relation between severe PE and connective tissue disorders. The aim of this study is to verify the clinical significance of such correlation.

SUBJECTS AND METHODS

Ninety-two consecutive patients, of whom 79 were males, between 6 and 34 years old, classified as having severe PE, were seen at our institution from June 2005 to September 2010. All patients underwent clinical, ophthalmological, cardiac, and radiological (chest and spine magnetic resonance imaging) screening. The following features were observed: skin stretch marks, scoliosis, joint hypermobility, echocardiographic signs, spinal defects, and myopia.

RESULTS

Classical connectivopathies such as MFS or EDS were present in only 5 patients (approximately 5%), whereas a single deformity was present in 4. The largest group (approximately 71%) was represented by phenotypical alterations such as mitral valve prolapse, aortic root enlargement, and skeletal and skin alterations (MASS). Among those patients, the most frequent clinical manifestations were the skeletal ones, followed by skin marks and mitral valve prolapse.

CONCLUSIONS

PE showed an evident association with an array of features that we describe as MASS. Although not one of this subgroup of patients has been described with increased aortic root diameter when screened (a feature widely present in MFS patients), they probably would require a thorough and longer follow-up than those affected by isolated PE because of the potential occurrence of severe cardiovascular complications such as aneurysms and dissection, which are major causes of morbidity and mortality in MFS.

One hundred patients with recurrent pectus excavatum repaired via the minimally invasive Nuss technique--effective in most regardless of initial operative approach

PURPOSE

Controversy exists as to the best operative approach to use in patients with failed pectus excavatum (PE) repair. We examined our institutional experience with redo minimally invasive PE repair along with the unique issues related to each technique.

METHODS

We conducted an institutional review board-approved review of a prospectively gathered database of all patients who underwent minimally invasive repair of PE.

RESULTS

From June 1987 to January 2010, 100 patients underwent minimally invasive repair for recurrent PE. Previous repairs included 42 Ravitch (RAV) procedures, 51 Nuss (NUS) procedures, 3 Leonard procedures, and 4 with previous NUS and RAV repairs. The median Haller index at reoperation was 4.99 (range, 2.4-20). Fifty-five percent of RAV patients and 25% of NUS patients required 2 or more bars (P = .01). Two RAV patients had intraoperative nonfatal cardiac arrest owing to thoracic chondrodystrophy--1 at insertion and 1 upon removal. Bar displacements occurred in 12% RAV and 7.8% NUS patients (P = .05). Overall reoperation for bar displacement is 9%.

CONCLUSIONS

The minimally invasive NUS technique is safe and effective for the correction of recurrent PE. Patients with prior NUS repair can have extensive pleural adhesions necessitating decortication during secondary repair. Patients with a previous RAV repair may have acquired thoracic chondrodystrophy that may require a greater number of pectus bars to be placed at secondary repair and greater risk for complications. We have a greater than 95% success rate regardless of initial repair technique.

Retrospective review of reoperative pectus excavatum repairs

BACKGROUND/PURPOSE

Despite success of several techniques described for pectus excavatum repair, a minority of patients require multiple reoperations for recurrence or other complications. We aimed to review our experience in reoperative pectus excavatum repairs and to identify features correlating with need for additional reoperations.

METHODS

Charts were reviewed of all patients undergoing reoperative pectus excavatum repair for 3 years at a university-based children's hospital. Number and type of previous repairs, time between operations, lengths of stay, analgesia, and complications were recorded.

RESULTS

From February 2004 to December 2007, 170 pectus excavatum repairs were performed. Among these, 27 were reoperative. Overall, 18.2% of reoperative patients required subsequent additional reoperations. 21.1% of patients undergoing repeat open repairs and 33.3% of patients undergoing repeat minimally invasive repairs required further operative interventions. There was no need for additional repairs among patients who had open repairs after minimally invasive repairs, nor for any patients who had minimally invasive repairs after open repairs.

CONCLUSIONS

We conclude that patients with failed open repairs will have better success with minimally invasive reoperations, whereas patients with failed minimally invasive repairs will have better success with open reoperations. When faced with reoperative pectus excavatum, we recommend consideration of an alternative operative approach from the initial procedure.

Pectus bar repair of pectus excavatum in patients with connective tissue disease

PURPOSE

Few studies address the surgical correction of pectus excavatum (PE) in patients with connective tissue disease (CTD). We have identified the preoperative characteristics, postoperative complications, and outcomes of patients with CTD undergoing bar repair of PE and compared these outcomes to a control group without CTD.

METHODS

A retrospective review of patients undergoing primary repair of PE with a bar procedure from 1997 to 2006 identified 22 patients with CTD. Of those, 20 (90.9%) had their bars removed. We identified 223 patients of similar age without CTD whose bars were removed. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes.

RESULTS

Among those with CTD, the median age at repair was 15.5 years, with a mean pectus index of 4.0 +/- 1.4. Three patients (13.6%) experienced bar displacement or upper sternal depression requiring surgical revision. Only 1 patient recurred after bar removal. Rates of bar displacement, upper sternal depression, and recurrence were not statistically different than those in the comparison group.

CONCLUSIONS

Patients with CTD benefit from primary bar repair of PE and experience excellent operative outcomes after repair, with complication rates being no different than those found in similarly aged control patients.

Pectus excavatum: historical background, clinical picture, preoperative evaluation and criteria for operation

Pectus excavatum is a depression of the sternum and costal cartilages which may present at birth, or more commonly during the teenage growth spurt. Symptoms of lack of endurance, shortness of breath with exercise, or chest pain are frequent. Although pectus excavatum may be a component of some uncommon syndromes, patients usually are healthy. Evaluation should include careful anatomic description with photographs, radiography to demonstrate the depth of the depression, extent of cardiac compression, or displacement, measurement of pulmonary function, and echocardiography to look for mitral valve prolapse (in 15%) or diminished right ventricular volume. Indications for surgical treatment include two or more of the following: a severe, symptomatic deformity; progression of deformity; paradoxical respiratory chest wall motion; computer tomography scan with a pectus index greater than 3.25; cardiac compression/displacement and/or pulmonary compression; pulmonary function studies showing restrictive disease; mitral valve prolapse, bundle branch block, or other cardiac pathology secondary to compression of the heart; or failed previous repair(s). The developmental factors, genetics, and physiologic abnormalities associated with the condition are reviewed.

The effect of costal cartilage resection on the chest wall development: a morphometric evaluation

OBJECTIVE

In repair of thoracic wall deformities, there is a debate in the literature regarding the optimal age and the type and number of costal cartilage resections. We evaluated the effect of costal cartilage resections on the chest wall development in young rabbits.

METHODS

Fifty apparently healthy, 6 weeks of age, male New Zealand white rabbits were evaluated in five groups, each including 10 subjects. Group 1 served as control for the observation of normal thoracic development. Rabbits in group 2 underwent partial and rabbits in group 3 underwent total resections of the right third and fourth costal cartilages; those in group 4 underwent partial and rabbits in group 5 underwent total resections of the right third to sixth costal cartilages. Anteroposterior, horizontal and vertical diameters of the chest were measured before operation and repeated at 24 weeks of age.

RESULTS

Upper and lower anteroposterior diameters of the thoracic wall and horizontal diameters of the left hemithorax differed significantly among groups (p=0.011, p=0.004, and p=0.002, respectively). Upper anteroposterior diameter was 49 mm in group 1 and 44 mm in group 3 (p=0.009). Lower anteroposterior diameter in group 5 (66 mm) was significantly less than that in group 1 (70 mm) (p=0.039) and there was also a statistically significant difference between group 4 (71 mm) and group 5 (66 mm) (p=0.002). Horizontal diameters of the left hemithorax in group 3 (32 mm; p=0.005) and 5 (32 mm; p=0.008) were significantly different when compared to group 1 (26 mm). Growth in right hemithorax was statistically less than that in left side in all operated groups except in group 2.

CONCLUSIONS

Thoracic resections in young rabbits have demonstrated that the costal cartilage resection is not an innocent procedure as it severely affects the chest wall development especially in anteroposterior direction and the thoracic growth is markedly retarded when growth centers of the ribs are not preserved and/or four or more ribs are resected.

The minimally invasive Nuss technique for recurrent or failed pectus excavatum repair in 50 patients

PURPOSE

The aim of this study was to demonstrate the efficacy of the minimally invasive technique for recurrent pectus excavatum.

METHODS

Fifty patients with recurrent pectus excavatum underwent a secondary repair using the minimally invasive technique. Data were reviewed for preoperative symptomatology, surgical data, and postoperative results.

RESULTS

Prior repairs included 27 open Ravitch procedures, 23 minimally invasive (Nuss) procedures, and 2 Leonard procedures. The prior Leonard patients were also prior Ravitches and are therefore counted only once in the analyses. The median age was 16.0 years (range, 3-25 years). The median computed tomography index was 5.3 (range, 2.9-20). Presenting symptoms included shortness of breath (80%), chest pain (70%), asthma or asthma symptoms (26%), and frequent upper respiratory tract infections (14%). Both computed tomography scan and physical exam confirmed cardiac compression and cardiac displacement. Cardiology evaluations confirmed cardiac compression (62%), cardiac displacement (72%), mitral valve prolapse (22%), murmurs (24%), and other cardiac abnormalities (30%). Preoperative pulmonary function tests demonstrated values below 80% normal in more than 50% of patients. Pectus repair was done using a single pectus bar (66%), 2 bars (32%), or 3 bars (2%). Stabilizers were used in 88% of the patients. Median length of surgical time did not significantly differ from that of primary surgeries. Complications were slightly higher than those in primary repairs and included pneumothorax requiring chest tube (14%), hemothorax (8%), pleural effusion requiring drainage (8%), pericarditis (4%), pneumonia (4%), and wound infection (2%). There were no deaths or cardiac perforations. Initial postoperative results were excellent in 70%, good in 28%, and fair in 2%. Late complications of bar shift requiring revision occurred in 8%. Seventeen patients have had bar removals with 9 patients being more than 1 year postremoval. For the 17 patients who are postremoval, excellent results have been maintained in 8 (47%), good in 7 (41%), fair in 1 (6%), and failed in 1 (6%). There have been no recurrences postremoval.

CONCLUSIONS

Although failed or recurrent pectus excavatum repairs are technically more challenging, reoperative correction by the Nuss procedure has met with excellent success.

Recurrent chest wall anomalies

Chest wall anomalies are a heterogeneous group of malformations requiring repair. Recurrence and the need for secondary repair may occur. Congenital anomalies, including bifid sternum, pentalogy of Cantrell, Jeunes's syndrome and Poland's anomaly, rarely recur. Pectus carinatum may recur in the original surgical area or an adjacent area and most often recurs in patients who undergo repair before completion of teenage growth. Pectus excavatum may recur in approximately 5% of patients. Simple recurrence, floating sternum, or Acquired Jeune's syndrome may result. All of these would require reoperation. Each chest wall anomaly recurrence requires an individualized approach to timing and type of repair. Overall excellent results should be obtained for operative repair of recurrences.

Repair of Recurrent Pectus Deformities

A paucity of information is available regarding the surgical repair of recurrent pectus deformities (RPD). From 1993 through 2001 35 patients ranging in age from 6 to 51 years (mean, 23 years) underwent repair of RPD a mean of 11 years after the original repair: modified Ravitch repair (31), prosthetic implantation (three), and Nuss procedure (one). All patients had accompanying symptoms including decreased stamina (76%), chest discomfort (53%), asthma (33%). The repair performed was dependent on the findings at operation. A modified Ravitch procedure with Adkins strut was performed for 21 patients. Three had reattachment of mobile costal cartilages and/or xiphoid process to the sternum; three patients had autologous bone or cartilage grafts, three had muscular reconstruction, and two had resection of a localized cartilage protrusion. Three patients could not be reconstructed safely. Very good to excellent results were achieved for 32 patients (mean follow-up, 24.8 months). There were no deaths or major complications. Minor complications occurred in five patients. The mean blood loss was 105 mL. The mean hospital stay was 2.8 days. We conclude that although it is technically difficult RPD can be repaired with low morbidity, short hospital stay, and very good physiologic and cosmetic results.

Minimally invasive bar repair for 'redo' correction of pectus excavatum

BACKGROUND/PURPOSE

A small percentage of patients who have undergone traditional, "Ravitch-type" pectus excavatum repair present with unsatisfactory results and require a second procedure for correction. Reoperative open surgery for pectus excavatum has been associated with extensive dissection and substantial blood loss. The minimally invasive (MIS) bar repair for the correction of pectus excavatum has been gaining acceptance. This study evaluates the authors results with patients who have undergone the MIS bar repair for redo correction of their pectus excavatum.

METHODS

A retrospective chart review of all patients undergoing MIS bar repair between December 1997 and August 2001 was performed. Information about demographics, deformity, operative course, complications, and early outcome was recorded.

RESULTS

Ninety-two patients underwent MIS repair during this period. Ten patients had redo MIS bar repair for unsatisfactory prior open correction. Operating time was 52 minutes for standard patients and 70 minutes for the redo patients (P <.001). Blood loss and postoperative hospitalization were similar between groups.

CONCLUSION

The minimally invasive pectus repair can be performed safely with minimal blood loss and short operating time in patients who have undergone prior unsatisfactory open repair of pectus excavatum and can be an alternative approach to reoperative open repair in these patients.

Management of a floating sternum after repair of pectus excavatum

PURPOSE

The aim of this study was to examine the authors' experience with patients who have floating sternum after correction of pectus excavatum via the classical Ravitch procedure. A floating sternum is defined as a sternum in which the only attachment to the chest wall is its superior (cranial) border, and in which the body is secured only by the manubrium and whatever lateral and inferior fibrous bands are present. Typically, a floating sternum is caused by either extensive resection of the costal cartilages and perichondrium during correction of pectus excavatum or failure of proper regrowth of these cartilages.

METHODS

The authors retrospectively assessed the charts of all patients diagnosed with a floating sternum noting age at original correction of pectus excavatum, time from original correction of pectus excavatum to diagnosis of floating sternum, age at correction of floating sternum, complaints before stabilization of the sternum, methods of repair, and postoperative complications.

RESULTS

Between July 1993 and June 1999, floating sternum was diagnosed in 7 patients. The mean age of patients who underwent operative correction of a floating sternum was 28.9 years (range, 16 to 42 years). The mean time interval between original correction of pectus excavatum, or "redo," and diagnosis of a floating sternum was 9.9 years (range, 2 to 20 years). Complaints before correction of the floating sternum included sternal pain and instability, exercise intolerance, and difficulty breathing. Operative repair consisted of mobilizing the lateral and inferior edges of the sternum, detaching the fibrous perichondrium, performing anterior sternal osteotomies, and finally supporting the sternum with substernal Adkins struts. All 7 patients had successful stabilization of the sternum. Two of 7 patients underwent 2 procedures to successfully stabilize the sternum. One patient has Adkins struts still in place because of hematopoetic malignancy. Six of 7 patients are now without symptoms.

CONCLUSIONS

A floating sternum is a morbid phenomenon that may manifest many years after the original procedure. It can cause significant sternal pain, chest wall instability, and respiratory dysfunction, which are the hallmark indications for correction. Repair of a floating sternum can be accomplished successfully.