Pectus excavatum

A Modfied Nuss Procedure for Recurrent Pectus Excavatum of Adults

Background

Limited data exist for adults with recurrent pectus excavatum (PE) treated with minimally invasive surgical repair.

Methods

Between July 2008 and December 2020, forty-two adult patients with recurrent PE underwent a modified Nuss procedure with a newly designed bar in our center. A small vertical subxiphoid incision was used to separate severe adhesions when necessary. Multiple steel wires were sutured, and the rib space was narrowed to firmly fix the bar. The primary end point was Haller index change after operation. The secondary end points included length of stay after operation, short-term and long-term complications.

Results

The mean patient age was 22.02 ± 3.49 years. The mean Haller index was 4.59 ± 1.09. A subxiphoid incision was performed in 12 patients. Thirty-nine patients had one bar placed, and 3 patients required two bars. Sixteen patients had 3 or more wires fixation, and 4 patients needed to have their intercostal space narrowed. There was no perioperative death, and the mean hospitalization was 5.57 ± 2.47 days. The Haller index reduced to 3.03 ± 0.41 after the operation (t = 11.85, p < 0.001). During the follow-up, there were 3 patients who developed non-infective wound effusion; bar rotations occurred in 3 patients. Twenty patients had the bar removed, post-bar removal Haller index was significantly reduced compared to the preoperative Haller index (2.89 ± 0.37 vs. 4.72 ± 1.05, t = 8.96, p < 0.001).

Conclusions

The modified Nuss procedure with a new titanium alloy bar can achieve good results for adult patients with recurrent PE.

Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum

This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric=0-21; adult 17-99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.

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.

Comparative pulmonary functional recovery after Nuss and Ravitch procedures for pectus excavatum repair: a meta-analysis

Background

Pectus excavatum (PE) is a common chest wall malformation, with surgery being the only method known to correct the defect. Although the Nuss and Ravitch procedures are commonly used, there is no consensus as to whether surgical repair improves pulmonary function. We therefore investigated whether pulmonary function recovers after surgical repair, and if recovery is dependent on the type of procedure or time after surgery.

Methods

Literature searches were performed using PubMed, EMBASE, Health Periodicals Database, and CNKI (Chinese National Knowledge Index) from January 1990 to December 2007. The following keywords were used: pectus excavatum, chest wall deformity, funnel chest, pulmonary function, respiratory, lung function, and pectus severity index. The primary outcome of interest was possible changes in pulmonary function following surgical repair.

Results

Meta-analysis of 23 studies showed that, although there was evidence of statistically significant heterogeneity among studies (Chi-square, 17.11, p < 0.05), changes in pulmonary functional indices, including forced expiratory volume over 1 s (FEV1), forced vital capacity (FVC), vital capacity (VC), and total lung capacity (TLC), were similar 1 year after the Ravitch and Nuss procedures. Several years after surgery and bar removal, however, the changes in pulmonary functional indices significantly favored the Nuss procedure.

Conclusions

Pulmonary function tends to improve after the surgical correction of pectus excavatum. Although the Nuss procedure was not significantly better 1 year after surgery, long-term postoperative pulmonary function improvement was significantly better after bar removal.

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.

Evaluation of the Nuss procedure using pre- and postoperative computed tomographic index

BACKGROUND

Objective assessment of the chest in patients with pectus excavatum after the Nuss procedure has not been published. This study evaluated the results of the Nuss procedure using computed tomographic (CT) index (CTi).

METHODS

We have performed the Nuss procedure in 382 patients since 1998, and 150 patients who underwent bar removal were included in this study. Computed tomographic scans were obtained before the Nuss procedure and after bar removal, and then preoperative CTi (pre-CTi) and postoperative CTi (post-CTi) were calculated. Computed tomographic scans of 62 age-matched patients without chest deformity were collected as controls. Patients were divided at 10 years of age into the younger and older groups, and groups with mild and severe deformity were defined using a pre-CTi value of 5 as border. These CT indices were compared and statistically analyzed.

RESULTS

Mean pre-CTi in all cases was 5.97 +/- 3.31 and improved to 3.08 +/- 0.64. Postoperative CTi was not significantly different from that of the control (2.47 +/- 0.32, P = .17). In the group with mild depression, pre-CTi was 4.15 +/- 0.62, and post-CTi was 2.88 +/- 0.50. Preoperative CTi in the group with severe deformity (7.44 +/- 3.82) improved to 3.25 +/- 0.69. Postoperative CTi values between the severe and mild groups were not significantly different (P = .75). Computed tomographic index of the young group improved from 6.20 +/- 3.58 to 2.93 +/- 0.49 and in older group from 5.50 +/- 2.64 to 3.40 +/- 0.79. These 2 post-CTi values were not significantly different (P = .73).

CONCLUSION

Postoperative CT scan could provide objective evaluation of sternal elevation. Mean CTi after the Nuss procedure was statically equivalent to that of the control cohort. Good sternal elevation can be achieved with the Nuss procedure regardless of the severity of chest depression or age.

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.

Prospective Multicenter Study of Surgical Correction of Pectus Excavatum: Design, Perioperative Complications, Pain, and Baseline Pulmonary Function Facilitated by Internet-Based Data Collection

BACKGROUND

Given widespread adoption of the Nuss procedure, prospective multicenter study of management of pectus excavatum by both the open and Nuss procedures was thought desirable. Although surgical repair has been performed for more than 50 years, there are no prospective multicenter studies of its management.

STUDY DESIGN

This observational study followed pectus excavatum patients treated surgically at 11 centers in North America, according to the method of choice of the patient and surgeon. Before operation, all underwent evaluation with CT scan, pulmonary function tests, and body image survey. Data were collected about associated conditions, hospital complications, and perioperative pain. One year after completion of treatment, patients will repeat the preoperative evaluations. This article addresses early results only.

RESULTS

Of 416 patients screened, 327 were enrolled; 284 underwent the Nuss procedure and 43 had the open procedure. Median preoperative CT index was 4.4. Pulmonary function testing before operation showed mean forced vital capacity of 90% of predicted values; forced expiratory volume in 1 second (FEV(1)), 89% of predicted; and forced expiratory flow during the middle half of the forced vital capacity (FEF(25% to 75%)), 85% of predicted. Early postcorrection results showed that operations were performed without mortality and with minimal morbidity at 30 days postoperatively. Median hospital stay was 4 days. Postoperative pain was a median of 3 on a scale of 10 at time of discharge; the worst pain experienced was the same as was expected by the patients (median 8), and by 30 days after correction or operation, the median pain score was 1. Because of disproportionate enrollment and similar early complication rates, statistical comparison between operation types was limited.

CONCLUSIONS

Anatomically severe pectus excavatum is associated with abnormal pulmonary function. Initial operative correction performed at a variety of centers can be completed safely. Perioperative pain is successfully managed by current techniques.

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.

Índice antropométrico para classificação quantitativa do pectus excavatum

INTRODUÇÃO: O pectus excavatum caracteriza-se por uma depressão do esterno e das cartilagens para-esternais inferiores. Medidas clínicas para classificar essas depressões são poucas e de difícil aplicação. OBJETIVO: Criar medidas clínicas para quantificar a deformidade e poder comparar os resultados entre os períodos pré e pós-operatório. MÉTODO: Dez pacientes portadores de pectus excavatum, foram operados utilizando-se a técnica de Robicsek modificada pelo grupo de Cirurgia Torácica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, sendo também medidos clínica e radiologicamente nos periodos pré e pós operatõrio. Dez pacientes controles que não apresentavam anormalidades torácicas clínicas e ou radiológicas foram medidos da mesma forma. O defeito foi avaliado no nível do manúbrio e da maior deformidade através do índice antropométrico e do índice de Haller. RESULTADOS: A análise multivariada para as médias do índice antropométrico mostrou diferenças significativas entre o pré operatório e o grupo controle e entre as médias do pré e do pós operatório, e diferença não significativa entre o pós operatório e o grupo controle. A mesma análise, aplicada às médias do índice de Haller, demonstrou os mesmos resultados. O estudo pareado entre as médias do pré e do pós operatório mostrou tratarem-se de grupos diferentes. A correlação canônica evidenciou que o índice antropométrico e o índice de Haller têm correlação de 86%. CONCLUSÃO: Pacientes portadores de pectus excavatum podem ter a deformidade quantificada através de medidas do índice antropométrico no pré e no pós operatório, as quais permitem uma avaliação objetiva e comparativa dos resultados, e são de fácil realização.

Pectus Excavatum / Pectus Carinatum: tratamento cirúrgico

OBJETIVO: Apresentar os resultados obtidos com técnica única para tratamento do Pectus Excavatum e Pectus Carinatum. MÉTODO: De 1976 a 2000 foram operados, 183 portadores de Deformidades da Parede Torácica Anterior sendo 98 Pectus Carinatum (70 P. Carinatum Simétrico, 18 P. Carinatum Lateral a Direita e 10 P. Carinatum Lateral a esquerda), 62 Pectus Excavatum (57 P. Excavatum Simétrico, 4 P. Excavatum Lateral a Direita e um P. Excavatum Lateral a Esquerda), 17 Pectus Carinatum Superior, um Pectus Combinado, quatro Protusões Costais Inferiores e uma Depressão Costal. A indicação foi exclusivamente estética em 182 (99,4%) dos pacientes. Foi utilizada técnica única para Pectus Carinatum e Pectus Excavatum: incisão transversal inframamária; ressecção subpericondral de todas as cartilagens envolvidas na deformidade; dissecção retroesternal mínima; osteotomia esternal anterior, fixação da osteotomia esternal com fios de aço;utilização da placa retroesternal em casos selecionados de Pectus Excavatum; pregueamento dos feixes pericondriais para dar maior rigidez a parede torácica e auxílio na manutenção do esterno na sua posição; drenagem do tecido celular subcutâneo e do plano submuscular, sutura intradérmica da pele. RESULTADOS: Bom ou excelente em 175 (95,6%) dos pacientes. Complicações ocorreram em 14 (7,6%) pacientes: oito casos (4,5%) de seroma; um (0,5%)hematoma de parede; dois (1,0%) caso de dor torácica intensa no pós-operatório; um(1,0%) caso de deiscência parcial da sutura da pele e dois casos (1,0%) de cicatriz hipertrófica que foram tratados com ressecção e betaterapia. CONCLUSÃO: Pelos resultados estéticos alcançados, a esternocondroplastia apresentada está indicada para correção de Pectus Excavatum/Carinatum.

Treatment of pectus excavatum with bioabsorbable polylactide plates: Preliminary results

BACKGROUND/PURPOSE

Pectus excavatum usually is corrected by thoracoplasty using metal plates. Recently bioabsorbabe polylactide plates have been developed. The aim of this study was to compare outcome after use of metal and bioasorbable plates in thoracoplasty performed for correction of pectus excavatum.

METHODS

Eighty-three children (<16 years old) underwent thoracoplasty (Sulamaa's technique). In 75 patients, metallic plates, and in 8 patients, self-reinforced poly-L-lactide (SR-PLLA) plates, were used. Seven patients in the SR-PLLA group and 13 patients in the metal plate group were assessed 0.5 to 13 years postoperatively.

RESULTS

The mean operating time was 121 minutes in the metal plate group, and 87 minutes in the SR-PLLA plate group. In the metal plate group, complications were pain caused by instability of the metal plates (n = 17), wound infection (n = 3), recurrence of deformity (n = 3), postoperative pain (n = 3), pneumothorax (n = 1), and nonspecific postoperative fever (n = 1). Thirteen patients underwent reoperation to refix the position of the metallic plates. In the SR-PLLA group, one case of pneumothorax occurred, and plate fragment palpability caused local pain in one patient. Cosmetic results and lung function values were similar.

CONCLUSION

Our preliminary results show that bioabsorbable plates are a useful option in the treatment of pectus excavatum in children.

Early and long-term results of surgical repair of pectus excavatum

From 1990 to 1998, 30 patients underwent surgery for correction of pectus excavatum. There were 19 (63%) males and 11 (37%) females, aged 4 to 32 years (mean, 12.57 years). Bilateral excision of 4 to 6 costal cartilages and sternal wedge osteotomy were performed on 27 (90%) patients, and Kirschner wires were used for substernal support in 25 (83%). A median sternotomy was carried out in males and a submammary transverse incision was preferred in females. All patients were followed up at yearly intervals. Early results were excellent in all except 2 cases: a 14-year-old boy developed contralateral sternal depression after costochondral excision without sternal elevation for correction of one-sided costochondral hyperplasia; and an 8-year-old girl in whom no Kirschner wires had been inserted developed recurrent minimal sternal depression. Long-term follow-up showed recurrent sternal depression 6 years postoperatively in a boy who had undergone surgery at 4 years old, with early removal of the Kirschner wires. It is recommended that correction of pectus excavatum should be carried out in prepubertal children, and Kirschner wires should be used for substernal support.

Long-term observation in 68 patients operated on for pectus excavatum: surgical repair of funnel chest

BACKGROUND

Recurrence after correction of pectus excavatum may sometimes occur, but its origin is not clear. The type of deformity, surgical technique, and patient lifestyle after operation can all affect the final shape of the thorax. The purpose of the present study was to compare the short-, medium-, and long-term cosmetic results of funnel chest repair.

METHODS

Sixty-eight patients (mean age, 12.1+/-5.4 years; 48 male) were operated on for pectus excavatum using the same surgical technique: subperichondrial resection of the abnormal costal cartilages and stabilization of the elevated anterior chest wall with Kirschner's wires. The patients were followed up every year (1 to 10 years) after operation, and the anterior chest wall contour was checked by physical examination and x-ray film.

RESULTS

Excellent to good cosmetic results 1 year after operation were achieved in 66 patients (97.1%). During the later follow-up period, a mild or moderate degree of recurrent sternal depression was noted in 6 patients (8.8%), teenagers only, 3 to 9 years after primary repair.

CONCLUSIONS

Our technique for correction of pectus excavatum yields good short-term cosmetic results. Late recurrence of the deformity occurs during pubertal growth and does not appear to depend on surgical technique or length of follow-up.

A 26-year review of pectus deformity repairs, including simultaneous intracardiac repair

BACKGROUND

We reviewed our operative experience and long-term results with repair of pectus excavatum and carinatum deformities through a vertical midline approach, including those cases with simultaneous intracardiac repair.

METHODS

From 1972 through 1998, 120 children underwent pectus deformity repair. Operative technique used a vertical midline incision with subperichondrial resection of deformed cartilages and an anterior sternal osteotomy. Thirty-five patients had a temporary metal bar for retrosternal support for 6 months; 85 underwent repair without a bar. Patients and parents were asked to assess the outcome after pectus repair as poor, fair, good, or excellent.

RESULTS

There were 94 male and 26 female patients (mean age, 8.4 years; range, 3 to 21 years). There were 111 cases of pectus excavatum and 9 of pectus carinatum. Fourteen children (11.5%) had an associated congenital heart defect; 9 patients had simultaneous pectus and intracardiac repair. One patient was referred for emergent open heart repair and pectus repair after attempted "Nuss" repair resulted in a perforated right atrium, perforated right ventricle, and partially disrupted tricuspid valve apparatus. There were no deaths and only one significant complication, which required a return to the operating room for bleeding. Morbidity was not higher in patients with simultaneous intracardiac repair. Long-term follow-up was established in 83% of patients. Results were classified as excellent in 64 patients (64%), good in 25 (25%), fair in 8 (8%), and poor in 3 (3%). Thirty (86%) of 35 patients with a sternal bar had excellent results versus 34 (52%) of 65 without a bar (p = 0.004); 97% of patients who underwent repair with a sternal bar classified the result as excellent or good.

CONCLUSIONS

Long-term results of pectus excavatum and carinatum repair through a vertical midline approach are excellent. Outcome with a temporary sternal bar is superior to outcome without a bar. Concomitant repair of congenital heart defects and pectus deformity may be performed successfully without additional morbidity.

A 10-year review of a minimally invasive technique for the correction of pectus excavatum

PURPOSE

The aim of this study was to assess the results of a 10-year experience with a minimally invasive operation that requires neither cartilage incision nor resection for correction of pectus excavatum.

METHODS

From 1987 to 1996, 148 patients were evaluated for chest wall deformity. Fifty of 127 patients suffering from pectus excavatum were selected for surgical correction. Eight older patients underwent the Ravitch procedure, and 42 patients under age 15 were treated by the minimally invasive technique. A convex steel bar is inserted under the sternum through small bilateral thoracic incisions. The steel bar is inserted with the convexity facing posteriorly, and when it is in position, the bar is turned over, thereby correcting the deformity. After 2 years, when permanent remolding has occurred, the bar is removed in an outpatient procedure.

RESULTS

Of 42 patients who had the minimally invasive procedure, 30 have undergone bar removal. Initial excellent results were maintained in 22, good results in four, fair in two, and poor in two, with mean follow-up since surgery of 4.6 years (range, 1 to 9.2 years). Mean follow-up since bar removal is 2.8 years (range, 6 months to 7 years). Average blood loss was 15 mL. Average length of hospital stay was 4.3 days. Patients returned to full activity after 1 month. Complications were pneumothorax in four patients, requiring thoracostomy in one patient; superficial wound infection in one patient; and displacement of the steel bar requiring revision in two patients. The fair and poor results occurred early in the series because (1) the bar was too soft (three patients), (2) the sternum was too soft in one of the patients with Marfan's syndrome, and (3) in one patient with complex thoracic anomalies, the bar was removed too soon.

CONCLUSIONS

This minimally invasive technique, which requires neither cartilage incision nor resection, is effective. Since increasing the strength of the steel bar and inserting two bars where necessary, we have had excellent long-term results. The upper limits of age for this procedure require further evaluation.

Pulmonary function before surgery for pectus excavatum and at long-term follow-up

Pulmonary function tests were performed before surgery on 152 patients who were operated on for pectus excavatum between 1970 and 1987 and at long-term follow-up to assess the degree of impairment and to investigate any changes caused by surgical correction. The mean age at surgery was 15.3 +/- 5.5 years. Pulmonary function was found to be restricted preoperatively. Multivariate analysis showed that preoperative pulmonary function was not related to age, the severity of the deformity at physical examination, or to pulmonary complaints. Only the patients with obstructive disease showed significantly more pulmonary complaints (p = 0.042). The total lung capacity (TLC) and inspiratory vital capacity (IVC) were significantly related to the age-corrected (delta) anteroposterior diameter of the chest (lower vertebral index [LVI]) (p = 0.0001). At follow-up (mean, 8.1 +/- 3.6 years), the restriction of pulmonary function was increased despite improvement in the symptoms of most patients and despite a significant increase in the anteroposterior diameter of the chest (p = 0.0001): the TLC was decreased from 83.7 percent predicted (pred) preoperatively to 73.8 percent pred (p = 0.0001) and the IVC from 78.3 percent pred to 70.7 percent pred (p = 0.0001). The surgical results were satisfactory in 83.6 percent. No relation was found between the changes in pulmonary function measured at follow-up and the surgical results. Only the age at surgery and the changes in the TLC and IVC at follow-up were significantly related (p = 0.0036, 0.0043, respectively), although the correlation coefficients were low (r = 27 percent and 28 percent, respectively). The reduction in lung function at follow-up was most pronounced in the patients who had the least functional impairment (TLC > 75 percent pred) preoperatively. No correlation was found between the changes in the pulmonary function test results at follow-up and follow-up interval, preoperative delta LVI, and the change in delta LVI at follow-up.

Reconstruction of congenital chest-wall deformities

Pectus deformities and Poland's syndrome are two relatively common congenital deformities of the chest wall that are amenable to reconstruction. The extent of the structural deformity in pectus deformity and the degree of associated cardiopulmonary dysfunction are critical variables in preoperative assessment. The operative approaches range from more extensive sternal eversion to the more popular subperichondrial cartilage resection with or without internal fixation. In Poland's syndrome, the options for reconstruction include anterior transfer of the ipsilateral latissimus dorsi muscle through a transaxillary tunnel and attachment to the clavicle and sternum. Submuscular insertion of a mammary prosthesis can be added in the female patient.

Cardiac performance in children with pectus excavatum

Fourteen children with pectus excavatum and 14 normal control patients underwent graded exercise testing using a cycle ergometer and the James protocol. All the subjects were preoperative. The children were exercised to exhaustion during the test. The pectus and control groups were broken down into subgroups consisting of subjects less than or equal to 10 years of age and subjects greater than or equal to 11 years of age (pectus and controls less than or equal to 10 years old, PI and CI, respectively; pectus and controls greater than or equal to 11 years old, PII and CII, respectively). Maximal workload, oxygen consumption, cardiac output, and stroke volume were not significantly different when comparing the total groups or when each of the respective subgroups were compared. However, maximal diastolic BP was significantly elevated when the entire pectus and control groups were compared. When the subgroups were compared, maximal diastolic BP was elevated only in the older pectus patients (PII) and remained so until five minutes after exercise. Additionally, left ventricular systolic time intervals were measured immediately after exercise in all the children. The ratio of preejection period to left ventricular ejection time (P/L) was significantly shortened in the total pectus group. When the subgroups were compared, the P/L ratio was significantly decreased only in the older patients. Also, the preejection period (PEP) was significantly shortened in the older pectus patients. It appears that children with pectus excavatum have a normal exercise tolerance and oxygen transport. However, older pectus children develop an increased diastolic BP and a shortened P/L and PEP in response to exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

Preoperative and postoperative abnormalities in chest x-ray indices and in lung function in pectus deformities

In 88 patients with pectus deformities radiologic chest indices and routine pulmonary function tests were measured before and 1 to 20 years after corrective surgery. A combination of anteroposterior indices at the upper and lower level of the chest were investigated to quantitate and to discriminate the different pectus deformities. The study comprised four groups: pectus excavatum, pectus carinatum, pectus deformatum and pectus excavatum with scoliosis. These indices were also assessed in 250 healthy males and females. Generally, several indices showed significant and discriminative changes in the different patient groups and improved again after surgery. Preoperative lung function was decreased in pectus excavatum only. In all groups lung function worsened after surgery. A stepwise discriminant analysis performed on the large group with pectus excavatum indicated that postoperative lung function was decreased if the preoperative value of FEV1 or VC was more than about 75 percent predicted and vice versa, but that it was not related to other factors such as radiologic indices, age at operation or time since operation.

Repair of pectus excavatum by sternal eversion

Pectus excavatum was repaired by the sternal eversion (turnover) technique in 26 patients over a 7-year period. Vascular supply to the sternal graft was maintained by preservation of one internal mammary vascular pedicle. Good results were obtained in 21 (81%) patients followed for periods ranging from 2 to 76 months (mean, 32 months) postoperatively. Four patients (15%) had fair results; 2 patients with Marfan's syndrome had partial recurrence, as did 1 patient with skin necrosis and 1 with hypertrophic scar. One patient (4%) had a poor early result due to wound infection and distal sternal necrosis requiring reoperation. Other complications were minor: superficial wound seroma in 2 patients and pneumothorax in 1. The sternal eversion technique for repair of pectus excavatum utilizes the concave shape of the sternum when turned over to create a cosmetically acceptable convex anterior chest wall contour. Judicious tailoring of the costal cartilages and shaping of the anterior sternum corrects asymmetrical deformities. The chest wall is very stable after repair. Since no prosthetic struts or pins are used, a second operation for removal is avoided. Preservation of the vascular supply to the sternum should allow normal growth of the anterior chest wall. The results have been sufficiently encouraging for us to recommend sternal eversion as the primary method for repair of pectus excavatum.