Recurrent chest wall anomalies

Same day discharge for pectus excavatum-is it possible?

PURPOSE

The use of intercostal nerve cryoablation (INC) has been an effective modality for treating pain in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate if PE patients undergoing Nuss procedures with INC and intercostal nerve block (INB) could safely be discharged the same day of surgery.

METHODS

A prospective study with IRB approval of 15 consecutive patients undergoing PE Nuss repair with INC, INB, and an enhanced recovery after surgery (ERAS) protocol was conducted. The primary outcome measure was hospital length of stay (LOS) in hours. Secondary variables included same day discharge, postoperative complications, emergency department (ED) visits, urgent care (UC) visits, opioid use, and return to the operating room (OR).

RESULTS

LOS averaged 11.9 h amongst 15 patients. Ten patients (66.7%) went home on postoperative day (POD) 0, and the rest went home on POD 1. No patients stayed in the hospital due to pain. Reasons for failure to discharge included urinary retention, drowsiness, vomiting, and anxiety, but not pain. No patients were readmitted to the ED. One patient visited UC for constipation. One patient had bar migration requiring return to the OR for revision. Ten (66.7%) patients did not use opioids after discharge.

CONCLUSIONS

Same day discharge is feasible and safe in PE patients undergoing Nuss procedure with INC and INB. INC with INB can adequately control pain without significant complications. Same day discharge can be safely considered for PE patients undergoing Nuss procedure with INC with INB.

TYPE OF STUDY

Prognosis study LEVEL-OF-EVIDENCE RATING: Level II.

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.

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.

Operative management of acquired Jeune's syndrome

BACKGROUND

Acquired Jeune's syndrome is a severe iatrogenic deformity of the thoracic wall following a premature and aggressive open pectus excavatum repair. We report herein our technique and experience with this rare condition.

METHODS

From 1996 to 2011, nineteen patients with acquired Jeune's syndrome were retrospectively identified in a tertiary referral center. The technique used to expand and reconstruct the thoracic wall consisted of 1) release of the sternum from fibrous scar tissue, 2) multiple osteotomies along the lateral aspect of the ribs with anterior advancement of costal-cartilages to protect the heart, 3) stabilization of the thorax by placing a curved bar for retrosternal support and, 4) restoration of the sterno-costal junction by wiring the lower cartilages to the edge of the sternum.

RESULTS

Major complications observed in this series were: bar displacement (seven cases), postoperative death from cardiac arrest following bronchoscopy (one case), late cardiac tamponade from migration of wire suture fragment (one case), and need for multiple reoperations (one case). Long-term cosmetic results and improvement in daily quality of life were reported as positive in the majority of cases.

CONCLUSIONS

Anterior chest wall reconstruction successfully treated our series of patients with acquired Jeune's syndrome. This multifaceted technique is an effective procedure that allows expansion of the thoracic cavity and improvement of aerobic activity.

Pectus carinatum

PURPOSE OF REVIEW

Pectus carinatum has been termed the undertreated chest wall deformity. Recent advances in patient evaluation and management, including the development of nonoperative bracing protocols, have improved the care of children with this condition.

RECENT FINDINGS

Recent evidence confirms that children with pectus carinatum have a disturbed body image and a reduced quality of life. Treatment has been shown to improve the psychosocial outcome of these patients.

SUMMARY

Patients with pectus carinatum are at risk for a disturbed body image and reduced quality of life. Until recently, treatment required surgical reconstruction. A growing body of literature, however, now supports the use of orthotic bracing as a nonoperative alternative in select patients. This article reviews the current literature and describes the evaluation and management of children with pectus carinatum deformity.

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.

Correlation of asymmetric chest wall deformity and growth in patients with pectus excavatum

PURPOSE

Pectus excavatum involves wide range of chest wall depression. The degree of depression or asymmetry varies between young and adolescent patients. It has not been clear how the deformity progresses as patients grow. To elucidate the change of asymmetric deformity, preoperative computed tomography (CT) scan was evaluated according to different age groups.

METHODS

Preoperative CT scans of 154 patients with pectus excavatum were collected and analyzed using Haller's CT index, asymmetric index and sternal rotation angle. Patients were divided into 5 age groups as follows; group 1: 4-6 y (n=53), group 2: 7-9 y (n=25), group 3: 10-12 y (n=25), group 4: 13-15 y (n=23), group 5: 16-23 y (n=28). The degree of asymmetric chest wall deformity was expressed using sternal rotation angle as follows; symmetrical (-5º to +5º), left-mild (-5º to -15º), right-mild (+5º to +15º), right-moderate (+15º to +25º) and right-severe (over +25º).

RESULTS

As the age of patients increased, asymmetric index increased from 1.025±0.065 in group 1 to 1.124±0.111 in group 5 and sternal rotation angle also increased from 6.11±8.61 in group 1 to 15.41±11.98 in group 5. In these two parameters, significant difference was seen between group 1 and 4, group 2 and 4, group 1 and 5 and group 2 and 5. However, average CT index revealed no significant difference in any age groups. In group 1, 83% of patients were classified in symmetrical or left- and right-mild. The incidence of right-moderate plus right-severe was 17% in group 1, 20% in group 2, 40% in group 3, 52.1% in group 4 and 50% in group 5.

CONCLUSIONS

The degree of chest depression did not show any change in all age groups. Asymmetric deformity on the right side progressed around the age of 10 to 12. Half of patients over the age of 13 showed moderate or severe asymmetry. These results were suggestive to consider the optimum age for the correction of pectus excavatum.

Bracing is an effective therapy for pectus carinatum: interim results

BACKGROUND

Pectus Carinatum is a common congenital chest wall malformation. Until recently the mainstay of treatment was surgical remodeling of the deformed chest wall. Initial results suggest that non-operative bracing may be an effective therapy, but the optimal strategy for correction is not known. Herein we report the results of a self-adjustable low profile bracing system worn continuously until the defect is corrected (correction phase), then worn at night (8 h/day) until completion of axial growth (maintenance phase)-the Calgary Protocol.

METHODS

Patients referred to a pediatric surgery chest wall clinic were prospectively asked to join an IRB approved outcomes monitoring study. 124 patients were evaluated from 2007 to 2011, and 98 were prescribed a brace and counseled to follow the protocol.

RESULTS

98 patients consented to follow-up at starting bracing age: 14.4 ± 1.9 years, Tanner stage: 3.6 ± 0.5, protrusion: 2.1 ± 1.0 cm, self-rating of appearance: 2.9 ± 1.1, and exercise tolerance: 4.4 ± 1.1 (1-5 with 5 = normal). 10 patients are in correction phase, and 44 patients have completed correction after 7.0 ± 7.3 months: Tanner stage: 3.8 ± 0.1, protrusion: 0.5 ± 0.6 cm*, appearance: 4.3 ± 0.3* and exercise tolerance 4.6 ± 1.0. Correction occurred more quickly in patients prior to achieving Tanner stage IV (4.2 ± 0.9 months) vs. Tanner stage IV (8.0 ± 7.1 months) at the beginning of bracing. 21 patients completed maintenance bracing after 17.9 ± 19.0 months: Tanner stage: 3.9 ± 0.2, protrusion 0.5 ± 0.7 cm*, appearance: 4.3 ± 0.9*, and exercise tolerance: 4.8 ± 1.4. Average follow-up after bracing is 13.9 ± 16.0 months (mean ± S.D., *P < .05). There was one recurrence, likely due to early discontinuation of maintenance. This responded to an additional 6 months of bracing. 42 patients failed therapy secondary to non-compliance or were lost in follow up, while 2 patients did not respond to bracing and required open operation.

CONCLUSIONS

If patients are compliant, a self- adjusting brace system can give rapid correction of the pectus carinatum protrusion with excellent patient satisfaction. These interim results suggest that continued bracing until skeletal maturity gives long term durability to the correction. Further studies will be required to further refine this promising therapy.

Repair of a floating sternum with autologous rib grafts and polylactide bioabsorbable struts in an 18-year-old male

Failed regeneration of costal cartilage after open repair of pectus chest wall deformities can result in a floating sternum. A floating sternum can be repaired by insertion of a rib graft between the rib and sternum, and stabilization with a metal strut. The metal implant is usually removed with a second operation. We report use of bioabsorbable struts to stabilize rib grafts during repair of a floating sternum in an 18-year-old male with a failed open repair of pectus carinatum. He had an uncomplicated peri-operative course. One year later, the sternum had a normal appearance and was sturdy. A second operation for removal of hardware was not necessary.

Growth spurt-related recurrence after Nuss procedure

We report 2 cases of growth spurt-related recurrence after Nuss procedure. Each of the 2 cases underwent bar insertion at the age of 6 and 11 years, respectively. The support bar was removed 2 years later followed by severe redepression during the growth spurt. One patient underwent redo Nuss procedure elsewhere. The other patient was diagnosed as idiopathic precocious puberty and is in treatment. The possibility of growth spurt-related recurrence must be explained to those who undergo early correction before surgery, and follow-up is mandatory at least until patients' puberty is over.

Poland's syndrome

The main purpose of surgical correction in Poland's syndrome is to improve chest wall symmetry and correct breast hypoplasia. Creation of an anterior axillary fold and smoothing out the infraclavicular defect greatly improves the final result. Cardiorespiratory function may be impaired, but serious conditions requiring early operative correction are rare. When present, unilateral costochondral agenesis involves one to three segments in the mid-anterior chest and sternal depression to that side. Operative planning in such cases includes a multi-layered approach to provide a solid base for soft tissue reconstruction of the more superficial layers.

Jeune's syndrome (asphyxiating thoracic dystrophy): congenital and acquired

Familial asphyxiating thoracic dystrophy (ATD), also known as Jeune's syndrome, is a rare autosomal recessive disorder with variable severity and multiple musculo-skeletal manifestations. Respiratory distress may be severe, resulting in death during infancy. Surgical repair techniques have typically involved median sternotomy (with graft interposition), resulting in poor outcomes. Acquired ATD may rarely result from impairment of chest wall growth following "open" (Ravitch-type) repair of pectus excavatum or carinatum deformities. Symptomatic patients may have profound restriction of pulmonary function. Repair techniques typically involve re-do Ravitch-type procedures or median sternotomy with rib graft interposition. Mild to moderate improvements in pulmonary function tests have been documented.

Minimally invasive surgical repair of pectus excavatum

The minimally invasive repair of pectus excavatum has become widely accepted. The number of patients presenting for repair has increased dramatically. There have been many technical improvements over 20 years that have made the procedure much safer and more successful. The complications have been identified and preventative measures instituted. The long-term results have shown a 95% good to excellent outcome, and patient satisfaction studies have shown similar results.

Anatomic Variation and Asymmetry in Female Anterior Thoracic Contour

This study examines the prevalence of anatomic variation and asymmetry in female thoracic contour and evaluates their effect on breast projection. A consecutive series of 50 female cross-sectional thoracic computed tomography (CT) scans was examined at the level of the fourth rib. Patients with thoracic wall trauma (including surgery) were excluded. Lateral width, anterior-posterior diameter, and 3 internal angles were compared bilaterally and were used to evaluate overall shape and thoracic contour. All patients demonstrated some degree of asymmetry between their right and left sides. A wide range of thoracic shapes was observed. Patients with sloped anterior chest walls have lateral projection of the nipple, while patients with flatter chest walls have anterior projection of the nipple. Evaluating anterior chest wall slope prior to augmentation can help physicians predict postoperative breast projection and thus prepare their patients for the future breast appearance and the potential for contact cleavage.

Pectus excavatum

One of the more common chest wall anomalies seen in children is pectus excavatum. Although some studies suggest a physiologic impact of this anomaly on cardiac function during exercise, this remains somewhat controversial. Regardless, a number of children are symptomatic from either the appearance of the deformity or from the standpoint of tolerance to exercise. Most are relieved of these symptoms with surgical repair. Several different operations have been utilized for repair of this anomaly, but two techniques now are the predominant methods in use today. These are the modified Ravitch procedure and the Nuss procedure. Both have been shown to provide satisfactory results.

Nonoperative management of pectus carinatum

BACKGROUND

Although surgery has been the mainstay of treatment of chondrogladiolar pectus carinatum (PC), several authors have advocated the benefits of nonoperative approaches to induce chest wall remodeling. Based on our initial success with compression bracing, we have integrated this modality into our treatment algorithm.

METHOD

We reviewed the charts of all patients treated for PC at our pediatric hospital between 1997 and 2004. Patients were managed with observation, operative repair, and orthotic bracing that provides continuous anteroposterior sternal compression. The brace was worn for 14 to 16 hours per day until linear growth was complete or for a minimum of 2 years.

RESULTS

One hundred patients were diagnosed with PC. Fifty-seven patients had no treatment and were monitored. Twenty-nine patients were fitted with a brace. Of these 29 patients, 3 were noncompliant, resulting in a compliance rate of 90%. Of the remaining brace patients, all have had positive outcomes with no observed complications. Seventeen patients underwent surgical repair. Their outcomes were also positive with no major complications.

CONCLUSION

Our findings clearly demonstrate that compression bracing is a safe and effective treatment for children with chondrogladiolar PC. We currently offer this approach as a first-line treatment, reserving surgery for patients who are noncompliant and those who fail the nonoperative modality.

Further experience with the operative management of asphyxiating thoracic dystrophy after pectus repair

BACKGROUND/PURPOSE

Asphyxiating thoracic dystrophy (ATD) can occur years after a Ravitch-type repair of pectus excavatum, resulting in debilitating alteration in pulmonary function (PFT). An operation was devised to attempt repair of this deformity.

METHODS

After institutional review board approval, the records of 10 children (ages 9-18 years) with ATD that developed 4 to 12 years postpectus operation who underwent attempted repair of ATD were reviewed. Data obtained before ATD operation and at 6, 12, and 24 months afterward included chest computed tomography, pulmonary functions (PFT), and a quality of life questionnaire. The operation consisted of sternal split with rib graft placement to permanently hold the sternum apart.

RESULTS

All children survived and the bone grafts healed solidly. Computed tomography showed a change from a flat to a round chest contour on cross section, with increased anteroposterior dimension. Two patients had no change in PFT at 24 months whereas the other 8 had 21% to 30% improvement in PFT parameters. All patients reported improved exercise tolerance, and 3 began sports activities who were previously unable to do so. Two patients on oxygen, essentially bedridden, are now active, breathing only room air. Seven of 10 patients continue to have cosmetic concerns.

CONCLUSIONS

A small population of patients who had postoperative pectus repair developed severe, debilitating ATD. The repair described improves most patients, some dramatically, but does not significantly improve cosmetic appearance. The operation is undergoing further refinement to address these issues.