Management of deep pectus excavatum (DPE)

Recent Advancements in Pectus Surgery: Crane Lifting, Multiple-Bar Approach, Bridge Stabilization, and Sandwich Technique

PURPOSE

The most recent procedure for pectus excavatum repair involves crane-powered entire chest wall remodeling, which employs crane lifting, multiple-bar approach, bridge stabilization, and sandwich techniques. This resulted in a paradigm shift in pectus deformity repair from merely lifting the sunken bone to remodeling the chest wall into normal anatomy.

METHODS

We analyzed 649 patients who underwent surgery for pectus excavatum or complex combined deformities between March 2018 and January 2022. A crane with sternal wiring or screwing was used to lift the chest wall without using the pectus bar turning power. Multiple bars with bridge connections were placed to eliminate bar displacement. Modified sandwich techniques were applied to relieve the lower coastal flare (flare-buster) and focal protuberance (magic string).

RESULTS

The mean age of the patients included in the study was 12.2 years (range: 3-45 years). A single bar was used for 202 patients until 2021. For the multiple-bar technique, parallel bars (n = 142), crossbars (n = 166), and crossbars plus upper horizontal bars (XI pattern; n = 139) were used. The overall complication rate was 6.2 %. There was no cases of bar displacement were observed, but other minor complications such as pneumothorax (n = 20, 3.1 %), pleural effusion (n = 7, 1.1 %), and wound infection (n = 5, 0.8 %) were detected. Three patients required reoperation (infection, two: hemorrhage, one).

CONCLUSIONS

The crane-powered entire chest wall remodeling technique improved the safety and comprehensiveness of the repair procedure. By incorporating bridge stabilization and the use of multiple bars, we effectively resolved the issues related to bar displacement and incomplete repair.

TYPE OF STUDY

Retrospective Cohort Study.

LEVEL OF EVIDENCE: 3

Occurrence of Diastasis of the Rectus Abdominis Muscles in Patients with Medial Pectus Excavatum

Since 1994, we have used soft silicone blocks sculpted intraoperatively to correct pectus excavatum in male patients. This technique involves a horizontal access incision in the region of the lower edge of the sternum. During the dissection to expose the sternum, we observed a constant diastasis of the rectus abdominis muscle and changes of the anatomy at its superior insertion. There is no report on this association.

Methods

Male patients with untreated medial pectus excavatum with indication for silicone block correction were enrolled. Age, weight, height, and the presence of other associated conditions were noted. Ultrasound examination was performed. During the surgery, the width of the linea alba was evaluated and the anatomical positioning of the insertion of rectus abdominis muscle was noted.

Results

From 2017 to 2019, 10 patients were submitted to surgery. The mean age was 27 years. All patients presented diastasis at the preoperative physical examination. Imaging examination reports showed diastasis of the rectus abdominis muscle: seven partial epigastric separations and three total separations, two of which were associated with umbilical hernia. The intraoperative findings showed the line alba with a minimum of 23 mm and a maximum of 45 mm width at 4 cm from the xiphoid process edge. The muscle borders presented a curved lateral deviation up to the insertion in the costal arches with a distance ranging from 35 mm to 60 mm.

Conclusions

This study confirms the anatomical alterations of the superior portion of the rectus abdominis muscle. The authors discuss the surgical consequences and suggest that the semiology of rectus abdominis muscle is an important preoperative action in pectus excavatum patients.

Nuss Procedure for a Patient with Negative Haller Index

Introduction  Minimally invasive repair for pectus excavatum (MIRPE) is controversial in extremely severe cases of pectus excavatum (PE) and an open repair is usually favored. Our aim is to describe a case of a patient with an extremely severe PE that underwent a minimally invasive approach. Case report  An 8-year-old girl with severe sternum depression was assessed. She had a history of exercise intolerance, nocturnal dyspnea, fatigue, and shortness of breath. Chest computed tomography showed that sternum depression was posterior to the anterior vertebral column; therefore, Haller and correction index could not be measured. Spirometry indicated an obstructive ventilation pattern (forced expiratory volume in 1 second = 74.4%), and echocardiogram revealed a dilated inferior vena cava, mitral valve prolapse with normal ventricular function. After multidisciplinary committee evaluation, a MIRPE approach was performed. All symptoms had disappeared at the 3-month postoperative follow-up; the desired sternum shape was achieved and normalization of cardiopulmonary function was observed. The Nuss bars were removed after a 2-year period. After 18-month follow-up, the patient can carry out normal exercise and is content with the cosmetic result. Conclusion  Nuss procedure is feasible in our 8-year-old patient. In this case, both the Haller and correction index were not useful to assess the severity of PE. Therefore, under these circumstances, other radiologic parameters have to be taken into consideration for patient evaluation.