Complex Repair of Pectus Excavatum Recurrence and Massive Chest Wall Defect and Lung Herniation After Prior Open Repair (original) (raw)
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Simplified open repair for anterior chest wall deformities. Analysis of results in 205 patients
Orthopaedics & Traumatology: Surgery & Research, 2012
Introduction: Pectus deformities are the most frequently seen congenital thoracic wall anomalies. The cause of these conditions is thought to be abnormal elongation of the rib cartilages. We here report our clinical experience and the results of a sternochondroplasty procedure based on the subperichondrial resection of the elongated cartilages. Hypothesis: This technique is a valuable surgical strategy to treat the wide variety of pectus deformities. Patients and methods: During the period from October 2001 through September 2009, 205 adult patients (171 men and 34 women) underwent pectus excavatum , carinatum (19) or arcuatum (5) repair. The patients' pre and postoperative data were collected using a computerized database, and the results were assessed with a minimum 2-year follow-up. Results: The postoperative morbidity rate was minimal and the mortality was nil. The surgeon graded cosmetic results as excellent (72.5%), good (25%) or fair (2.5%), while patients reported better results. Patients with pectus excavatum were found to have much more patent foramen ovale (PFO) than the normal adult population, which occluded after the procedure in 61% of patients, and significant improvement was found in exercise cardiopulmonary function and exercise tolerance at the 1-year follow-up. Discussion: Our sternochondroplasty technique based on the subperichondrial resection of the elongated cartilages allows satisfactory repair of both pectus excavatum and sternal prominence. It is a safe procedure that might improve the effectiveness of surgical therapy in patients with pectus deformities. Level of evidence: Level IV. Retrospective study.
Journal of Thoracic Disease
Background: Traditionally open procedures have been replaced by minimally invasive techniques in the correction of pectus excavatum. Efforts to improve the extent of mobilization of the chest wall and its stabilization have led to constant modifications. There is currently no consensus about the best procedure for correction of pectus excavatum. Methods: Based on the contributions of a single institution for the last 60 years, we present the various strategies used for the correction of pectus excavatum and the evolution of operational procedures. These approaches are compared with those performed internationally at similar periods. Results: Resections with external extension achieved moderate results and were modified in 1962 to the "Shred" method. The establishment of the "Strut" method in 1963 and, in 1977, its extension with the erection of the lower rib arches significantly improved patient outcomes. The "minimization" of the procedure in 2006 was accompanied by an increase in wound healing disorders and recurrent deformities. Since 2010, elastic stable chest repair (ESCR) has provided lossless mobilization and sternal elevation for healing costosternal pseudarthrosis and allowed correction of complex recurrences with excellent cosmeticfunctional results. Strong asymmetric or broad-base deformities can now be stabilized using a modular hybrid technique of transsternal bar and locked plates. Conclusions: ESCR marks the end of the 60-year development of an open procedure and, after lossfree mobilization of the chest wall by elastic-stable biomechanical management, optimizes the possibility of anatomical reconstruction of the chest wall during initial and re-interventions, achieving a permanent, physiologically stable remodeling of the chest wall.
Elastic stable chest repair and its hybrid variants in 86 patients with pectus excavatum
Journal of Thoracic Disease
Background: Complex and mature funnel chest deformities are traditionally managed with open surgical procedures. Elastic stable chest repair (ESCR) has been used successfully and safely for relapse corrections. Does pure plate osteosynthesis in ESCR allow comparable corrective potency and implant safety as hybrid methods with metal bars? Methods: Data from 86 patients with open funnel chest correction between 2011 and 2015 were analyzed in this retrospective study. Exclusion criteria included being under 12 years of age, and having a history of septic wound healing disorder or other malignant diseases. Main groups consisted of ESCR and hybrid techniques, subgroups were primary and recurrence correction. Correction results and follow-up examinations at six and 12 weeks and at 1 year were statistically analyzed. Results: A total of 38 ESCR and 48 hybrid methods were analyzed. Bar implantation was required in 77% (recurrence 34%) of patients. All patients received plates with different combinations e.g., longitudinalsternal, costosternal and costo-sterno-costal. In all groups, follow-up uptake showed a funnel chest correction result at the anatomical level with healthy values according to the Haller index (ESCR 4.36-2.84, hybrid 6.99-2.74, P<0.001). No material dislocations were observed in any subgroup. Conclusions: ESCR and hybrid techniques represent promising and safe therapeutic approaches.
Use of sternal plate for pectus excavatum repair in adults leads to minimal postoperative pain
Journal of surgical case reports, 2018
Pectus excavatum is a chest wall deformity that results in caved-in or sunken appearance of lower half of anterior chest. Surgical treatment is favored when functional or cosmetic concerns arise. We present a case and series of six patients (mean haller index: 4.28) who had repair with minimal pleural disruption and sternal plate. After a broad bilateral inframammary skin incision, the anterior aspect of sternum is identified and incised. Next, the surgeon hyperextends and fixates the bone in its desired position by applying manual dorsal pressure through a small intercostal incision. Superior and inferior fasciocutaneous flaps are raised and then advanced to reconstruct the soft tissue defect. All patients had durable repair of the chest wall abnormalities and they had minimal pain during the postoperative period. No analgesia medication was necessary 1 month post-operatively. This may provide significantly less pain compared to the Nuss or Ravitch procedures to fix Pectus excavatum.
European Journal of Cardio-Thoracic Surgery
OBJECTIVES: Patients with pectus excavatum (PE) after prior sternotomy for cardiac surgery present unique challenges for repair of PE. Open repairs have been recommended because of concerns about sternal adhesions and cardiac injury. We report a multi-institutional experience with repair utilizing substernal Nuss bars in this patient population. METHODS: Surgeons from the Chest Wall International Group were queried for experience and retrospective data on PE repair using substernal Nuss bars in patients with a history of median sternotomy for cardiac surgery (November 2000 to August 2015). A descriptive analysis was performed. RESULTS: Data for 75 patients were available from 14 centres. The median age at PE repair was 9.5 years (interquartile range 10.9), and the median Haller index was 3.9 (interquartile range 1.43); 56% of the patients were men. The median time to PE repair was 6.4 years (interquartile range 7.886) after prior cardiac surgery. Twelve patients (16%) required resternotomy before support bar placement: 7 preemptively and 5 emergently. Sternal elevation before bar placement was used in 34 patients (45%) and thoracoscopy in 67 patients (89%). Standby with cardiopulmonary bypass was available at 9 centres (64%). Inadvertent cardiac injury occurred in 5 cases (7%) without mortality. CONCLUSIONS: Over a broad range of institutions, substernal Nuss bars were used in PE repair for patients with a history of sternotomy for cardiac surgery. Several technique modifications were reported and may have facilitated repair. Cardiac injury occurred in 7% of cases, and appropriate resources should be available in the event of complications. Prophylactic resternotomy was reported at a minority of centres.
Principles of complex chest wall reconstruction
Shanghai Chest, 2020
The complex chest wall reconstruction is a procedure required to repair large defects of the chest wall using a combination of materials including various flaps, omentoplasty, a microvascular technique and artificial replacements. The main indication for chest wall reconstruction is thoracic defects after resection of lung cancer, the repair of congenital deformities, post traumatic deformity and complications of surgery. It is commonly used for defects of more than 5 cm in diameter when four or more ribs are absent with the risk of lung herniation and paradoxical motion of the chest wall. The main technical principles of chest wall reconstruction are of a stable repair, compatibility of materials and meticulous surgical technique to minimise potential complications and the combination of available technologies. In lung cancer surgery chest wall reconstruction required after chest wall resection performed due to direct invasion of the tumour into the chest wall. The metal bars may be used to recreate the anatomically acceptable shape of the chest wall with or without artificial mesh. For large defects of the chest wall a combination of cement and natural flaps could be an ideal option. In young adults with pectus excavatum or pectus carinatum titanium bars allow to maintain stability after the open repair, but these bars require removal at a later stage, which is the down side of this procedure. The sternum may be alternatively secured with strips of Prolene Mesh positioned under the sternum and attached to the ribs in a tight fashion. Repair of late dehiscence of the sternum after median sternotomy requires firm stabilisation with metal bars, filling the defect with bone grafts and omentoplasty to improve blood supply of the affected sternum. Modern techniques of chest wall resection and reconstruction expand the surgical options of patients with chest wall defects and reconstruction should always be considered as part of the treatment plan for patients.
Chest wall anomalies: pectus excavatum and pectus carinatum
Adolescent Medicine Clinics, 2004
Adolesc Med 15 (2004) 455-471 omphalocele in the case of bifid sternum, all of which complicate the management of these patients (see Table 1). Surgical management has undergone major changes over the last 15 years. In the 1960s and 1970s, radical surgical operations were in vogue, even in very young children. It came to be realized, however, that pulmonary function actually decreased over time because of the scarring of the anterior chest wall, and some patients developed acquired asphyxiating chondrodystrophy from resections that were too extensive and performed at too early an age. As a result, surgeons stopped operating on prepubertal patients and reverted to modified resections of the deformed cartilages. Recently, a minimally invasive procedure with no resection, only internal bracing, has been introduced.
Journal of Thoracic Disease, 2016
Background: We report short and long-term results with the dedicated Synthes ® titanium plates system, introduced 5 years ago, for chest wall stabilization and reconstruction. Methods: We retrospectively analyzed (January 2010 to December 2014) 27 consecutive patients (22 males, 5 females; range 16-83 years, median age 60 years), treated with this system: primary [3] and secondary [8] chest wall tumor; flail chest [5]; multiple ribs fractures [5]; sternal dehiscence-diastasis [3]; sternal fracture [1]; sternoclavicular joint dislocation [1]; Poland syndrome [1]. Short-term results were evaluated as: operating time, post-operative morbidity, mortality, hospital stay; long-term results as: survival, plates-related morbidity, spirometric values, chest pain [measured with Verbal Rating Scale (VRS) and SF12 standard V1 questionnaire]. Results: Each patient received from 1 to 10 (median 2) titanium plates/splints; median operating time was 150 min (range: 115-430 min). Post-operative course: 15 patients (55.6%) uneventful, 10 (37%) minor complications, 2 (7.4%) major complications; no post-operative mortality. Median post-operative hospital stay was 13 days (range: 5-129 days). At a median follow-up of 20 months (range: 1-59 months), 21 patients (78%) were alive, 6 (22%) died. Three patients presented long-term plates-related morbidity: plates rupture [2], pin plate dislodgment [1]; two required a second surgical look. One-year from surgery median spirometric values were: FVC 3.31 L (90%), FEV 1 2.46 L (78%), DLCO 20.9 mL/mmHg/min (76%). On 21 alive patients, 7 (33.3%) reported no pain (VRS score 0), 10 (47.6%) mild (score 2), 4 (19.1%) moderate (score 4), no-one severe (score >4); 15 (71.5%) reported none or mild, 6 (28.5%) moderate pain influencing quality of life. Conclusions: An optimal chest wall stabilization and reconstruction was achieved with the Synthes ® titanium plates system, with minimal morbidity, no post-operative mortality, acceptable operating time and post-operative hospital stay. Long-term restoration of a normal respiratory function was achieved, with minimal plates-related morbidity and chest pain.