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Surgical Management of Pectus Carinatum

      Pectus carinatum (from the Latin, “chest with a keel”), or pigeon breast, is the term applied to various protrusion deformities of the anterior chest.
      • Lam CR
      • Taber RE
      Surgical treatment of pectus carinatum.
      The disorder encompasses a spectrum of protrusion anomalies with greater variation than that observed with the excavatum deformities. The most common type comprises anterior displacement of the mid and lower sternum (gladiolus) and attached costal cartilages, often asymmetric and usually first recognized during early adolescence.
      • Brodkin HA
      Pigeon breast congenital chondrosternal prominence: Etiology and surgical treatment by xiphosternopexy.
      Asymmetric deformities are also common and often involve a tilted sternum, with localized depression of a few cartilages of the lower antral lateral chest on one side or occasionally both sides. Least common is a chondromanubrial prominence, with protrusion of the manubrium and upper sternum and adjacent cartilages and less protrusion of the lower sternum, commonly appearing during the first few years of life.
      Carinatum deformities are approximately 6 times less common than excavatum anomalies and occur more than 4 times as often in men than in women.
      • Shamberger RC
      • Welch KJ
      Surgical correction of pectus carinatum.
      Approximately 25% of patients have a familial occurrence of carinatum deformities. Approximately 20% of patients have been reported to have congenital heart disease, and 22% have scoliosis.
      Many physicians have indicated that there is no correlation between carinatum deformities and cardiorespiratory dysfunction, and that surgical repair should be considered primarily for cosmetic benefits.
      • Pickard LR
      • Tepas JJ
      • Shermeta DW
      • et al.
      Pectus carinatum: Results of surgical therapy.
      Others have observed decreased respiratory excursions of the thorax, with the increased anteroposterior chest diameter leading to reduced chest movement with respiration
      • Robicsek F
      • Cook JW
      • Daughtery HK
      • et al.
      Pectus carinatum.
      (Fig. 1).
      Pectus carinatum is recognized only infrequently in early childhood, except in those few patients with the early appearance of chondromanubrial prominence. Although many adolescent children with pectus carinatum deformity indicate to parents and physicians that they are experiencing shortness of breath, often with only mild exercise, most physicians are likely to indicate that the deformity is only a cosmetic problem, and that surgical correction is difficult, is only minimally effective in providing physiologic benefit, and thus, is unnecessary. Each of these views is incorrect, however, given our present knowledge of pectus carinatum deformities and the current techniques for surgical repair.
      Objective measurements to document the severity of physical limitations caused by pectus carinatum have often been imprecise and misleading, and should be performed during exercise. The symptoms expressed by the patient often appear far out of proportion to the apparent mild protrusional deformity that is visible. With carinatum sternal protrusion, the thorax is held in a partially expanded position with increased residual air capacity and reduced vital capacity. Some very competitive patients have been able to compensate for the pectus carinatum-induced limitations in chest expansion in short-duration athletic activities by wider diaphragmatic excursions, at a cost of greater energy expenditure. In our experience, asthmatic symptoms are more frequent in patients with carinatum than in those with excavatum. Pain from pressure on the protruding sternum and/or cartilages has been expressed by several patients. The symptomatic patient often requests that the family seek help in correcting the deformity.
      Although various carinatum deformity configurations have been described, we have observed 2 basic types. Young children generally have protrusion of the manubrium and upper sternum, as noted by Shamberger and Welch,
      • Shamberger RC
      • Welch KJ
      Surgical correction of chondromanubrial deformity (Currariano-Silverman syndrome).
      and often experience shortness of breath and frequent respiratory infections compared to other children. Repair may be a formidable task in these young children, because 3 or more upper cartilages on each side may require resection and the sternum may require 2 or more transverse osteotomies.
      Repair of the more common mid and lower sternal protrusion in adolescents and adults often requires resection of 4 or 5 lower cartilages on each side. For those patients with asymmetric deformities with prominent unilateral cartilaginous protrusion, resection of the abnormal cartilages on one side and partial excision of a few cartilages on the less involved side will often allow the sternum to depress to the desired level without performing an osteotomy. Placement of a sternal bar across the chest anterior to the sternum for 4 to 6 months provides stability and prevents recurrent sternal protrusion. For patients with bilateral costal and sternal protrusion after subperiosteal resection of the deformed cartilages, a transverse osteotomy is made across the anterior sternum, and a wedge of cartilage is inserted to depress the sternum to the desired position. A sternal support bar is placed for in almost all cases. The sternal support bar eliminates postoperative flail chest and paradoxical respirations, which reduces pain, permitting early ambulation and deeper respiratory excursions and thus reducing the length and cost of hospitalization. The bar is easily removed and ensures good long-term results, with recurrent protrusion or depression very uncommon.
      Costal cartilage regeneration from the perichondrial sheaths is remarkably rapid in children, with the chest becoming very stable within 4 to 5 weeks. We prefer surgical repair in the early adolescent years in those patients who are experiencing symptoms and who have a low pectus severity index, because the operation is technically easier in this age group than in adults.
      A paucity of reports are available regarding the physiologic limitations caused by pectus carinatum deformities during exercise. A comprehensive review of many published reports indicating improvement in cardiac or respiratory function after pectus repair was provided by Shamberger and Welch.
      • Shamberger RC
      • Welch KJ
      Cardiopulmonary function in pectus excavatum.
      Because of the high cost and often invasive nature of the procedures used for physiologic evaluation before and after pectus repair, we do not favor the routine use of such tests. The severity of the pectus protrusion can be easily measured by calculating the pectus severity index from chest radiographs.
      • Haller JA
      • Kramer SS
      • Lietman SA
      Use of CT scans in selection of patients for pectus excavatum surgery: A preliminary report.

      Fonkalsrud EW, Beanes S: Surgical management of pectus carinatum: 30 years experience. World J Surg (in press)

      Clinical Experience

      During the past 31 years, we have performed surgical correction of carinatum deformities in 80 patients, 71 men and 9 women. Minimal deformity was observed in 73 of the patients (92%) before age 11 years. Of the 7 children in whom sternal protrusion was noted during the first 4 years of life, all had chondromanubrial deformities, whereas only 1 of the 73 patients with later onset of pectus carinatum had this type of deformity. Protrusion of the mid and lower sternum was first noted after age 10 years in 73 of the patients, 41 of whom had asymmetric protrusion. The age at the time of operation ranged from 3 to 37 years (mean = 16.6 years). Chest radiographs in almost all patients showed an increased anteroposterior diameter of the chest, emphysematous lungs, and a very narrow cardiac silhouette. The distance between the sternum and the spine in all patients was considerably greater than that in normal patients of the same age. The pectus severity index, determined by dividing the inner width of the chest at its widest point by the distance between the posterior surface of the sternum and the anterior surface of the spine, ranged from 1.46 to 2.06 cm (mean = 1.75). The mean pectus severity index of normal persons is 2.56, as reported by Haller and associates
      • Haller JA
      • Kramer SS
      • Lietman SA
      Use of CT scans in selection of patients for pectus excavatum surgery: A preliminary report.
      and as noted in our own experience with excavatum patients.
      • Fonkalsrud EW
      • Dunn JCY
      • Atkinson JB
      Repair of pectus excavatum deformities: 30 years experience with 375 patients.

      Surgical Technique

      Figure thumbnail fx1
      1Lateral chest radiograph from a 17-year-old boy with severe pectus carinatum showing the great distance between the sternum and the spine. The pectus severity index is 1.54.
      Figure thumbnail fx2
      2The operative technique used for repair for each of the 80 patients with carinatum deformities was a modification of that detailed in previous reports on pectus excavatum repair.
      • Fonkalsrud EW
      • Salman T
      • Guo W
      • et al.
      Repair of pectus deformities with sternal support.
      The type of repair for pectus carinatum depends on the location of the sternal protrusion, the degree of asymmetry, and the severity of any associated depression, but includes some common elements. Repair begins with a transverse incision across the lower or mid anterior chest, depending on the location of the protrusion. Patients with more than 5 deformed costal cartilages will benefit from a short cephalad extension of the incision. Limited skin flaps are elevated over the pectoralis muscles, and the pectoralis major muscles are reflected laterally to expose the deformed cartilages.
      Figure thumbnail fx3
      3The perichondrium is incised on the mid anterior surface of the deformed costal cartilages bilaterally, extending from the sternum medially to the point laterally where the rib has a near-normal position. Abnormal costal cartilages are resected, carefully preserving the entire perichondrium. In those patients with a posterior depression of the xiphoid, it is detached from the lower end of the sternum. The intercostal muscles and perichondrial sheaths of the lower cartilages are detached from the sides of the lower sternum in almost all patients. The retrosternal space is mobilized, the right pleural space is electively opened, and a small chest tube is inserted. A transverse osteotomy is made through the anterior table of the sternum at the level where it begins to extend outward from the normal chest contour. The posterior table of the sternum is gently fractured but not displaced, so the sternum is lowered posteriorly. Occasionally, a patient with chondromanubrial prominence will require a second or third osteotomy across the anterior table of the sternum where it begins to depress posteriorly.
      Figure thumbnail fx4
      4For patients with severe symmetrical protrusion, a small triangular wedge of costal cartilage is placed into the anterior sternal osteotomy and secured to the sternum with nonabsorbable sutures to provide stability and hemostasis. A thin stainless steel bar (Adkins strut) is placed across the lower anterior chest over the lower tip of the sternum and secured to the appropriate rib on each side with fine wire.
      • Adkins PC
      • Blades B
      A stainless steel strut for the correction of pectus excavatum.
      For those patients with sternal twisting, or combined protrusion and depression defects, the steel strut is placed posterior to the lower tip of the sternum and the sternum is then manually manipulated to the desired position. The xiphoid and perichondrial sheaths are reattached to the sternum, and the pectoralis muscles are sutured together in the midline. The skin is closed with subcuticular absorbable sutures and steristrips. For those patients in whom retrosternal dissection with chest tube placement was not performed, a small Hemovac suction catheter is placed across the anterior chest between the sternum and overlying muscles. Thorough hemostasis is achieved with needlepoint electrocautery, and the wound is copiously irrigated with antibiotic solution throughout the operation. Figure shows technique for repair of protrusion deformity of upper sternum.
      Figure thumbnail fx5
      5(A) Severe pectus carinatum involving the mid and lower sternum in an 18-year-old man. (B) Appearance of the chest in the same patient 6 weeks after repair.

      Postoperative Care

      The chest tube is removed within 24 hours after the operation. An intravenous antibiotic is given for 48 hours, and oral cephalexin (Keflex) is given for 4 additional days. Postoperative pain is remarkably mild for almost all patients and is controlled with intravenous analgesics for the first 48 hours and by oral medications thereafter. Analgesic medications are rarely used after 1 week. Epidural analgesia is not used.
      The duration of the operation averaged 2.7 hours, and the total period of hospitalization rarely exceeded 3 days (mean = 2.6 days). Mean blood loss was 85 mL; none of the patients received blood transfusions. Full physical activity, except for body contact sports, was resumed by almost all patients within 6 to 8 weeks. The sternal struts were removed on an outpatient basis between 5 and 6 months after repair through a small incision with the patient under light general anesthesia, rarely taking more than 15 minutes.

      Results and Comments

      Each of the patients with preoperative severe shortness of breath and/or limitation in stamina and endurance with exercise experienced marked improvement within 3 to 4 months after surgery. Patients with asthmatic symptoms experienced fewer episodes of wheezing and a decreased need for medications. Each of the patients with chest discomfort noted considerable improvement within 3 months. With a mean follow-up of 8.6 years, only 2 of the 80 patients did not achieve a very good or an excellent long-term result, and both of these had other major anomalies. Figure 5 shows typical cosmetic improvement. Postoperative complications included wound seroma in 5 patients, pleural effusion in 3 patients, unintentional pneumothorax in 2 patients, and recurrent mild protrusion in 3 of the early patients in whom a sternal support bar was not used. Mild-to-moderate hypertrophy of the cutaneous scar occurred in 8 patients.
      The described operative technique has provided excellent results in more than 96% of patients with short hospitalization, low rate of complications, and low cost. The high frequency of improvement in respiratory symptoms, exercise tolerance, and endurance, as well as cosmetic appearance, supports the view that symptomatic patients with pectus carinatum at all ages will benefit from repair.

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        Surgical correction of pectus carinatum.
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        Cardiopulmonary function in pectus excavatum.
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        Repair of pectus deformities with sternal support.
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