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Pectus excavatum is the most common congenital abnormality of the chest wall and frequently requires repair and reconstruction. Historically, the open repair has been the standard approach, though the minimally invasive Nuss bar approach has become more common over the last two decades. Our operative description of the Ravitch-type repair with modifications remains a valuable tool in complex cases and re-do operations.
The congenital anterior chest wall deformities encompass a wide variety of abnormalities. They range in severity from minor cosmetic defects to life-threatening conditions with cardiopulmonary compromise. Although the diagnosis is readily made by examination, the indications for and timing of surgical intervention remain debated in all but the most dramatic cases.
Pectus excavatum is the most common congenital anterior chest wall deformity seen in clinical practice. It occurs in 1 of 400 live births with a 5:1 male-to-female ratio. Although several familial cohorts have been reported, most cases are sporadic and a genetic basis has not been established. This disorder is often accompanied by other congenital abnormalities. The incidence of associated musculoskeletal abnormalities ranges from 15%-20%. Scoliosis is the most commonly associated abnormality and affects approximately 15% of patients. Concomitant congenital cardiac abnormalities also occur and should be considered for simultaneous correction when pectus repair is planned.
The diagnosis of pectus excavatum is based on the clinical examination. It is characterized by a “funnel” chest and the severity of the deformity can be quite variable. Almost all of these defects are recognized within the first year of life. The deformity is well tolerated from a physiological standpoint through childhood and most patients are asymptomatic. During rapid growth phases, the deformity becomes more pronounced. This is especially evident around puberty. Despite decades of study, no consistently reproducible cardiopulmonary measurements have documented preoperative impairment or postoperative improvement after surgical repair. Nevertheless, the literature is replete with reports of significant symptomatic improvement, both physically and psychologically after repair.
The indications for open repair of pectus excavatum remain elusive. In our practice, most candidates for open repair present after puberty. Many patients are asymptomatic, and at times it can be challenging to tease out whether their symptoms are related to the pectus vs the psychological aspects of the pectus. A number of classification systems have been proposed to assist in grading the severity of the deformity and selecting patients for operative repair. The Congenital Heart Surgery Nomenclature and Database Project classifies deformities of less than 2 cm in depth as mild, those 2-3 cm in depth as moderate, and those greater than 3 cm as severe. No clear-cut surgical recommendations based on this classification have been established. The most commonly used classification system is based on the “Haller index.” The index is calculated by dividing the inner width of the chest at its widest point by the distance between the posterior table of the sternum and the spine. The measurements can be taken from either an anteroposterior (AP) and lateral chest radiograph or a computed tomographic scan of the chest. A Haller index score of greater than 3.2 suggests severe disease that should be corrected. Although these classification systems are useful when classifying and comparing among series of patients reported in the literature, we have not found them always helpful in determining which patient to offer corrective surgery.
The optimal age for correction of pectus excavatum also remains unclear. Corrective procedures involving cartilage resection are clearly easier in children between 2 and 5 years of age; however, concern exists over subsequent malformation of the chest wall with a resultant chest wall constriction. Open repair in young children was far more common in the past, but the incidence of chest wall restriction has significantly decreased the performance of this operation in the younger age group. In general, open operative repair is offered to patients older than 10 years.
We obtain AP and lateral chest radiographs for preoperative and postoperative comparison; however, we do not routinely calculate radiographic indices of sternal depression finding them to have little use in clinical decision making. The diagnosis is confirmed on physical examination. The assessment of spinal curvature is also undertaken. Other associated conditions such as Marfan disease are ruled out clinically. The patient and the parents are counseled as to the details of the procedure and the expected outcomes .
Patients are managed in the hospital for 5-7 days postoperatively. The limiting factor for their discharge is pain management and resolution of pleural effusions. During the hospital stay, we obtain a portable AP chest x-ray on postoperative day 1. Then, before discharge, we obtain a high-quality posteroanterior and lateral chest x-ray. Patients are transitioned from an epidural catheter to oral pain medications on postoperative day 2 or 3.
After discharge, patients are instructed to stay on oral antiinflammatories (ie, ibuprofen), oxycodone, and muscle relaxants as needed. They are encouraged to not lie on their side and avoid bending over for 3 weeks. We also have patients perform deep breathing exercises several times throughout the day and emphasize the need for a straight posture. After 3 months, patients are permitted to resume light aerobic activity and then upper body lifting by 6 months postoperatively. Patients are strongly discouraged from engaging in contact sports for several years.
Open repairs based on modifications of the original technique as described by Ravitch provide excellent results. Several series have supported these open procedures as the gold standard producing acceptable results with very low complication and recurrence rates. Fonkalsrud recently reported on 275 patients operated on with his minimal cartilage resection procedure over a 3-year period. All but 5 patients had results that were very good to excellent and there were no major complications or deaths. The most common intraoperative complication from any of the open procedures is pneumothorax due to inadvertent entrance into the pleural cavity. Usually, this is resolved with aspiration and a formal chest tube is not required. Common postoperative complications include wound infection and seroma formation. These almost always respond to conservative measures.
Open repair of pectus excavatum with minimal cartilage resection.