Concept: Pectus carinatum
Several techniques exist for the repair of complex pectus excavatum. The placement of retrosternal metal bars improves the results by reducing the recurrence rate, but entails several possible risks, complications and disadvantages. A new method, specifically conceived for the repair of severe, asymmetric forms in adult patients, is reported. The corrected bone is fixed in the proper position by two, patient-customized, titanium struts, externally screwed to the manubrium and sternal body. Any retrosternal bar is thus avoided, reducing possible complications, without hampering the chest wall dynamic. In this particularly difficult issue, this technique provides long-term good functional, mechanical and cosmetic results and does not entail a second surgery for struts removal.
: This article reviews pectus excavatum and the role of the primary care provider in correct identification. Historically, pectus excavatum was viewed as a cosmetic concern. Research indicates that severe cases result in cardiopulmonary impairment and physiologic limitations. Evidence demonstrates that surgical repair improves cardiovascular function, exercise tolerance, and body image.
Surgical correction of pectus excavatum (PE) has shifted to the modern minimally invasive Nuss procedure, which proved to be safe and effective. In order to restore the dented deformity, custom-curved metal bars provide continuous retrosternal pressure but cross the habitat of the internal mammary arteries (IMAs) directly affecting their patency. In this initial report, we sought to assess the patency of the IMAs in the first 6 patients who underwent Nuss bar removal in our department.
The aim of study was to introduce technical innovation of MIRPE which reduces the risk of cardiac injury. Modification of MIRPE method with semiflexible thoracoscope and sternum elevating technique has been used. Volkmann bone hook has been inserted percutaneously to the sternum. The hook elevates the sternum forward and enlarges the retrosternal space for safer passage of thoracoscopically guided introducer. Using semiflexible thoracoscope allows better view from various angles via one site of insertion. During the period 2005-2012, the MIRPE was performed on 29 girls and 151 boys; the mean age at the time of surgery was 15.9 years (range 13-18.7 years). The mean Haller index was 4.7 (range 2.7-20.5). The most common complication was pneumothorax (3.3 %) and the incidence of bar displacement was 2 %. The most serious complication was cardiac perforation when inserting Lorenz introducer. This occurred in a 16-year-old girl; she required urgent sternotomy with right atrial repair and recovered well. External elevation of sternum with the hook was used since this case. Subsequent 113 patients underwent surgery without any serious complications. Technical innovation using semiflexible thoracoscope and hook elevation of the sternum reduces the risk of cardiac injury. The hook opens the anterior mediastinum space effectively and makes the following dissection relatively safe and straightforward.
Pectus excavatum results in compression of the heart and may compromise cardiac function. Several studies have shown that surgical correction improves cardiac function as assessed on echocardiography. However, morphologic changes to support this have not been reported.
This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric = 0-21; adult 17-99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.
Marfan syndrome (MFS) is an autosomal dominant genetic disease caused by abnormal formation of the extracellular matrix with an incidence of 1 in 3, 000 to 5, 000. Patients with Marfan syndrome experience poor quality of life caused by skeletal disorders such as scoliosis, and they are at high risk of sudden death from cardiovascular impairment. Suitable animal models of MFS are essential for conquering this intractable disease. In particular, studies employing pig models will likely provide valuable information that can be extrapolated to humans because of the physiological and anatomical similarities between the two species. Here we describe the generation of heterozygous fibrillin-1 (FBN1) mutant cloned pigs (+/Glu433AsnfsX98) using genome editing and somatic cell nuclear transfer technologies. The FBN1 mutant pigs exhibited phenotypes resembling those of humans with MFS, such as scoliosis, pectus excavatum, delayed mineralization of the epiphysis and disrupted structure of elastic fibres of the aortic medial tissue. These findings indicate the value of FBN1 mutant pigs as a model for understanding the pathogenesis of MFS and for developing treatments.
Cryoanalgesia in Patients Undergoing Nuss Repair of Pectus Excavatum: Technique Modification and Early Results
- Journal of laparoendoscopic & advanced surgical techniques. Part A
- Published 8 months ago
The Nuss procedure for surgical correction of pectus excavatum often causes severe postoperative pain. Cryoanalgesia of intercostal nerves is an alternative modality for pain control. We describe our modification of the cryoICE™ probe that allows for nerve ablation through the ipsilateral chest along with early results utilizing this technique.
Sterile sternotomy nonunion is a recognized complication after median sternotomy. It is defined as sternotomy that persists after 3 months without evidence of bony healing but with healing of the overlying soft tissues. It is a morbid condition associated with pain and sternal instability. We present two challenging cases of sterile sternotomy nonunion after cardiac operations that were treated successfully with novel methods adopted from the Elastic Stable Chest Repair for complex pectus deformity repair, using transverse costal to costal external cortical plates and bicortical screws, after debridement, autologous bone grafting and double loop wire sternal approximation.
Pectus excavatum can lead to right ventricle compression. Although extremely rare, congestive hepatopathy should be considered when patients with severe pectus excavatum present with cardiovascular involvement.