Pectus excavatum is the most common congenital

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1 Nonprosthetic Surgical Repair of Pectus Excavatum Hiroshi Iida, MD, PhD, Yoshio Sudo, MD, PhD, Yasuyuki Yamada, MD, PhD, Yasushi Matsushita, MD, PhD, Kunihiro Eda, MD, PhD, and Yuho Inoue MD, PhD GENERAL THORACIC Department of Cardiovascular Surgery, Kimitsu Central Hospital, Sakurai Kisarazu, Japan, and Department of Cardiothoracic Surgery, Dokkyo University School of Medicine, Mibu, Tochigi, Japan Background. Previously, a method was reported to correct pectus excavatum in which a convex steel bar is inserted beneath the sternum. This method gained popularity, but a relatively high incidence of complications has been reported. We review our experience of nonprosthetic repairs of pectus excavatum. Methods. From 1993 through 2004, 62 patients underwent repair of pectus excavatum. Sternocostal elevation was adopted for 54 patients ( years old). A part of the third or fourth to the seventh costal cartilages was resected. All of the stumps were pulled to generate tension and resutured with the sternum. Cortical osteotomy of upper sternum and introduction of exogenous material were not employed. Sternal turnover and overlap was adopted for 8 adults ( years old) with severe asymmetric deformities. The sternum was cut at the level of the second or third intercostal space. The lower part of the sternum was turned over and secured in a position so that it overlapped with the upper sternum, and the stumps of cartilages were reattached to the plastron. In these procedures, the natural tension exerted by the patient s ribs is sufficient to elevate and fix the sternum. Results. Mechanical ventilation was not required after emergence from anesthesia. None of the patients experienced threatening complications or required reoperation. Fifty patients (81%) were graded as excellent, and 12 patients (19%) were graded as good at 1 month after surgery. Conclusions. The procedures described here yielded excellent results with low morbidity and no mortality, and produced high patient satisfaction. (Ann Thorac Surg 2006;82:451 6) 2006 by The Society of Thoracic Surgeons Pectus excavatum is the most common congenital chest deformity. Repair of pectus excavatum is undertaken to alleviate symptoms such as dyspnea on effort, diminished endurance, and chest pain, as well as to treat cosmetic or psychological impairment [1 7]. The methods for correcting pectus excavatum are the subject of some controversy. Conventional techniques included resection or cutting of sternum and cartilages. The basic principles involved in these procedures, which were originally described by Ravitch [8] and have subsequently been modified and adapted by many others [1 3, 9 11], required potentially major invasive procedures. Since Nuss and colleagues [12] first described a new method for repair of pectus excavatum for pediatric patients using a pectus bar without anterior chest wound or resection of cartilage, the popularity of this operation has increased [13 17]. However, a high incidence of complications associated with this method has been reported [12 17]. We review our experience of pectus excavatum repair in which the introduction of exogenous material is not a requirement. Accepted for publication March 20, Address correspondence to Dr Iida, Department of Cardiovascular Surgery, Narita Red-Cross Hospital, Iidachou Narita, Chiba , Japan; iidahomburg@hotmail.com. Patients and Methods Patients From July 1993 to December 2004, 62 patients underwent repair of pectus excavatum; all of the procedures were performed by a single surgeon. The study was approved by the Institutional Review Board, and individual informed consent was obtained from each patient before surgery. There were 52 male and 10 female patients. Mean age was years, ranging from 4 to 43 years of age. Three of the patients simultaneously underwent cardiac procedures. The indication for surgery was decided by a visual comparison of the depth and volume of the excavation with the patient s clenched fist. If the depth and volume of the excavation were observed to exceed that of patient s fist, the patient was recommended for surgical repair. A computed tomography (CT) scan was taken preoperatively to inspect for abnormalities in other thoracic structures before surgery. The CT index of Haller and colleagues [18] exceeded 3.6 in all patients. Operative Technique We adopted two types of techniques, both of which were modified from the method described by Wada and coworkers [19] and Kasagi and Hino [20]. Sternocostal elevation was used for 54 patients ( years old), a group that included all of pediatric patients and adult patients with relatively symmetric deformities. The second technique used was sternal turnover and overlap, 2006 by The Society of Thoracic Surgeons /06/$32.00 Published by Elsevier Inc doi: /j.athoracsur

2 GENERAL THORACIC 452 IIDA ET AL Ann Thorac Surg PECTUS EXCAVATUM REPAIR WITHOUT PROSTHESIS 2006;82:451 6 Fig 1. Basic surgical technique of sternocostal elevation. An area of the third to seventh costal cartilages was resected (marked in black). All of the cartilage stumps were then affixed to the sternum with braided polyester sutures. No triangular resection of the upper anterior sternal cortex was performed. which was employed for 8 adult patients ( years old) with severe asymmetric deformities, such as those characteristic of Marfan syndrome. Sternocostal Elevation In males, a median vertical incision was made superficial to the defect, whereas in female patients, an inframammary incision with upward curvature in the middle was used to reduce scar visibility. Diluted epinephrine (0.005 mg/ml) was injected subdermally to reduce bleeding and burns caused by the use of electrocautery. The median section of the bilateral pectoralis muscles was exfoliated from the sternum and associated cartilages. The rectus muscle and xiphoid were freed from the sternum at the xiphosternal junction. A part of the third or fourth to the seventh costal cartilages was resected using a periosteal knife. The mediastinal aspect of the pericartilage was preserved from cutting and resection to prevent injury to mammary vessels and pleura. All of the stumps of cartilages were reattached to the sternum using 1 (for pediatric patients) or 3 (for adult) braided polyester sutures (Fig 1). The number and length of cartilages resected was determined by the degree of deformity. In the case of asymmetric deformity, different lengths and different numbers of cartilages were resected on each side. Adequate lengths of cartilages, 5 to 60 mm, generally longer lengths in the lower cartilage, were resected so that the resected and reshaped cartilages and ribs generated 0.5 to 7 kg of tension on reattachment to the sternum. The secured ribs pulled the sternum toward both sides so that the resultant force caused the sternum to raise anteriorly. This same pulling force served to elevate the ribs in patients whose ribs tilted downward to a greater extent than in a normal population. A triangular resection of the upper anterior sternal cortex, which was made by the Ravitch method, was not performed. The sternum exhibits pliability without cortical tearing, especially in pediatric patients. The lower part of sternum below sixth cartilage junction was resected in the 29 most recent cases. In most cases, this part of the sternum was not completely ossified and tilted back toward the vertebrae. This modification made it possible to secure the sixth and seventh costal cartilages to the lower cutting face of the sternum, causing these cartilages to pull the sternum caudally. The resultant force pulled the sternum up ventrally, while protruding costal arches, which were frequently observed in patients with funnel chest, was pulled down and corrected. Since all of the cartilage stumps were secured, the tension exerted by the patient s ribs was enough to flatten and fix the sternum without exogenous materials and cortical osteotomy of upper sternum, but did not disturb respiration. Two small-gauge tubes less than 5 mm connecting to closed portable evacuating drainage system (Relia Vac; DAVOL, Cranston, Rhode Island; or SB Vac; Sumitomo Bakelite, Tokyo, Japan) were placed around the sternum and cartilages. The rectus muscle and xiphoid was attached to anterior face of the lower sternum by braided polyester suture. The inner layer of the pectoralis muscle was secured to the edge of the sternum. Both sides of the outer layer of pectoralis muscle were sutured together at the midline, and the lower edges of the pectoralis and rectus muscles were sutured together, so that the muscle layer covered the corrected costal cartilage and sternum. The repair was completed by suturing the overlying skin. Drains were removed in 3 to 5 days, after the discharge declined to less than 20 ml per day. Sternal Turnover and Overlap The sternal turnover and overlap technique was employed for adult patients whose sterna were both severely distorted and sufficiently ossified. Incisions of slightly greater length were made in essentially in the same sites as in sternocostal elevation. The muscles were exfoliated, and the xiphoid was cut in the same manner as in the sternocostal elevation procedure. Costal cartilages were cut at the middle of the cartilage, and the sternum was also cut at the height of the second or third intercostal space. The lower part of the sternum with costal cartilages was then removed from the wound, and the distortion was corrected, if necessary by tearing the cortex. The lower sternum was turned over and fixed on the upper sternum with an overlap of 1 to 1.5 cm using two metal wires. An adequate length of each cartilage was resected, and all of the stumps of cartilages were

3 Ann Thorac Surg IIDA ET AL 2006;82:451 6 PECTUS EXCAVATUM REPAIR WITHOUT PROSTHESIS 453 GENERAL THORACIC Fig 2. (A) Chest of 4-year-old boy with pectus excavatum before surgery. Severe asymmetric pectus excavatum and protrusion of costal arches were seen. (B) Resected costal cartilages and lower tip of sternum. (C) One year after sternocostal elevation, the length of the wound was 3.5 cm. Normal chest contour was seen. attached to the plastron with sufficient tension to achieve good correction of defects and to prevent flail chest in the same manner as achieved in sternocostal elevation. Methods of repairing muscles and skin were as described for sternocostal elevation, above. Results Mechanical ventilation was not needed after emergence from anesthesia, and all of the patients were returned immediately from the operating room to an ordinary ward, with the exception of 3 cases who underwent simultaneous cardiac repair. None of them needed blood transfusion, except for 2 patients with Marfan syndrome who underwent simultaneous aortic root replacement. The depression of the anterior chest wall was corrected, asymmetric chest walls reshaped to symmetric, protruding costal arches were corrected (Figs 2 and 3), in some cases scoliosis was improved, and cardiac shadows observed in thoracic roentgenogram returned to near midline in pediatric patients. Fifty patients (81%) were graded as excellent, and the remaining 12 (19%) patients were graded good, with marked improvement in appearance at 1 month after surgery. None of the patients have had fair or poor results. The wound was inconspicuous, and most of patients reported satisfaction with the wound and the shape of the corrected chest. The median length of incision was cm in patients undergoing sternocostal elevation, and cm in patients undergoing sternal turnover and overlap. All of the patients under 16 years old (n 39) underwent sternocostal elevation; the median length of the vertical wound of males in this age group was cm. In the most recent 10 patients less than 7 years old, the length of the anterior chest wound was cm. None of the patients had pneumonia or any lifethreatening postoperative complications. One adult female patient had superficial wound infection at the apical point of the convex inframammary incision. Two patients had pneumothorax and required tube drainage. One adult patient had a seroma requiring puncture and suction. No other postoperative complications were seen, and no reoperations were required in any of the patients for any reasons. At the recommendation of the anesthesiologist, epidural analgesia was used in two of the adult patients, and was removed 1 day after surgery. Analgesia injection by any route was discontinued within a day after operation, and orally administered analgesia was Fig 3. (A) Chest computed tomography of same patient before surgery showed asymmetric pectus excavatum with severe cardiac compression and displacement. (B) Chest computed tomography at 1 month after sternocostal elevation. The depression was corrected.

4 GENERAL THORACIC 454 IIDA ET AL Ann Thorac Surg PECTUS EXCAVATUM REPAIR WITHOUT PROSTHESIS 2006;82:451 6 provided for as long as 7 postoperative days in adult patients, as needed. In almost all pediatric patients, analgesia was needed for only 1 to 2 days after surgery. One adult female patient complained of slight discomfort in the right side of her chest for 6 months, but did not require analgesia. For this reason, we concluded that none of the patients experienced residual pain. Preadolescent patients were able to return to their preoperative daily activities within a week of surgery, whereas adult patients took little bit longer. We advise our patients to avoid contact sports for 3 months as a precaution, but in general these patients experience no restrictions on normal activities and do not need to undergo any subsequent surgery. All of the patients were followed up for at least 1 year. The rating of a single patient who had undergone sternocostal elevation and been classified as excellent at 1 month after surgery was later revised to good at 1 year after surgery. Three adult patients with tall, thin Marfan-like physiques who underwent sternal turnover and overlap exhibited slight chest depression and were classified as fair at 1 year after surgery, but even these patients exhibited marked improvement in chest shape compared with that before the operation. No other patient has experienced deterioration of chest contour. Comment The majority of patients with severe pectus excavatum experience progressive shortness of breath on exercise, decreased endurance, recurrent upper respiratory tract infections, chest pain, and discomfort in the anterior chest, as well as psychological complaints [1 3]. Improvement of physiologic data and symptoms after surgical correction of pectus excavatum has been reported for years [4 7], but the most common consideration for family physicians relate to the aesthetic appearance of the chest. Now, the spread of Internet access has made more patients aware that these deformities could lead to physical problems and that they can be corrected [11]. Since we launched a website describing pectus excavatum correction in October 2001, 25 of 36 (69%) of the patients who underwent surgery reported that they came to our outpatient clinic as a result of their own Internet searches. We did not use CT for determination of surgical indication. We chose not to use this technology as it involves relatively high-dose radiologic exposure for children. The position of the apex of the depression, the ratio of sagittal to lateral diameter, and the protrusion of the costal arches were different in each case. We relied on physical examinations and interview to determine indication for surgical correction. We note that the indicative criteria have been empiric in most other series reported to date as well [9]. Most conventional techniques for the repair of pectus excavatum were based on methods first described by Ravitch [8], including a long incision in the anterior chest wall, resection of deformed rib cartilages, and the tearing of the sternal cortex in order to remodel it. Others have made several modifications in the operative procedures, such as the introduction of a metal bar that used to stabilize the lower part of sternum [1 3, 9 11]. Such procedures can be employed in any age group, but are considered to be invasive because of the large wound opened in the anterior chest wall and the resection or tear that must be made in cartilages and sternum. A revolutionary procedure first reported by Nuss and colleagues [12] has been described as minimally invasive repair for pediatric patients, because this approach does not require either an anterior wound or the cut of cartilage or sternum. In this procedure, a metal bar is placed behind the sternum through pleural spaces, and is secured to the ribs. The Nuss procedure has gained substantial popularity [13 17], but has also involved a relatively high morbidity rate [12, 15 17], especially during the learning curve [13, 14]. Migration of the bar has been reported in 3.6% to 8.8% of patients [12 14]. Perioperative and late complications including infection of the bar, pneumonia, pleural effusion, hemothorax, wound seroma, skin necrosis, pericarditis, and even cardiac perforation have been reported [12 17]. Reoperation for complications was needed in 4.1% to 11% [13, 15 17]. Severe pain is one of the unpleasant complications of the Nuss procedure [12, 15, 16]. Sedation and thoracic epidural analgesia is often utilized for several days after the Nuss procedure [12], and Croitoru and associates [14] reported that transient Horner s syndrome occurred in 74.8% of patients who received epidural analgesia. Some patients suffered from residual pain and required analgesia for extended periods [16]. We believe that the complications associated with the Nuss procedure may be caused, at least in part, by the introduction of the metal bar, as the chest wall moves with respiration and body movements, and grows for years, and the ribs are sensitive to the stress of being subjected to stabilization with a metal bar. In addition, the extent of the physical and mental burden that may be associated with the introduction of a foreign body into the chest of a growing, preadult patient remains unknown. Because the majority of pectus excavatum corrections are performed in young patients, and candidates for surgical correction rarely exhibit life-threatening complaints and are able to maintain acceptable quality of life preoperatively, surgeons have a strong obligation to avoid the risk of complications requiring long-term medical treatment or reoperation. Wada and colleagues [19] described sternal turnover for pectus excavatum in We have adapted this technique to make it less invasive. We realized that, especially for preadolescent patients, the sternum is quite pliable, and could be corrected without the requirement of turnover, wedge osteotomy on the cortex, or the insertion of a foreign body [20]. Ithas been shown in the Nuss procedure that the sternum can be corrected without the resection of cartilages or

5 Ann Thorac Surg IIDA ET AL 2006;82:451 6 PECTUS EXCAVATUM REPAIR WITHOUT PROSTHESIS sternal osteotomy, and indeed, in our method, the deformed sternum is easily corrected by the shortening of cartilages. The sternum is pulled laterally by shortened and resutured costal cartilages, and the resultant force raises the sternum ventrally. The same force prevents flail chest and allows patients to breathe on their own in the operating room immediately after surgery. Because we secure the stumps of all cartilages, while only a subset of the lower cartilages are secured in the Ravitch method, the resilience of each rib and the chest wall as a whole helps to correct chest wall deformity, and even asymmetric deformities and projecting costal arches can be corrected. For some patients, asymmetry of the thorax and projection of costal arch may be the chief aesthetic complaints. In adult patients with Marfan syndrome or severe asymmetrical deformity, the sternum is so twisted and resistant to reconformation that it must be cut and turned over. However, even in these cases, the chest wall is moderately stabilized by the tension exerted by the ribs, and the patients can breathe independently immediately after surgery. None of our patients experienced major complications resulting in an extended hospital stay, needed extensive outpatient treatment, or required reoperation for any reason. In this procedure, no exogenous material is left within the chest wall, and cartilages and sternum are covered with a muscle layer having a rich blood supply, making it possible to expect prompt wound healing and tolerance to infection. None of our patients suffered from residual pain that disturbed the resumption of their normal participation in society. Subsequent surgery to remove foreign bodies was also unnecessary. In these procedures, as sections of cartilage longer than those in the normal chest were partially resected and were secured to the sternum, relapse was rare [20]. Haller and coworkers [21] have cautioned against extensive cartilage resection in children, because of the occasional occurrence of constricting asphyxiation thoracic dystrophy. Because only a part of the cartilages are resected, and all of the stumps are secured with the sternum in our methods, the growth of the remaining cartilages and chest wall after surgery is not affected. We employed sternocostal elevation or sternal turnover and overlap in patients of all age groups and achieved satisfactory surgical correction; but we believe, for several reasons, that the most appropriate age for this procedure is before puberty, with 4 to 6 years of age being the optimal range [10]. Before the onset of puberty, the chest is more malleable, sternocostal elevation for children usually takes less than 2 hours to perform, but corrections may take more than twice as long in adults. The surgical wound in sternocostal elevation is shorter than that in sternal turnover and overlap. In addition, after the age of 30, cartilage becomes more rigid and brittle. Because adult patients may present with a greater number of complaints than children before surgery [1, 11], we believe that it is important to relieve structural compression of the chest and allow normal growth of the thorax, and do surgical repair to reduce potential physical and psychological impact. Children in our recommended age range are sufficiently emotionally mature and are more likely to expect a positive experience from their hospital stay. Children at this age are also generally young enough not to have suffered psychological impairment secondary to the perception of abnormal body image [10]. In conclusion, an excellent postoperative chest contour was achieved in most of the patients, and none of our patients had major complications requiring longterm hospitalization. We believe that the risk of complications is one of the most important factors in determining the appropriateness of major surgical invasion, especially in pediatric patients. The procedures described here include the resection of cartilage, but we believe that our technique represents a less invasive and lower risk procedure for the repair of pectus excavatum. References Mansour KA, Thourani VH, Odessey EA, Durham MM, Miller JI Jr, Miller DL. Thirty-year experience with repair of pectus deformities in adults. Ann Thorac Surg 2003;76: Fonkalsrud EW, Dunn JCY, Atkinson JB. Repair of pectus excavatum deformities: 30 years of experience with 375 patients. Ann Surg 2000;231: Lacquet LK, Morshuis WJ, Folgering HT. Long-term result after correction of anterior chest wall deformities. J Cardiovasc Surg 1998;39: Morshuis WJ, Folgering HT, Barentsz JO, Cox AL, van Lier HJ, Lacquet LK. Exercise cardiorespiratory function before and one year after operation for pectus excavatum. J Thorac Cardiovasc Surg 1994;107: Kowalewski J, Brocki M, Dryjanski T, Zolynski K, Koktysz R. Pectus excavatum: increase of right ventricular systolic, diastolic, and stroke volumes after surgical repair. J Thorac Cardiovasc Surg 1999;118: Malek MH, Fonkalsrud EW, Cooper CB. Ventilatory and cardiovascular responses to exercise in patients with pectus excavatum. Chest 2003;124: Zhao L, Feinberg MS, Gaides M, Ben-Dov I. Why is exercise capacity reduced in subjects with pectus excavatum? J Pediatr 2000;136: Ravitch MM. The operative treatment of pectus excavatum. Ann Thorac Surg 1949;129: Davis JT, Weinstein S. Repair of pectus deformity: results of the Ravitch approach in the current era. Ann Thorac Surg 2004;78: Haller JA Jr, Scherer LR, Turner CS, Colombani PM. 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6 GENERAL THORACIC 456 IIDA ET AL Ann Thorac Surg PECTUS EXCAVATUM REPAIR WITHOUT PROSTHESIS 2006;82:451 6 minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37: Fonkalsrud EW, Beanes S, Hebra A, Adamson W, Tagge E. Comparison of minimally invasive and modified Ravitch pectus excavatum repair. J Pediatr Surg 2002;37: Watanabe A, Watanabe T, Obama T, et al. The use of a lateral stabilizer increases the incidence of wound trouble following the Nuss procedure. Ann Thorac Surg 2004;77: Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg 2000;35: Haller JA Jr, Kramer SS, Lietman SA. Use of CT scans in selection of patients for pectus excavatum surgery: a preliminary report. J Pediatr Surg 1987;22: Wada J, Ikeda K, Ishida T, Hasegawa T. Results of 271 funnel chest operation. Ann Thorac Surg 1970;10: Kasagi Y, Hino T. Operative method of funnel chest. In: Wada J, ed. Chest deformities. Tokyo, Japan: Nankodo, 1987: Haller JA Jr, Colombani PM, Humphries CT, Azizkhan RG, Loughlin GM. Chest wall constriction after too extensive and too early operations for pectus excavatum. Ann Thorac Surg 1996;61: Notice From the American Board of Thoracic Surgery Regarding Trainees and Candidates for Certification Who Are Called to Military Service Related to the War on Terrorism The Board appreciates the concern of those who have received emergency calls to military service. They may be assured that the Board will exercise the same sympathetic consideration as was given to candidates in recognition of their special contributions to their country during the Vietnam conflict and the Persian Gulf conflict with regard to applications, examinations, and interruption of training. If you have any questions about how this might affect you, please call the Board office at (312) Carolyn E. Reed, MD Chair The American Board of Thoracic Surgery 2006 by The Society of Thoracic Surgeons Ann Thorac Surg 2006;82: /06/$32.00 Published by Elsevier Inc