Pectus Excavatum Example Journal PDF
Pectus Excavatum Example Journal PDF
Pectus Excavatum Example Journal PDF
Background
Results
Objective
Methods
Hospital records from 375 patients who underwent repair of
pectus excavatum deformities between 1969 and 1999 were
reviewed. Decrease in stamina and endurance during exercise was reported by 67%; 32% had frequent respiratory infections, 8% had chest pain, and 7% had asthma. The mean
pectus severity score (width of chest divided by distance between posterior surface of sternum and anterior surface of
spine) was 4.65 (normal chest 2.56). All patients had
marked cardiac deviation into the left chest. Repair was performed with subperiosteal resection of the abnormal carti-
Congenital chest wall deformities have long been considered as curious and essentially unimportant anomalies of
thoracic contour. During the past several years, however,
pectus malformations have come to be recognized as fairly
common and much more symptomatic than previously believed. Pectus excavatum is by far the most common congenital chest deformity, occurring in approximately one in
every 700 births (personal communication, March of Dimes
Birth Defects Foundation, March 1995), but the recognition
of symptoms and the recommendation for surgical correction remain highly controversial: less than 15% of patients
undergo surgery. Few medical conditions arouse such opin-
Correspondence: Eric W. Fonkalsrud, MD, Dept. of Surgery, UCLA Medical Center, Los Angeles, CA 90095.
Accepted for publication June 25, 1999.
The mean hospital stay was 3.1 days. With a mean follow-up
of 12.6 years, all patients with preoperative respiratory symptoms, exercise limitation, and chest pain experienced improvement. Vital capacity increased 11% (mean) within 9
months in 35 patients evaluated. There were no deaths.
Complications included hypertrophic scar formation (35), atelectasis (12), pleural effusion (13), recurrent sternal depression
(5), and pericarditis (3). More than 97% had a very good or
excellent result.
Conclusion
Pectus excavatum deformities can be repaired with a low rate
of complications, a short hospital stay, and excellent longterm physiologic and cosmetic results.
ionated views from physicians as does the discussion regarding whether pectus excavatum is primarily a cosmetic
disorder, or whether it causes physiologic impairment and
limitations to the patient. The timeliness of this controversy
has been accentuated in recent years as the insurance coverage for many medical conditions has been restricted by
managed health care.
Compounding the decision of whether to correct pectus
excavatum disorders by surgery is the lack of reliable and
consistent standard investigative studies that clearly indicate
the physiologic limitations on a specific patient by pectus
excavatum, or the improvement that occurs after surgery.
Because only a few hospitals have compiled a large surgical
experience, and because most surgeons perform only a few
pectus operations each year using a variety of surgical
techniques, the reported results have been inconsistent, fur443
444
Table 1.
Age Range
26
611
1116
1620
20
No. of Patients
102
75
87
73
38
47%
375
severe spinal deformities. Two patients had Marfan syndrome. Other anomalies were present in 26 patients (7%).
Almost all patients showed a narrow anterior-posterior
diameter of the chest; only two patients were slightly overweight. Thirty-nine of the 55 patients tested had electrocardiographic evidence of right ventricular strain, and 30 (8%)
had mitral valve prolapse. Almost all patients had displacement of the heart into the left chest. The mean pectus
severity score as determined on chest x-ray or computed
tomography scan by measuring the internal width of the
lower chest and dividing by the distance between the posterior surface of the sternum and the anterior surface of the
spine, was 4.65 (range 3.54 9.50); the normal chest is 2.56
(Fig. 1).1 There was a tendency for patients with a high
pectus severity score to have the most severe symptoms.
Approximately 15% of the patients, largely those younger
than 6 years, had minimal measurable physiologic impairment.
The surgical technique used for each of the 375 patients
was a modification of that described by Ravitch2 and
Welch,3 and has been extensively detailed in previous reports.4,5 The repair of pectus excavatum includes the following essential features:
1. A transverse curvilinear incision is made midway
between nipples and costal margin, extending from
mid-nipple line bilaterally.
2. Limited skin flaps are elevated over the pectoralis
muscles using needle-point electrocautery to minimize blood loss.
3. The pectoralis muscles are reflected laterally over a
short distance from attachments to the sternum and
deformed costal cartilages; the abdominal muscles
are mobilized from the lower costal cartilages.
4. The perichondrium is incised on the midanterior surface of the lower four to five costal cartilages bilaterally, extending from the costochondral junction to
the sternum.
5. Abnormal costal cartilages are resected subperichondrially, carefully preserving the perichondrium.
6. The xiphoid is detached from the sternum.
7. The intercostal muscles and perichondrial sheaths of
the resected cartilages are transected from the sternum.
8. The lower retrosternal space is mobilized.
Table 2.
ASSOCIATED DISORDERS
90 (24%)
60 (16%)
30 (8%)
13 (3%)
2 (0.5%)
26 (7%)
445
9. The pleura is incised on the right side of the mediastinum and a small chest tube is inserted.
10. A transverse anterior wedge osteotomy of the sternum is made at the level where the sternum depresses
posteriorly.
11. The posterior table of the sternum is gently fractured
without displacement and then elevated and twisted
to the desired position.
12. Nonabsorbable sutures are placed through the anterior table of the sternum across the osteotomy.
13. A stainless-steel (Adkins) strut (Baxter Healthcare
Corp., Operating Room Division, McGaw Park, IL)
is placed across the lower anterior chest to support
the tip of the sternum and is wired to the appropriate
rib on each side (fifth or sixth).6
14. The xiphoid and perichondrial sheaths are sutured
back to the sternum. The perichondrial sheaths are
closed loosely.
15. The pectoralis and abdominal muscles are sutured
together over the sternum.
16. Thorough hemostasis is achieved with needle-point
electrocautery, and the wound is copiously irrigated
with cefazolin solution.
17. The skin is closed with subcuticular absorbable sutures and Steri-Strips or staples.
The endotracheal tube is removed in the recovery room
within 2 hours. The chest tube is removed within 24 hours
after surgery. Intravenous cefazolin is given for 3 days, and
oral cephalexin is given for 3 additional days. Postoperative
pain was remarkably mild in all patients and was controlled
with intravenous analgesics for the first 2 postoperative days
and by oral medications thereafter. Epidural analgesia was
not used.
During the past 15 years, the mean duration of the operation has been 2.7 hours (2.2 hours for patients younger than
12 years, 3.2 hours for older patients). Only the infrequent
patient with cardiac anomalies has been placed in an intensive care unit after surgery during the past 18 years. The
RESULTS
Each of the 251 patients with preoperative limitation in
stamina and endurance with exercise experienced marked
improvement within 4 months after surgery, and most were
able to participate in vigorous exercise, including running,
swimming, hiking, basketball, and tennis, before removal of
the sternal bar. Body contact sports, including football, were
resumed after removal of the sternal bar. Of the 120 patients
with preoperative respiratory symptoms, 115 had a decrease
in frequency and severity of pulmonary infections after
repair. Twenty-four of the 26 patients with asthmatic symptoms showed clinical improvement after surgery, as evidenced by fewer episodes of wheezing and a 25% to 40%
decrease in requirement for medications. Each of the 48
patients with chest pain reported considerable improvement
within 3 months. Thirty-three of the 35 patients who underwent preoperative measurement of vital capacity with an
incentive spirometer experienced improvement within 6
months (mean improvement 11%). Although objective measurements of physiologic improvement after surgery are not
available for all patients, almost all showed a shifting of the
heart from the left chest to a normal position on chest
radiograph within a few weeks (Figs. 2 and 3). Functional
heart murmurs were no longer audible in 74 of the 90
patients.
Postoperative complications included wound seroma in
446
hypertrophy becomes apparent. Only seven patients reported mild or moderate discomfort from the sternal bar.
There were no deaths within 12 months after surgery.
DISCUSSION
Symptoms from pectus excavatum are recognized infrequently during early childhood, apart from an unwillingness
to go without a shirt while swimming or to participate in
other athletic or social activities. Most patients are therefore
advised by well-meaning family physicians or pediatricians
that the deformity will improve with age, that it will not
affect heart or lung performance, that it is primarily a
cosmetic problem, and that surgical repair is dangerous,
minimally effective, and unnecessary. It is clear that each of
these views is incorrect with our present knowledge of
447
448
References
1. 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; 22:904 906.