Staged management of pectus carinatum

Background: Simple external compression of pectus carinatum seems to have its limitations, particularly the repair of asymmetric pectus carinatum or excavatum/carinatum complex. We devised the sandwich technique (press-molding) to remodel the entire chest wall. The purpose of this study is to introduce the sandwich technique and appraise the early results.Methods: Between January 2007 and January 2016, 523 consecutive patients with pectus carinatum and its variants were analyzed retrospectively. No patients were excluded during the study period. The sandwich 1 and 2 techniques using the internal and external pectus bars were for pectus carinatum repair. Modified techniques using the external string and the internal bar were to treat the lower costal flare (the flare-buster) and focal protuberances (the magic string) in pectus excavatum repair. Statistical analyses were carried out using paired and unpaired t-test or Wilcoxon signed rank tests. Results:The sandwich repair with the external and internal bars was applied to 58 pectus carinatum patients: seven symmetric (12.1%), 14 asymmetric (24.1%), and 37 carinatum-excavatum complex (63.8%).After pectus excavatum repair, 426 patients had the flare-buster and 39 patients received the magic string.The sandwich 1 technique achieved near-complete resolution of carinatum in 52 patients (86.2%). The sandwich 2 technique accomplished almost symmetric configuration with no residual carinatum in all six cases. Conclusions:The sandwich technique using the external and internal bars seems to be effective in treating asymmetric pectus carinatum and complex excavatum/carinatum deformities. The flare-buster and the magic string effectively relieve the costal flare and focal protuberances in pectus excavatum repair.

Section: Discussionmentioning

confidence: 99%

The sandwich technique for repair of pectus carinatum and excavatum/carinatum complex

Park¹,

Kim²

2016

“…Brace therapy for pectus carinatum was first reported in 1993, but in 2008 Ferro and Fraire reported their results using an innovative dynamic pressure brace. Brace therapy is reported to be successful in up to 80% of pectus carinatum patients (21,22).…”

mentioning

confidence: 99%

Pectus excavatum from a pediatric surgeon’s perspective

Nuss

Obermeyer

Kelly

2016

Historically, pectus excavatum (PE) was reported to be congenital, but in our experience only 22% are noticed in the first decade of life. Thus far, genetic studies support an autosomal recessive heritability, which coincides with only 40% of our patients having some positive family history, but is also contradictory given a constant sex ratio of 4:1 in favor of males. This inconsistency may be explained by the effect of more than one pectus disease-associated allele. Once the deformity is noticed, it tends to progress slowly until puberty, when rapid progression is often seen. We recommend surgical repair at around 12-14 years of age since the chest wall is still typically flexible and because this allows us to keep the bar in place as the patient progresses through puberty which may help decrease growth-related recurrences. Patients with mild to moderate PE are treated with therapeutic deep breathing, posturing, and aerobic exercises, and in appropriately selected patients, the vacuum bell may also be offered. Patients that have severe symptomatic PE are offered Minimally Invasive Repair of Pectus Excavatum (MIRPE). The surgical technique in children is similarto that of adults, except for the higher forces involved that often necessitate sternal elevation and more involved stabilization strategies. Postoperative management includes pain control, deep breathing, and early ambulation. Exercise restriction is mandatory for the first six weeks with slow resumption of normal activity after 12 weeks.

“…More recently these patients have been offered treatment with the Vacuum Bell (19,20) The advent of the MIRPE resulted in a dramatic increase in the number of patients presenting for repair (15,21). This large increase in the numbers of patients undergoing repair has allowed many centers to develop technical refinements, thereby making the procedure even safer and has allowed numerous pre-and post-operative studies to be performed, showing that pectus excavatum causes significant cardiac and pulmonary compression and dysfunction which is markedly improved after repair (22)(23)(24).…”

Section: Surgical Indicationsmentioning

confidence: 99%

“…The most common complaints are shortness of breath with exercise, lack of endurance, and chest pain. If the patient has a mild deformity and does not fulfill the abovementioned criteria for surgical correction, then he/she will be started on a deep breathing with breath holding and posture exercise program, and may be offered non-operative treatment with the Vacuum Bell (19,20). These patients are typically re-evaluated every 3 to 6 months to ensure that they are complying with the conservative treatment and to check whether the deformity is improving or progressing.…”

Section: Pre-operative Evaluationmentioning

confidence: 99%

“…New approaches to the problem will also appear, as exemplified by Klobe's Vacuum Bell, which is now finding a place as the treatment of choice in younger patients with a soft and malleable chest who have a mild to moderate deformity (19,20). At one time there was only one procedure available for patients with pectus excavatum and that was the Ravitch procedure.…”

Section: Futurementioning

confidence: 99%

See 1 more Smart Citation

Nuss bar procedure: past, present and future

Nuss¹,

Obermeyer²,

Kelly³

2016

Self Cite

234

Repair of pectus excavatum began at the beginning of the 20 th century before endotracheal intubation was standard practice. Surgeons therefore developed techniques that corrected the deformity using an open procedure via the anterior chest wall. Initial techniques were unsatisfactory, but by the 1930s the partial rib resection and sternal osteotomy technique had been developed and was used in combination with external traction post-operatively to prevent the sternum from sinking back into the chest. In 1949, Ravitch recommended complete resection of the costal cartilages and complete mobilization of the sternum without external traction, and in 1961 Adkins and Blades introduced the concept of a substernal strut for sternal support. The wide resection resulted in a very rigid anterior chest wall, and in some instances, the development of asphyxiating chondrodystrophy. The primary care physicians therefore became reluctant to refer the patients for repair. In 1987, Nuss developed a minimally invasive technique that required no cartilage or sternal resection and relied only on internal bracing by means of a sub-sternal bar, which is inserted into the chest through two lateral thoracic incisions and guided across the mediastinum with the help of thoracoscopy. After publication of the procedure in 1998, it became widely accepted and a flood of new patients suddenly started to appear, which allowed for rapid improvements and modifications of the technique. New instruments were developed specifically for the procedure, complications were recognized, and the steps taken to prevent them included the development of a stabilizer and the use of pericostal sutures to prevent bar displacement. Various options were developed for sternal elevation prior to mediastinal dissection to prevent injury to the mediastinal structures, allergy testing was implemented, and pain management improved. The increased number of patients coming for repair permitted studies of cardiopulmonary function, which showed that patients with a severe degree of pectus excavatum have right-sided cardiac compression, decreased filling, and decreased stroke volume. The degree of pulmonary restriction and obstruction is related to the degree of deformity and degree of cardiac displacement into the left chest. The indications for surgical repair have been clearly outlined, the procedure has been standardized, and post-operative management protocols are now available. A review of our prospective database showed that 98% of patients have a good to excellent outcome. This review of the "Past" outlines the progression of the surgical techniques during the 20 th century, the review of the "Present" outlines the important modifications and results of the closed technique, and the review of the "Future" outlines the various new options that are becoming available for the treatment of pectus excavatum.