Surgical Repair of Complex (Recurrent) Pectus Excavatum in Adults




Introduction



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Since the first pectus repair was reported by Meyer in 1911, several different techniques have been described.1,2 The Ravitch procedure, first described in 1949,3 became the mainstay of repair until Nuss described a minimally invasive repair in the early 1990s.4 The techniques for primary repair of congenital chest wall deformities, including pectus excavatum, are described in Chapter 140. None of these techniques is perfect, however, and recurrences do occur. Although the incidence of recurrent pectus excavatum in the adult population is most rare, it is usually a consequence of technical failure. The rate of recurrence, although significantly reduced in the hands of a more experienced surgeon, ranges from 2% to 10%.




General Principles



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The open repair, described by Ravitch and modified by Haller,5 involves the excision of all deformed costal cartilages from the sternum to the costochondral junctions. The overlying perichondrium is left intact. This procedure is combined with a transverse sternal osteotomy at the point of maximal declination, elevation of the inferior sternal fragment, and placement of a transverse metal bar or rod to maintain the sternum in this elevated position. The ends of the bar are supported on either side by the bony ribs of the lateral chest wall.4,6 The bar is left in place until the costal cartridges have regenerated and the chest wall has become firm and rigid. This process usually takes 6 to 9 months in adults.



The rates of recurrence from a series of experienced centers are depicted in Table 141-1. The most common reasons for recurrence may be divided into two categories: technical and disease-related. As with any operation associated with remodeling in which there are several sequential steps to which one needs to adhere, there is a learning curve. Failure to tackle the full extent of the deformity aggressively, inadequate stabilization of the bar resulting in early displacement, premature removal of the bar before adequate healing has taken place, failure to resect the xiphoid process and mobilize the retrosternal space, significant injury to the perichondrial sheaths, and failure to pay sufficient attention to the asymmetry of the defect, all can result in a technical failure of the primary repair.




Table 141-1Rates of Recurrence From Various Series of Initial Repair



Patients with connective tissue disorders such as Marfan syndrome are at increased risk for recurrence. In these instances, the repair should be delayed until skeletal maturity has been reached. Also, children who undergo a rapid adolescent growth phase may overcome the benefits of an early repair, resulting in a suboptimal cosmetic outcome. The appropriate timing for surgical correction of a pectus deformity is the subject of controversy and continues to be debated.



Since introduction of the minimally invasive Nuss technique, an increasing number of children are being treated for pectus deformities according to this method. The benefits of the Nuss technique include the avoidance of extensive dissection and cartilage resection and smaller incisions. The complications of this procedure include severe postoperative discomfort or pain, longer periods of bar retention before removal, catastrophic injuries to the heart and pulmonary outflow tract, and inadequate cosmetic results with asymmetric defects. Miller and colleagues report a series of children (mean age 11.4 years) who underwent a redo of the minimally invasive repair after a failed initial procedure. The average time to repeat procedure was approximately 9 years.7 In adults with recurrent pectus deformity, the role of minimally invasive repair is unproved and may not permit a satisfactory or safe repair.




Patient Selection and Preoperative Assessment



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The selection of patients for repair of recurrent pectus deformities should be undertaken very carefully. Unfortunately, not every patient can undergo intervention. In a series of 19 patients who had an original Ravitch procedure and presented with recurrence, three patients had such severe adhesions between the sternum and pericardium that reconstruction was too dangerous to attempt.8 The most important questions to be answered before undertaking a reoperation include the underlying physiologic status of the patient, the reasons for failure of the primary repair, and the patient’s expectations of a satisfactory cosmetic result.



A chest CT scan is a useful tool to assess the degree of deformity and asymmetry, to determine the extent of substernal and pleural adhesions, and to assess the presence of cardiac displacement or compression. This information is helpful in planning and carrying out a successful reoperation. Patients who are considered for reoperation should undergo preoperative physiologic testing, including a battery of pulmonary function tests and an echocardiogram. Should underlying cardiac disease be identified, this needs to be addressed before embarking on an elaborate repair. Patients must be adequately counseled on their reasons for seeking a reoperation and warned of the potential surgical risks, including an unsatisfactory cosmetic result. A multidisciplinary approach with involvement of the plastic surgery service also should be considered.




Technique



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Anesthesia


The use of an epidural catheter is an important adjunct in patients undergoing reoperation because it will alleviate postoperative pain and reduce morbidity. General anesthesia is necessary because the operation is usually protracted, and there is significant dissection. Hemodynamic monitoring may be necessary depending on the patient’s underlying physiologic status. Patients usually are extubated at completion of the repair.

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Dec 30, 2018 | Posted by in VASCULAR SURGERY | Comments Off on Surgical Repair of Complex (Recurrent) Pectus Excavatum in Adults
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