7Thoracic wall

7.1Introduction

7.2Pectus excavatum

Leonardo da Vinci was the first to depict it and the first description of PE was provided by Bauhinus in 1594. The first attempt to correct it was made by the German surgeon Ludwig Meyer in 1911. The modern era of correction started after 1949 where Ravitch from the US published his first paper [1]. This was an open technique with resection of ribs and cartilages. The technique was later modified with smaller incisions, preserving the perichondrium and introduction of supporting material under the sternum to retain the position. This technique was the gold standard until Nuss published his technique of minimal invasive repair in 1998 [2]. Other methods have also been used such as reversing the sternum and treatment with braces.

7.2.1Indication

For many years it was thought that PE was only a cosmetic problem for the patients and the cosmetic complains are stated an indication in around 90% of the published papers in this field. Several papers studying the quality of life in patients with PE have shown a significantly better quality of life after correction, exhibiting higher self-esteem. More of these studies have also shown that patients after treatment feel that they have a better physical performance. More than 60% have symptoms like exercise intolerance, lack of endurance and shortness of breath [3].

It is obvious from CT-scans that the heart is moved more to the left in PE patients because of the pressure from the sternum and it is also seen in many patients that the right side of the heart is compressed. This does not influence the cardiac performance at rest but restricts the filling of the heart under physical activity. The cardiac performance is found to be reduced about 20% in adolescent age 14–17 years with a PE, but after treatment it becomes equal to normal controls [4]. In adults it has been shown that cardiac performance is significantly raised after correction by the modified Ravitch.

In most cases patients with PE have normal lung function but in the lower area. The reduced lung function has a restrictive picture. Studies have shown decreased movement of the chest in PE patients, which improves after correction.

Some surgeons use the Haller index as an indication. The Haller index is the ratio between the internal diameter of the chest at the level of the deepest point of the excavation and the distance from the backside of the sternum to the anterior part of the spine. If this is >3, 25, there might be indication for treatment. The index is dependent on the chest shape, because the same excavation seen from outside may give different indexes depending on if the chest is barrel-shaped or more flat.

There is no evidence for the optimal age for performing the procedure. In the eastern part of the world surgeons often correct patients in the age group 2–6 years. It is difficult to understand that such young children are complaining about the cosmetic and they do probably not have any symptoms. Nuss has seen that there is a trend to see more recurrences if the bar is removed before puberty, when the growth spurt starts. I would not treat a patient younger than the age of 11 years. It is important that the child understand what is going on and what one might expect in terms of postoperative pain following the correction. My optimal age is 11–13 years, but many girls are even older so they have had a demarcation of the breasts which allows placement of the incisions in the groove between the breast and the chest wall. The upper limit for doing the Nuss procedure is not defined. When the procedure was published it was said that only children and adolescents were candidates for this treatment, but with growing experience even patients older than 60 years have been corrected with good results and few complications.

7.2.2Preoperative evaluation

7.2.3Technique

Today more surgeons are using a shorter bar as proposed by Pilegaard [5]. A short bar is easier to place. The median length of bars is in 840 corrected patients 10”. The bar may be guided in a better way through the chest and is also easier to remove. The stabilizer can be placed very close to the hinge point which gives a very stable situation, so you do not need additional sutures around the bar and the rib.

How many bars are needed in the patient is dependent on the depth of the excavation and the age of the patient. If you are in doubt of the numbers of bars needed to correct the patient it might often be better to insert two bars instead of only one to have the best correction. Two bars may in many cases be inserted through the same incisions especially in females, where the skin of the breasts is often more moveable. More bars will probably decrease the pain because they will deliver the pressure to a larger surface. In very few cases three bars may even be needed to get a good correction (Tab. 7.2.1).

One bar should normally support the deepest point. If the PE is very long, like a grand canyon type, a bar is often placed at the level of the nipples. In such a case a periareolar incision around the nipple on the left side makes it easier to put the stabilizer on. If the PE is very low and the deepest point is below the sternum you should use two bars where the upper one supports the sternum and the lower one is under the deepest point. The deepest point is sometimes between two levels of intercostal spaces. Here it might be a good idea to use an oblique bar (Fig. 7.2.1). If the excavation is very deep it is a good idea to place the first introducer higher than the deepest point as this will work like a crane and facilitate going under the deepest point with the next introducer. Different types of crane systems might also be used.

Tab. 7.2.1: Number of bars in 840 patients.

The procedure is done under general anesthesia. All patients should in my opinion have an epidural catheter for postoperative pain treatment. This stays for two days. The patient is intubated with a single lumen tube, and only if you expect problems inside the chest cavity because of previous intervention or infections do you need a double lumen tube. You may use CO2 gas to get a better view in the chest cavity, but it is often not necessary in my experience. The patient is located to the right on the table with the arm in front of the head (Fig. 7.2.2). The thoracoscope is inserted through the right lateral chest wall at the level of the nipple (Fig. 7.2.3). This gives you free movement of the scope and no problems with a very low bar.

Fig. 7.2.1: The X-ray shows an oblique bar.

Fig. 7.2.2: The position of the patient on the table.

Fig. 7.2.3: The level of the insertion of the scope.

The deepest point is identified, and the intercostal spaces related to this are marked just medially to the highest point (Fig. 7.2.4). You may check this by putting a finger where you have marked and push, you can then see through the scope if it is at the correct point related to the deepest point. A template is shaped to the desired shape of the chest and even with some overcorrection (Fig. 7.2.5), because the bar will flatten in some way by the pressure from the elevated sternum (Fig. 7.2.6).

Fig. 7.2.4: Marking of the spots where the bar passes in and out of the chest.

Fig. 7.2.5: Overcorrection of the bar.

Fig. 7.2.6: Flattening of a bar after ten minutes in the body.

The bar is bent in the same way. The tunnel under the sternum is normally done by one of the introducers and the large one will in most cases be the one you should use. If there previously has been surgery inside the chest cavity and adhesions are found, they should all be cut and the tunnel created by blunt dissection using a long instrument with a peanut. If it is a long excavation and two bars are needed, it is often advantageous to place both the introducers at first and then replace one after the other with a bar (Fig. 7.2.7).

Fig. 7.2.7: Two introducers in the patient.

The bar is guided by a tape or a suture under the sternum and inserted like a U and turned 180°. Generally the stabilizer is located on the left side. The bar is placed asymmetrically on the chest, so the end with no stabilizer has a base of two ribs (Fig. 7.2.8). No additional sutures are necessary. The position of the stabilizer to the left might be a good idea to avoid compression of the heart if the end of the bar without a stabilizer should drop into the chest.

Fig. 7.2.8: Asymmetric position of the bars.

7.2.4Postoperative care and follow up

7.2.5Complications

The complication rate should be low. The infection rate is about 1%–2%. The risk of bleeding is <1%. The rate of rotation or dislocation is approximately 1% (Tab. 7.2.2). Doing this kind of surgery you need to be able to open the chest by a sternotomy if lesions to the heart develop and there should be access to cardiac surgeons who can help if such a complication should occur. The number of procedures which is needed to keep the complication rate low and have good results are not known, but two to four cases a month might be an acceptable number.

Tab. 7.2.2: Complications in 840 patients.

7.2.6Removal of the bar(s)

This is done 3 years after insertion as an outpatient surgery procedure in most cases. The patient comes to the hospital in the morning prepared for general anesthesia. The bar is removed and the patient may be discharged later in the day without further control [6].

The recurrence rate is low, around 1%.

Hyung J. Park

My principles for symmetric repair for asymmetrical types are the morphological classification, and the morphology tailored repair technique (Terrain Contour Matching, TERCOM): asymmetric bar technique, crest compression technique, and the press-molding (the sandwich) technique for pectus carinatum [7, 8].

Pectus bar displacement has been overcome mainly by two different approaches: the one is the shorter bar technique by Dr. Pilegaard as described in the text, and the other is my approach with inventions of new devices to make the bar un-rotatable.

Dr. Pilegaard’s superb technique using the shorter bar overcomes the issues of bar displacement nicely. The principle of the technique is placing the chest wall entry points (the hinge points) more medially, at the anterior aspect of the chest wall. The stabilizers on the anterior wall make it prop against the wall and thus, prevents the bar rotation [9].

His shorter bar technique has a very low bar displacement rate, but not without drawbacks. First, the short bar only covers a smaller area of the chest wall to remodel, whereas the regular bar can lift the whole anterior chest wall. Second, the shorter bar requires the skin incisions at the anterior chest. Third, this technique may not be efficient for eccentric asymmetry repair. Fourth, the bar may sink into the chest cavity when the hinge points are not supportive.

However, I have tried to resolve this crucial issue without hurting the quality of repair and ended up inventing new devices, which was different from the conventional stabilizer. My devices are devised to fix the bar to the ribs, the strongest structure in the chest wall. The claw fixator (Fig. 7.2.9), the hinge plate and the bridge connection in the parallel bars and the crossed bars (Fig. 7.2.10) covers all different mechanisms of bar dislocations. Consequently, these devices have made the bar displacement rate of “zero,” “Pectus repair without bar dislocations!” The crane system and pectoscope have ushered the Pectus surgery into a new era; making the pectus repair procedure exceptionally safe and easy [10, 11].

In conclusion, Dr. Pilegaard’s technique has shown a high achievement in pectus bar security and in setting adult pectus repair on the track. My techniques and devices may also contribute to a better outcome for the patients: “Zero” bar dislocations; no devastating complications; more surgeon friendly; and the only technique to repair all different asymmetric pectus excavatum and pectus carinatum.

Fig. 7.2.9: The claw fixators to fix the bar to the ribs. CFT: Claw Fixator.

Fig. 7.2.10: The hinge plates to prevent intercostal muscle stripping at the hinge points. The bridge connection of the two bars in the parallel bar technique (a), and in the crossed bar technique (b). B: Bridge; HP: Hinge Plate.

Prof. Pilegaard has presented his excellent experience with pectus excavatum. In our experience 8% of the patients presented before 5 years, 13% before 10 years, 47% between 11 and 15 years and 32% thereafter. We also favor doing the repair during the pubertal growth spurt but will do the repair earlier if indicated. We only operate on patients who are symptomatic and have a severe degree of deformity with evidence of cardiac and/ or pulmonary compression on CT or ECHO. All surgical candidates are tested for metal allergy.

Since publication of the minimally invasive technique there has been a huge increase in the number of patients requesting repair – we only did 45 cases in the ten years from 1987 to 1996 and over a 1000 cases in the next decade. This dramatic increase in numbers has allowed numerous centers to study the cardiopulmonary effects of pectus excavatum and the outcome of the repair. These studies have confirmed what the patients have been telling us for seventy years, namely that there is right heart compression with decreased filling and increased resistance, which is corrected immediately after repair, and that that there is a restrictive pulmonary effect which is significantly improved after the bar is removed. We have reported on static (resting) pulmonary function in a multi-institutional study which showed a decrease of 10%–15% or about one standard deviation [12], and is related to depth of the depression [13]. There was significant improvement after surgical correction [14]. The mechanism appears to be poor movement of the sternum: instead of the normal motion with inspiration the lower sternum is fixed. This poor bellows action is reversed with surgical correction, and chest wall motion after the Nuss procedure is indistinguishable from controls [15]. Exercise and ECHO studies by Pilegaard from Denmark, by Sigalet from Canada, Coln and Jaroszewki from the US have confirmed the cardiopulmonary effects mentioned above with significant increase in stroke volume, cardiac output, cardiac index, oxygen pulse and VO2 max after repair. In our series 14% of patients had mitral valve prolapse pre-operative and in half of those it was resolved postoperatively, which is consistent with findings by Schamberger and Coln.

Body image concern is one of major reasons patients seek treatment. Patients frequently avoid activities which require taking their shirts off in public to swim or exercise which leads to social withdrawal. After repair, patients’ body image concerns are dramatically improved [13, 16].

Technical points include proper bar length [17]; we continue to have good results with a bar 2.5 cm shorter than the distance between mid-axillary lines, which is slightly longer than Pilegaards bar but it is symmetric and we have had no problems with bar migration. Thoracoscopy is essential. We strongly endorse sternal elevation with crane, vacuum bell or subxiphoid bone hook to improve visualization and minimize any chance of cardiac injury during sub-sternal dissection. Two bars should be used if they will better distribute the force of the chest wall than a single bar. The bar must be prevented from rotating, with a stabilizer on the left side and PDS wraps of the bar/ rib crossings. We do not use thoracic epidural anesthesia.

We generally hospitalize until the fourth post-operative day. Pain medications are stopped by 4 weeks post-op. Return to activity is similar. Bar removal is 2 to 3 years later. Bar removal includes opening both incisions, removing any bony overgrowth until the bar moves easily in its fibrous tunnel, flattening the bar at both ends, not twisting the bar, and applying gentle traction. Recurrence is less than 1%.

Dawn E. Jaroszewski

Treatment of pectus excavatum (PE) has evolved over the past century with minimally invasive repair techniques being recommended for the majority of symptomatic, severe patients. Symptoms such as exertional dyspnea, chest pain, palpitations and exercise intolerance have been shown to result from the cardiopulmonary restriction of the defect and are mostly resolved with surgical repair [20]. With surgical repair, right heart compression is relieved and increased right-sided cardiac output can be expected for most patients [18].

There are a number of technique modifications from the original procedure as published by Nuss [21]. These modifications have been useful for the extension of the minimally invasive repair technique into the repair of older patients and include placement of multiple support bars [22] and assisted sternal elevation [19]. The use of thoracoscopy and forced elevation prior to passing the introducer and bars improves visualization and may also decrease procedure risks (Fig. 7.2.11a–c). In agreement with Dr. Pilegaard, our own experience has led to the use of multiple bars in older patients with more than 40% of our adult patient receiving three support bars.

Fig. 7.2.11: (a) perforating bone clamp is placed on the sternum and attached to the bedside RulTract retractor forced sternal elevation. (b) and (c) thoracoscopic view of excavatum defect and cardiac compression before (left) and after (right) forced elevation with RulTract.

Good postoperative pain control is essential in this patient population. Epidurals, intravenous patient controlled anesthesia and subcutaneous pain catheters have all been reported with excellent results. In our adult patient experience, the use of a tunneled On-Q catheter with oral analgesics (ibuprofen, gabapentin and oxycodone) has been successful with few complications. At completion of the procedure, 7.5-inch soaker catheters (PM050-A, On-Q, Halyard Health, Inc, Irvine, CA) are placed anterior along the ribs using a disposable, 17-gauge, 10-inch tunneling system (Model T17X10, On-Q, Halyard Health, Inc) (Fig. 7.2.12a). The On-Q catheters are primed and attached to a 750-mL reservoir (Fig. 7.2.12b). Variable rate controllers (Select-A-Flow, Halyard Health, Inc) are locked at a rate of 7 mL/ h, infusing ropivacaine, 0.2%. The reservoir is refilled at 48 hours and patients are discharged home with catheters in place. Removal is planned on day 4–5.

Fig. 7.2.12: 7.5-inch soaker catheters placed anterior along the ribs (a) and On-Q catheters attached to a 750-mL reservoir (b).

However, some points regarding indications are still debated: many surgeons consider this technique for mild to moderate deformities only with moderate asymmetry and sternal rotation less than 15–20°. The most controversial point is the presence of inferior costal flaring, as can be seen on Fig. 7.2.2 in an adult patient. Such an important component may only be completely treated by open surgery including inferior costo-chondroplasty during a Ravitch-type correction of PE [23] (Fig. 7.2.13).

The optimal age for MIRPE is increasing in a worldwide trend in recent publications and I personally favor the age of 15 years, considering that the age for bar removal will then be 18 years, corresponding to both the end of growth and a definitive reduced risk of recurrence.

But the most important parameter of a good indication, regardless of age, is the general flexibility of the chest and especially the anterior plastron, not considered here. This clinical evaluation is easy and simply consists of an “auto-correction” test: the patient is asked to do a strong Valsalva manoeuvre which acts like a “pneumatic Nuss” and shows the potential of reduction of the deformity Fig. 7.2.14. This test is best made in front of a mirror, to show the patient (and the parents) an instant level of correction of 60%–70% of action of the definitive bar(s) (Fig. 7.2.14 and Video 7.1 Cavum excavatum).

Fig. 7.2.13: Costo-chondroplasty for inferior costal flaring.

Video showing a man with a cavum excavatum

https://www.degruyter.com/view/supplement/9783110419825_Cavum_excavatum.mp4

Preoperative evaluation must also include a routine CT scan (using new protocols with low doses) that allows surgeons to better assess cardiac compression, asymmetry, a prospective sternal rotation (not seen on chest X-rays only) and inferior costal flaring in 3D reconstruction [24]. CT scan data may not only change the indication for MIRPE, but may also help to better plan placement and shaping of the bars.

Fig. 7.2.14: Auto-correction test.

A routine echocardiography is mandatory as well, especially in case of clinical heart murmur, to disclose the known association of PE with mitral valve abnormalities (prolapse or insufficiency) or others, including aortic root enlargement in Marfan patients [25].

There is no mention about a possible allergy to the alloy of the stainless steel bar containing chrome and nickel, which can be tested by a 48-hour skin-test using a small bar sample.

In the Nuss procedure technique, the reason for the original bar length was obviously to have the support of at least two or three (with the stabilizers) levels of ribs bilaterally to counteract the pressure of the corrected plastron and sternum and distribute the forces on several ribs on each side and in a balanced way. Such a placement may be observed in Fig. 7.2.8 but only on the right side for both cases, instead of an equal distribution bilaterally with a classical length. On Fig. 7.2.1, the right bar support is only a single rib and there is a risk of droping in the chest in case of sliding, being more likely with short bars.

Having the end of the bars paralell to the lateral chest wall was actually not recommended to avoid an “hour glass” effect, especially in still growing teenagers. For many authors, the proper length is today one or two inches shorter than the original with a support zone on both anterior axillary line, but not as short as Dr. Pilegaard’s concept however [26]. The oblique contact of both ends allows lateral growing of the rib cage during the 3 years and some manufacturers developped sliding stabilizers which may be placed closer to the hinge points but still keeping the initial security of medium size bars against lateral sliding [27]. Another advantage is a slight anteroposterior movement possible during respiratory cycle compared to wired stabilizers as seen on Figs. 7.2.1 and 7.2.8, thereby reducing pain.

Caroline Fortmann, Claus Petersen

7.3Pectus carinatum

In 1987 Donald Nuss introduced a minimally invasive procedure, entitled the Nuss procedure, which transformed the treatment of pectus excavatum (PE). The operation involved inserting a stainless steel bar to correct any deformity of the anterior wall of the chest. After further research and trials spanning 7 years, the procedures involved in PE were effectively transferred to pectus carinatum (PC). This approach was based on the assumption that both pectus excavatum and carinatum share common characteristics and require similar therapeutic strategies. However, is that true? As we know, both deformities of the anterior chest wall are frequent, and boys are more often affected than girls. It is also a known fact that both entities can concomitantly occur together with scoliosis, whereas it is unclear whether one or the other deformity induces or interferes with the other, or if they are distinct phenomena. Similarly to PE, a genetic predisposition of PC is likely, although the onset of the latter corresponds more frequently to the beginning of puberty. Research in the associated symptoms, such as dyspnea, palpitations, etc. are inconsistent in PC, while both deformities are concomitant features in patients with Marfan and Noonan Syndrome [28]. For the sake of completeness, it should be noted that many chest wall deformities, including PC, can also occur as a result of a surgical procedure to correct a congenital disease, e.g. diaphragmatic hernia, or following sternotomy, which is mostly performed in cardiosurgical procedures.

In terms of the developmental process, a similar pathomechanism is suggested for both kinds of sternal dislocation. Researchers agree that the inappropriate growth of the costosternal cartilage can result in sternal shifting. However, it remains unclear as to which factor determines whether the sternum moves to a position above or below the ideal line, and why these osteochondral deformities occur either symmetrically or asymmetrically. It is also enigmatic whether additional pathologic angulations of the sternum are due to the abovementioned mechanism, or if another factor solely targets the osseous malformation. Another unanswered question concerns the onset of chest wall deformities, because PE, more often than PC, occurs in early infancy and remains stable over years before a rapid dislodgment of the sternum progresses as puberty starts [28].

Therapeutic concepts for the surgical repair of PC date from the early 1950s, when Ravitch published his technique for the correction of both pectus excavatum and carinatum [29]. However, this topic received very little attention from researchers and scientists and, over the course of 50 years following the introduction of Ravitch’s technique, just three papers per year on average were published that examined PE and PC. The majority of those studies that were published described an individual’s experience with surgery in PC, but the operative concept remained largely rare.

This situation did not change until 2005, at which point Abramson demonstrated the inverse use of the Nuss pectus bar [30]. His concept spurred the community as a whole to pay more attention to the use of surgical concepts to correct PC, and research into the modification of instruments and implants commenced. Stimulated by this discussion, promoters of the open repair of PC reappeared in the field, advocating for the open approach and refining their technique and implants. From that point onwards, the frequency of PC-related publications increased to up to 17 papers on average per year. However, in contrast to the treatment of pectus excavatum, for which the Nuss procedure had already become state of the art, the diverging concepts on how to best treat PC remained open to debate. In the meantime, the conservative approach to treating PC, which was first proposed in the mid-1970s, experienced a renaissance. Pediatric surgeons from Argentina [31] and Canada [32] introduced their newly developed devices, protocols and study results. They demonstrated that bracing PC patients during puberty had a high success rate. However, treatment strategies for PC remain under debate to this day. Table 7.3.1 focuses on the pros and cons of the three diverging approaches, while Table 7.3.2 (supplementary material online: http://www.degruyter.com/books/9783110425291)compares the results and outcomes of existing studies in this area.

The crucial and most diverging point about the treatment of chest wall deformities is to define the right indication, particularly for major procedures, including the risks and side effects of radiation, anesthesia and surgery. Despite the fact that recent studies demonstrate a slight improvement in cardiopulmonary function following PE repair, it is still the patients with PC and PE who indicate the time and mode of the procedure. In other words, we are experiencing a paradigm shift through which the affected young people do not visit cosmetic surgeons but requiring surgery that is predominantly not medically indicated from thoracic and pediatric surgeons. All the more, it remains the surgeon’s responsibility to decide whether or not to follow the patient’s desire. However, those adolescents who suffer from conspicuous thoracic deformities, or who suffer greatly from an impairment of self-image, should be considered candidates for surgery, even when the indication is primarily not medical. In consequence, the outcome measures also have to be newly defined. Meeting the patients’ expectations is the main goal to be achieved, and success rates of either procedure have to be measured against the satisfaction of the patient and the improvement of his or her self-esteem.

Taking into account the fact that patients with PC do not suffer from physical limitations, further medical investigation depends on the therapeutic concept. Planning a surgical procedure requires appropriate diagnostic work, while scanning the thoracic surface without radiation and photographic documentation are sufficient for bracing therapy. Unnecessary exposure to radiation has to be avoided whenever possible.

Most open procedures for PC repair follow the principle of Ravitch‘s technique [29]. The key steps in this approach involve the dissection of the pectoralis muscles, resection of the costosternal cartilages, osteotomy of the sternum, if necessary, and intermediate fixation of the corrected sternum with variable devices and material. Several authors have published methods that incorporate slight modifications to the technique, the majority of which involve shortening the skin incision, minimizing the surgical trauma and avoiding secondary interventions for the removal of implants. The overall results of open surgery for PC are good according to the abovementioned parameters.

The inverse use of the pectus bars for PC was introduced by Abramson [31]. He showed how the protruding sternum could be pressed down into a normal position and fixed by use of an individually bent bar, which was subcutaneously introduced. The principle of this procedure was adopted by other authors, whereby they developed different solutions as to how to fix the bars to the ribs. However, the flexibility of the sternum is a crucial precondition for the use of this approach.

The flexibility of the thorax is also essential for the conservative approach to PC. Herein, thoracic plasticity can be tested by slow, but forced, manual pressure on the prominent sternum. When the sternum can be replaced into a normal position, bracing is a promising option (Fig. 7.3.1). Several studies have already shown that the effect of this treatment can be observed within a few weeks, and complete reposition is a question of months [32]. The most striking argument for this orthopedic approach is that no side effects are threatening, except for skin irritation and general discomfort when using the device. On the other hand, no evidence is given when diverging concepts are recommended concerning the design of the brace, minimal and maximal pressure rates and the appropriate time of use. Another advantage is that, in case of a relapse, the same treatment can be started once again with a reasonable chance of success.

Fig. 7.3.1: Patient with PC before treatment (a), under treatment with a brace (b) and after treatment (c).

In contrast to PE patients, where surgical correction should preferably be scheduled for late adolescence, the orthopedic approach to PC has to be started as soon as the deformity becomes evident. This alleged contradiction has to be passed to the pediatricians, orthopedics and surgeons who see those patients first. Pros and cons of three different approaches are listed in Tab. 7.3.1. The challenge for the upcoming years will be to optimize the treatment modality of the non-operative approach to PC and to elucidate the complexity of thoracic and concomitant spinal deformities.

Tab. 7.3.1: Treatment of pectus carinatum: pros and cons of three diverging approaches.

Horatio Abramson

Comment

The establishment of appropriate techniques to correct asymmetric malformations of the thorax is challenging. The fixing plate’s location, the length and shape of the compressing bar and the horizontal or oblique position of the bar are the key to achieve a successful result Fig. 7.3.2. In those patients presenting PC with contra-lateral PE, it is important to consider the extent to which the use of one bar to compress the protruded region will cause an elevation of the PE. In patients with predominant PE with contra-lateral PC, it is important to predict if the use of the retro-sternal bar alone will be sufficient. Patients that exhibit asymmetric PE or PC with the contralateral side of a standard shape can be treated with only pre-sternal or retro-sternal implants.

Other therapeutic alternatives are a) insertion of one retro-sternal bar and another pre-sternal either simultaneously or in sequence; b) insertion of a pre-sternal bar then, in a deferred action, removing it and inserting another in a lower position; c) implanting a bar with intra-thoracic journey in the depressed hemithorax and pre-sternal position in the protruded hemithorax; d) resection of costal fragments favoring compression.

In order to effectively deal with asymmetric malformations the surgeon and his team need to have extensive experience in choosing and recommending the best approach to the patient.

Fig. 7.3.2: Pectus carinatum before (a) and after (b) minimally invasive surgical repair correction.

Consequently, two different pressure measurements were established: pressure of correction (PC) and pressure of treatment (PT). When analyzing the recorded pressure data, it was concluded that PC indirectly measures the thoracic elasticity, increases with age and can be used to predict the treatment duration. We observed that patients with lower pressures ended the treatment faster and that PC could also help to predict the final cosmetic outcome, albeit with less precision. However, PT measurement enabled the additional observation that applying pressures greater than 2.5 PSI diminished tolerance, mostly because of skin irritation and ulceration. Accordingly, in the last 251 patients treated with the device, PT was set up with equal or less than 2.5 PSI and, as a result, the FMF® Dynamic Compressor System resulted in satisfactory treatment tolerance and compliance (see also supplementary material Figs. 7.3.3 and 7.3.4, http://www.degruyter.com/books/9783110425291).

Francis Robicsek

Comment

In treatises written on the treatment of pectus deformities, we have to cease using the long time defunct “Ravitch procedure” as a “straw man”. However, contrary to those who recommend that PC should be treated conservatively or using temporarily in-dwelling rods, we believe that PC, just like it’s “sister deformity” PE, should be treated by up to date, minimally invasive, open technique in line with the following principles [33].

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