Chest Wall Deformities
PECTUS EXCAVATUM Posterior depression of the sternum and costal cartilages produces the characteristic findings of pectus excavatum: funnel chest. The first and second ribs and the manubrium are usually in their normal position. The lower costal cartilages and the body of the sternum are depressed. The deformity rarely resolves with increasing age. It may worsen during the period of rapid adolescent growth. Scoliosis in 26% of patients with pectus excavatum (asymmetric pectus excavatum)
Etiology and Incidence 1 in 300-1000 births M:F = 3:1 4:1 Etiology - unknown. Caused by overgrowth of costal cartilages. Abnormality of the diaphragm. Abdominal musculature deficiency syndrome. 37% of patients had a family history of chest wall deformity.
Symptoms Well tolerated in infancy and childhood. Older children may complain of pain in the area of the deformed cartilages or of precordial pain after sustained exercise. A few patients have palpitations, presumably due to transitional atrial arrhythmias (mitral valve prolapse and associated atrial arrhythmias).
Coincidence Scoliosis Kyphosis Myopathy Cerebral palsy Tuberous sclerosis Congenital diaphragmatic hernia Marfan syndrome Ehlers-Danlos syndrome Neurofibromatosis type I Myotonic dystrophy. Fetal alcohol syndrome. Osteogenesis imperfecta. Poland syndrome.
Cardiovascular A systolic ejection murmur is frequently identified Electrocardiographic abnormalities: Right axis deviation Depressed ST-T segments Tall P waves Right bundle branch block Combined block Left ventricular hypertrophy Left atrial hypertrophy Paroxysmal atrial tachycardia
Pulmonary Function The mean TLC - 79% of predicted. Maximum breathing capacity diminished (50% or more) increased an average of 31% after surgical repair. BUT Deterioration in pulmonary function at long-term evaluation (attributable to increased chest wall rigidity after surgical repair). Improvement in exercise tolerance after surgical repair.
Pectus severity index The Haller index. Used to assess severity of incursion of the sternum into the mediastinum. Maximal transverse diameter/narrowest AP length of chest. Normal Haller index is 2.5. Significant pectus excavatum has an index greater than 3.25 standard for determining candidacy for repair .
Pectus excavatum: treatment Thypical course of the deformity ? Who should be operated on ? What are the long-term cosmetic and functional results of surgical treatment ?
Indications for surgical treatment Cosmetic and psychological reasons. Pulmonary and cardiac disfunction due to the deformity. Optimal age for surgery: 4-6 y ?
Methods Subcutaneous fulfilment of the „funnel”. Ravitch procedure. Turn-over operation. Nuss procedure. Non surgical treatment.
Donald Nuss procedure: 1999 Minimally invasive repair !? Without resection of the costal cartilages. Elevation of the sternum with a retrosternal bar. Good cosmetic results. Pain ?
Patient is draped and marked for surgery
Confirming preoperative measurments using a Pectus Bar Template
Advancing the Pectus Bar Itroducer to dissect a tunnel for the pectus bar
Guiding the convex bar through the chest with the convexity facing anteriorly
Pectus correction and implant stability are evaluated
Suture to the chest wall muscles to anchor the device
Patient ready for recovery
Pectus bars
Before and after surgery
Complications of Pectus Excavatum Repair Major or mild recurrence. Limited pneumothorax. Wound infection (dehiscence). Bar (wire) migration. Wound hematoma Pneumonia Seroma Hemoptysis Hemopericardium
Seroma with dermatitis
Silicone solid implant
Silicone solid implant
Non surgical treatment
Non surgical treatment: suction bell (boy model).
Non surgical treatment: suction bell (girl model).
PECTUS CARINATUM Pigeon breast. 16.7% of all chest wall deformities. Much less frequently than pectus excavatum. Overgrowth of the costal cartilages with forward buckling and anterior displacement of the sternum. The deformity may appear in mild form at birth, but often progresses during early childhood, particularly in the period of rapid growth at puberty.
PECTUS CARINATUM Deformities Chondrogladiolar Symmetric Asymmetric Mixed carinatum and excavatum Chondromanubrial
Surgical Technique The placement of the skin incision, mobilization of the pectoral muscle flaps, and subperichondrial resection of the costal cartilage are identical to the method described for pectus excavatum. + A single or double osteotomy.
Complications of Pectus Carinatum Repair Pneumothorax Atelectasis Wound infection Local tissue necrosis
Non surgical treatment
Thank You