1. Chest Wall Deformities

2. 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)

5. Etiology and Incidence
1 in 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.

6. 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).

7. 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.

8. 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

9. 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.

16. 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 .

19. 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 ?

20. Indications for surgical treatment
Cosmetic and psychological reasons.
Pulmonary and cardiac disfunction due to the deformity.
Optimal age for surgery: 4-6 y ?

21. Methods Subcutaneous fulfilment of the „funnel”. Ravitch procedure.
Turn-over operation.
Nuss procedure.
Non surgical treatment.

27. 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 ?

29. Patient is draped and marked for surgery

30. Confirming preoperative measurments using a Pectus Bar Template

34. Advancing the Pectus Bar Itroducer to dissect a tunnel for the pectus bar

35. Guiding the convex bar through the chest with the convexity facing anteriorly

36. Pectus correction and implant stability are evaluated

37. Suture to the chest wall muscles to anchor the device

38. Patient ready for recovery

43. Pectus bars

44. Before and after surgery

46. Complications of Pectus Excavatum Repair
Major or mild recurrence.
Limited pneumothorax.
Wound infection (dehiscence).
Bar (wire) migration.
Wound hematoma
Pneumonia
Seroma
Hemoptysis
Hemopericardium

47. Seroma with dermatitis

48. Silicone solid implant

49. Silicone solid implant

52. Non surgical treatment

53. Non surgical treatment: suction bell (boy model).

54. Non surgical treatment: suction bell (girl model).

55. 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.

56. PECTUS CARINATUM Deformities
Chondrogladiolar
Symmetric
Asymmetric
Mixed carinatum and excavatum
Chondromanubrial

62. 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.

64. Complications of Pectus Carinatum Repair
Pneumothorax
Atelectasis
Wound infection
Local tissue necrosis

65. Non surgical treatment

67. Thank You