ORIGINAL CONTRIBUTION
Early and Long-Term Results of Surgical Repair of Pectus Excavatum

Abdullah Erdoğan, MD, Arife Ayten, MD, Necdet Öz, MD, Abid Demircan, MD
Thoracic Surgery Clinic Akdeniz University Faculty of Medicine Antalya, Turkey For reprint information contact: Abdullah Erdoğan, MD Tel: 90 242 227 4343 Fax: 90 242 227 4490 email: aerdogan66@hotmail.com Meltem mah. Günes Sitesi, B Blok 14/57, Antalya 07050, Turkey.

ABSTRACT

From 1990 to 1998, 30 patients underwent surgery for correction of pectus excavatum. There were 19 (63%) males and 11 (37%) females, aged 4 to 32 years (mean, 12.57 years). Bilateral excision of 4 to 6 costal cartilages and sternal wedge osteotomy were performed on 27 (90%) patients, and Kirschner wires were used for substernal support in 25 (83%). A median sternotomy was carried out in males and a submammary transverse incision was preferred in females. All patients were followed up at yearly intervals. Early results were excellent in all except 2 cases: a 14-year-old boy developed contralateral sternal depression after costochondral excision without sternal elevation for correction of one-sided costochondral hyperplasia; and an 8-year-old girl in whom no Kirschner wires had been inserted developed recurrent minimal sternal depression. Long-term follow-up showed recurrent sternal depression 6 years postoperatively in a boy who had undergone surgery at 4 years old, with early removal of the Kirschner wires. It is recommended that correction of pectus excavatum should be carried out in prepubertal children, and Kirschner wires should be used for substernal support.

INTRODUCTION

Pectus excavatum is the most common congenital deformity of the chest wall, with an incidence of 1 in 300 to 400 live births, or 1 in 700 births in black people, and a positive family history of deformity in 37% of cases.1–4 The condition is more common in men and often coexists with other thoracic abnormalities. The indications for surgical correction of pectus excavatum are contro-versial.1,3,4 A decision to perform surgery is generally based on cosmetic and psychological factors.1,2 The most common form of surgery is the method described by Ravitch.5 Correction is preferably performed before the age of puberty.2,5,6 Postoperative follow-up is essential to detect recurrent sternal depression.1–4 The cause of recurrence has not been identified; suggestions include insufficient physical activity following surgical correction, the presence of other chest wall abnormalities such as scoliosis, and rapid pubertal growth.2–4 The aim of this study was to determine the medium and long-term results of surgery for pectus excavatum using substernal wire support, and to investigate the factors involved in recurrence.

PATIENTS AND METHODS

Between January 1990 and December 1998, 30 patients with pectus excavatum underwent surgical correction. There were 19 (63%) males and 11 (37%) females; their mean age was 12.57 years with a range of 4 to 32 years. Preoperative characteristics are shown in Table 1[IMG]file:///C:/icons/fig-down.gif[/IMG]. Before surgery, all patients underwent a physical examination, an electrocardiogram (ECG), echocardiography, spiro-metric respiratory function test (if over 6 years old), chest radiography, and routine blood biochemistry tests. Echocardiography in one patient indicated a secundum type of atrial septal defect; there were no symptoms and a physical examination revealed no pathological findings. The criteria of Kowalewski and colleagues3 were used to define the degree of pectus excavatum. The 20 patients with moderate pectus excavatum had normal respiratory function but investigations showed exercise limitations, right bundle branch block, and right axis deviation. One of these patients reported frequent lung infections, one had symptoms resembling asthma (computed tomography of the chest was normal in both), and the others were asymptomatic. The 10 patients with severe deformities had respiratory function tests below normal as well as exercise limitations and minimal right axis deviation. Two male patients had a positive family history; a younger sibling of one, and the mother of the other had minimal pectus excavatum. Chest radiography showed a shift of the heart towards the left hemithorax in all cases. The indications for surgery were based on medical and cosmetic objectives in 10 (33%) patients, and on psychological and cosmetic objectives in the other 20 (67%). No pressure to undergo surgery was applied.
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Table 1. Profile of 30 Patients With Pectus Excavatum

In most cases, surgery and subsequent follow-up were performed by the same surgical team. All operations were carried out under endotracheal general anesthesia after premedication. A broad-spectrum cephalosporin antibiotic (cefazolin sodium, 50 mg•kg-1•day-1) was administered prophylactically preoperatively and for 5 days post-operatively. A median sternotomy incision was performed on male patients, and a transverse submammary incision was preferred for females. In 29 typical pectus excavatum patients with bilateral diffuse depression, decortication was performed on the skin and skin flaps. Following this, 4 to 6 abnormal cartilages were removed from the perichondrium, and segments of 3 to 4 cm were excised. Osteotomy was subsequently carried out on the anterior wedge of the depressed section of the sternum. The desired degree of elevation was achieved by resecting the xiphoid section of the sternum, separating it and supporting it from underneath by performing an ostectomy, and then cutting but not moving the sternum. Stabilization of the sternal wedge osteotomy was achieved with absorbable sutures. Kirschner wire supports were passed underneath the sternum in 25 patients. In 5 patients with 4 or less bilateral excisions, complete stabilization was achieved without support wires, using absorbable sutures only. Sternal wedge osteotomy was not performed on a patient with unilateral abnormal costochondral hyperplasia and minimal sternal depression; after unilateral excision of abnormal costal cartilages, absorbable sutures were applied to the perichondrium. During costal cartilage excision, care was taken to avoid incising the pectoral muscles or the pleura. After resection, cut muscles were sutured. If the pleura had been opened, a thoracostomy tube was inserted and a drain was placed under the skin at the top of the sternum. The skin was closed in layers with absorbable sutures.

Kirschner support wires were removed after 8 to 28 days (mean, 18 days). Patients were discharged after 5 to 14 days (mean, 8 days), and followed up at 10 days, 1 month, 6 months, and then yearly for 3 years. Follow-up examinations included chest radiography and an ECG. If considered necessary, an echocardiogram, a spirometric respiratory function test, and a physical examination were performed. Scar development, recurrent sternal depression, and thoracic deformities such as scoliosis were assessed.

RESULTS

There was no perioperative death. All patients were extubated at an early stage while on the operating table. Complications (Table 2) included opening of the pleura in 7 patients, 6 of whom had chest drainage. Atelectasia developed in 3 cases and resolved with respiratory physiotherapy. An abscess formed under the skin in one patient, which was drained under local anesthesia. One patient required treatment for seroma at the incision site and opening of the sutures. Two females and one male developed hypertrophy and keloid at the incision site; one benefited from a local steroid injection, the other 2 underwent keloid excision. Postoperative drainage of more than 150 mL was not observed. All patients were ambulated on the 1st or 2nd postoperative day.
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Table 2. Complications After Correction of Pectus Excavatum in 30 Patients
Full resumption of physical activity was recommended at the 3-month postoperative follow-up. Excellent results in all except 2 patients were noted at the 1-year evaluation. Medium-term follow-up at 2 and 3 years showed that despite excellent results, one patient experienced psychological disturbances. This patient was referred to the psychiatric clinic and antidepressant medication was recommended. Development of breast tissue in female patients together with pubertal growth and correction of the chest wall contour resulted in excellent psychological improvement and increased self-confidence. The 2 patients who had suffered frequent lung infections or asthma symptoms and 10 who had limited exercise tolerance due to serious deformity showed no symptoms at the 1-year follow-up.

Recurrent sternal depression was observed in 3 patients. A 14-year-old boy who had been treated for unilateral atypical costochondral hyperplasia, developed contra-lateral costochondral hyperplasia and sternal depression. An 8-year-old girl with bilaterally diffused sternal depression had undergone bilateral costal cartilage resection and anterior sternal wedge osteotomy; Kirschner wire was not used because sternal support with sutures was considered adequate. Cosmetic results in both patients were good after the first year, but minimal sternal depression increased during follow-up, although they had no symptoms and no exercise limitation. Long-term follow-up showed recurrent sternal depression 6 years postoperatively in a boy with bilaterally diffused sternal depression who had undergone correction at 4 years old; his wires had been removed on the 8th postoperative day. Two of these 3 patients required reoperation for sternal depression; follow-up after 1 year indicated good results. All except the patient with Down's syndrome were successful at school and there was no regression in physical development.

DISCUSSION

Recurrent sternal depression may occur postoperatively, generally due to inadequate sternal fixation or early removal of substernal support wires.1–4,5 The etiology of long-term sternal depression is uncertain. It is believed to be related to prepubertal growth, 6 or more costal cartilage excisions, rapid pubertal growth, postoperative posture, physical activity, and lifestyle.1,2 A number of surgical techniques for correction of pectus excavatum have been reported.5–7 We chose the Ravitch technique which proved safe and simple and avoided a large number of costal cartilage excisions, especially in children less than 8 years old. Experimental studies showed that more than 6 costal cartilage excisions in prepubertal animals resulted in abnormal chest wall development in later stages of growth.8–10 We were reluctant to completely excise the deformed sections of cartilage as it has been reported that excision of 1-cm segments bilaterally is sufficient.1

Use of Kirschner wires for substernal support accelerates primary osseous healing in the short term, and in the long term, they serve to stabilize the results of the early healing.11 This is very important in preventing recurrence postpuberty and in older patients.3–6 We used Kirschner wires in postpubertal corrective surgery and in sternal wedge osteotomy patients. As a result, rigid fixation was achieved and no case of paradoxical chest wall movement during respiration was observed. Pericardium, muscle, and endothoracic fascia have been reported to be useful as substernal support tissue for sternal stabilization.12–14 However, none of these methods were considered necessary in this series.

Special consideration was given to patients less than 13 years old and at the prepubertal stage. Surgery in older patients with moderate and severe deformities was performed more frequently with cosmetic objectives. There is no consensus on age criteria for pectus excavatum correction.2–4,6,15 Generally, surgeons prefer to operate before the pubertal growth stage and in early child-hood.2,12,16,17 On the other hand, some observed that repair performed during early childhood resulted in frequent recurrence and abnormal development of the chest contour in the postpubertal term.4,9,15 Recurrence related to surgical technique was not detected in this series. In young children (< 6 years old), complications are usually related to inadequate surgical technique. Because osseous develop-ment is completed on cessation of pubertal growth, surgical inadequacy, complications, and prolonged hospital stay are observed more frequently in older patients. Based on our experience, if there is no medical indication for surgery, the most appropriate age for cosmetic correction is 6 to 12 years. This age group has the most rapid healing of cartilage tissue. Chest wall stability in the early post-operative period determines a good thoracic contour.5,8,11 To ensure this, light exercise is advised at 2 months postoperatively, and active physical exercise should be commenced at 3 months after surgery, with the aim of strengthening the pectoral muscles. The use of Kirschner wires is recommended for substernal support in the immediate postoperative period.

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