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PubMed1980

Pectus excavatum: resolution after surgical removal of upper airway obstruction.

A six-year-old child with obstruction of the upper airway and a pectus excavatum defect ("funnel chest") is presented. Correction of the funnel-chest deformity was observed four years after the performance of a tonsillectomy and adenoidectomy to relieve the obstruction of the upper airway. The relationship between chronic upper-airway obstruction and a pectus excavatum deformity is discussed, and the reversibility of such a deformity is documented.

Adenoidectomy↗
PubMed1989

[Re-operation of pectus excavatum].

We performed surgical reconstruction on 1655 cases of deformed thoracic cage, we later operated again on 11 of these to repair postoperatively re-deformed anterior chest walls. Based on these experiences, we have concluded as follows. 1: Postoperative recurrence of funnel chest deforming is mainly due to insufficient resection of costal cartilages. In particular transection of the sternum at low levels during sternal turn-over procedure results in postoperative recurrence of depression in the upper anterior chest wall. 2: In young children who have undergone sternal turn-over procedure, the first and second costal bones and cartilages overgrow and protrude anteriorly, and in compensation their junctions to the sternum recess posteriorly. This results in a depression in the upper anterior chest wall. 3: We recommend sternal turn-over with overlapping of the sternum for repair of postoperative funnel chest deformity. Through this procedure, the extent of resection of costal cartilages can easily be determined and the depression of the anterior chest wall satisfactorily reconstructed. 4: In re-do surgery, we obtained pathological evidence confirming our clinical experience that our sternal turn-over technique does not interfere with blood circulation or development of the turned-over sternum even though the sternum is not connected to the rectus abdominus muscle pedicle, preserved internal mammary vessels, or anastomosis of the internal mammary vessels.

Adolescent↗
PubMed1997

[Electrocardiographic changes in chest deformities. Apropos of 20 cases in black subjects].

The objective of this study is to describe the electrocardiographic signs associated with certain chest deformities. This is a prospective, case-control study comparing 20 black subjects with chest deformity (11 cases of flat back syndrome, 5 cases of pigeon chest, 4 cases of funnel chest) with 20 age- and sex-matched healthy controls. Cardiac duplex ultrasound was performed for each individual to exclude associated heart disease. Atypical electrocardiographic signs were observed in 15 subjects with chest deformity versus only 3 in the control group. The anomalies observed consisted of signs of atrial or ventricular hypetrophy, right branch block, abnormalities of repolarization on the T wave or ST segment. Chest deformities are therefore associated with several electrical signs simulating most cardiac diseases. A good knowledge of these modifications should help to avoid the numerous diagnostic traps associated with these signs.

Adolescent↗
PubMed2006

Difficulties and limitations in minimally invasive repair of pectus excavatum--6 years experiences with Nuss technique.

OBJECTIVE: In 1998, Dr Donald Nuss proposed minimally invasive repair of pectus excavatum (MIRPE) which did not require the osteochondrous parts of the anterior chest wall to be resected. The paper aims at presenting the authors' own 6 years of experience in funnel chest repair with MIRPE technique. Also, many technical problems of this method are discussed. MATERIALS AND METHODS: Between 1999 and 2005, 461 patients (99 female and 362 male, aged 3-31 years, mean age 15.2 years) with pectus excavatum were operated with the Nuss technique. All patients were operated-on according to the original operative protocol proposed by Donald Nuss. With growing experience, own modifications were introduced. Insertion of two bars was done in 17.4%, transverse sternotomy in adolescents with rigid anterior chest wall in 7.8%, limited excision of the rib cartilages in 5.9%, and parasternal fixation of the bar to prevent it from rotating in 59.7% of patients. RESULTS: There were no deaths. Intraoperative complications were noted in 19 (4.1%) patients and postoperative ones were observed in 43 (9.3%) patients. The operative time ranged from 25 to 130 min (52 min on average). In 192 (41.6%) patients, an epidural block was used. The hospital stay ranged from 4 to 12 days with the mean of 5.3 days. A redo procedure for the bar rotation was necessary in 13 (2.8%) patients. The support bar has been removed in 260 (56.4%) patients so far. In all the patients, an adequate contour of the anterior chest wall has been maintained. CONCLUSIONS: MIRPE proposed by Nuss has all the features of a minimally invasive procedure and is straightforward. Better clinical results are achievable in patients under 12 years of age with a symmetric deformity. In older patients (over 15 years of age) with a rigid chest or with an asymmetric deformity, additional procedures are required to achieve a comprehensive correction of the deformity. Recent results and forward clinical observations may give proof to establish MIRPE as a method of choice in funnel chest correction.

Adolescent↗
PubMed1993

[Simultaneous operation of Cabrol's operation and sternal turnover with rectus abdominal flap].

We performed simultaneous operation of sternal turnover and Cabrol operation for a 28-year-old man, who had 3rd grade funnel chest and annuloaortic ectasia with 3rd grade aortic regurgitation. We think when both annuloaortic ectasia and funnel chest are indicated for operation, simultaneous operation is to be considered and the combination of Cabrol operation and sternal turnover with rectus abdominal flap is the best procedure.

Adult↗
PubMed1981

[Indication and operative technique in chest deformities (author's transl)].

From 1956-1980, 1112 thoracic deformities were operated on in the Surgical Clinic of the University of Erlangen. These are divided into 11 different types, according to whether a funnel chest (4 types), a pigeon chest (4 types), combinations of these, or a split-sternum was present. The indication for operation is given in patients where the depression is more than 25% of the a/p diameter of the chest. Scolioses - deformities of the spinal column - are found in 40-50%, depending on the type of funnel chest. They are rarely found in small children, but are fixed and irreversible in teenagers and older patients. Reconstruction of the thorax is carried out through a double-segment chondrotomy parasternal and at the apex of the funnel, using a horse-shoe-shaped metal support. Average length of stay in hospital is 7-10 days. Alternative procedures are Rehbein's operation, or Ravitch and Hecker's procedure. Postoperative physiotherapy is extremely important. Late results, on average 10.5 years after operation, showed recurrence of the funnel in 2.1% of cases, partial recurrence, ugly scars and cartilage nodules in 6.7%.

Adolescent↗
PubMed1991

Importance of morphological findings in the progress and treatment of chest wall deformities with special reference to the value of computed tomography, echocardiography and stereophotogrammetry.

Patients with chest wall deformities have many particular anatomical, physiological, genetic, biomechanical and psychological characteristics. It is generally recognized that surgical correction of funnel chest and pigeon breast may be done for psychosocial reasons alone. Morphological and dynamic investigations are done to identify the function of the deformed chest wall and to permit objective assessment of the cosmetic and functional outcomes of the operation. There is no universally agreed standard for the diagnosis of funnel chest and pigeon breast. Non-invasive investigations, such as computed tomography (CT), echocardiography (ECG) and stereophotogrammetry (SP), improve the quality of the diagnostic assessment, including evaluation of its functional aspects, without directly influencing the decision to operate, which is still made mainly on subjective grounds. The value of these techniques in the diagnosis of chest wall deformities is assessed and the results of our personal experience are presented.

Adolescent↗
PubMed1997

[Congenital deformities of the chest wall. Surgical treatment].

BACKGROUND AND AIMS: Malformations of the front chest wall are congenital defects that have been reported since the seventeenth century and which include the clinical syndromes of funnel chest, pigeon chest and Poland's syndrome. Although they have been reported for such a long time, their pathogenesis is in many ways still unknown and the theories proposed up until now reveal uncertain and unsatisfactory findings. Attempts to gather precise information regarding their real incidence are equally ineffective given that frequently those cases which are not particularly severe are not referred for specialist care. These malformations usually involve severe psychological problems caused by the deformity and, in more severe cases, may lead to alterations in normal cardiac and respiratory function which are above all evident during intense physical effort. METHODS: The authors critically review the cases of chest malformation corrected by the Department of Pediatric Surgery at the G. Gaslini Institute during the period from 1986 to date. They describe the surgical techniques used, justifying their choice and discussing any postoperative complications. RESULTS: This experience shows that there is a clear preference for less invasive surgery for the correction of funnel chest compared to the technique proposed by Ravitch in which the sternum was totally mobilised following its extensive detachment from the other bone and muscular structures of the thoracic cage, with a high risk of damaging the internal mammary artery. The operation that was felt to be most suitable for correcting this defect was that described by Wesselhoett and De Luca in 1982. It is easier to perform and less invasive: it eliminates the detachment phase by inserting a support in titanium alloy through the sternal frame. Autologous grafts taken from the bottom contralateral ribs to the defect were used to treat Poland's syndrome in line with the technique suggested by Ravitch, thus achieving good stability of the whole chest; in view of the young age of the patients undergoing correction, it was not thought appropriate to proceed with the cosmetic reconstruction of the pectoral muscles using a peduncled flap of latissimus dorsi. A total of 70 patients were operated in this way; the cosmetic results were very satisfactory, whereas complications were limited to 5 cases of intraoperative pneumothorax, 5 cases of serohematic subcutaneous collection which were treated conservatively, and 1 case of hypertrophic scarring.

Child↗
PubMed1989

[Simultaneous corrections Bentall procedure, mitral valve replacement and sternoplasty for a patient with Marfan's syndrome].

A successful case of simultaneous modified Bentall' procedure, MVR and sternoplasty was presented for a 42 years old man of Marfan's syndrome who had funnel chest, combined with mitral regurgitation, aortic regurgitation and annuloaortic ectasia. A few reports of one stage operation for the combination of funnel chest and heart disease in Marfan's syndrome has been published. A median sternotomy was made, with total cardiopulmonary bypass, heart was arrest and cor cooling hypothermia with crystalloid cardioplegic solution. Mitral valve was replaced with #31 B-S prosthetic valve. The ascending aorta proximal to the innominate artery and the aortic valve were replaced en-bloc with composite graft made of a vascular graft and aortic valve prostheses. Coronary artery orifices cut to the button-shaped, were sutured to the composite graft. Finally, sternoplasty was completed through modified Ravitch sterno-elevation. This is the first report in Japanese journals.

Adult↗
PubMed2000

[Surgical repair of pectus excavatum by internal metal strut fixation. Clinical experience in 51 cases].

BACKGROUND: Broad is the spectrum of congenital chest wall deformities. Fortunately the severe life-threatening deformities (i.e. ectopia cordis and Jeune's disease) are rarer than the more frequent pectus excavatum and carinatum. Funnel chest is the most common anterior chest wall deformity, it results from posterior depression of the sternum and cartilages, from the third to the eighth; it occurs more frequently in boys than in girls (4:1 ratio). While the deformity may be recognizable at birth, especially during crying spells, it progressively worsens during childhood, producing, sometimes, respiratory and cardiac impairment. METHODS: The authors report their experience, from April 1970 to December 1998, in correction of Pectus Excavatum using a single surgical technique, at the Borgo Roma Hospital of Verona. During this period 51 patients (mean age 14 years) affected by this deformity, were treated performing a sterno-chondroplasty with internal fixation. Most of the patients (94%) required operation for the esthetic and psychological reasons only. The grade of funnel chest (according to the Chin Classification) was: type I in 59.6% of patients, type II in 31.4% and type III in 11.7%. The surgical technique consisted in the modification of the Ravitch's technique (subperichondrial cartilage resection, transverse osteotomy with internal stainless steel strut fixation). We considered the intervention advisable to correct an existing defect or to prevent its progression. We don't think, in fact, that spontaneous recession of the deformity may occur. RESULTS: The follow-up varied from 4 to 18 years. The result was classified according to the classification of Humphreys and it was excellent in 64.7%, good in 17.7%, fair in 9.8% and poor in 7.8%. CONCLUSIONS: This technique proved to be safe and effective, it can be performed with no mortality, very low complication rate and satisfactory results.

Adolescent↗
PubMed1984

Surgical correction of pectus excavatum for adults and adolescents.

As an operative procedure for the correction of funnel chest in adult and adolescents, a strut method using AO-plates was used. All of the concaved parts of the sternum, costae, and cartilages contributing to the formation of the deformity were osteotomized to mobilize and elevate the deformed part. A vertical plate was used for fixation of the transected sternum, and three transverse plates were used as the portions which are curved appropriately to remodel the reconstructing chest wall. These plates were removed twelve to eighteen months after implantation. To date, thirty-one patients have undergone this repair. For the first eight, a single transverse plate was used, however, re-retraction of the region around the transverse plate became evident in the long term follow-up. Therefore, two or three plates were inserted for an improvement. When three transverse plates were used, retraction at the costal arch was relieved. Although a second operation is required to removal of the plates, we hold the view that this is the most effective operative procedure for the correction of funnel chest in adults and adolescents.

Adolescent↗
PubMed2000

The efficacy of predeposited autologous blood transfusions in general pediatric surgery.

Allogeneic blood transfusions are associated with a risk of infection, immunological reactions, immunosuppression, and the induction of antibodies in blood cells. We report our results of giving predeposited autologous blood transfusions (PABT) to children when it was anticipated that transfusions would be required for an elective operation. Autologous blood was collected for deposit from 16 patients ranging in age from 1 to 11 years old (mean 5.6 years old, mode 4 years old), and weighing from 9.7 to 42 kg (mean 20.8kg). They included 12 patients with pectus excavatum (funnel chest) and 4 patients with choledochal cyst (CBD). Blood was collected once from 2 patients and twice from the other 14 patients, then centrifuged and stored in a freezer at -80 degrees C. Between 7 and 14 ml/kg was collected at one time, the total mean volume of predeposited blood being 21.0 +/- 3.3 ml/kg for the children operated on for funnel chest, and 16.2 +/- 4.5 ml/ kg for those operated on for CBD. None of the patients required allogeneic transfusions and no complications occurred. PABT was found to be a safe and effective means for elective general pediatric surgical procedures for avoidance of allogeneic blood transfusion.

Blood Transfusion, Autologous↗
PubMed2006

Forces to be overcome in correction of pectus excavatum.

OBJECTIVE: The Erlangen technique of funnel chest correction is carried out through an anterior incision, and an essential step is retrosternal mobilization. After elevation of the funnel, the chest wall is stabilized with a lightweight transsternal metal implant. Forces necessary to elevate the chest wall were measured at defined intervals during the operation to prospectively assess the effect of peristernal and retrosternal dissection. METHODS: Over a 3-year period, systematic tension measurements were carried out on 100 consecutive patients with symmetric funnel chest to assess the effect of individual steps in mobilization of the sternum. RESULTS: Whereas in adolescents the extraction force is about 175 N, in adults it is not possible to elevate the sternum to the desired level without surgical mobilization because the force required is, on average, more than 200 N. Only about 50% of this tension can be eliminated by costal chondrotomy. To reduce the tension further and achieve a stable result without the need for heavy-duty internal fixation, we carry out a retrosternal dissection, including removal of the slips of the diaphragm and the insertions of the transversus thoracis muscle. The mean tension at the end of the procedure is 25 N. CONCLUSIONS: Our measurements show that retrosternal dissection is the decisive step in the Erlangen technique, which might explain the low relapse rate and allow for a less extensive anterolateral mobilization.

Adolescent↗
PubMedDate not supplied

[Structural characteristics of collagens from the skin and rib cartilage of patients with Ehlers-Danlos syndrome type II].

Collagens were analyzed in skin and rib cartilage of 9 patients with Ehlers-Danlos syndrome of the II type. Electrophoresis and CNBr-peptide mapping showed that extended inserts and deletions as well as rough impairments of post-translation processing were not detected in collagens of the I, II and III types from these patients. In the patients with Ehlers-Danlos syndrome of the II type distinct increase was observed both in the total ratio of collagens III/I (P = 0.95) and in the ratio of intact collagens III/I free of cross-links. A decrease in content of dimers beta 11 and beta 12 was found in two patients. The data obtained suggest that the Ehlers-Danlos syndrome of the II type involved deteriorations in the structure of collagens I responsible for decrease in stability and sometimes for impairments in cross-link formation. Increase in content of collagen II fraction, predisposed to proteolytic hydrolysis of terminal sites, as well as elevated sensitivity of collagen II to pepsin hydrolysis were found in collagens of rib cartilage from patients with the syndrome and with funnel chest deformation. This suggests the lowered stability of collagen II from rib cartilage in funnel chest deformation.

Cartilage↗
PubMed1998

Cardiorespiratory function before and after operation for pectus excavatum: medium-term results.

OBJECTIVE: The study was undertaken in order to assess the degree of impairment of the cardiovascular system in patients with funnel chest and to investigate any changes caused by surgical correction. METHODS: Echocardiographic examinations with systolic, diastolic and ejection volume indices calculation as well as pulmonary function tests were performed before surgery and at medium-term follow-up on 34 patients who were operated on for pectus excavatum between 1987 and 1992. RESULTS: The mean age was 13.4 years. There were 70.6% males. Pulmonary function was found to be restricted preoperatively in 18 patients. Inspiratory vital capacity and forced expiratory volume were increased or did not change at follow-up (5 years) in these patients. In cases with normal or moderately restricted pulmonary function (inspiratory vital capacity, forced expiratory volume more than 75% predicted) the reduction of lung function was noted after surgery. Marked haemodynamic improvement was found with the increase of diastolic and ejection volume of both heart ventricles (mainly right one). The improvement was more evident in patients with severe deformations. CONCLUSION: Only in case of severe reduction of lung function in a patient with funnel chest can one expect improvement after surgery. Sternocostal elevation improves function of both heart ventricles at rest.

Adolescent↗
PubMed1999

Pectus excavatum: increase of right ventricular systolic, diastolic, and stroke volumes after surgical repair.

OBJECTIVE: The study was undertaken to assess how a surgical correction of funnel chest modifies right ventricular structure and function. METHODS: Before and 6 months after surgery in 42 patients (27 male and 15 female patients, aged 5-31 years), a pectus index was calculated and echocardiographic examinations of the right ventricle were performed, with calculation of systolic, diastolic, and stroke volume indices. Right ventricular volume was estimated by subtracting the left ventricular volume from that of the entire heart. The values of the right ventricular volumes and the pectus index before and after the operation, as well as the changes in the indices, were compared. RESULTS: Statistically significant changes in the pectus index and the right ventricular volume indices after surgery were noted. No correlation was observed between the changes in the pectus index and the changes in any right ventricular volume indices. CONCLUSION: Surgical treatment of funnel chest causes an increase in right ventricular systolic, diastolic, and stroke volumes, although there is no correlation between these changes and the degree of sternocostal elevation.

Adolescent↗
PubMed2004

Common pleural cavity in combination with pectus excavatum.

A very rare case is being described; common pleural cavity was accidentally diagnosed in a 3-year-old boy operated for funnel chest (pectus excavatum). During 36 years 516 patients were operated in our department and we often notice pectus excavatum associated with other types of congenital pathology but only one had the common pleural space. In normal human beings pleural space is divided into left and right chambers separated by the mediastinum with no communication in between. In some mammals such as pigs, cows etc. a congenital communication is found between the pleural cavities, but this type of communication is very rare in humans and most often is of acquired origin. Pleural communication may also develop after major cardiothoracic surgery. In this case a 3-year-old male patient was admitted for the elective surgery on pectus excavatum. Clinical examination showed a very deep funnel chest. Both the heart and the mediastinum are left-shifted by the deformed breastbone; it is clearly demonstrated on a plain and lateral X-ray. On the left, beside the main vessels, an indistinct patch is noted. Typical M. Ravitch procedure was performed, by accident the pleural space was opened. Both pleural cavities had an evident communication along the anterior mediastinum. The torn pleura was sutured, the excess air removed by a puncture. Postoperative period was uneventful, additional treatment was not needed; currently the boy is feeling well. The postoperative X-ray showed the heart and the mediastinum to return to normal position.

Abnormalities, Multiple↗