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A case of Horner syndrome occurring secondary to the high insertion of a chest tube is reported. Horner syndrome from this cause can easily be avoided. The tip of the chest tube should be kept at or below the third posterior rib unless the clinical situation dictates otherwise.
Various surgical approaches to pectus excavatum repair concomitant with surgery have been recommended. In this article the authors describe their approach to the problem that they applied in 1989 and onward, successfully, in six consecutive patients. The favorable early and long-term results of these cases illustrate that the simultaneous correction of pectus excavatum and the underlying diseases of the ascending aorta, aortic arch, and the heart can be performed successfully even in emergency situations. The technique recommended provides good cosmetic results and a stable chest wall. It is well applicable in patients of adult age.
Since 2002, the Eckart Klobe vacuum has been used in our Service as an innovate and non-invasive procedure in patients with pectus excavatum. This vacuum method contributes not only to hold promise as a valuable adjunct in minimally invasive surgery, but also as an effective method to lift and fix the funnel for repairing pectus excavatum in some patients. Our experience is limited to the use of this device in 10 patients, during the Nuss technique. This procedure has been useful for safer passage of the introducer, and as a definitive treatment in a 10 years old girl with pectus excavatum and a Haller index of 5.1 with successful result after one year of treatment. The aim of this study is to report the safety and efficacy of this procedure in appropriate patients. Long-term results will be necessary to confirm this method as an alternative to more invasive techniques.
In conclusion, the following points are reemphasized: 1) The abnormal (either depressed or protruding) cartilages should always be resected. This resection, especially in pectus excavatum abnormalities, should not be overdone because the highest point that the chest wall and sternum can be elevated to with these types of operations is only the level of the most anterior rib and the thickness of the sternum itself. 2) Marlex mesh is an ideal material to support the sternum in its corrected position. It is strong and holds well until the chest wall solidifies. Also, it is resistant to infection and it may be left in place permanently. The application of different metallic splints, rods, and so on, as well as costal allografts, was found to be absolutely unnecessary. 3) Intercostal strips detached from the sternum may be left in place. Also, the surgeon should not waste time in performing a meticulous "classic" subperichondrial resection of the cartilages and ribs but should just leave enough perichondrium and periosteum behind to ensure the regeneration of the ribs. For the same reason, a segment of the most lateral portion of the cartilage should be left in continuity with the ribs. 4) It is strongly recommended that in excavatum anomalies, one of the pleural cavities should be deliberately opened and wide communication established between the pleural and the retrosternal space; the entire operative area should be drained for a day or two using an intracostal water-sealed catheter. This will make the use of any other subcutaneous or mediastinal drainage devices unnecessary and will ensure appropriate drainage of blood or serum. It is also recommended that the resection of the cartilages should be done on the left side first, where inadvertent entering of the pleura is less likely because of the backing of the pericardium. If it happens, drainage of the right hemithorax is not necessary. Carinatum anomalies are handled with subcutaneous drainage. 5) To confirm appropriate results, the chest should be carefully inspected after closure of the skin, and flaws, if they exist, should be corrected right then. Also, surgical repair of all pectus anomalies, especially excavatum deformities, should be supplemented in due time with an appropriate exercise program. Swimming and weight lifting are especially useful. 6) We found that the age limit imposed on small children by some authors is unnecessary, and as a matter of fact it is preferable to operate on children at an early age, around 2 years, because of commonly existing psychologic problems at a later age. The author advises restraint in operating on individuals past the teenage years unless the deformity is physiologically restricting. 7) The jury is still out regarding procedures using limited exposure and that do not use transverse sternotomy to correct the depressed or elevated sternal axis. 8) The usage of cosmetic procedures, or in other words, operations that do not correct the anomaly of the bony chest wall but use various implants as camouflage, should be restricted to cases of moderate excavatum anomalies in late teenage patients and to adults without cardiorespiratory symptoms.
An internally supported technique employing selective subperichondral cartilage resection and wedge sternal osteotomy reinforced with multiple transverse nonabsorbable mesh bands was performed in 52 patients undergoing surgical repair of severe asymmetric pectus excavatum chest wall deformity. The short-term structural and cosmetic results were excellent, the length of hospital stay was short (3.1 days), and complications were few. The long-term results were also excellent at 5 to 161 months (mean, 79 months) after repair. The procedure is well accepted by patients and families as a treatment for the severe variants of this chest wall lesion and as such is recommended as a satisfactory alternative to current techniques.
BACKGROUND: Surgery to correct pectus deformities entail substantial destruction of the thoracic skeleton and thus may cause significant postoperative pain. AIMS: To evaluate the efficacy of intravenous ketoprofen, a NSAID, as an adjunct to PCA morphine in pain treatment in children having pectus surgery. METHODS: Thirty-one children aged 10-15 years completed the study according to protocol. Children (n=14) in the ketoprofen-group received ketoprofen 1mg/kg i.v. at the skin closure, and at 8 and 16 h after surgery, while children (n=17) in the placebo-group received normal saline, respectively. For rescue analgesia the patient had an access to PCA-morphine. The children expressed their pain by a coloured VAS. RESULTS: Mean cumulative 24h morphine dose used was less in the ketoprofen-group (mean+/-SD: 490+/-240 microg/kg) than in the placebo-group (670+/-200 microg/kg) (mean difference 180 microg/kg, 95% CI for diff: 15-340 microg/kg, P=0.03). The area under the pain intensity-time-curve was lower in the ketorpofen-group (49+/-26 score hour) than in the placebo-group (68+/-24 score hour) (mean difference 21 score hour, 95% CI for diff: 3-40 score hour, P=0.026). There was no difference between the two groups in adverse events, 4/14 in the ketoprofen group and 8/17 in the placebo-group developed oxygen desaturation, and one patient in the ketoprofen-group developed bleeding at 5h after surgery. CONCLUSIONS: Intravenous ketoprofen in adjunct to PCA morphine provided a significant opioid sparing effect and improved analgesia in children having chest wall correction surgery.
Many methods for surgical correction of anterior chest deformities has been described; the modified Ravitch's technique is the most performed. We reviewed the clinical reports of 15 patients who had corrected chest deformity from 1991 to 1999. We compared the photographies, CT images and Haller's pre and postsurgery indexes. The modified Ravitch's technique was performed in 14 cases and the Nuss's technique in one. A postoperative questionnaire was done to know the grade of satisfaction that the patients reported after surgery. Of 15 patients, 14 were male. The mean age at the moment of surgery was 11 year old (range: 4-17). Nine patients (60%) had pectus excavatum and six (40%) pectus carinatum. In all cases, the postsurgery photographies and CT images showed neither chest depression nor protrussion. The mean of Haller's pre and postsurgery indexes changed from 4.75 (range: 2.8-7.7) to 3.12 (range: 2.4-3.7). The grade of satisfaction after surgery was high in the 80% of the patients. In our limited experience, the most of the patients with anterior chest deformities are satisfied with the results of the surgical management.
Chest wall anomalies are a heterogeneous group of malformations requiring repair. Recurrence and the need for secondary repair may occur. Congenital anomalies, including bifid sternum, pentalogy of Cantrell, Jeunes's syndrome and Poland's anomaly, rarely recur. Pectus carinatum may recur in the original surgical area or an adjacent area and most often recurs in patients who undergo repair before completion of teenage growth. Pectus excavatum may recur in approximately 5% of patients. Simple recurrence, floating sternum, or Acquired Jeune's syndrome may result. All of these would require reoperation. Each chest wall anomaly recurrence requires an individualized approach to timing and type of repair. Overall excellent results should be obtained for operative repair of recurrences.
Surgical correction of pectus excavatum (PE) has been well established since Ravitch's publication in 1949. However, Ravitch's procedure, even if modified, was associated with the relatively radical nature of the operation. The aim of this study was to report our early experience and results in treatment of PE by a novel less invasive surgical technique through a small skin incision. From 1998 to 2003, a novel surgical correction through a small transverse incision was performed for 11 patients with PE, including 9 males and 2 females. The mean age was 9.2 years (range, 3 to 17 years). The less invasive surgical technique consisted of a small transverse skin incision over the deepest part of the PE deformity, subcutaneous dissection to the margin of the depressed deformity, elevation of pectoralis musculature from the midline toward the lateral border of the operative field, subperichondrial resection of the short segment (1 to 2 cm) of the involved costal cartilages, detachment of the xiphoid process and elevation of the sternum with sharp or blunt dissection, retrosternal titanium miniplate strutting, placement of drainage tubes in the mediastinum or pleural spaces, and closure of the operative wound. No sternal osteotomy was performed in this series. The average length of the skin incision was 3.2 cm. The number of the resected cartilages varied from 3 to 6 ribs on each side. The average blood loss was 41 mL (range, 10 to 80 mL), and the operation time was 3.1 hours. The duration of hospitalization was 4.4 days on average. There was no surgical complication or mortality. All patients were satisfied with their cosmesis, and no migration of the retrosternal strut was found in chest radiographs until the date of analysis. This less invasive surgical technique, which did not require osteotomy, could be effectively performed through a small skin incision and was associated with steady recovery of chest wall deformity, as well as excellent cosmetic results.
Pectus excavatum is the most common congenital chest wall deformity; it is manifest by abnormal costal cartilage segments causing sternal depression and rotation. The most popular repair involves resection of the abnormal costal cartilage segments, followed by sternal osteotomy and fixation to the adjacent chest wall. Methods of sternal fixation have included metal bars and struts, K-wires, pins, sutures, synthetic mesh, vascularized rib struts, and large AO plates, but they have not included more recent rigid fixation technology. Current rigid fixation techniques allow incorporation of malleable, low-profile reconstruction plates that can be contoured to correct the three-dimensional aspect of these defects. Three pediatric patients are presented in whom plate fixation was utilized for sternal fixation. Current reconstruction plate technology provides an improved fixation alternative for the correction of congenital chest wall anomalies, as well as offering similar potential advantages for traumatic, oncologic, and reconstructive surgery of the thorax.
Anterior chest wall asymmetry is sometimes encountered in patients presenting for consideration of breast augmentation. The chest wall asymmetry or deficiency may be significant enough to consider reconstruction at the same time as breast augmentation in a small number of cases. Customized and prefabricated chest wall implants have been used in a variety of conditions including Poland syndrome, pectus excavatum, and sunken anterior chest. Careful moulage preparation and on-table implant modification are needed to "seat" these implants on the skeletal chest wall under the pectoralis major muscle. The chest wall implant provides a base for the subsequent breast prostheses and fills up a bony deficit that cannot be camouflaged by the breast prostheses alone.
Nine children with severe pectus excavatum deformity were operated on in the Department of Pediatric Surgery, Thoracic Unit, Ege University Faculty of Medicine, Izmir, Turkey. There were four boys and five girls, and the mean age at operation was 6.3 years. A modified Ravitch technique was performed by using two polytetrafluoroethylene bars placed retrosternally for fixation and stabilization of the reconstituted anterior chest wall. The bars were removed 6 months after the operation. Results were satisfactory in all cases, with no surgical complications.
Flat chests, characterised by a dorsoventral flattening of the rib cage, affect 3 to 4 per cent of all Burmese kittens born in the United Kingdom. Similar deformities have been reported in kittens born to taurine-depleted queens. In an investigation of whether there might be a relationship between whole blood taurine levels and the appearance of flat chests it was found that Burmese kittens had significantly (P < 0.05) higher whole blood taurine levels than Burmese queens. In addition, flat-chested Burmese kittens had higher mean (sd) levels (789 [189] mumol/litre) than unaffected Burmese kittens (702 [166] mumol/litre) and non-Burmese kittens (597 [93] mumol/litre), although these differences were not statistically significant. Higher levels of taurine were found in the skeletal muscle and lower levels in the heart muscle of the flat-chested Burmese kittens than in normal non-Burmese kittens.
A vascularized rib strut based on the anterior intercostal branch of the internal mammary artery was applied to provide rigid internal fixation of the chest wall after correction of pectus excavatum. The procedure is simple and has substantial advantages when compared with techniques using metallic struts or nonvascularized free rib grafts.
Pectus excavatum, the most common congenital chest wall abnormality, is manifested by deformity of the costal cartilages resulting in a depressed and often rotated sternum. Although there are conflicting data to support and reject the concept that physiologic improvement can be a consequence of surgical repair, correction is frequently indicated for aesthetic improvement alone. The most popular current repair involves resection of abnormal costal cartilages, sternal osteotomy and mobilisation, followed by fixation of the sternum in the corrected position. Improved fixation techniques have evolved, but generally have not employed current concepts of rigid fixation. The correction of pectus excavatum using reconstruction plates incorporates the benefits of rigid fixation, while allowing custom chest wall contouring and sternal reorientation. Reconstruction plate fixation of the sternum should be considered during correction of pectus excavatum in adult and adolescent patients.
A variety of focal processes and diffuse abnormalities are found predominantly in children. In addition, thoracic manifestations of trauma differ in children because of increased chest wall compliance. Familiarity with both these abnormalities as well as the common normal variations provides optimal imaging evaluation.
Fifty-five children and adolescents with different types of pectus deformities and a minimum follow-up of 1 year were assessed to determine the effectiveness of nonoperative treatment with a dynamic chest compressor orthosis. Thirty-seven patients were treated and compared with 18 untreated patients. The treated patients had a better outcome. Reshaping of the contour of the chest wall was observed in 21 patients with inferior and lateral types of pectus carinatum. The dynamic chest compressor has minimal morbidity and is a valuable treatment option of pectus deformities in the growing period.
One of the major remaining problems in the management of children with anterior chest wall deformities is the lack of a widely accepted objective method of evaluating the severity of the deformity. This deficiency has made it difficult to evaluate indications for operation or the results of operative repair. Moiré phototopography is a new method of accurately measuring human body contours utilizing recent developments in applied optics and has been used successfully in scoliosis screening programs. This technique has been applied to the evaluation of anterior chest wall deformities and the initial results of this study are presented. Moiré phototopography has proven to be a sensitive, reproducible, and easy to perform method of quantitating pectus deformities. While further evaluation is required, this early experience suggests this technique may provide a means of accurately and objectively measuring chest wall deformities so that their physiologic significance can be precisely investigated and the results of therapy critically reviewed.