Repair of pectus excavatum and carinatum in adults

doi:10.1016/S0002-9610(98)00316-X

The American Journal of Surgery

Volume 177, Issue 2, February 1999, Pages 121-124

https://doi.org/10.1016/S0002-9610(98)00316-X Get rights and content

Abstract

BACKGROUND: There is sparse published information regarding the repair of pectus chest deformities in adults. This report summarizes our clinical experience with the surgical repair of pectus excavatum and carinatum deformities in 25 adults.

METHODS:

During the past 11 years, 25 patients 20 years of age or older (mean 31) with symptomatic pectus excavatum (23) or carinatum (2) deformities underwent surgical repair using a temporary internal sternal support bar.

RESULTS:

Each of the patients with decreased stamina and endurance or dyspnea with exercise experienced marked clinical improvement within 4 months postoperation. Exercise-induced asthma was improved in 6 of 7 patients; chest pain was reduced in each of 9 patients. Postoperative complications included pneumothorax (1), keloid (2), and discomfort from sternal bar (2). The sternal bar was removed 7 to 10 months postoperation in 19 patients; there has been no return of preoperative symptoms or recurrent depression in any patient with a mean follow-up of 4.8 years.

CONCLUSIONS:

For adults who have symptoms and activity limitations related to uncorrected pectus chest deformities, surgical repair can be performed with low morbidity, low cost, minimal limitation in activity, and a high frequency of symptomatic improvement. The operation in adults is more difficult than in children, although the results are similar.

Section snippets

Materials and methods

During the 30-year period from 1968 through 1998, 373 patients underwent repair of pectus excavatum, and 45 had correction of carinatum deformities at the UCLA Medical Center. During the same period 25 of the patients were operated upon when they were 20 years or older, all during the past 11 years (19 during the past 5 years). The age of these adult patients has ranged from 20 to 52 years (mean 31) at the time of operation. Only 3 of the 25 patients were female. Twenty-three patients had

Results

Each of the patients with preoperative limitation in stamina and endurance with exercise experienced marked improvement within 4 months after operation, and each was able to participate in vigorous exercise, including running, swimming, hiking, and tennis, before removal of the sternal bar (Figure 2). Twelve of the 13 patients with frequent respiratory infections had a decrease in frequency and severity within 4 months. Six of the 7 patients with exercise-induced asthma experienced fewer

Comments

Symptoms from pectus excavatum are infrequently recognized during early childhood, apart from an unwillingness to expose the chest while swimming or participating in other athletic or social activities. The majority of parents are therefore advised by well-meaning family physicians or pediatricians that (1) the deformity will improve with age; (2) the malformation produces few symptoms and is primarily a cosmetic problem, and (3) that surgical repair is dangerous, minimally effective, and

Conclusions

Data from the present clinical experience suggests that many patients who do not undergo repair of severe pectus chest deformities in childhood will experience worsening symptoms in adult life. For those adults who have symptoms and activity limitations related to pectus chest deformities, surgical repair can be performed with low morbidity, low cost, minimal limitation in activity, and a high frequency of symptomatic improvement. Repair of pectus deformities is technically easier and is

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Cited by (34)

Pectus carinatum
2010, Thoracic Surgery Clinics
Cardiovascular magnetic resonance in patients with pectus excavatum compared with normal controls
2010, Journal of Cardiovascular Magnetic Resonance
To assess cardiothoracic structure and function in patients with pectus excavatum compared with control subjects using cardiovascular magnetic resonance imaging (CMR).
Thirty patients with pectus excavatum deformity (23 men, 7 women, age range: 14-67 years) underwent CMR using 1.5-Tesla scanner (Siemens) and were compared to 25 healthy controls (18 men, 7 women, age range 18-50 years). The CMR protocol included cardiac cine images, pulmonary artery flow quantification, time resolved 3D contrast enhanced MR angiography (CEMRA) and high spatial resolution CEMRA. Chest wall indices including maximum transverse diameter, pectus index (PI), and chest-flatness were measured in all subjects. Left and right ventricular ejection fractions (LVEF, RVEF), ventricular long and short dimensions (LD, SD), mid-ventricle myocardial shortening, pulmonary-systemic circulation time, and pulmonary artery flow were quantified.
In patients with pectus excavatum, the pectus index was 9.3 ± 5.0 versus 2.8 ± 0.4 in controls (P < 0.001). No significant differences between pectus excavatum patients and controls were found in LV ejection fraction, LV myocardial shortening, pulmonary-systemic circulation time or pulmonary flow indices. In pectus excavatum, resting RV ejection fraction was reduced (53.9 ± 9.6 versus 60.5 ± 9.5; P = 0.013), RVSD was reduced (P < 0.05) both at end diastole and systole, RVLD was increased at end diastole (P < 0.05) reflecting geometric distortion of the RV due to sternal compression.
Depression of the sternum in pectus excavatum patients distorts RV geometry. Resting RVEF was reduced by 6% of the control value, suggesting that these geometrical changes may influence myocardial performance. Resting LV function, pulmonary circulation times and pulmonary vascular anatomy and perfusion indices were no different to controls.
Preoperative Assessment of Chest Wall Deformities
2009, Seminars in Thoracic and Cardiovascular Surgery
Citation Excerpt :
This repair will provide an excellent cosmetic result and protect underlying visceral organs. Patients who have had previous repair of their pectus excavatum with either modified Ravitch procedure or a Nuss procedure, as well as patients who may have had pectus carinatum repair as a younger patient, may present with recurrent disease.10,14,15 As a rule of thumb, these patients should be evaluated as thoroughly as any patient who may present initially with either of these defects.
Minimally Invasive Repair of Pectus Excavatum
2009, Seminars in Thoracic and Cardiovascular Surgery
Citation Excerpt :
It is important to note that operative correction of pectus excavatum should not be viewed as an operation limited exclusively to pediatric patients. Indeed, the open technique has been used in adult patients with excellent results.31 However, experience with the MIRPE in adult patients has been limited to a few cases, reported mainly in anecdotes.
The minimally invasive approach for repair of pectus excavatum has become widely accepted by pediatric and thoracic surgeons primarily because of increased patient awareness and good long-term outcomes. Although the technique is considered fairly new, it was quickly embraced by many, resulting in a significant increase in the number of such procedures being performed in North America over the last decade. Early reports demonstrated the potential risks and complications of this procedure. Important technical modifications were implemented, and the operation as well as selection criteria for surgery were modified to minimize risks and improve overall outcomes. This article reviews the indications for treatment of patients with pectus excavatum, with emphasis on the evolution and outcomes of the procedure known as the minimally invasive repair or Nuss technique.
Lorenz Bar Repair of Pectus Excavatum in the Adult Population: Should it be Done?
2008, Annals of Thoracic Surgery
Citation Excerpt :
Several studies have established the safety of the Lorenz bar repair in adults, but few have considered its efficacy in this population [4, 6–11, 17–21]. All of the studies that have addressed Ravitch repairs of adult PE patients have found that the repair does an adequate job in mitigating or eliminating preoperative symptoms, with a short hospital stay and relatively few postoperative complications [12–16]. However, operative times can often be long, especially in adult patients, usually more than 3 hours and even longer in adults presenting with recurrence [13, 16].
Although extensive literature exists on the Lorenz bar repair of pectus excavatum (PE) in pediatric patients, few data examine this repair in adults or compare long-term outcomes in adults with the pediatric population. We identified the preoperative characteristics, postoperative complications, and outcomes of adult patients undergoing Lorenz bar repair of PE who had bar removal and compared these outcomes with a pediatric population undergoing the same procedure.
A retrospective review (1997 to 2006) of patients undergoing primary repair of PE with a Lorenz bar identified 107 individuals aged older than 18 and 137 patients aged 6 to 14, of whom 52 and 80 had their bar(s) removed, respectively. These latter patients were the focus of analysis. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes.
The median (interquartile range, IQR) age and pectus index of adult patients (81% men) at the time of repair was 23 (18 to 30) years and 3.8 (3.5 to 4.3), respectively. In 2 adults (3.9%), PE recurred after bar removal, and 6 (11.6%) required surgical revision for bar displacement or upper sternal depression. These rates of complications were similar to those found in children undergoing Lorenz bar repair of PE at our institution.
Lorenz bar placement to correct PE in adults can be performed safely and effectively, with rates of bar displacement, sternal depression, recurrence, and reoperation that are not statistically different than those found in a younger pediatric population.
Thirty-year experience with repair of pectus deformities in adults
2003, Annals of Thoracic Surgery
A plethora of studies have described repair of pectus deformities in children, but only few reports have described this repair in adults. The purpose of this study was to review our 30-year experience with surgical repair of pectus deformities in adults.
A retrospective review of all adult patients (> 16 years old) who underwent repair of congenital pectus deformities from 1971 through 2001.
There were 77 patients, 64 men and 13 women. Sixty-eight patients underwent surgery for pectus excavatum and 9 for pectus carinatum; median age was 22 years old (range, 16 to 68 years old). Indication for repair was medical concerns in all patients. Preoperative symptoms were dyspnea on exertion in 43 patients, shortness of breath at rest in 22 patients, chest pain in 8 patients, and palpitations in 8 patients. Preoperative electrocardiogram findings included right bundle branch block in 9 patients, sinus bradycardia in 8 patients, left atrial enlargement in 6 patients, and right atrial dilatation in 5 patients. Patterns of the pectus defect were symmetric and localized in 29 patients, symmetric and diffuse in 21, asymmetric and localized in 18, and asymmetric and diffuse in 9 patients. Intraoperative classifications were severe in 38 patients, moderate in 33 patients, and mild in 6 patients. There were no operative deaths. Complications occurred in 11 patients (14.3%). Mean hospital stay was 4 days (range, 2 to 8 days). Mean follow-up was 12 ± 7 years (range, 4 months old to 24 years old); 1 patient (1.3%) required reoperation for recurrent pectus excavatum. Patient satisfaction and relief of medical symptoms was excellent in 70 patients (90.9%), good in 6 patients, and fair in 1 patient.
Repair of congenital defects of the sternum in adults can be performed safely with low morbidity and no mortality. Long-term results are excellent with requirement for reoperation rare.

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Scientific PapersRepair of pectus excavatum and carinatum in adults

Abstract

Section snippets

Materials and methods

Results

Comments

Conclusions

J Thorac Surg

J Pediatr Surg

J Thorac Cardiovasc Surg

J Pediatr Surg

Am J Surg

Chest wall deformities

Scientific Papers
Repair of pectus excavatum and carinatum in adults