The ‘Re-Do’ Chest Wall Deformity
By
Dick
G. Ellis,
Charles
Fort
Background:
A small
percentage
surgical
correction
of a chest wall
so unsatisfactory
that a second
“re-do,”
will be required.
L. Snyder,
Worth,
of patients
who
undergo
deformity
will have results
procedure,
the so-called
Conclusions:
The literature
contains
very
little information
regarding
the technique
and results
of these
procedures.
Based on experience
with 18 “re-do”
procedures,
the authors
believe
that recurrent
deformities
should
be surgically
corrected.
Although
this is a somewhat
diverse
group
based on
S
INCE 1980, we have performed reoperative chest
wall surgery on 18 patients including two adult
women. Twelve of the 13 boys originally had an excavaturn deformity as did four of the five girls (Table 1). Of
these, we performed the original surgery on two boy
excavatum patients, one boy carinatum patient, and one
girl excavatum patient. Of the other 14 patients, 10 boys
and 3 girls originally had an excavatum deformity,
including 1 adult woman. The other patient was an adult
woman who had a persistent carinatum deformity. One
carinatum patient experienced recurrence as an excavaturn deformity, and in this patient, no substernal bar had
been used. The patients were age 5 years to 36 years at the
time of the re-do with a median of 1.5years. The patients’
ages at the time of the original surgery ranged from 35
months to 30 years with a median of 5 years. The
intervals between surgeries varied from 12 months to 11
years with a median of 9 years. We only have knowledge
of one boy excavatum patient of ours who underwent
reoperation elsewhere. The postoperative follow-up was
as short as 3 months and as long as 13 years, with a
median of 1’/2 years. Six patients had follow-up for over 6
years. We have operated on 271 patients who have
undergone no previous chest wall surgery, and our five
recurrences represent a reoperative rate of 1.8%. Selection of patients for surgery was based entirely on the
chest wall appearance and on the wishes of the patient
and the family.
MATERIALS
Surgical
AND
Care
ofPediatric
Surgery,
Vol32,
Charles
M. Mann
Texas
age at the first
and second
procedure,
type
of original
operative
procedure,
and interval
between
the procedures,
the operative
approach
is standard,
and the results
are
predictable.
J Pediatr
Surg
32:1267-1271.
Copyright
o 1997 by W.B.
Saunders
Company.
INDEX
WORDS:
carinatum.
Funnel
chest,
pectus
excavatum,
pectus
An attempt was made to use the old incision site and to extend it if
necessary. We prefer to use a transverse
incision with elevation of all
soft tissue layers of the chest wall in one layer. A description
of this
technique is described
elsewhere.’
Previous surgery has not made this
particularly
difficult.
Intraoperatively,
the deformity
is again assessed.
The most common
finding in patients from our state, not originally
operated by us, has been undisturbed
deformed cartilages. The regenerated costal cartilages are usually riblike in consistency,
ie, osseous, and
are very adherent
to the surrounding
soft tissues. Robicek
et al?
described
these findings well. There is great variability
in the status of
the tissue planes depending on the extent of the previous surgery. When
the original
procedure
was limited, virginal
tissue planes may be
present. We feel that it is essential to remove enough of this bony tissue
to allow complete mobilization
of the sternum anteriorly.
Bony tissue
removal is performed
using a Freer type periosteal elevator and a fine
tipped rongeur. A curved nasal cartilage type elevator may be helpful. A
thyroid
tenaculum
works well to grasp tissue to be elevated. If the
regenerated perichondrial
bundles remain taut after bony tissue removal
they must be divided perpendicular
to their long axis using electrocautery. This is usually on the right inferior side (Fig 1). Although
sternal
mobilization
is essential.
soft tissue connection
to the sternum
is
preserved to the extent possible. An osteotomy
of the anterior table of
the sternum was used in most patients as well as a supporting
substernal
bar (Baxter
V. Muellar, Dearfield,
IL). The osteotomy
is performed
using a one-half inch, curved osteotome, using only enough of the tip to
cut the anterior table without cutting the posterior table. Usually this is
performed
in the second intercostal
space from left to right (Fig 2). On
four occasions,
two bars were used. one superiorly
and one inferiorly.
The bar is stainless steel, smooth, nonperforated,
and non-notched3
(Fig
3). The bar is bent to the curvature of the chest wall and is passed behind
the sternum through a perichondrial
bed. A small parasternal
opening is
made on each side, and a curved tonsil hemostat, with its tip pressed
against the posterior
aspect of the sternum, is passed to the opposite
side. The bar is grasped with this clamp and is pushed behind the
sternum, following
the path of the hemostat (Fig 4). The bent bar is
METHODS
Preoperatively,
no special studies were required,
although
we did
perform type and crossmatch
tests on these patients because blood loss
is greater in these cases than in primary cases. Patients were carefully
instructed
in deep breathing and coughing. A perioperative
antibiotic,
usually nafcillin, was given. We now prefer an epidural anesthetic.
Journal
and
Correction
No 9 (September),
1997: pp 1267-1271
From the Department
of Surges,
Cook Children i Medical Center.
Fort Worth, 7X.
Address reprint requests to Dr Dick Ellis. 1325 Pennsylvania
Ave,
Suite 670, Fort Worth, TX 76104.
Copyright
o 1997 by WB. Saunders Company
0022-3468/97/3209-0001$03.00/0
1267
ELLIS,
1268
Table
Patient
NO.
1. Clinical
Characteristics
Age at
k-Do lyrl
15’/2
16%
36
Deformity
1
2
M
F
Carinatum
Excavatum
30
3
F
M
Excavatum
Excavatum
3
5
M
Excavatum
M
F
M
Excavatum
Carinatum
Excavatum
5
8
F
Excavatum
M
M
Excavatum
Excavatum
M
M
Excavatum
Excavatum
M
M
Excavatum
Excavatum
M
M
Excavatum
Excavatum
4%
5
4
M
Excavatum
3%
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Length of
Follow-Up (yr)
4%
4%
Excellent
Good
Excellent
Good
1%
1
15%
1%
Excellent
Good
Good
15%
5%
14
1%
Excellent
9%
1
Excellent
Excellent
1
16
17
11%
4
Result
13%
1
6
15
23
4%
7
3
MANN
Excellent
13%
15%
11
20
AND
and Outcome
Age First
Surgery (vr)
Sex
SNYDER,
1
12
133/i
14%
2
11%
7%
14
1
7
Good
Good
‘/a
Excellent
Good
Fair
11
passed with its concavity
facing anteriorly
and is then rotated 180”. The
tips are placed in muscular pockets in the serratus anterior laterally with
the bar resting on a rib. The bar is held in position with #l PDS sutures
(Ethicon, Somerville,
NJ, Z69OG) and passed around the bar and the rib.
It may be possible to place three of these on each side, two around the
ribs medially and laterally, and the other immediately
adjacent to the
sternum catching the perichondrium
(Fig 5). The bar usually is passed
through the fourth perichondrial
bed. Once the bar is secured, additional
bending is possible if needed. An F15 Jackson-Pratt
drain (Baxter
Medivac;
McGraw
Park, IL) is placed beneath the upper musculocuta-
neous flap just superficial
to the sternum and intercostal
muscles. In
several cases when the pleura was entered, a small pleural tube was
placed on one or both sides and removed the next day.
Fig 1.
intercostal
Fig 2.
posterior
Division
of right
muscles.
5th. 6th. and 7th perichondrial
bundles
and
Complications
There was one postoperative
pneumothorax.
A wound infection
developed in two patients. One of these was localized and responded to
antibiotics.
The other manifested
itself several weeks postoperatively
and required substemal
bar removal. This same patient experienced
a
drug overdosage,
while on a patient controlled
analgesia
device,
associated
with an intravenous
infusion
infiltration.
One patient re-
Division
of the
table intact.
anterior
table
of the
sternum
leaving
the
‘RE-DO’
CHEST
WALL
DEFORMITY
Fig 3.
CORRECTION
Bars and bending
turned 12 years postoperatively
Ulcerative
colitis
developed
postoperatively.
1269
iron.
with a broken bar. which was removed.
in one teenage boy several
months
RESULTS
Ten of the 18 patients were considered to have an
excellent result based on the return of the sternum to a
normal. properly oriented, anterior position (Table 1).
Seven were judged to have a good result with minimal
loss of correction. One boy had been previously operated
on twice elsewhere and was judged to have a fair result.
He regained an excellent chest wall contour after placement of a SILASTIC@ (Dow Corning, Midland, MI)
implant. Nine of our 18 patients underwent transfusion,
although six of the last seven did not.
DISCUSSION
We agree with Robicek et al? that the postoperative
results of chest wall surgery cannot be measured objectively. They reported that 73 of their 608 patients ( 12%)
had an “unsatisfactory” result, and of these 73, they
reoperated on 42 (58%). Because there are no objective
measurements, series results cannot be compared. Each
Fig 4.
Bar behind
the elevated
sternum.
Fig 5.
ribs.
Bar secured
in place
behind
the sternum
and in front
of the
investigator describes the less than satisfactory results in
different terms. Recurrence rates reported are 2% by
Fonkalsrud? 10% by Gilbert et aL5 5% by Haller et al,6
16% by Peiia et al,’ 6% by Sanger et aLs 2.4% by
Shamberger,9 and 11.8% by Singh.‘O Sixty percent of the
patients who experienced recurrences in Gilbert’s5 series
were over 12 years of age. Jensen et al3 reported
“unsatisfactory” results in 5 of 57 patients (8X%),
Golladay et al I I reoperated on 7 of 177 patients (4%), and
Prevoti? also did reoperative surgery on 4% of his
patients. Willital and Meierr3 saw a recurrent deformity in
20.5% of their cases if no internal supporting bar was
used, but this decreased to 8.9% if the bar was used.
Moghissir4 had 37% “bad” results among 54 cases. In
1970, Haller et ali5 reported 17% poor results.
It seems that the incidence of recurrence is higher if the
patient has Marfan’s syndrome. We have operated on
eight patients who had Marfan’s syndrome and an
excavatum deformity without a recurrence, but an internal metal bar support was used in all. Am et ali6 reported
recurrence in 11 of 28 such patients (39%) and all of
these patients underwent operation at a “young” age and
without use of a bar for internal support. The reported
recurrence rate is lower with carinatum deformities
(Shamberger and Welch.” Robicek et al,‘* ie, in the 2% to
5% range.
Age at the time of operation may be a factor in
recurrence. Backer et ali9 found the results to be poorer in
patients undergoing operation at a later age. FonkalsrudJ
operated on his patients between ages 2 and 4, and
reported a recurrence rate of only 2%. Prevot” found the
ELLIS,
1270
results to be best in patients operated on between 3 and 6
years of age, and suggested that patients operated on
between ages 16 and 18 years suffered the most “deterioration.” Welch20 stated that the best results were in
patients undergoing operation between ages 2 and 5
years. Merge?’ recorded an increased recurrence rate if
the patient was younger than 6 years or between 9 and 12
years at the time of surgery. Humphreys and Jaretzki**
noted that the late results deteriorated through adolescence and were best if the patients underwent operation
before age 6 years. Rehbein and Wemickez3 stated that
the “late results do not always come up to expectations,”
and all of their postoperative photos show residual
deformities. We agree with Gilbert and Zwiren5 and
others that some loss of correction often occurs during the
adolescent growth spurt. Although they preferred to
operate at age 4 to 5 years, 60% of the recurrences seen
by Gilbert and Zwiren5 were in those patients over 12
years of age. Willital and Meier13 believe that most
recurrences are seen within the first 2 or 3 years. It is
interesting that Haller et alz4 recently advised against
operation in patients younger than 4 years of age. They
also advise against removal of five or more “ribs,”
otherwise, the patients may have retarded chest wall
growth and chest wall constriction.
We prefer to operate on pectus excavatum patients at
age 6 years if the deformity warrants surgery.25.26Excavaturn deformities do not initially have associated posterior
angulation of the medial ends of the ribs. However, with
time, these “secondary deformities” do develop and are
not correctable. In this situation, the sternum may be
returned to a normal position, but a parastemal depression may remain because of the posterior angulation of
SNYDER,
AND
MANN
the rib tips. Therefore, the surgeon must choose when to
operate earlier. Carinatum deformities are virtually all
operated on in the school-age period.
Both Humphreys and Jaretzkiz2 and Robicek et al2 felt
that the recurrence rate was related to a limited procedure
at the first operation. This was strikingly obvious in three
of our cases. We believe that all deformed cartilages and
their contralateral partners should be subperichondrially
removed, leaving a few millimeters of cartilage at the rib
and sternal ends. Possibly, this will allow improved chest
wall growth compared with removal of the entire length
of cartilage. The remaining perichondrium will regenerate bony tissue and will even do it after a secondary
procedure, although Mullard27 opposed any attempt at
reoperation because of his belief that there would be no
tissue that could regenerate after a secondary procedure.
The re-do procedure demands methodical removal of
enough regenerated cancellouslike bone to mobilize the
sternum. Sometimes the perichondrial bundles are still
rigid after considerable bone has been removed. Usually
this is on the lower right side and we do not hesitate to
divide these bundles. Although on virgin cases we avoid
the retrostemal area, we will invade this area to properly
mobilize the sternum. One, or even two, anterior table
osteotomies may be used. A substemal bar, or even two,
is a must. Our patients have toIerated this more extensive
surgery very well. The results have been very pleasing.
Patients who have recurrent deformities should undergo a
“re-do” operation.
ACKNOWLEDGMENT
Appreciation
is expressed
to Judy Moore
for secretarial
assistance.
REFERENCES
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‘RE-DO’
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