All Title Author
Keywords Abstract


Advances in the management of pectus deformities in children

DOI: 10.4236/ojped.2013.33038, PP. 211-223

Keywords: Chest Wall Deformity, Pectus Excavatum, Pectus Carinatum, Chest Wall Repair

Full-Text   Cite this paper   Add to My Lib

Abstract:

Pectus excavatum (PE) and pectus carinatum (PC) are relatively common deformities involving the anterior chest wall, occurring in 1:1000 and 1:1500 live births, respectively. While the etiology remains an enigma, the association of pectus deformities with other skeletal abnormalities suggests that connective tissue disease may play a role in their pathogenesis. Clinical features of these deformities vary with severity, as determined by the Haller index and Backer ratio, but frequently include cardiac and respiratory abnormalities. Importantly, there exist profound psychosocial implications for children afflicted with these defofrmities, including but not limited to feelings of embarrassment and maladaptive social behaviors. These debilitating characteristics have prompted the development of novel medical and surgical corrective techniques. The correction of pectus deformities reduces the incidence of physiological complications secondary to chest wall malformation, while simultaneously improving body image and psychosocial development in the affected pediatric population. The Ravitch (open) and Nuss (minimally invasive) procedures remain the most frequently employed methods of pectus deformity repair, with no difference in overall complication rates, though individual complication rates vary with treatment. The Nuss procedure is associated with a higher rate of recurrence due to bar migration, hemothorax, and pneumothorax. Postoperative pain management is markedly more difficult in patients who have undergone Nuss repair. Patients undergoing the Ravitch procedure require less postoperative analgesia, but have longer operation times and a larger surgical scar. The cosmetic

results of the Nuss procedure and its minimally invasive nature make it preferable to the Ravitch repair. Newer treatment modalities, including the vacuum bell, magnetic mini-mover procedure (3MP), and dynamic compression bracing (DCB) appear promising, and may ultimately provide effective methods of noninvasive repair. However, these modalities suffer from a lack of extensive published evidence, and the limited number of studies currently published fail to adequately define their long-term effectiveness.

References

[1]  Chung, C.S. and Myrianthopoulos, N.C. (1975) Factors affecting risks of congenital malformations. I. Analysis of epidemiologic factors in congenital malformations. Report from the collaborative perinatal project. Birth Defects Original Article Series, 11, 1-22.
[2]  Blanco, F., Elliott, S. ad Sandler, A. (2011) Management of congenital chest wall deformities. Seminars in Plastic Surgery, 25, 107-116. doi:10.1055/s-0031-1275177
[3]  Coran, A.G., Adzick, N.S., Krummel, T.M., Laberge, J.M., Shamberger, R.C. and Caldamone, A.A. (2012) Pediatric Surgery. 7th Edition, Elsevier Saunders, Amsterdam, 779-796.
[4]  Fonkalsrud, E.W. (2003) Current management of pectus excavatum. World Journal of Surgery, 27, 502-508. doi:10.1007/s00268-003-7025-5
[5]  Kotzot, D. and Schwabegger, A.H. (2009) Etiology of chest wall deformities—A genetic review for the treating physician. Journal of Pediatric Surgery, 44, 2004-2011. doi:10.1016/j.jpedsurg.2009.07.029
[6]  Romano, A.A., Allanson, J.E., Dahlgren, J., Gelb, B.D., Hall, B., Pierpont, M.E., et al. (2010) Noonan syndrome: Clinical features, diagnosis, and management guidelines. Pediatrics, 126, 746-759. doi:10.1542/peds.2009-3207
[7]  Creswick, H.A., Stacey, M.W., Kelly Jr., R.E., Gustin, T., Nuss, D., Harvey, H., et al. (2006) Family study of the inheritance of pectus excavatum. Journal of Pediatric Surgery, 41, 1699-1703. doi:10.1016/j.jpedsurg.2006.05.071
[8]  Chu, Z., Yu, J., Yang, Z., Peng, L., Bai, H. and Li, X. (2010) Correlation between sternal depression and cardiac rotation in pectus excavatum: Evaluation with helical CT. American Journal of Roentgenology, 195, W76-W80. doi:10.2214/AJR.09.3199
[9]  Chin, E.F. (1957) Surgery of funnel chest and congenital sternal prominence. The British Journal of Surgery, 44, 360-376. doi:10.1002/bjs.18004418607
[10]  Iida, H. (2010) Surgical repair of pectus excavatum. General Thoracic and Cardiovascular Surgery, 58, 55-61. doi:10.1007/s11748-009-0521-2
[11]  Morshuis, W., Folgering, H., Barentsz, J., van Lier, H. and Lacquet, L. (1994) Pulmonary function before surgery for pectus excavatum and at long-term follow-up. Chest, 105, 1646-1652. doi:10.1378/chest.105.6.1646
[12]  Jaroszewski, D., Notrica, D., McMahon, L., Steidley, D.E. and Deschamps, C. (2010) Current management of pectus excavatum: A review and update of therapy and treatment recommendations. Journal of the American Board of Family Medicine, 23, 230-239. doi:10.3122/jabfm.2010.02.090234
[13]  Saint-Mezard, G., Chanudet, X., Duret, J.C., Larrue, J., Bonnet, J. and Bricaud, H. (1986) Mitral valve prolapse and pectus excavatum: Expressions of connective tissue dystrophy? Archives des Maladies du Coeuret des Vaisseaux, 79, 431-434.
[14]  Shamberger, R.C. (1998) Congenital chest wall deformities. In: O’Neill, J., Rowe, M.I. and Grosfeld, J.L., Eds., Pediatric Surgery, 5th Edition, Mosby, St. Louis, 787.
[15]  Martinez-Ferro, M., Fraire, C. and Bernard, S. (2008) Dynamic compression system for the correction of pectus carinatum. Seminars in Pediatric Surgery, 17, 194-200. doi:10.1053/j.sempe dsurg.2008.03.008
[16]  Nuchtern, J.G. and Mayer, O.H. (2012) Pectus carinatum. In: Redding, G., Ed., UpToDate, UpToDate, Waltham.
[17]  Brigato, R.R., Campos, J.R.M., Jatene, F.B., Moreira, L.F.P. and Rebeis, E.B. (2008) Pectus excavatum: Evaluation of Nuss technique by objective methods. Interactive Cardiovascular and Thoracic Surgery, 7, 1084-1088. doi:10.1510/icvts.2008.184580
[18]  Haller, J.A., Kramer, S.S. and Lietman, S.A. (1987) Use of CT scans in selection of patients for pectus excavatum surgery: A preliminary report. Journal of Pediatric Surgery, 22, 904-906. doi:10.1016/S0022-3468(87)80585-7
[19]  Schwabegger, A.H. (2011) Congenital thoracic wall deformities: Diagnosis, therapy and current developments. Springer-Verlag/Wien, New York, 79-80. doi:10.1007/978-3-211-99138-1
[20]  Ji, Y., Wenying, L., Chen, S., Xu, B., Tang, Y., Wang, X., Yang, G. and Cao, L. (2011) Assessment of psychosocial functioning and its risk factors in children with pectus excavatum. Health and Quality of Life Outcomes, 9, 1-8. doi:10.1186/1477-7525-9-28
[21]  Kelly, R.E. (2008) Pectus excavatum: Historical background, clinical picture, preoperative evaluation and criteria for operation. Seminars in Pediatric Surgery, 17, 181-193. doi:10.1053/j.semped surg.2008.03.002
[22]  Kelly Jr., R.E., Cash, T.F., Shamberger, R.C., Mitchell, K.K., Mellins, R.B., Lawson, M.L., et al. (2008) Surgical repair of pectus excavatum markedly improves body image and perceived ability for physical activity: Multicenter study. Pediatrics, 122, 1218-1222. doi:10.1542/peds.2007-2723
[23]  Lam, M.W., Klassen, A.F., Montgomery, C.J., LeBlanc, J.G. and Skarsgard, E.D. (2008) Quality-of-life outcomes after surgical correction of pectus excavatum: A comparison of the Ravitch and Nuss procedures. Journal of Pediatric Surgery, 43, 819-825. doi:10.1016/j.jpedsurg.2007.12.020
[24]  Krasopoulos, G., Dusmet, M., Ladas, G. and Goldstraw, P. (2006) Nuss procedure improves the quality of life in young male adults with pectus excavatum deformity. European Journal Cardio-Thoracic Surgery, 29, 1-5. doi:10.1016/j.ejcts.2005.09.018
[25]  Steinmann, C., Krille, S., Mueller, A., Weber, P., Reingruber, B. and Martin, A. (2011) Pectus excavatum and pectus carinatum patients suffer from lower quality of life and impaired body image: A control group comparison of psychological characteristics prior to surgical correction. European Journal of Cardiothoracic Surgery, 40, 1138-1145.
[26]  Ebstein, W. (1882) Ueber die trichterbrust. Deutsches Architektur, 30, 411.
[27]  Meade, R.H. (1961) A history of thoracic surgery. Thomas, Springfield.
[28]  Sauerbruch, F. (1920) Die chirurgie der brustorgane. Springer, Berlin.
[29]  Goretsky, M.J., Kelly Jr., R.E., Croitoru, D. and Nuss, D. (2004) Chest wall anomalies: Pectus excavatum and pectus carinatum. Adolescent Medicine, 15, 455-471. doi:10.1016/j.admec li.2004.06.002
[30]  Sauerbruch, F. (1931) Operative beseitigung der angeborenentrichterbrust. Deutsche Zeitschrift furChirurgie, 234, 760. doi:10.1007/BF02797645
[31]  Brown, A.L. and Cook, O. (1951) Funnel chest (pectus excavatum) in infancy and adult life. California Medicine, 74, 174-178.
[32]  Krueger, T., Chassot, P.G., Christodoulou, M., Cheng, C., Ris, H.B. and Magnusson L. (2010) Cardiac function assessed by transesophageal echocardiography during pectus excavatum repair. Annals of Thoracic Surgery, 89, 240-244. doi:10.1016/j.athoracsur.2009.06.126
[33]  Nasr, A., Fecteau, A. and Wales, P.W. (2010) Comparison of the Nuss and Ravitch procedure for pectus excavatum repair: A meta-analysis. Journal of Pediatric Surgery, 45, 880-886. doi:10.1016/j.jpedsurg.2010.02.012
[34]  Ravitch, M.M. (1949) The operative treatment of pectus excavatum. Annals of Surgery, 129, 429-444. doi:10.1097/00000658-194904000-00002
[35]  Luu, T.D., Kogon, B.E., Force, S.D., Mansour, K.A. and Miller, D.L. (2009) Surgery for recurrent pectus deformities. The Annals of Thoracic Surgery, 88, 1627-1631. doi:10.1016/j.athoracsur.2009.06.008
[36]  Colombani, P.M. (2003) Recurrent chest wall anomalies. Seminars in Pediatric Surgery, 12, 94-99. doi:10.1016/S1055-8586(02)00018-5
[37]  Boehm, R.A., Muensterer, O.J. and Till, H. (2004) Comparing minimally invasive funnel chest repair versus the conventional technique: An outcome analysis in children. Plastic and Reconstructive Surgery, 114, 668-673. doi:10.1097/01.PRS.0000130938.87402.B0
[38]  Fonkalsrud, E.W., Dunn, J.C.Y. and Atkinson, J.B. (2000) Repair of pectus excavatum deformities: 30 years of experience with 375 patients. Annals of Surgery, 231, 443-448. doi:10.1097/00000658-200003000-00019
[39]  Chen, C.H., Liu, H.C., Hung, T.T. and Chen, C.H. (2010) Restrictive chest wall deformity as a complication of surgical repair for pectus excavatum. The Annals of Thoracic Surgery, 89, 599-601. doi:10.1016/j.athoracsur.2009.06.091
[40]  Haje, S.A. and Bowen, J.R. (1992) Preliminary results of orthotic treatment of pectus deformities in children and adolescents. Journal of Pediatric Orthopedics, 12, 795-800. doi:10.1097/01241398-199211000-00018
[41]  Kim, D.H., Hwang, J.J., Lee, M.K., Lee, D.Y. and Paik, H.C. (2005) Analysis of the Nuss procedure for excavatum in different age groups. The Annals of Thoracic Surgery, 80, 1073-1077. doi:10.1016/j.athoracsur.2005.03.070
[42]  Nuss, D., Kelly Jr., R.E., Croitoru, D.P. and Katz, M.E. (1998) A 10-year review of a minimally invasive technique for the correction of pectus excavatum. Journal of Pediatrics, 33, 545-552.
[43]  Nuss, D., Kelly Jr., R.E., Croitoru, D.P. and Swoveland, B. (1998) Repair of pectus excavatum. Pediatric Endosurgery and Innovative Techniques, 2, 205-221. doi:10.1089/pei.1998.2.205
[44]  Haecker, F.-M. and Mayr, J. (2006) The vacuum bell for treatment of pectus excavatum: An alternative to surgical correction? European Journal of Cardiothoracic Surgery, 29, 557-561. doi:10.1016/j.ejcts.2006.01.025
[45]  Fonkalsrud, E.W., Beanes, S., Hebra, A., Adamson, W. and Tagge E. (2002) Comparison of minimally invasive and modified Ravitch pectus excavatum repair. Journal of Pediatric Surgery, 37, 413-417. doi:10.1053/jpsu.2002.30852
[46]  Antonoff, M.B., Erickson, A.E., Hess, D.J., Acton, R.D. and Saltzman, D.A. (2009) When patients choose: Comparison of Nuss, Ravitch, and Leonard procedures for primary repair of pectus excavatum. Journal of Pediatric Surgery, 44, 1113-1118. doi:10.1016/j.jpedsurg.2009.02.017
[47]  Castellani, C., Windhaber, J., Schober, P.H. and Hoellworth M.E. (2010) Exercise performance testing in patients with pectus excavatum before and after Nuss procedure. Pediatric Surgery International, 26, 659-663. doi:10.1007/s00383-010-2627-0
[48]  Ohno, K., Nakamura, T., Azume, T., Yamada, H., Hayashi, H. and Masahata, K. (2009) Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation. Journal of Pediatric Surgery, 44, 2426-2430. doi:10.1016/j.jpedsurg.2009.09.006
[49]  Nagasao, T., Noguchi, M., Miyamoto, J., Jiang, H., Ding, W., Shimizu, Y., et al. (2010) Dynamic effects of the Nuss procedure on the spine in asymmetric pectus excavatum. The Journal of Thoracic and Cardiovascular Surgery, 140, 1294-1299. doi:10.1016/j.jtcvs.2010.06.025
[50]  Kelly Jr., R.E., Shamberger, R.C. and Mellins, R.B. (2007) Prospective multicenter study of surgical correction of pectus excavatum: Design, perioperative complications, pain, and baseline pulmonary function facilitated by internet-based data collection. Journal of the American College of Surgeons, 205, 205-216. doi:10.1016/j.jamcollsurg.2007.03.027
[51]  Harrison, M.R., Gonzales, K.D., Bratton, B.J., Christensen D., Curran, P.F., Fechter, R. and Hirose, S. (2012) Magnetic mini-mover procedure for pectus excavatum III: Safety and efficacy in a food and drug administrationsponsored clinical trial. Journal of Pediatric Surgery, 47, 154-159. doi:10.1016/j.jpedsurg.2011.10.039
[52]  Haller Jr., J.A., Scherer, L.R., Turner, C.S. and Colombani P.M. (1989) Evolving management of pectus excavatum based on a single institutional experience of 664 patients. Annals of Surgery, 209, 578-582. doi:10.1097/00000658-198905000-00010
[53]  Kelly Jr., R.E., Goretsky, M.J., Obermeyer, R., Kuhn, M.A., Redlinger, R., Haney, T.S., Moskowitz, A. and Nuss, D. (2010) Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Annals of Surgery, 252, 1072-1081. doi:10.1097/SLA.0b013e3181effdce
[54]  Inge, T.H., Owings, E., Blewett, C.J., Baldwin, C.E., Cain, W.S., Hardin, W. and Georgeson, K.E. (2003) Reduced hospitalization cost for patients with pectus excavatum treated using minimally invasive surgery. Surgical Endoscopy, 17, 1609-1613. doi:10.1007/s00464-002-8767-0
[55]  Wang, L.S., Kuo, K.T. and Wang, H.W. (2005) A novel surgical correction through a small transverse incision for pectus excavatum. Annals of Thoracic Surgery, 80, 1951-1954. doi:10.1016/j.athoracsur.2004.05.029
[56]  Nuss, D. and Kelly Jr., R.E. (2010) Indications and technique of Nuss procedure for pectus excavatum. Thoracic Surgery Clinics, 20, 583-597. doi:10.1016/j.thorsurg.2010.07.002
[57]  Mansour, K.A., Thourani, V.H., Odessey, E.A., Durham, M.M., Miller Jr., J.I. and Miller, D.L. (2003) Thirty-year experience with repair of pectus deformities in adults. Annals of Thoracic Surgery, 76, 391-395. doi:10.1016/S0003-4975(03)00441-7
[58]  Hellwig and Ansgar, (2012) Pectus1.jpg. Digital image. Wikimedia Commons, Wikimedia Foundation. http://commons.wikimedia.org/wiki/File:Pectus1.jpg
[59]  Jprealini (2012) Pectus carinatum Mmf.JPG. Digital image. Wikimedia Commons, Wikimedia Foundation. http://commons.wikimedia.org/wiki/File:Pectus_carinatum_mmf.JPG

Full-Text

comments powered by Disqus