Minimally Invasive Sternal Lowering Operation for the Correction of Pectus Carinatum_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

XIAO Haibo , ZHANG Fuxian , DING Fangbao , XIE Xiao , HU Fengqing , MEI Ju.

Department of Cardiothoracic Surgery，Xinhua Hospital，School of Medicine，Shanghai Jiao Tong University，Shanghai 200092，P. R. China;

Corresponding author：

Keywords：

Pectus carinatum; 　Minimally invasive; 　Sternal lowering operation

DOI：

10.7507/1007-4848.20130173

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Objective To investigate surgical indications，techniques，safety and clinical outcomes of minimallyinvasive sternal lowering operation for the treatment of pectus carinatum （PC）. Methods Clinical data of 40 PC patientswho underwent minimal invasive sternal lowering operation in Xinhua Hospital，School of Medicine，Shanghai Jiao Tong University from July 2009 to August 2012 were retrospectively analyzed. There were 39 male patients and 1 female patientwith their average age of 14.5 （12-22）years. All the patients underwent their surgical correction for the first time，and their chest deformity were characterized by a significant protrusion of the sternum and ribs including 21 symmetric and 19 asymmetric protrusions. Preoperative evaluation included electrocardiogram，CT scan of the chest，echocardiogram and pulmonary function test. Preoperative mean Haller index was 1.91±0.23. Sixteen patients had mild restrictive ventilatory disorder. Allthe patients received minimally invasive sternal lowering operation with a curved Nuss steel bar. Aggravating activities wererestricted within 3 months postoperatively，and the steel bar was removed 2 years later. Results All the operations were completed successfully，and thoracic appearance was significantly improved after correction. All the patients and their relativeswere very satisfied with the corrective outcomes. The operation time was 65-115 （82.0±15.6）minutes and average intraop-erative blood loss was less than 10 ml. Postoperative hospital stay was 3-5 （3.5±0.8） days. Postoperative Haller index was2.39±0.17，which was significantly higher than preoperative Haller index （P＜0.01） . Postoperative complications included wound infection in 2 patients，pneumothorax in 1 patient （cured by closed thoracostomy），subcutaneous effusion in 3 patients，and persistent pain （longer than 14 days） in 2 patients. There was no other serious postoperative complication. All the 40 patients were followed up for 3-36 months after discharge. A steel bars was removed ahead of schedule because of wound infection in one patient. Other steel bars were in normal position in 39 patients and there was no displacement of the steel bars or the stabilizers. Eight patients received removal of the steel bars without PC recurrence. Conclusion Juveniles with PC who have good chest wall compliance are the best candidates for minimally invasive sternal lowering operation which is an easy，safe，reliable，minimally invasive and esthetic procedure with satisfactory corrective outcomes.

Citation： XIAO Haibo,ZHANG Fuxian,DING Fangbao,XIE Xiao,HU Fengqing,MEI Ju.. Minimally Invasive Sternal Lowering Operation for the Correction of Pectus Carinatum. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2013, 20(5): 555-559. doi: 10.7507/1007-4848.20130173 Copy

1.	Fokin AA， Steuerwald NM， Ahrens WA， et al. Anatomical， histologic， and genetic characteristics of congenital chest wall deformities. Semin Thorac Cardiovasc Surg， 2009， 21 （1）：44-57.
2.	Williams AM， Crabbe DC. Pectus deformities of the anterior chest wall. Paediatr Respir Rev， 2003， 4 （3）：237-242.
3.	Mavanur A， Hight DW. Pectus excavatum and carinatum：new conceptsin the correction of congenital chest wall deformities in the pediatric age group. Conn Med， 2008， 72 （1）：5-11.
4.	Fonkalsrud EW. Surgical correction of pectus carinatum：lessons learned from 260 patients. J Pediatr Surg， 2008， 43 （7）：1235-1243.
5.	Del Frari B， Schwabegger AH. Ten-year experience with the muscle split technique， bioabsorbable plates， and postoperative bracing for correction of pectus carinatum：the Innsbruck protocol. J Thorac Cardiovasc Surg， 2011， 141 （6）：1403-1409.
6.	Nuss D， Kelly RE， Croitoru DP， et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg， 1998， 33 （4）：545-552.
7.	Goretsky MJ， Kelly RJ， Croitoru D， et al. Chest wall anomalies：pectus excavatum and pectus carinatum. Adolesc Med Clin， 2004， 15 （3）：455-471.
8.	Fokin AA. Pouter pigeon breast. Chest Surg Clin N Am， 2000， 10 （2）：377-391.
9.	Obermeyer RJ， Goretsky MJ. Chest wall deformities in pediatric surgery. Surg Clin North Am， 2012， 92 （3）：669-684.
10.	Groves S， Roberts C， Johnstone C， et al. A high status burial from ripon cathedral， North Yorkshire， England：differential diagnosis of a chest deformity. Int J Osteoarchaeol， 2003， 13 （6）：358-368.
11.	Coelho MS， Guimarães PS. Pectus carinatum. J Bras Pneumol， 2007， 33 （4）：463-474.
12.	Robicsek F， Watts LT. Pectus Carinatum. Thorac Surg Clin， 2010， 20 （4）：563-574.
13.	Coskun ZK， Turgut HB， Demirsoy S， et al. The prevalence and effects of pectus excavatum and pectus carinatum on the respiratory function in children between 7-14 years old. Indian J Pediatr， 2010， 77 （9）：1017-1019.
14.	Steinmann C， Krille S， Mueller A， et al. Pectus excavatum andpectus carinatum patients suffer from lower quality of life and impairedbody image：a control group comparison of psychological characteristicsprior to surgical correction. Eur J Cardiothorac Surg， 2011， 40 （5）：1138-1145.
15.	Moreno C， Delgado MD， Martí E， et al. Conservative treatment of the pectus carinatum. Cir Pediatr， 2011， 24 （2）：71-74.
16.	Brichon PY， Wihlm JM. Correction of a severe pouter pigeon breast by triple sternal osteotomy with a novel Titanium rib bridge fixation. Ann Thorac Surg， 2010， 90 （6）：97-99.
17.	Schaarschmidt K， Lempe-Sellin M， Schlesinger F， et al. New Berlin-Buch “reversed Nuss” endoscopic pectus carinatum repair using eight-hole stabilizers， submuscular CO2， and presternal Nuss bar compression：first results in 35 patients. J Laparoendosc Adv Surg Tech A， 2011， 21 （3）：283-286.
18.	Yüksel M， Bostanci K， Evman S. Minimally invasive repair of pectus carinatum using a newly designed bar and stabilizer：a single-institution experience. Eur J Cardiothorac Surg， 2011， 40 （2）：339-342.
19.	Robicsek F， Watts LT， Fokin AA. Surgical repair of pectus excavatum and carinatum. Semin Thorac Cardiovasc Surg， 2009， 21 （1）：64-75.
20.	Abramson H， D'agostino J， Wuscovi S. A 5-year experience with a minimally invasive technique for pectus carinatum repair. J Pediatr Surg， 2009， 44 （1）：118-123.
21.	Kálmán A. Initial results with minimally invasive repair of pectus carinatum. J Thorac Cardiovasc Surg， 2009， 138 （2）：434-438.
22.	Hock A. Minimal access treatment of pectus carinatum：a preliminary report. Pediatr Surg Int， 2009， 25 （4）：337-342.
23.	Bell R， Idowu O， Kim S. Minimally invasive repair of symmetricpectus carinatum：bilateral thoracoscopic chondrotomies and supras-ternal compression bar placement. J Laparoendosc Adv Surg Tech A， 2012， 22 （9）：921-924.
24.	鲁亚南，刘锦纷，徐志伟，等. 改良Nuss手术纠治小儿漏斗胸. 中国胸心血管外科临床杂志， 2007， 14 （2）：93-96.
25.	刘平波，高纪平，马乐龙，等. 倒T形内固定术在漏斗胸矫治中的应用. 中国胸心血管外科临床杂志， 2006， 13 （4）：288.
26.	Robicsek F. The Nuss operation for pectus carinatum. Eur JCardiothorac Surg， 2013， 43 （1）：127.

1. 　Fokin AA， Steuerwald NM， Ahrens WA， et al. Anatomical， histologic， and genetic characteristics of congenital chest wall deformities. Semin Thorac Cardiovasc Surg， 2009， 21 （1）：44-57.
2. 　Williams AM， Crabbe DC. Pectus deformities of the anterior chest wall. Paediatr Respir Rev， 2003， 4 （3）：237-242.
3. 　Mavanur A， Hight DW. Pectus excavatum and carinatum：new conceptsin the correction of congenital chest wall deformities in the pediatric age group. Conn Med， 2008， 72 （1）：5-11.
4. 　Fonkalsrud EW. Surgical correction of pectus carinatum：lessons learned from 260 patients. J Pediatr Surg， 2008， 43 （7）：1235-1243.
5. 　Del Frari B， Schwabegger AH. Ten-year experience with the muscle split technique， bioabsorbable plates， and postoperative bracing for correction of pectus carinatum：the Innsbruck protocol. J Thorac Cardiovasc Surg， 2011， 141 （6）：1403-1409.
6. 　Nuss D， Kelly RE， Croitoru DP， et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg， 1998， 33 （4）：545-552.
7. 　Goretsky MJ， Kelly RJ， Croitoru D， et al. Chest wall anomalies：pectus excavatum and pectus carinatum. Adolesc Med Clin， 2004， 15 （3）：455-471.
8. 　Fokin AA. Pouter pigeon breast. Chest Surg Clin N Am， 2000， 10 （2）：377-391.
9. 　Obermeyer RJ， Goretsky MJ. Chest wall deformities in pediatric surgery. Surg Clin North Am， 2012， 92 （3）：669-684.
10. 　Groves S， Roberts C， Johnstone C， et al. A high status burial from ripon cathedral， North Yorkshire， England：differential diagnosis of a chest deformity. Int J Osteoarchaeol， 2003， 13 （6）：358-368.
11. 　Coelho MS， Guimarães PS. Pectus carinatum. J Bras Pneumol， 2007， 33 （4）：463-474.
12. 　Robicsek F， Watts LT. Pectus Carinatum. Thorac Surg Clin， 2010， 20 （4）：563-574.
13. 　Coskun ZK， Turgut HB， Demirsoy S， et al. The prevalence and effects of pectus excavatum and pectus carinatum on the respiratory function in children between 7-14 years old. Indian J Pediatr， 2010， 77 （9）：1017-1019.
14. 　Steinmann C， Krille S， Mueller A， et al. Pectus excavatum andpectus carinatum patients suffer from lower quality of life and impairedbody image：a control group comparison of psychological characteristicsprior to surgical correction. Eur J Cardiothorac Surg， 2011， 40 （5）：1138-1145.
15. 　Moreno C， Delgado MD， Martí E， et al. Conservative treatment of the pectus carinatum. Cir Pediatr， 2011， 24 （2）：71-74.
16. 　Brichon PY， Wihlm JM. Correction of a severe pouter pigeon breast by triple sternal osteotomy with a novel Titanium rib bridge fixation. Ann Thorac Surg， 2010， 90 （6）：97-99.
17. 　Schaarschmidt K， Lempe-Sellin M， Schlesinger F， et al. New Berlin-Buch “reversed Nuss” endoscopic pectus carinatum repair using eight-hole stabilizers， submuscular CO2， and presternal Nuss bar compression：first results in 35 patients. J Laparoendosc Adv Surg Tech A， 2011， 21 （3）：283-286.
18. 　Yüksel M， Bostanci K， Evman S. Minimally invasive repair of pectus carinatum using a newly designed bar and stabilizer：a single-institution experience. Eur J Cardiothorac Surg， 2011， 40 （2）：339-342.
19. 　Robicsek F， Watts LT， Fokin AA. Surgical repair of pectus excavatum and carinatum. Semin Thorac Cardiovasc Surg， 2009， 21 （1）：64-75.
20. 　Abramson H， D'agostino J， Wuscovi S. A 5-year experience with a minimally invasive technique for pectus carinatum repair. J Pediatr Surg， 2009， 44 （1）：118-123.
21. 　Kálmán A. Initial results with minimally invasive repair of pectus carinatum. J Thorac Cardiovasc Surg， 2009， 138 （2）：434-438.
22. 　Hock A. Minimal access treatment of pectus carinatum：a preliminary report. Pediatr Surg Int， 2009， 25 （4）：337-342.
23. 　Bell R， Idowu O， Kim S. Minimally invasive repair of symmetricpectus carinatum：bilateral thoracoscopic chondrotomies and supras-ternal compression bar placement. J Laparoendosc Adv Surg Tech A， 2012， 22 （9）：921-924.
24. 　鲁亚南，刘锦纷，徐志伟，等. 改良Nuss手术纠治小儿漏斗胸. 中国胸心血管外科临床杂志， 2007， 14 （2）：93-96.
25. 　刘平波，高纪平，马乐龙，等. 倒T形内固定术在漏斗胸矫治中的应用. 中国胸心血管外科临床杂志， 2006， 13 （4）：288.
26. 　Robicsek F. The Nuss operation for pectus carinatum. Eur JCardiothorac Surg， 2013， 43 （1）：127.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Minimally Invasive Sternal Lowering Operation for the Correction of Pectus Carinatum

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