Child pectus excavatum: correction by minimally invasive surgery.
BACKGROUND
Pectus excavatum (PE) is a congenital deformity essentially responsible for an unattractive aspect, much more rarely for compression problems. The classical treatments consist either in filling the excavation or in open thoracic reconstruction (the Ravitch technique). Alternatively, the treatment described by Nuss raises the sternum with a retrosternal metallic bar placed under thoracoscopic guidance. We present the preliminary results of a series of 25 children operated on using this technique.


OBJECTIVE
The minimally invasive procedure described by Nuss is a valid surgical strategy to treat PE.


METHODS
Twenty-five patients were operated on between February 2004 and April 2007 by the same surgeon. Nineteen of these patients presented a purely cosmetic indication. The six other patients were considered to have a more severe form of PE, with cardiorespiratory repercussions. In this group, there were two cases of Marfan syndrome and two patients presenting a history of previous cardiothoracic surgery. The technique has always consisted in placing a retrosternal bar through two lateral incisions. The surgery was always performed with right lung exclusion and was guided by thoracoscopy in 21 cases. In four particularly severe cases, a subxiphoid approach was required, making endoscopic guidance unnecessary. The severity of the lesion was evaluated by the Haller Index. All the patients had regular clinical follow-up (at three weeks, three months, and then every six months); assessment of pain, satisfaction with the cosmetic results, and perceived improvement in respiratory function were the criteria used for this follow-up.


RESULTS
The cosmetic result was judged to be positive by 24 patients. One patient was dissatisfied (because of the asymmetrical shape resulting from the use of a single implant). Five patients presented minor complications with no repercussions on the cosmetic or functional result. One case of secondary bar displacement required revision on day 15. Following this revision evolution was uncomplicated (discharge on day 7 and activities resumed at three weeks). Finally, the hardware was removed at a delay after implantation ranging from one to two years. As of today, 13 patients have had their hardware removed with no complications or loss of the initial result.


CONCLUSIONS
The original indication of the Nuss technique remains symmetrical PE in seven to 14-year-old children. The insubstantial scarring makes the technique valuable in the purely cosmetic forms of the condition. Based on this series, our technique has evolved toward certain adjustments depending on the severity and the etiology of the lesion. The most reported complication in the literature is secondary displacement of the bars. This problem is easily controlled by attaching the bar to a rib. Over the years, we have modified the implant design so as to improve its tolerance and stability. In asymmetrical forms of PE, implanting two bars has provided better efficacy. When a major form is present or when there is a history of cardiorespiratory problems, we recommend a short subxiphoid incision to release the pleural and pericardial adherences, precluding the need for thoracoscopic guidance. With these simple adjustments, this technique gains in reliability for cosmetic indications and its use can be extended to specific forms such as collagenosis or postoperative deformities.


METHODS
Level IV. Therapeutic Study.
Felts
E
E
Department of Pediatric Orthopaedic Surgery, Children Timone Hospital, rue Saint-Pierre, boulevard Jean-Moulin, Marseille, cedex 513385 France.
Jouve
J-L
JL
Blondel
B
B
Launay
F
F
Lacroix
F
F
Bollini
G
G
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004954:Esthetics; D005260:Female; D005500:Follow-Up Studies; D005660:Funnel Chest / Q000000981:diagnostic imaging* / Q000601:surgery*; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D009984:Orthopedic Fixation Devices; D011183:Postoperative Complications / Q000175:diagnosis; D013902:Radiography, Thoracic; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013249:Sternum / Q000000981:diagnostic imaging / Q000601:surgery; D013906:Thoracoscopy / Q000009:adverse effects / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome