Open repair of pectus deformity in the era of minimally invasive repair

Pectus excavatum and carinatum are the most common chest wall deformities with wide spectrum of severity and morphologic diversity. Bostanci et al. described details of traditional open technique and its modifications including removal of costal cartilages, osteotomy and fixation materials, which is a good review for open technique and very informative. Minimally invasive repair (MIR) of chest wall deformities have been popular since Nuss et al. have introduced his innovative technique (1). The most important benefit of MIR is cosmetic aspect from small incisions. Moreover, MIR had better operative related outcomes; shorter operative time and less intraoperative blood loss compared to open technique (2). Recently, MIR with evolving additional refinement resulted in satisfactory outcomes with improved safety and complete correction of deformities. Minimally invasive method with technical modification including new devices; video-scope guidance; claw fixator; bridge device; crane technique, and other technical advancements including flare-buster and sandwich technique have been introduced (3-5). Simulating method was also introduced and could guide to localize bar insertion level and length of elevation in less experienced hands (6). In addition, several conservative treatment such as bracing device and vacuum bell device have been used for chest wall deformities with favorable outcomes (7,8).

Early correction may reduce psychological impairment and prevent undergrowth in young children (9-12). However, traditional open repair in children has a potential to induce acquired asphyxiating thoracic dystrophy (AATD), also known as acquired Jeune’s syndrome, the most troublesome late complication of traditional open repair. Younger age and excessive rib resection were the risk factors of AATD in the initial case series of Ravitch et al. (13). Suppression of cartilage growth leads to restrictive pulmonary function and impaired growth (14). Some studies with regard to treatment for AATD have been reported (15,16). However, experience had been limited and technical difficulty arising from extensive calcification and dense adhesion between sternum and vital organs was noted as well. Furthermore, true incidence of AATS has not been reported because most patients are not diagnosed if they had no symptoms. On the other hand, theoretically, MIR technique can minimize the development of AATD in the patients who are pre-school aged.

Despite of several advantages of MIR, data supported that MIR had more bar rotation and higher reoperation rate in the adult patient due to the stiffness and rigidity of the chest wall (17). Although there are some manageable complications including pneumothorax, seroma, etc., devastating disasters such as cardiac perforation, massive bleeding, and malignant arrhythmias have been reported occasionally. Catastrophic cardiac injuries, which might be under-reported, can occur during the insertion or removal of the pectus bar. Frequently, it led to mortality and severe neurologic sequelae (18). Prior cardiac surgery or severe pectus excavatum are highly associated with development of catastrophic complication intra- and postoperatively. Thoracoscopic guidance with lifting the sternum was used to prevent such events during the procedure. Notably, symmetric pectus excavatum can be easily corrected with MIR, but if the chest wall is stiff like an adult patient the MIR alone may be difficult to perform a complete correction particularly in asymmetric type or complex deformity like as pectus arcuatum. In such cases, open repair technique including chondrotomy, osteotomy and various fixation methods can facilitate to obtain successful correction (19). Even, in cases of recurrent pectus excavatum after failed open repair or previous cardiac surgery, MIR achieved satisfactory outcomes with simple combination of open repair (16,20,21). Obviously, the terms, Hybrid Nuss or Modified Ravitch technique, imply the benefit and usefulness of combined surgical methods in nature, which can result in a complete correction of complex chest wall deformities.

The repair of chest wall deformity aims to restore functional impairment and achieve better cosmetic result. Cosmetic goal is highly subjective and hard to define depending on the severity of the disease, patient’s needs and surgeon’s ability. Therefore, the outcome of repair may vary depending on the surgeon’s technique. Surgeon’s ability to manipulate various surgical techniques is the key for the best outcome, which can expand surgical indications eventually. In my opinion, in the era of minimally invasive surgery, traditional open repair has an important role as an adjunctive treatment with MIR for difficult clinical settings; adults with severe complex chest wall deformity, particularly, underlying connective tissue disease, and stiff chest wall from prior thoracic or cardiac surgeries. Minimally invasive technique became main procedure for chest wall deformities; however, selection of proper indications and adequate surgical method is crucial for the successful and safe correction. Thoracic cage is a dynamic model comprising mechanics of sternum, ribs and spine. Future research should focus on comprehensive understanding of the thoracic cage to predict responses to correction for the satisfactory results.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned and reviewed by the Section Editor Jianfei Shen, MD (Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Taizhou, Zhejiang, China).

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/shc.2018.01.02). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Nuss D, Kelly RE Jr, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-52. [Crossref] [PubMed]
2. Mao YZ, Tang S, Li S. Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis. J Pediatr Surg 2017;52:1545-52. [Crossref] [PubMed]
3. Park HJ, Jeong JY, Jo WM, et al. Minimally invasive repair of pectus excavatum: a novel morphology-tailored, patient-specific approach. J Thorac Cardiovasc Surg 2010;139:379-86. [Crossref] [PubMed]
4. Park HJ, Kim KS, Lee S, et al. A next-generation pectus excavatum repair technique: new devices make a difference. Ann Thorac Surg 2015;99:455-61. [Crossref] [PubMed]
5. Park HJ, Kim KS. The sandwich technique for repair of pectus carinatum and excavatum/carinatum complex. Ann Cardiothorac Surg 2016;5:434-9. [Crossref] [PubMed]
6. Xie L, Cai S, Xie L, et al. Development of a computer-aided design and finite-element analysis combined method for customized Nuss bar in pectus excavatum surgery. Sci Rep 2017;7:3543. [Crossref] [PubMed]
7. Lee RT, Moorman S, Schneider M, et al. Bracing is an effective therapy for pectus carinatum: interim results. J Pediatr Surg 2013;48:184-90. [Crossref] [PubMed]
8. Haecker FM, Sesia S. Vacuum bell therapy. Ann Cardiothorac Surg 2016;5:440-9. [Crossref] [PubMed]
9. Luo L, Xu B, Wang X, et al. Intervention of the Nuss Procedure on the Mental Health of Pectus Excavatum Patients. Ann Thorac Cardiovasc Surg 2017;23:175-80. [Crossref] [PubMed]
10. Steinmann C, Krille S, Mueller A, et al. 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. Eur J Cardiothorac Surg 2011;40:1138-45. [PubMed]
11. Park HJ, Sung SW, Park JK, et al. How early can we repair pectus excavatum: the earlier the better? Eur J Cardiothorac Surg 2012;42:667-72. [Crossref] [PubMed]
12. Park HJ, Kim JJ, Park JK, et al. A cross-sectional study for the development of growth of patients with pectus excavatum. Eur J Cardiothorac Surg 2016;50:1102-9. [Crossref] [PubMed]
13. Ravitch MM. The Operative Treatment of Pectus Excavatum. Ann Surg 1949;129:429-44. [Crossref] [PubMed]
14. Haller JA Jr, Colombani PM, Humphries CT, et al. Chest wall constriction after too extensive and too early operations for pectus excavatum. Ann Thorac Surg 1996;61:1618-24; discussion 1625. [Crossref] [PubMed]
15. Sacco Casamassima MG, Goldstein SD, Salazar JH, et al. Operative management of acquired Jeune's syndrome. J Pediatr Surg 2014;49:55-60; discussion 60. [Crossref] [PubMed]
16. Johnson KN, Jaroszewski DE, Ewais M, et al. Hybrid Technique for Repair of Recurrent Pectus Excavatum After Failed Open Repair. Ann Thorac Surg 2015;99:1936-43. [Crossref] [PubMed]
17. Kanagaratnam A, Phan S, Tchantchaleishvili V, et al. Ravitch versus Nuss procedure for pectus excavatum: systematic review and meta-analysis. Ann Cardiothorac Surg. 2016;5:409-421. Review Erratum in: Ann Cardiothorac Surg 2016;5:593. [Crossref] [PubMed]
18. Bouchard S, Hong AR, Gilchrist BF, et al. Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum. Semin Pediatr Surg 2009;18:66-72. [Crossref] [PubMed]
19. Kim SY, Park S, Kim ER, et al. A Case of Successful Surgical Repair for Pectus Arcuatum Using Chondrosternoplasty. Korean J Thorac Cardiovasc Surg 2016;49:214-7. [Crossref] [PubMed]
20. Kocher GJ, Gstrein N, Jaroszewski DE, et al. Nuss procedure for repair of pectus excavatum after failed Ravitch procedure in adults: indications and caveats. J Thorac Dis 2016;8:1981-5. [Crossref] [PubMed]
21. Li S, Yang D, Ma Y, et al. Hybrid Nuss Procedure for Pectus Excavatum With Severe Retrosternal Adhesions After Sternotomy. Ann Thorac Surg 2017;103:1573-7. [Crossref] [PubMed]