Surgical Management of Funnel Chest (Pectus Excavatum) J. ALEX HALLER, JR., M.D., F.A.C.S.* GEORGE N. PETERS, M.D.** JOHN J. WHITE, M.D.***
Pectus excavatum is a disturbing chest deformity for many children and their parents. There is little objective evidence that a child with pectus excavatum suffers any physiologic embarrassment to his heart or lungs. However, the cosmetic impact of this deformity on a child's developing personality may be of lasting importance, as well as his poor posture, which is characterized by slumping shoulders and a protuberant abdomen. For these two reaons we have had an active interest in operative reconstruction of severe pectus excavatum. In spite of our ignorance of the causative factors in this condition, several principles of surgical therapy of pectus excavatum have evolved over the past several decades.Limited operations which were designed to free the diaphragm from the anterior chest wall have been abandoned. The stabilization of the sternum in its normal anatomic position is necessary, but methods vary. External and internal fixation devices,1· 2 • 4 - 6 • 8 rib graft buttresses,3 and even complete reversal of the sternum 7 have all been used to prevent recurrence of the pectus excavatum. In 1949, eight patients from The Johns Hopkins Hospital were reported whose conditions had been surgically corrected using a technique based on cartilage resection and anterior cuneiform osteotomy of the sternum. 7 Posterior sternal osteotomy was later introduced to prevent localized depressions in the sternum at the osteotomy site. In a subsequent modification, the most cephalad paired normal cartilages were divided obliquely after excision of the abnormal ones. When the sternum ·''Robert Garrett Professor of Pediatric Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland **Colorado Permanente Medical Group, Denver, Colorado; formerly Chief Resident in Pediatric Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland ***Associate Professor of Surgery and Robert Garrett Scholar in Pediatric Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Surgical Clinics of North America- Vol. 50, No.4, August, 1970
J, ALEX HALLER, JR., GEORGE
N. PETERS, JoHN J. WHITE
was fractured and placed in over-corrected position, the sternal ends of the cartilage rested on the costal ends and supported the sternum in an anterior position. This type of natural internal stabilization is referred to as "tripod fixation" because the sternum is supported by its anterior periosteum as well as the two cartilages. With the addition of these modifications, the same basic principles of surgical correction have been used at The Johns Hopkins Hospital from 1949 through 1969.
CLINICAL STUDY The hospital records of 183 patients under the age of 21 years who had surgical correction of pectus excavatum deformities at The Johns Hopkins Hospital from 1949 through 1969 were reviewed. The adequacy of surgical correction in effecting satisfactory late results was evaluated in two ways. First, the quality of the surgical result was judged from physician follow-up at The Johns Hopkins Hospital in 53 patients. Second, a questionnaire was mailed to all183 patients or their families to get a s_ubjective assessment of the late results. One hundred eight patients were followed for one year or more either by physicians at The Johns Hopkins Hospital or by both methods. Late results were graded into one of three groups: excellent, acceptable, and poor. In an "excellent" result, the anterior chest wall was restored to normal, or near normal, contour; the cosmetic appearance of the surgical scar was acceptable to the patient; and the expectations of the patient or family were fulfilled. The "acceptable" group included patients in whom a mild degree of pectus excavatum remained or recurred; the surgical scar was objectionable; or the appearance of the final result was not entirely satisfactory. "Poor" results were frank recurrences. A separate category included all patients who had a secondary operation because of unsatisfactory results. Most of these patients ultimately were classified as excellent or acceptable and are, therefore, not considered as permanent poor results (Table 1).
RESULTS The diagnosis of severe pectus excavatum was established in 170 of the 183 patients before the age of 2 years, and usually dated from
Table 1. GROUP
Excellent Acceptable Poor Re-operation Total
Long-Term Follow-Up Results, 7.8 Years NUMBER
65 24 9 10
60% 22% 8% 9%
SURGICAL MANAGEMENT OF FUNNEL CHEST
the first 6 months of life. The youngest operative patient was 3 months of age, and the oldest was 20 years. While the majority of patients had corrective surgery in the 2 to 14 year age group, 38 patients were operated upon before the age of 2 years (Table 2). The defects of another 18 patients were repaired between 14 and 20 years of age. The few patients who were operated upon after 21 years were arbitrarily excluded from the series. To determine the safety of the procedure, the following factors of hospital morbidity were studied: (1) length of operation, (2) use of blood transfusions, (3) incidence of pneumothorax, and (4) incidence of wound complications. Subperichondrial excision of four to six pairs of costal cartilages along with osteotomy and stabilization of the stemum was performed in 3 hours or less in 86 per cent of the patients. Half of these operations were performed in 2 hours or less. Blood transfusion was administered during the operation in 28 per cent of the 183 patients. In recent years electrocautery has been used for dissection and hemostasis, and the current use of blood transfusion is much less frequent than in the overall series. In addition, younger patients are less likely to require blood transfusions because the operation is of relatively lesser magnitude. Seventeen per cent had a pneumothorax, all but three being on the right side. The majority of these were treated by needle aspiration but an occasional small pneumothorax was allowed to resolve spontaneously. No morbidity resulted from operative pneumothorax, since it was frequently noted at the operating table and promptly treated in the immediate postoperative period. An aggressive approach to pulmonary toilet was universally applied, since postoperative chest x-ray films frequently showed small areas of atelectasis, particularly in the left lower lobe. In one patient an emergency tracheostomy was performed for laryngeal edema secondary to difficult tracheal intubation at the time of operation. A second patient with associated choana! stenosis had prophylactic tracheostomy, with satisfactory recovery. In no case was mechanical ventilatory support necessary for an unstable anterior thorax. This is remarkable in view of the extensive area of paradoxical anterior respiratory movement, but this created no special problems to the patients. Some of the· early cases were Table 2.
2 years and under 3 through 5 6 through 14 15 through 20 Total
Late Results-7.8 Year Follow-Up
TOTAL NO. OF PATIENTS
19 54 24 11
14 35 10 6
3 11 6 4
1 4 3 1
1 4 5 0
]. ALEX HALLER, ]R., GEORGE
PETERS, ]OHN ]. WHITE
treated prophylactically with antibiotics; our current policy is to use antibiotics only when specifically indicated. Blood and serum frequently accumulated in the substernal space due to the extensive dissection. This complication was present in 72 of the patients (39 per cent). Most of these accumulations were treated by needle aspiration. Half of these patients required aspiration three or more times. A mediastinal chest tube with 20 or 30 em. of water suction has been employed in the last 30 cases; only 3 required additional needle aspirations. Only one patient had a major wound complication-suppurative mediastinitis that ultimately contributed to a poor result. Seven other patients had superficial wound separations or necrosis of skin edges. The last 27 patients had transverse skin incisions and no wound complications. The late results of surgical correction of pectus excavatum in 108 patients with at least one year of follow-up are seen in Table 2. A second operation was performed in 6 patients to correct recurrent pectus excavatum. Four others had less extensive secondary procedures to improve the cosmetic results. A permanently poor result was obtained in only one patient, and another was not followed. The majority of this group (8 of 10) were converted to either an excellent or acceptable result by the second operation. There appeared to be a decreasing incidence of excellent or acceptable results with increasing age of the child. Early correction of pectus excavatum seemed to yield the best results (Table 3).
INDICATIONS FOR OPERATION Pectus excavatum is usually asymptomatic in childhood, and surgical correction is undertaken only because a severe deformity is present (Figure 1). This attitude is justified if the surgeon is convinced that the child and his family are psychologically affected by the pectus deformity. The decision to correct such a deformity must therefore be based on thoughtful communication with the patient or his family. Prevention of further progression of the associated postural abnormality, which is characterized by slumping shoulders and pot belly, is another reason for reconstructing the anterior thoracic wall (Figure 2). Significant compression of the heart or lungs with alteration of their function was not evident in the review of our experience with the deformity in children and teenagers. In our opinion, restoration
Excellent or Acceptable Results After 7.8 Years
AGE AT REPAIR
2 3 6 15
years and under through 5 through 14 through 20
89% 85% 67%
Figure 1. Lateral chest roentgenogram. A barium paste strip outlines the declivity of the pectus excavatum. Note the spinal concavity and severe pot belly.
Figure 2. Poor posture associated with pectus excavatum. Note severe slope shoulders and flared lower rib cage with pot belly.
J. ALEX HALLER, JR., GEORGE
N. PETERS, JOHN J. WHITE
of the anterior chest wall to its normal anatomy is reason enough to recommend surgical correction if the operation is safely performed and the patient can be reasonably sure of a lasting satisfactory result.
SUMMARY Surgical correction of severe pectus excavatum is indicated for cosmetic reasons and for correction of associated poor posture. An operation consisting of subperichondrial excision of abnormal cartilages and suture stabilization of the sternum has been used in 181 patients from 1949 through 1969. Pneumothorax was frequent but easily recognized and treated. Wound complications were minimal and have been further reduced by use of a transverse skin incision and mediastinal tube drainage. Satisfactory late results (excellent and acceptable) were obtained in 82 per cent of patients after an average of 7.8 years. In addition, a secondary operation led ultimately to excellent or acceptable results in 8 of 17 original failures. We feel that the low operative morbidity and satisfactory late results of pectus repair are strong recommendations for its continued use in selected patients.
REFERENCES 1. Adkins, P. C., and Blades, B.: A stainless steel strut for correction of pectus excavatum. Surg. Gynec. Obstet. 113:111, 1961. 2. Adkins, P. C., Graff, D. B., and Blades, B.: Experiences with metal struts for chest wall stabilization. Ann. Thorac. Surg., 5:246, 1968. 3. Dorner, R. A., Keil, P. G., and Schissel, D. J.: Pectus excavatum. J. Thorac. Surg., 20:444, 1950.
4. May, A. M.: Operation for pectus excavatum using stainless steel wire mesh. J . .Thorac. Cardiovasc. Surg., 42:122, 1961. 5. Mayo, P., and Long, G. A.: Surgical repair of pectus excavatum by pin immobilization. J. Thorac. Cardiovasc. Surg., 44:53, 1962. 6. Peters, R. M., and Johnson, G., Jr.: Stabilization of pectus deformity with wire strut. J. Thorac. Cardiovasc. Surg., 47:814, 1964. 7. Ravitch, M. M.: Technical problems in the operative correction of pectus excavatum. Ann. Surg., 162:29, 1965. 8. Rehbein, F., and Wernicke, H. H.: The operative treatment of the funnel chest. Arch. Dis. Child., 32:5, 1957. Department of Surgery The Johns Hopkins Hospital Baltimore, Maryland 21205