Minimally Invasive Repair of Pectus Carinatum

Mustafa Yuksel, MD, Nezih Onur Ermerak, MD
Minimally Invasive Repair of Pectus Carinatum is a topic covered in the Pearson's General Thoracic.

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Key Points

  • Abramson described a modification of Nuss procedure to be used for the correction of PC in 2005 and defined it as “Minimally Invasive Repair of Pectus Carinatum” (MIRPC) which is based on compression of the sternum by implanting a metal bar in the presternal region and securing it bilaterally to the posterolateral portion of the ribs.
  • It is important to measure the optimum pressure that corrects the deformity. If the pressure is less than 14 psi, the patient is appropriate for brace treatment. Between 10–25 psi the patients are considered to be an optimum candidate for MIRPC. If the pressure is over 25 psi, Ravitch sternoplasty is the choice of surgical treatment.
  • New modifications had been developed due to the necessity for specific group of patients. Sandwich technique is used for mixed type of deformities which basically can be defined as a deformity having both pectus excavatum and carinatum.
  • MIRPC is a minimally invasive technique with shorter operation time, low morbidity and highly satisfactory results. This technique is optimal for correcting PC deformities and improving quality of life. Thus, MIRPC should be the treatment of choice for Pectus Carinatum patients

Pectus Carinatum (PC) is the second mostly encountered congenital chest wall deformity (1 in 1000 live births) following Pectus Excavatum (PE). It is characterized by convex protrusion of costal cartilages, anterior chest wall and sternum. PC is classified into two subgroups as "chondrogladiolar" and "chondromanubrial" according to the anatomic location of protrusion. Chondrogladiolar deformity is defined as asymmetric or symmetric protrusion of inferior costal cartilages and sternum. Asymmetric deformity results secondary to unilateral overgrowth of costal cartilages and rotation of the sternum. In chondromanubrial deformity, manubrium sterni and superior costal cartilages are protruded. Due to this arched appearance, the deformity is termed as “Pectus Arcuatum (PA)”. PA is less than 1% of all PC cases[1] and Ravitch sternoplasty is the treatment of choice in these group of patients.

Although the etiology of PC is unclear, 25% of the patients have positive family history for chest wall deformity which strongly supports genetic inheritance.[2] Prominent protrusion of PC is seen less than 10% of the patients before 11 years of age. Deformity becomes apparent during puberty due to active growth; which leads to cosmetic and psychosocial problems during this period.[3] PC is encountered at a ratio of 1:5 similar to PE patients, seen 5 times more in males than females.[2] It is more common among Hispanic population and rare in Asian and African populations. PC may be an isolated problem or can be seen as it may be a part of genetic disorders like Marfan Syndrome, trisomy 18, homocystinuria, Morque Syndrome, and Ehlers–Danlos Syndrome. PC may accompany some congenital heart diseases and connective tissue disorders as well. Scoliosis is the most common accompanying anomaly of the skeletal system at a ratio of 15%.[2],[3],[4]

Most of the PC patients are asymptomatic but the most frequent symptoms are shortness of breath, fatigue, pain over the deformity.[5] Indication for surgical correction is based on cosmetic and psychosocial problems.

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Key Points

  • Abramson described a modification of Nuss procedure to be used for the correction of PC in 2005 and defined it as “Minimally Invasive Repair of Pectus Carinatum” (MIRPC) which is based on compression of the sternum by implanting a metal bar in the presternal region and securing it bilaterally to the posterolateral portion of the ribs.
  • It is important to measure the optimum pressure that corrects the deformity. If the pressure is less than 14 psi, the patient is appropriate for brace treatment. Between 10–25 psi the patients are considered to be an optimum candidate for MIRPC. If the pressure is over 25 psi, Ravitch sternoplasty is the choice of surgical treatment.
  • New modifications had been developed due to the necessity for specific group of patients. Sandwich technique is used for mixed type of deformities which basically can be defined as a deformity having both pectus excavatum and carinatum.
  • MIRPC is a minimally invasive technique with shorter operation time, low morbidity and highly satisfactory results. This technique is optimal for correcting PC deformities and improving quality of life. Thus, MIRPC should be the treatment of choice for Pectus Carinatum patients

Pectus Carinatum (PC) is the second mostly encountered congenital chest wall deformity (1 in 1000 live births) following Pectus Excavatum (PE). It is characterized by convex protrusion of costal cartilages, anterior chest wall and sternum. PC is classified into two subgroups as "chondrogladiolar" and "chondromanubrial" according to the anatomic location of protrusion. Chondrogladiolar deformity is defined as asymmetric or symmetric protrusion of inferior costal cartilages and sternum. Asymmetric deformity results secondary to unilateral overgrowth of costal cartilages and rotation of the sternum. In chondromanubrial deformity, manubrium sterni and superior costal cartilages are protruded. Due to this arched appearance, the deformity is termed as “Pectus Arcuatum (PA)”. PA is less than 1% of all PC cases[1] and Ravitch sternoplasty is the treatment of choice in these group of patients.

Although the etiology of PC is unclear, 25% of the patients have positive family history for chest wall deformity which strongly supports genetic inheritance.[2] Prominent protrusion of PC is seen less than 10% of the patients before 11 years of age. Deformity becomes apparent during puberty due to active growth; which leads to cosmetic and psychosocial problems during this period.[3] PC is encountered at a ratio of 1:5 similar to PE patients, seen 5 times more in males than females.[2] It is more common among Hispanic population and rare in Asian and African populations. PC may be an isolated problem or can be seen as it may be a part of genetic disorders like Marfan Syndrome, trisomy 18, homocystinuria, Morque Syndrome, and Ehlers–Danlos Syndrome. PC may accompany some congenital heart diseases and connective tissue disorders as well. Scoliosis is the most common accompanying anomaly of the skeletal system at a ratio of 15%.[2],[3],[4]

Most of the PC patients are asymptomatic but the most frequent symptoms are shortness of breath, fatigue, pain over the deformity.[5] Indication for surgical correction is based on cosmetic and psychosocial problems.

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