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Complications of Pectus Deformity Repair

Francis Robicsek, Jeko Madjarov
Complications of Pectus Deformity Repair is a topic covered in the Pearson's General Thoracic.

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Key Points

  • Specific complications of pectus deformity repair may be divided into (1) acute life-threatening conditions resulting from injury to the heart and great vessels and (2) residual/recurrent deformities caused by inadequate surgical repair.
  • Pre-existing conditions, such as predisposition to keloid formation, scoliosis, and congenital cardiac or pulmonary abnormalities, as well as a detailed family history together with genetic counseling, should be carefully evaluated before surgical correction of pectus deformities.
  • Careful planning of the timing of the procedure and method of surgery, along with prolonged sternal support, should be applied in patients with pectus deformities associated with connective tissue disorders, such as Marfan’s syndrome. Aortic surgery, if needed, and simultaneous pectus deformity repair in such patients should be considered.
  • To prevent the development of acquired restrictive thoracic dystrophy, the substernal suturing of the rib’s perichondrium, should be avoided.
  • For the same reason, the growth centers at the costochondral junctions should be spared to allow further growth of the thorax. The synovial joints at the sternochondral junctions should also be spared to allow mobility of the anterior chest wall.
  • Surgical experience and familiarity with different techniques should allow adequate correction of deformities at any age, even in cases in which there is no functional impairment, but repair is done in order to prevent future psychological distress.
  • The pre-operative evaluation of pectus excavatum should include the degree of the concavity, asymmetry, and progression.

Surgical trials to treat pectus excavatum began as early as 1911, when Meyer attempted to correct congenital sternal depression by sternocostal resection.[1]However, surgical treatment of this deformity became popular only after Ravitch in 1949 and our group in the 1960s recognized the pathophysiologic features of this disease and laid down the basic principles of surgical correction.[2],[3],[4]

These original techniques are still practiced by many, using a plethora of new methods-most of them based on modification of the same techniques. As it usually happens, new operations led to new complications, some of which were never before seen. These complications ranged from support-rod dislodgement to acquired restrictive thoracic dystrophy and, last but not least, true recurrence of the previously existing anomaly. More often than not, these complications were linked to particular faults in the technique of surgical repair.

The purpose of this chapter is to discuss the cause, prevention, consequences, and treatment of these iatrogenic conditions. Postoperative complications that are not specific to pectus deformity repair, such as incisional site infections, are not included in this chapter.

Complications occurring after pectus deformity repair can be classified as shown in Box 1.

Box 1: Complications After Pectus Deformity Repair

Injury to the heart and great vessels

Residual deformity

Sternal rotation

Acquired pectus carinatum

Pneumothorax (after Nuss) and/or hemothorax

Asymmetry and/or retarded growth of the breasts

Floating sternum

Sternal sequestration

Keloid formation

Psychological effects

Peri-incisional numbness/pain

Dislodgement or fracture of the substernal rods

Allergy to metals

Pericarditis-like syndrome

Acquired scoliosis

Thoracic outlet syndrome

True recurrence of the pectus deformity

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Key Points

  • Specific complications of pectus deformity repair may be divided into (1) acute life-threatening conditions resulting from injury to the heart and great vessels and (2) residual/recurrent deformities caused by inadequate surgical repair.
  • Pre-existing conditions, such as predisposition to keloid formation, scoliosis, and congenital cardiac or pulmonary abnormalities, as well as a detailed family history together with genetic counseling, should be carefully evaluated before surgical correction of pectus deformities.
  • Careful planning of the timing of the procedure and method of surgery, along with prolonged sternal support, should be applied in patients with pectus deformities associated with connective tissue disorders, such as Marfan’s syndrome. Aortic surgery, if needed, and simultaneous pectus deformity repair in such patients should be considered.
  • To prevent the development of acquired restrictive thoracic dystrophy, the substernal suturing of the rib’s perichondrium, should be avoided.
  • For the same reason, the growth centers at the costochondral junctions should be spared to allow further growth of the thorax. The synovial joints at the sternochondral junctions should also be spared to allow mobility of the anterior chest wall.
  • Surgical experience and familiarity with different techniques should allow adequate correction of deformities at any age, even in cases in which there is no functional impairment, but repair is done in order to prevent future psychological distress.
  • The pre-operative evaluation of pectus excavatum should include the degree of the concavity, asymmetry, and progression.

Surgical trials to treat pectus excavatum began as early as 1911, when Meyer attempted to correct congenital sternal depression by sternocostal resection.[1]However, surgical treatment of this deformity became popular only after Ravitch in 1949 and our group in the 1960s recognized the pathophysiologic features of this disease and laid down the basic principles of surgical correction.[2],[3],[4]

These original techniques are still practiced by many, using a plethora of new methods-most of them based on modification of the same techniques. As it usually happens, new operations led to new complications, some of which were never before seen. These complications ranged from support-rod dislodgement to acquired restrictive thoracic dystrophy and, last but not least, true recurrence of the previously existing anomaly. More often than not, these complications were linked to particular faults in the technique of surgical repair.

The purpose of this chapter is to discuss the cause, prevention, consequences, and treatment of these iatrogenic conditions. Postoperative complications that are not specific to pectus deformity repair, such as incisional site infections, are not included in this chapter.

Complications occurring after pectus deformity repair can be classified as shown in Box 1.

Box 1: Complications After Pectus Deformity Repair

Injury to the heart and great vessels

Residual deformity

Sternal rotation

Acquired pectus carinatum

Pneumothorax (after Nuss) and/or hemothorax

Asymmetry and/or retarded growth of the breasts

Floating sternum

Sternal sequestration

Keloid formation

Psychological effects

Peri-incisional numbness/pain

Dislodgement or fracture of the substernal rods

Allergy to metals

Pericarditis-like syndrome

Acquired scoliosis

Thoracic outlet syndrome

True recurrence of the pectus deformity

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Last updated: March 21, 2020