SURGICAL TREATMENT OF INBORN PECTUS EXCAVATUM IN NON-ADULTS OF KUZBASS REGION
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
The rate of inborn pectus excavatum in the pediatric population varies from 0.2 % to 1.4 % according to the data from various authors [2, 3, 8, 9, 10]. Currently, most cases of pectus excavatum are associated with dyschondroplasia. Development of cartilaginous cells of the ribs and the sternum retards at early stages of fetus formation. As result, by the time of delivery, premordial cartilage is characterized by insufficient strength because of excessive development of soft tissue structures and quantitative shortage of chondrocytes. Dishistogenesis of hyaline cartilaginous tissue is the main factor of development and progression of chest deformation. It leads to non-uniform development of chest structures because of outrunning growth of the ribs and subsequent disorder of blood circulation and respiratory biomechanics [2, 4].
A combination of chest deformation with spinal curvature and identification of dynamic changes allow considering chest deformation as one of the variants of systemic dysplasia of osteochondral tissue [7, 8].
The importance of surgical treatment of pectus excavatum does not raise doubts and is conditioned by a trend of progression that is accompanied by disordered function of respiratory and cardiovascular system, as well as physical and moral suffering in patients.
Objective – to estimate the results of surgical mobilization of the sternocostal complex with retrosternal fixation with titanium metal plate in surgical treatment of children with inborn pectus excavatum.
MATERIALS AND METHODS
The study was conducted in compliance with World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects 2013, with the written consent from the parents for participation in the study. The study was approved by the local ethical committee of Regional Clinical Center of Miners’ Health Protection.
The materials are based on the analysis of the results of surgical thoracoplasty of inborn pectus excavatum in 58 children (age of 3-17) who were treated in the pediatric unit of traumatology and orthopedics, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, in 1993-2015. According to gender distribution, the rate of the pathology was 37 cases (64 %) in the men and 21 cases (36 %) in the women.
| Distribution of the children with pectus excavatum according to age and gender |
During the period of diagnostics and preparation to surgical treatment all patients received full volume of examination including collection of complaints, anamnesis with consideration of inborn signs of chest and spine pathology in their relatives, ECG and ultrasonic examination. External respiratory function, lung capacity, inspiratory and expiratory reserve volume were examined for objective estimation of the internal organs in the patients with pectus excavatum.
The obligatory procedure was X-ray imaging of the chest in two planes with estimation of Gizicka index. The index was estimated with lateral planes by means of the lowest size of retroperitoneal space (from the lateral surface of the sternum to the anterior surface of the spinal column) to the highest one. The ratio of 0.8-1 (the normal value is 1) characterizes a deformation of degree 1, 0.7-0.5 – degree 2, < 0.5 – degree 3.
The indications for surgical treatment of pectus excavatum were a deformation of degree 2-3 according to the classification by Gizicka and presence of age cardiorespiratory disorders. As result of the complex examination with consideration of functional disorders and degrees of chest deformations, all children were distributed into the groups with different degrees of deformations: degree 2 – 36 (62 %), degree 3 – 22 (38 %).
Thoracoplasty was conducted with endotracheal narcosis, with 24 hour postsurgical observation in the pediatric intensive care unit.
The surgical correction was based on the operation according to Ravich-Gross with subchondral resection of malformed costal cartilages on both sides within the borders of a deformation and transverse sternotomy near the upper border of a deformation. Stabilization of the sternocostal complex was conducted with a titanium plate (chest-shaped), which was placed behind the sternum from left to right, with further 180° turning around the longitudinal axis and fixation with free ends to the ribs. The muscles over the resected ribs were sutured with tight interrupted sutures.
A feature of submammary surgical approach was minimal mobilization of a subcutaneous-cutaneous flap within the limits of a deformation for exclusion of marginal necrosis of a postsurgical scar. It was achieved with our modified surgical approach [1, 5, 6]. The surgery was completed with layer-by-layer suturing of the wound with application of cosmetic stitches and reservation of silicone drains in the subcutaneous space.
The intrasurgical blood loss was 100-110 ml during mobilization of the sternocostal complex, resection of the ribs and sternotomy. The negative surgical influence on the child’s body was minimized with readiness of the surgical team, low volume of blood loss, minimal time (60 min) for surgical thoracoplasty and adequate anesthesiology.
Dynamic monitoring of hemodynamics, breathing, diuresis and general condition was conducted in the early postsurgical period with aim of timely identification of complications. After restoration of independent breathing the patients were transferred to the unit of pediatric orthopedics. After transfer to the specialized unit the complex of the medical measures was indicated in cooperation with the physicians of medical rehabilitation department: respiratory gymnastics, physiotherapy. All patients were discharged for outpatient treatment on 11th day on average.
All children received regular medical check-up each two months. Hereafter the examination was conducted 1-2 times per year. Considering the features of regeneration of cartilaginous and bone tissue, the fixator was removed not sooner than 6 months after surgery for the children at the age of 10, and after 12 months for the older children.
Hospital treatment for removal of the plate was realized within 3 bed-days. Skin incision of 1 cm was done under combined narcosis in the region of the edge of the metal plate. The plate was removed by means of its traction. The wound was without removal of drains. 24 hours after surgical treatment the control X-ray examination of the chest was performed. In case of satisfactory condition the patient was discharged for following orthopedic observation.
RESULTS AND DISCUSSION
The study included the analysis of the short term (up to 1 year) and long term results (up to 5 years) in all 58 operated patients, in 44 patients – up to 19 years within 1993-2015. With the voluntary consent from our patients we have been maintaining the photo register including the presurgical pictures and the pictures of the follow-up period.
The results of thoracoplasty for pectus excavatum were estimated as good, satisfactory or unsatisfactory. A good outcome was absence of complaints, Gizicka index – 1.0, restoration of anatomic shape of the anterior wall of the chest. The satisfactory outcome included complaints about insignificant deformation of the anterior wall of the chest (insignificant impaction of the sternum or local impaction of the ribs), Gizicka index – 0.8. An unsatisfactory outcome was recurrent deformation with return to the basic values, Gizicka index < 0.7 and complaints about cosmetic defects [8].
The good outcomes were in 47 children (81.8 %), satisfactory ones – in 9 (14.7 %), unsatisfactory ones – in 2 (3.4 %). All children with the good and satisfactory outcomes demonstrated absence of complaints and absent regression of a deformation, with the final outcomes, which were not influenced by some insignificant local changes in the region of postsurgical scars.
2 unsatisfactory results (3.4 %) were found 2 years after removal of the fixator: regression of a deformation to degree 1, a rough cosmetic defect in the region of a cheloid scar of the skin. A recurrent deformation and return to the basic state was explained by rapid growth of both children in the initial period of school education. Metal plate migration and purulence of the postsurgical wound were not identified.
The following complications should be noted: pneumothorax after parietal pleura injury during mobilization of the sternocostal complex in 5 (8 %) patients. It required pleural cavity draining according to Bulau (for 1 day). The dynamic control of the process was done by means of auscultation and X-ray examination.
Subcutaneous hematoma was found in 6 (10.3 %) in early postsurgical period. It required a single puncture for blood removal in 4 children (about 20-30 ml) and additional draining with counterincisions in 2 children.
Before use of the modified surgical approach, 4 (6.8 %) children demonstrated boundary necrosis of the skin of the postsurgical scar as result of extensive mobilization of the cutaneous-subcutaneous flap. Additional surgical intervention was not required. We have not found such complication after administration of our approach with substantiated separation of the skin flap within the boundaries of a deformation beginning from 2003.
Considering the results of surgical treatment, we recommend to use the technique with mobilization of the sternocostal complex with subchondral resection of the malformed part of the ribcage and transverse sternotomy at the level of deformation for improving results of surgical correction in non-adults with inborn pectus excavatum. Use of the strong and elastic titanium plate as a fixing device allows appropriate stabilization of the ribcage with improving regeneration of osteochondral structure of the sternocostal complex and restoration of its long term stability.
The figures 1-6 show a clinical example.
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Figure 1 A patient with pectus excavatum before surgery (the anterior view) |
Figure 2 A patient with pectus excavatum before surgery (the lateral view) |
Figure 3 The X-ray image of pectus excavatum before surgery (the lateral view) |
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Figure 4 A patient with pectus excavatum after surgery (the lateral view)
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Figure 5 A patient with pectus excavatum after surgery (the anterior view) |
Figure 6 The X-ray image of pectus excavatum after surgery (the lateral view)
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CONCLUSION
1. Mobilization of the sternocostal complex allows modelling the chest in children of various age groups with pectus excavatum of degrees 2-3, reducing the risk of recurrence up to 3.4 % and minimizing the amount of complications.
2. Retrosternal fixation with use of titanium plate for surgical correction of pectus excavatum in non-adults gives good and satisfactory results in 96 % that is supported by clinical and cosmetic results.