CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 8, September 2013
320
AFRICA
3%, and 2% of patients had an increased frequency of respiratory
infections.
Three patients had a sternal bar supporting the sternum using
a modified Ravitch technique. One patient had Ehler-Danlos
syndrome, and in another we removed a large amount of costal
cartilage and the patient needed support to stabilise a flail chest.
A third needed extra support because he underwent repair of a
second recurrence of PE deformities.
Each of the 77 patients was contacted by telephone, from
three months to three years after the operation. Fifteen patients
(19%) could not be located and were lost to follow up. In the
remaining 62 patients, repair was judged by the patient to be very
good or excellent. Each stated he/she would recommend repair
of pectus deformities to other patients.
All patients reported marked improvement in exercise
tolerance with much less dyspnoea. Most patients were able to
participate in exercise such as running, swimming or cycling. All
but three patients who had only limited exercise ability before
the repair, showed good physical activity six months after the
operation. Three patients (3.8%) experienced recurrence, one
after PC, and two after PE repair.
Discussion
The pathophysiology of congenital pectus deformities is poorly
understood. It is generally thought that abnormal cartilage
growth results in displacement of the sternum either anteriorly
in PC or posteriorly in PE.
3
The majority of children and their parents related to cosmesis
and public exposure of the body. A significant number of
patients, however, presented with easy fatigue, decreased stamina
and wheezing during physical activity, pain and palpitations.
Physiological testing is often normal, but both the cardiac index
and pulmonary function may be affected, particularly with
exercise conditions.
4
Symptoms of PE and PC are recognised infrequently during
early childhood, apart from a child not wanting to go without a
shirt while swimming or participating in other athletic or social
activities.
5
Pectus patients commonly try harder to keep up with
their peers, using wider diaphragmatic excursions to compensate
for diminished chest wall excursions caused by the PE or PC
deformity; however, almost all patients experience a worsening
of their symptoms with time.
A careful history is important in identifying appropriate
operative candidates. Symptoms such as chest pain, palpitations
and dyspnoea may indicate underlying cardiac or pulmonary
pathology. Inquiring about participation in athletic, physical
and social activities provides descriptive information regarding
limitations caused by the deformity on cardiopulmonary
performance as well as lifestyle.
5
The deformity gradually
worsens, until skeletal growth is complete in late adolescence,
and then changes little throughout adult life.
The results of PE repair should be excellent. Peri-operative
risks must be limited. The most significant complication is
a recurrence, which has been described in a large series as
occurring in 5–10% of patients.
6
A minimal pneumothorax
requiring aspiration is infrequent and sometimes needs a
thoracostomy tube. Wound infection should be rare with the use
of peri-operative antibiotics, especially with protective coverage
of the skin during the operative procedure to minimise any
contamination by skin flora.
4
Many improvements in the technique for surgical correction
of PE and PC have evolved during the eight decades since
the first repairs were performed. Adults with severe pectus
deformities and asymmetric defects are at a greater risk of
recurrence after a Nuss procedure. These patients may be better
repaired initially with a modified Ravitch repair.
7
A modification of the Ravitch technique for pectus repair was
originally described in 1949.
2
For example, for PE, the surgical
technique includes conservative sub-perichondrial resection of
the deformed costal cartilages and detachment of the xiphoid
process. The initial steps of the PC correction procedure are
similar to that for PE. The sternum, however, is not freed of
its environment. A length of 3–4 cm is resected from the distal
sternum and the xiphoid process is restored in the proper
anatomical direction.
8
Although the technical aspect of pectus repair is more tedious
in adults than in children, postoperative recovery and long-term
results have been similar.
9
The costal cartilages are usually thicker
in adults and occasionally they must be scooped out from the
perichondrial sheaths with a rongeur rather than being removed
with a small elevator. Minimising injury to the perichondrial
sheaths during removal of cartilage segments is considered
essential in order to permit maximum cartilage regeneration.
10
Placing minor fragments of fresh autologous cartilage into the
empty perichondrial sheaths appears to support costal cartilage
regeneration and does not increase the risk of infection.
11
The Nuss procedure is a minimally invasive technique
with a small wound size. The Ravitch procedure provides
good correction of pectus deformities. We described here a
modification of the Ravitch procedure for PE correction, adding
a steel bar under the sternum for support. This procedure has the
advantage of preventing postoperative flail chest and mediastinal
disorders with severe PE.
Placement of the sternal support across the lower anterior
chest appears to provide optimal support for the sternum and
may reduce late depression of the upper chest.
12
In three patients
with PE, we noted that placing the bar posterior to the costal
cartilages or perichondrial sheaths before attaching it to the
appropriate rib on each side elevated the anterolateral chest
as well as the sternum to provide optimal cosmetic as well as
physiological reconstruction. This technique is used for patients
with a higher level of pectus index, who would have developed
flail chest with respiratory stress after the postoperative period.
It prevents paradoxical respiration, reduces pain, permits early
movement, permits deeper inhalation, reduces hospitalisation
time and cost, and provides very good long-term results.
13
Minimal costal cartilage resection provides more stability
to the chest during the early postoperative period and more
consistent elevation of the anterior chest lateral to the sternum
than when more extensive cartilage excision is performed.
3
Furthermore, there is only moderate postoperative pain, few
complications, rapid recovery with early discharge, easy return
TABLE 1. AGE OF PECTUS PATIENTS
Age (years)
Number of patients
10–14
12
14–17
28
17–22
37
Total
77
