CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 8, September 2013
AFRICA
321
to physical activities, and consistently good to excellent results
compared to the techniques used previously.
14
Repair of pectus deformities is technically easier and is
therefore encouraged during childhood. However, for those
patients who have not undergone operations as children, repair
during the adult years should be considered by the recommended
treatment option of MIRPE (minimal invasive repair of pectus
excavatum), as described by Dr Nuss.
15
MIRPE does not require resection of the cartilage. Firstly the
heart and mediastinum are slowly and carefully pushed down
by the specific introducer, and the prepared convex steel bar
is inserted under the sternum and across the bilateral thoracic
incisions. The bar is turned, and the deformed sternum and costal
cartilages are then brought into the correct position. The bar is
left in place for at least two to three years, depending on the
patient and the severity of the deformity.
MIRPE is a minimally invasive procedure with shorter
operating time, minimal complication rate, short length of
hospitalisation and minimal postoperative pain.
15
This technique
requires neither cartilage incision nor resection.
16
However, in
Turkey, the bar has not been available in state hospitals, which
has limited its adoption.
Nowadays, thoracoscopic costal cartilage resection is described
for unilateral pectus deformities. This procedure is performed by
cutting the anomalous costal cartilages under thoracoscopic
imaging, with excellent visibility. The anomalous cartilages are
removed with the thoracoscopic view. The anomalous cartilages
are identified, and the posterior perichondrium is incised using
a hook. Both superior and inferior margins of the cartilage are
prepared using a thoracoscopic cautery hook, taking care not to
damage the intercostal vessels and nerves.
8
During the adolescent years of rapid skeletal growth, both PE
and PC deformities almost always become much more severe
at a time that coincides with increasing athletic activity. The
recognition of symptoms and the recommendation for surgical
correction remain controversial, with strongly divergent opinions
being expressed regarding whether PE and PC are primarily
cosmetic disorders, or if they cause physiological impairment
and limitations to the patient.
Conclusion
This retrospective clinical study confirms that pectus deformities
can be repaired with a low rate of complications and short
hospital stay. The improvement in respiratory symptoms, exercise
tolerance and endurance, as well as the cosmetic appearance of
more than 97% of the patients in this study supports the view
that symptomatic patients of all ages should undergo repair,
preferably during the pre-adolescent years.
Routine use of substernal support with minimal pre-operative
testing has provided excellent long-term clinical results at a
low cost. The most important aspect of pectus correction is to
achieve long-term stability of the sternum and thorax after the
removal of large amounts of cartilage and sternal osteotomy.
16
In three cases, use of a sub-sternal steel bar to stabilise the
chest proved advantageous compared to the standard Kirschner
wire technique. It is secure, reduces the risk of postoperative
complications and provides good cosmetic results.
Kim
et al
. reported successful sub-perichondrial resection,
sternal osteotomy and pectus bar insertion placed under the
depressed sternum after trauma, followed by internal bar rotation
for elevation of the chest wall. This case illustrates that a
modified Ravitch procedure using a pectus bar may be an
alternative for post-traumatic pectus excavatum.
17
The authors thank Dr Robert E Kelly (jun) for review of the manuscript and
assistance with its preparation.
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