Mini Review
A Look at the History of Surgery for Pectus Excavatum
Chih-Chun Chu
Formos J Surg 2011;44:1-5
Pectus excavatum is the most common deformity of
the anterior wall of the chest, in which several ribs,
costal cartilages and the sternum grow abnormally and
produc e s a caved- in appearance of the chest . PE is
usually considered to be cosmetic; however, depending
on its severity, the deformed chest wall can compress the
heart and reduce the thoracic volume, and impair cardiac
and respiratory function, distort spine curvature, and
cause pain in the chest.
A review of the literature shows that the first record
of pectus excavatum was probably written in the 16
the century by Johan Schenck ( 1 5 3 1 - 1 5 9 0 ) . Bauhinus
(1594) described a case in which the patient suffered
from shortness of breath and cough as a result of severe
pectus excava tum. In 1820, Coulson
cited a family including three brothers with a funnel chest. In 1872,
Williams
reported a patient born with a pectus
excavatum whose father and a brother also suffered from
the same condition. Ever since, the reported cases have
gradually increased, but treatment before the 20th
century was limited to fresh air, breathing exercises and
lateral pressure on the chest, all of which probably
exerted no substantial beneficial effect. During those
early days, technology of surgery and anesthesia was
unable to overcome lung collapse during thoracic
surgery, and the progress in treatment of pectus
excavatum remained stagnant until early 20th century.
Meyer in 1911 removed the first, second and third
costal cartilages of a patient with pectus excavatum, but
apparently did not attained the desired effect. Sauerbruch
in 1931,
performed surgery on a patient with pectus
excavatum suffering from severe dyspnea in a negative
pressure chamber wherein he removed a part of the
anterior chest wall which included the fifth to the ninth
costal cartilages, as well as a segment of the adjacent
sternum. After the procedure, the patient was able to
work, and even married three years later. It is difficult to
imagine how science and technology at the time was able
to complete such a type of operation. In the 1920’s, he
had already advocated bilateral removal of costal
cartilages and sternum transection in order to raise the
anterior chest wall. After the procedure, according to
Sauerbruch the patient had to stay in bed for external
traction to hold the anterior chest wall in position for 6
weeks or more. Although the process was very harmful,
the technology provided a method of treatment that had
not been achieved before, and it soon gained popularity
in Europe and the United States.
in 1939, Ochsner and DeBakey
published their
experience with the Sauerbruch's operation. In the same
year, Lincoln Brown
also published the experience with
two of his patients and theorized that the funnel chest is
caused by the short diaphragmatic ligaments and the
continuous pull of the diaphragm. Adopting the theory
and to avoid external retraction after operation, Ravitch
modified the operation by complete mobilization of the
sternum from its surrounding tissues, with transection of
all sternal attachments, including the intercostal bundles,
rectus muscles and diaphragmatic attachments. This
surgical technique eliminated the need after surgery of an
external device to lift the sternum. This is the current socalled traditional surgery most commonly referred to as
the Ravitch procedure. This procedure avoid the external
retraction but had a higher recurrence rate, and the
concept of internal support merged.
In 1956, Wallgren and Sulamaa
introduced for the
first time the concept of internal support technology.
They used a stainless steel bar pushed through the
sternum to lift the depressed chest wall from the inside.
In 1961, Adkins and Blades11 using a similar concept,
placed the steel bar beneath the sternum, rather than
through the sternum.
In 1958, Welch
modified the Ravitch procedure by
not cutting through all the intercostal bundles and rectus attachments and obtained good results. Pena
was
greatly disturbed by the idea of resecting the rib
cartilages of young children. Haller
also published a
report using the Ravitch procedure, but stated also that
the chest wall loses its elasticity, thus affecting the
respiratory function (acquired asphyxiating
chondrodystrophy). Therefore, he advocated to decrease
the amount of cartilage resected for surgical correction of
pectus excavatum.
Wada in 1961 reported a corrective operation for the
funnel chest wherein the sternum is turned over resulting
from a convex to a concave shape. The above-mentioned
surgicsl procedure is usually performed through a
vertical midline incision or a bilateral submammary
incision, and thus in addition to leaving an unsightly
scars, the procedure easily causes the anterior chest wall
to lose its organizational flexibility with a high
recurrence rate.
In 1986, while using the Ravitch procedure, Donald
Nuss was struck with the flexibility of the rib cartilages
and instead of removing it, he took advantage of its
flexibility and malleability. He used a U-shaped stainless
steel bar passed through small incisions on both sides of
the chest, and traversing between the pericardium and the
sternum. Under thoracoscopic guidance, the strut could
be easily passed through the retrosternal space, and also
behind the sternum without injuring the heart or lungs.
The strut was then flipped to elevate the depressed
thoracic wall. After ten years of closed-door study, Nuss
reported this new technique for correcting pectus
excavatum in 1998.
As a result, without resection of
costal cartilage or ribs, no sternal wedge resection, a
revolutionary change in pectus excavatu surgery
occurred, and the treatment for pectus excavatum
officially enters the era of minimally invasive surgery
( Fig 1 ). The simple design of the Nuss procedure
provides a universal way to correct pectus excavatum for
different types and age ranges (Fig 2) of patients. The
author has experienced patients from age 2 to age 48 with
excellent results. Because of its simplicity, the Nuss
procedure leaves much room for personal style and
surgeons can gradually develop their individual style and
characteristics.
Compared with traditional open surgery, the Nuss
procedure provides a lower recurrence rate, less injury,
better results, and a wide range of indications for
different type and severity of pectus excavatum. Some
severe complications, such as accidental penetration into
the lung or heart, have been reported in performing the
Nuss procedure, but under the direct vision of
thoracoscopy, such complications are almost entirely
avoidable. The prophylactic use of antibiotics and
stabilizers certainly reduces the complications of implant
infection and displacement of the the strut.
In failed Ravitch or sternum turn over cases, revision
has been made using the Nuss procedure that
demonstrated good results (Fig 3 & 4).
In 2005, Nuss was invited to Taiwan where he
introduced the innovated surgica l operation. So far,
Taiwan has had more than five hundred patients that have
undergone the Nuss procedure.
As with other surgery, the treatment of pectus
excavatum is geared towards the development of minimally invasive surgery. The Nuss procedure has been carried out under the guidance of thoracoscopy in our
series of 304 cases and is proved to be safe mostly with
satisfactory results. No life-threatening complications
were encountered. The incidence of minor complications,
such as displacement of the struts, wound infection,
unsatisfied chest contour, and pneumohemothorax are
totally less than 6%, and only 5 cases (less than 1.6%)
need a second operation. It is probably safe to predict that
minimally invasive surgery will be the mainstream in the
treatment of pectus excavatum.
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