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New Procedure Corrects Chest Deformity.

SEA ISLAND, GA. -- Anew, minimally invasive technique has made repair of pectus excavatum appropriate for more children and adolescents who have this troublesome chest deformity.

Twelve years of experience by Dr. Donald Nuss, professor of surgery at Eastern Virginia Medical School, Norfolk, suggests that the outcome with the thoracoscopically guided procedure is comparable to open surgery, Dr. William C. Boswell said at a pediatric meeting sponsored by the Georgia chapter of the American Academy of Pediatrics.

Pectus excavatum, which results from defects in the attachments between rib cartilage and sternum, is typically present at birth and progresses in early adolescence as growth and downward force create an increasingly concave shape to the chest. The condition affects 1 in 1,000 individuals, about three times as many males as females, said Dr. Boswell, a pediatric surgeon in private practice in Savannah, Ga.

About 10% of patients are symptomatic. Exercise intolerance is the most frequent complaint, but this must be documented. "There are marathon runners with pectus excavatum," he said.

Dyspnea and chest pain are also reported. In some patients, atelectasis makes patients prone to recurrent pneumonia. Mitral valve prolapse may occur, caused by compression of the mitral valve annulus, and heart murmurs may occur secondary to compression of the pulmonary artery.

Many patients, particularly in their teens, are functionally normal but want correction of the deformity for cosmetic reasons. "In many cases, the old procedure was worse than the disease," he said.

The conventional surgery involves extensive cartilage resection and sternal osteotomy. It takes up to 6 hours and can involve blood loss of 300 mL. Recovery may take 6 weeks, Dr. Boswell said.

With the new procedure, a thoracoscope is used to pass a curved strut under the chest; it is then turned to elevate the chest normally and left in place, typically for 2 years, to allow the cartilage to remodel and remold. "Even ossified cartilage can be remodeled," he said. The procedure typically takes under an hour and entails minimal blood loss; the patient can return to normal activity within 2 weeks.

The procedure was developed over a decade ago, but long-term outcome studies have just recently been reported. In one series of 30 patients followed up for a mean of 4.6 years, results were "excellent" in 22 cases, good in 4, and fair or poor in 4. "[Outcome] appears to be equal to the more invasive procedure," Dr. Boswell said.

The newer procedure makes pectus excavatum repair appropriate for more children at an earlier age. Open surgical repair for cosmesis was usually deferred until the patient was 15 or 16 years old, for more meaningful consent. But the new procedure may be performed around age 10-12, while cartilage is more malleable, he said.

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Title Annotation:pectus excavatum
Publication:Family Practice News
Date:Dec 1, 1999
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