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Combining Correction of Pectus Excavatum and Open Heart Surgery in a Single-Stage Procedure
Journal Pre-proof Combining correction of pectus excavatum and open heart surgery in a single-stage procedure Ara Shwan Media, MD, Hans K. Pilegaard, MD, Frank Vincenzo de Paoli, MD, PhD PII:
S0003-4975(19)31268-8
DOI:
https://doi.org/10.1016/j.athoracsur.2019.07.043
Reference:
ATS 32966
To appear in:
The Annals of Thoracic Surgery
Received Date: 19 June 2019 Revised Date:
11 July 2019
Accepted Date: 11 July 2019
Please cite this article as: Media AS, Pilegaard HK, Vincenzo de Paoli F, Combining correction of pectus excavatum and open heart surgery in a single-stage procedure, The Annals of Thoracic Surgery (2019), doi: https://doi.org/10.1016/j.athoracsur.2019.07.043. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by The Society of Thoracic Surgeons
Combining correction of pectus excavatum and open heart surgery in a single-stage procedure Short Title: Pectus Excavatum and Open Heart Surgery
Ara Shwan Media1, MD, Hans K. Pilegaard1,3, MD, Frank Vincenzo de Paoli1,2, MD, PhD
1
Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, DK-
8200 Aarhus N, Denmark; 2 Department of Biomedicine, Aarhus University, DK-8000 Aarhus C, Denmark
Corresponding Author: Frank de Paoli Department of Biomedicine Aarhus University
Ole Worms Allé, Aarhus DK-8000 Denmark E-mail: [email protected]
Word count: 1500
1
Abstract The presence of pectus excavatum (PE) in patients undergoing open heart surgery is rare and no consensus has been reached regarding the surgical approach. Thus, in this paper we present in details a single-stage procedure for correction of PE with the modified Nuss procedure ad modum Pilegaard in four patients undergoing open heart surgery. Three of four patients successfully underwent the single stage-procedure. At follow-up after bar removal, all patients had no complications related to the Nuss bar and all with excellent cosmetic results.
Key Words: Pectus excavatum, Cardiac Surgery, single-stage, Nuss Procedure
2
Pectus excavatum is the most common chest wall deformity in children and often an isolated abnormality with an incidence of 1:3-400 in new-born males1. For decades the traditional repair of pectus excavatum was an open Ravitch technique with resection of cartilage, however, repair of pectus excavatum by employing a retrosternal metal bar (Nuss procedure), is now a well-established operative procedure for correction2,3. By employing this minimally invasive repair the anterior chest wall is remodelled avoiding cartilage resection, and has gained general acceptance as the preferred method for pectus excavatum repair, featuring small skin incisions, a shorter operation time, minimal blood loss and early return to full activity. The incidence of concomitant pectus excavatum and cardiovascular diseases in need of open heart surgery is not described in the literature and no consensus is reached regarding ideal age of repair, operative techniques and timing of intervention (staged or simultaneous repair). Several papers have proposed a variety of operative approaches for simultaneous repair of pectus excavatum and open cardiac surgery4,5,6. Therefore, the aim of this report is to describe our technique in detail and present our results using a modified Nuss procedure ad modum Pilegaard (mNaP) for single-stage correction of pectus excavatum and open-heart surgery.
Technique From 2008 to 2012, 4 patients underwent single-stage cardiac procedure through a median sternotomy and pectus excavatum repair. The four selected cases met the following inclusion criteria: cardiac disease requiring surgical intervention, diagnosed with severe pectus excavatum, operative plan was to perform both procedures as a single-stage procedure and thoracic approach through a median sternotomy.
Details of the approach used for the pectus excavatum repair are as follows. A 30-degrees videothoracoscope was inserted into the right pleural space to define the deepest point under the funnel chest. A template was formed to shape the anterior thoracic wall and a pectus bar was bent to match the template. Routinely, short and asymmetric bars are used at our institution2. At the level of the deepest point subcutaneous tunnels were created from the anterior axillary line to the highest points of the funnel. An introducer was inserted into the preformed subcutaneous tunnel from the right and entered the thoracic cavity
3
just medially of the highest point of the funnel. The introducer was advanced across the mediastinum anterior to the pericardium to exit just medially of the highest point of the funnel at the left side. The prefitted pectus bar was placed in the preformed tunnel asymmetrically to the right, however, if an acceptable correction could not be achieved using one bar an additional bar was introduced in similar fashion7. A 0ethibond suture was attached to one end of the pectus bar and the bar was pulled out of the patient leaving the suture(s) in the tunnel(s). The heart procedures were performed through a classic median sternotomy. The 0-ethibond suture(s) remained in the preformed chest wall tunnels throughout the cardiac procedure. After the closure of the median sternotomy using stainless-steel wires and suturing of the skin, (Fig. 1 A and B) the pre-formed pectus bar was attached to the 0-ethibond suture and pulled through the pre-formed tunnel with the convex side facing the pericardium. Finally, the pectus bar was rotated 180 degrees lifting the osteosynthesized sternum upward (Fig. 1 C). The pectus bar was secured at the right and left side with 0polydioxane and one stabilizer at the left side to avoid rotation. Close monitoring on intensive care unit was performed on all patients postoperatively and pain control was managed by epidural block.
Perioperative complications and outcomes Due to excessive perioperative bleeding, the placement of pectus bars was postponed in patient no. 2 to the 3rd postoperative day but the 0-ethibond suture remained in the chest wall tunnels until bar insertion. Reoperation was performed on patient no. 2 due to a pericardial hematoma with the pectus bars in situ. The inferior part of the sternotomy incision was opened and the hematoma was evacuated by suction through a subxiphoid access. Patient no. 4 underwent pericardiocentesis due to pericardial effusion while patient no. 2 and 3 developed pleural effusion, which in both cases was evacuated by pleurocentesis. Patient no. 1 developed a superficial skin infection at sternum and patient no. 4 an infection without focus, which in both cases were treated sufficiently with antibiotics. All four patients had the bars removed after 25-36 months and without complications and with excellent cosmetic results. Pre- and postoperative chest x-rays of one of the patients are shown in Fig. 2 and Fig. 3, respectively. A deep PE is corrected with two asymmetric short bars and two stabilizers.
4
Comment The present report demonstrates that combining correction of pectus excavatum and open-heart surgery in a single-stage procedure can be accomplished safely and with excellent cosmetic results. To our knowledge only Casamassima et al.4 have previously presented larger case series of concurrent repair of pectus excavatum and open-heart surgery using the Nuss procedure. However, the pectus correction was performed at the end of the cardiac procedure before sternum closure creating a sternal angulation of the cut edges of the bisected sternum and consequently inadequate apposition (Fig. 1 D), which in the paper of Casamassima et al.4 had to be revised longitudinally before closure. The advantage of the described mNaP procedure in this report is a “close to” standard pectus correction before open heart surgery and an optimal anatomical adhesion of the sternum edges before lifting the sternum to the planned position (Fig. 1 C). Moreover, in all four patients the sternum was stable after pectus correction. Furthermore, the minimized surgical procedure after patients were weaned from bypass, reduce the risk of bleeding. The use of shorter bars placed asymmetrically is in contrast to the ones originally described by Dr. Nuss and facilitated placement of both bar and stabilizer. Moreover, this modification also made removal of bar and stabilizer easy and often possible with only one incision at the side of which the stabilizer was placed. The postoperative complications reported in this report is common to all open-heart surgeries and were not directly attributed to the mNaP procedure. Although, this report only includes 4 patients it seems reasonable to state that the mNaP procedure used in this report can be performed safely and effectively with open heart surgery in a single-stage procedure in adults.
5
FIGURE LEGENDS Figure 1. Illustration of the single-stage technique. A: the open sternum prior to closure. B: closure of the sternum with steel wires. C: insertion of pectus bar after closure of the sternum guided by the preinserted 0ethibond sutures. D: the risk of inadequate apposition of the bisected sternal edges when the pectus bar is inserted prior to closure of the sternum.
Figure 2. Preoperative chest x-ray showing the deep PE configuration.
Figure 3. Postoperative chest-x-ray showing two short, asymmetric pectus bars and stabilizers correcting the deep PE configuration. A chest tube in the pericardium in also seen in situ.
6
REFERENCES 1.
Kelly RE, Lawson ML, Paidas CN, Hruban RH. Pectus excavatum in a 112-year autopsy
series: Anatomic findings and the effect on survival. J Pediatr Surg. 2005;40(8):1275-1278. doi:10.1016/j.jpedsurg.2005.05.010 2.
Pilegaard HK. Single centre experience on short bar technique for pectus excavatum. Ann
Cardiothorac Surg. 2016;5(5):450-455. doi:10.21037/acs.2016.09.05 3.
Park HJ, Lee SY, Lee CS, Youm W, Lee KR. The Nuss procedure for pectus excavatum:
Evolution of techniques and early results on 322 patients. Ann Thorac Surg. 2004;77(1):289-295. doi:10.1016/S0003-4975(03)01330-4 4.
Sacco Casamassima MG, Wong LL, Papandria D, et al. Modified nuss procedure in
concurrent repair of pectus excavatum and open heart surgery. Ann Thorac Surg. 2013;95(3):1043-1049. doi:10.1016/j.athoracsur.2012.11.007 5.
Schmidt J, Redwan B, Keosek V, et al. Pectus Excavatum and Cardiac Surgery: Simultaneous
Correction Advocated Joachim. Thorac Cardiovasc Surg. 2014;62:238-244. doi:10.1055/s-0031-1297913 6.
Jaroszewski DE, Gustin PJ, Haecker FM, et al. Pectus excavatum repair after sternotomy: The
Chest Wall International Group experience with substernal Nuss bars. Eur J Cardio-thoracic Surg. 2017;52(4):710-717. doi:10.1093/ejcts/ezx221 7.
Hoffmann, T; Vad, H; de Paoli F. Correction of pectus excavatum using the modified Nuss
procedure, ad modum Pilegaard. Multimed Man Cardio-Thoracic Surg. 2018. https://mmcts.org/tutorial/1015.
7
S0003-4975(19)31268-8
DOI:
https://doi.org/10.1016/j.athoracsur.2019.07.043
Reference:
ATS 32966
To appear in:
The Annals of Thoracic Surgery
Received Date: 19 June 2019 Revised Date:
11 July 2019
Accepted Date: 11 July 2019
Please cite this article as: Media AS, Pilegaard HK, Vincenzo de Paoli F, Combining correction of pectus excavatum and open heart surgery in a single-stage procedure, The Annals of Thoracic Surgery (2019), doi: https://doi.org/10.1016/j.athoracsur.2019.07.043. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by The Society of Thoracic Surgeons
Combining correction of pectus excavatum and open heart surgery in a single-stage procedure Short Title: Pectus Excavatum and Open Heart Surgery
Ara Shwan Media1, MD, Hans K. Pilegaard1,3, MD, Frank Vincenzo de Paoli1,2, MD, PhD
1
Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, DK-
8200 Aarhus N, Denmark; 2 Department of Biomedicine, Aarhus University, DK-8000 Aarhus C, Denmark
Corresponding Author: Frank de Paoli Department of Biomedicine Aarhus University
Ole Worms Allé, Aarhus DK-8000 Denmark E-mail: [email protected]
Word count: 1500
1
Abstract The presence of pectus excavatum (PE) in patients undergoing open heart surgery is rare and no consensus has been reached regarding the surgical approach. Thus, in this paper we present in details a single-stage procedure for correction of PE with the modified Nuss procedure ad modum Pilegaard in four patients undergoing open heart surgery. Three of four patients successfully underwent the single stage-procedure. At follow-up after bar removal, all patients had no complications related to the Nuss bar and all with excellent cosmetic results.
Key Words: Pectus excavatum, Cardiac Surgery, single-stage, Nuss Procedure
2
Pectus excavatum is the most common chest wall deformity in children and often an isolated abnormality with an incidence of 1:3-400 in new-born males1. For decades the traditional repair of pectus excavatum was an open Ravitch technique with resection of cartilage, however, repair of pectus excavatum by employing a retrosternal metal bar (Nuss procedure), is now a well-established operative procedure for correction2,3. By employing this minimally invasive repair the anterior chest wall is remodelled avoiding cartilage resection, and has gained general acceptance as the preferred method for pectus excavatum repair, featuring small skin incisions, a shorter operation time, minimal blood loss and early return to full activity. The incidence of concomitant pectus excavatum and cardiovascular diseases in need of open heart surgery is not described in the literature and no consensus is reached regarding ideal age of repair, operative techniques and timing of intervention (staged or simultaneous repair). Several papers have proposed a variety of operative approaches for simultaneous repair of pectus excavatum and open cardiac surgery4,5,6. Therefore, the aim of this report is to describe our technique in detail and present our results using a modified Nuss procedure ad modum Pilegaard (mNaP) for single-stage correction of pectus excavatum and open-heart surgery.
Technique From 2008 to 2012, 4 patients underwent single-stage cardiac procedure through a median sternotomy and pectus excavatum repair. The four selected cases met the following inclusion criteria: cardiac disease requiring surgical intervention, diagnosed with severe pectus excavatum, operative plan was to perform both procedures as a single-stage procedure and thoracic approach through a median sternotomy.
Details of the approach used for the pectus excavatum repair are as follows. A 30-degrees videothoracoscope was inserted into the right pleural space to define the deepest point under the funnel chest. A template was formed to shape the anterior thoracic wall and a pectus bar was bent to match the template. Routinely, short and asymmetric bars are used at our institution2. At the level of the deepest point subcutaneous tunnels were created from the anterior axillary line to the highest points of the funnel. An introducer was inserted into the preformed subcutaneous tunnel from the right and entered the thoracic cavity
3
just medially of the highest point of the funnel. The introducer was advanced across the mediastinum anterior to the pericardium to exit just medially of the highest point of the funnel at the left side. The prefitted pectus bar was placed in the preformed tunnel asymmetrically to the right, however, if an acceptable correction could not be achieved using one bar an additional bar was introduced in similar fashion7. A 0ethibond suture was attached to one end of the pectus bar and the bar was pulled out of the patient leaving the suture(s) in the tunnel(s). The heart procedures were performed through a classic median sternotomy. The 0-ethibond suture(s) remained in the preformed chest wall tunnels throughout the cardiac procedure. After the closure of the median sternotomy using stainless-steel wires and suturing of the skin, (Fig. 1 A and B) the pre-formed pectus bar was attached to the 0-ethibond suture and pulled through the pre-formed tunnel with the convex side facing the pericardium. Finally, the pectus bar was rotated 180 degrees lifting the osteosynthesized sternum upward (Fig. 1 C). The pectus bar was secured at the right and left side with 0polydioxane and one stabilizer at the left side to avoid rotation. Close monitoring on intensive care unit was performed on all patients postoperatively and pain control was managed by epidural block.
Perioperative complications and outcomes Due to excessive perioperative bleeding, the placement of pectus bars was postponed in patient no. 2 to the 3rd postoperative day but the 0-ethibond suture remained in the chest wall tunnels until bar insertion. Reoperation was performed on patient no. 2 due to a pericardial hematoma with the pectus bars in situ. The inferior part of the sternotomy incision was opened and the hematoma was evacuated by suction through a subxiphoid access. Patient no. 4 underwent pericardiocentesis due to pericardial effusion while patient no. 2 and 3 developed pleural effusion, which in both cases was evacuated by pleurocentesis. Patient no. 1 developed a superficial skin infection at sternum and patient no. 4 an infection without focus, which in both cases were treated sufficiently with antibiotics. All four patients had the bars removed after 25-36 months and without complications and with excellent cosmetic results. Pre- and postoperative chest x-rays of one of the patients are shown in Fig. 2 and Fig. 3, respectively. A deep PE is corrected with two asymmetric short bars and two stabilizers.
4
Comment The present report demonstrates that combining correction of pectus excavatum and open-heart surgery in a single-stage procedure can be accomplished safely and with excellent cosmetic results. To our knowledge only Casamassima et al.4 have previously presented larger case series of concurrent repair of pectus excavatum and open-heart surgery using the Nuss procedure. However, the pectus correction was performed at the end of the cardiac procedure before sternum closure creating a sternal angulation of the cut edges of the bisected sternum and consequently inadequate apposition (Fig. 1 D), which in the paper of Casamassima et al.4 had to be revised longitudinally before closure. The advantage of the described mNaP procedure in this report is a “close to” standard pectus correction before open heart surgery and an optimal anatomical adhesion of the sternum edges before lifting the sternum to the planned position (Fig. 1 C). Moreover, in all four patients the sternum was stable after pectus correction. Furthermore, the minimized surgical procedure after patients were weaned from bypass, reduce the risk of bleeding. The use of shorter bars placed asymmetrically is in contrast to the ones originally described by Dr. Nuss and facilitated placement of both bar and stabilizer. Moreover, this modification also made removal of bar and stabilizer easy and often possible with only one incision at the side of which the stabilizer was placed. The postoperative complications reported in this report is common to all open-heart surgeries and were not directly attributed to the mNaP procedure. Although, this report only includes 4 patients it seems reasonable to state that the mNaP procedure used in this report can be performed safely and effectively with open heart surgery in a single-stage procedure in adults.
5
FIGURE LEGENDS Figure 1. Illustration of the single-stage technique. A: the open sternum prior to closure. B: closure of the sternum with steel wires. C: insertion of pectus bar after closure of the sternum guided by the preinserted 0ethibond sutures. D: the risk of inadequate apposition of the bisected sternal edges when the pectus bar is inserted prior to closure of the sternum.
Figure 2. Preoperative chest x-ray showing the deep PE configuration.
Figure 3. Postoperative chest-x-ray showing two short, asymmetric pectus bars and stabilizers correcting the deep PE configuration. A chest tube in the pericardium in also seen in situ.
6
REFERENCES 1.
Kelly RE, Lawson ML, Paidas CN, Hruban RH. Pectus excavatum in a 112-year autopsy
series: Anatomic findings and the effect on survival. J Pediatr Surg. 2005;40(8):1275-1278. doi:10.1016/j.jpedsurg.2005.05.010 2.
Pilegaard HK. Single centre experience on short bar technique for pectus excavatum. Ann
Cardiothorac Surg. 2016;5(5):450-455. doi:10.21037/acs.2016.09.05 3.
Park HJ, Lee SY, Lee CS, Youm W, Lee KR. The Nuss procedure for pectus excavatum:
Evolution of techniques and early results on 322 patients. Ann Thorac Surg. 2004;77(1):289-295. doi:10.1016/S0003-4975(03)01330-4 4.
Sacco Casamassima MG, Wong LL, Papandria D, et al. Modified nuss procedure in
concurrent repair of pectus excavatum and open heart surgery. Ann Thorac Surg. 2013;95(3):1043-1049. doi:10.1016/j.athoracsur.2012.11.007 5.
Schmidt J, Redwan B, Keosek V, et al. Pectus Excavatum and Cardiac Surgery: Simultaneous
Correction Advocated Joachim. Thorac Cardiovasc Surg. 2014;62:238-244. doi:10.1055/s-0031-1297913 6.
Jaroszewski DE, Gustin PJ, Haecker FM, et al. Pectus excavatum repair after sternotomy: The
Chest Wall International Group experience with substernal Nuss bars. Eur J Cardio-thoracic Surg. 2017;52(4):710-717. doi:10.1093/ejcts/ezx221 7.
Hoffmann, T; Vad, H; de Paoli F. Correction of pectus excavatum using the modified Nuss
procedure, ad modum Pilegaard. Multimed Man Cardio-Thoracic Surg. 2018. https://mmcts.org/tutorial/1015.
7