40-year experience in surgical treatment of congenital chest deformations--ethiopathogenesis, operative techniques and clinical results.
PURPOSE OF THE STUDY: The aim of this study was to assess the results of surgical treatment of 58 patients with pectus excavatum and 11 with pectus carinatum and discuss the problems connected with ethiopathogenesis and operative techniques. MATERIAL: 69 chest deformations treated between 1961-2001. METHODS: The clinical results were analyzed with 1) Kopera-Król Rtg-index, 2) Gizycka's Rtg-index of chest flattening, 3) Haller and Nakahara CT-index, 4) Heart position after operation, 5) Frequency of upper respiratory infections, 6) Appearance of postoperative scar, 7) Patient's opinion. Histopathological investigations were used to assess ethiopathogenesis of chest deformations. RESULTS: 90% permanent correction achieved in group of patients operated in the age from 12 to 17. Otherwise we noted between the patients who were operated in the age from 6 to 10-37% recurrence of deformity. Generally we had 70% excellent and good results. The opinion of patients (including cosmetics effects, psychical state and exercise tolerance) was much better-86.6%. Particularly correction of pectus carinatum gives good cosmetics effects as well as improvement of exercise tolerance. DISCUSSION: Nuss modified correction employing a substernal stabilizing plate is an alternative for transsternal traction in the classical Ravitsch' procedure. Authors present advantages and disadvantages of both methods. The optimal age for surgical correction and inter and post operative procedure are discussed. CONCLUSIONS: Ethipathogenesis of pectus excavatum and carinatum remains unsettled. Disturbances in endochondral ossification and growth of costal cartilage seem to be more probable cause of the deformities than diaphragm underdevelopment. Mild and severe forms of the two deformities result in circulatory-respiratory malfunctions, cosmetic defects and psychical problems. Due to possible circulatory-respiratory disorder, appropriate premedication as well as intra- and postoperative monitoring of RR, ECG, O2, CO2 are very important on the first day after the surgery. Ravistch-Garnier procedure for pectus excavatum and Chen procedure for pectus carinatum remain operations of choice. Transsternal traction can be replaced with internal stabilisation with a bar placed under the sternum what considerably reduces the time of hospitalisation but requires one more hospitalisation to remove the bar. Correction of pectus carinatum is permanent, correction of pectus excavatum turned out to be permanent in 90% cases providing that they were performed in patients aged 12-16. When patients were at the age 6-10, recurrence of the deformity occurred in 37% of cases. According to the clinical assessment, in both age groups, the proportion of very good or good scores equalled 70% and according to patient's evaluation--86.6%.