J Thorac Cardiovasc Surg 1995;110:277-278
© 1995 Mosby, Inc.
Treatment of pectus excavatum: Bioabsorbable or metal strut?
Guglielmo M. Actis Dato, MD,
Michele Di Summa, MD,
Alberto Actis Dato, MD,
Giuseppe Zattera, MD,
Guglielmo Fortunato, MD
Italian Institution of Cardiac Surgery
Via Genova, 4
10126 Torino, Italy
To the Editor:
We appreciate the article by Matsui and colleagues
1 reporting their use of a bioabsorbable poly-L-lactide strut for chest wall reconstruction in 23 patients with chronic sternal dehiscence and 33 patients with pectus excavatum. Use of this material is an alternative to temporary fixation by a metal strut, which requires surgical removal at a variable period after implantation. However, 6% of the patients with pectus excavatum treated with poly-L-lactide needed the strut to be removed because of overgrowth of granulation tissue around the poly-L-lactide, maybe because the bioabsorbable strut was not thick enough to support the severe chest deformity.
Since 1958 we have treated pectus excavatum by means of a personal technique (Actis Dato-Panero) involving internal strut fixation by a self-retaining seagull wing prosthesis. 2 The surgical technique consists of a longitudinal and a transverse sternotomy in the higher portion of the convex zone and in the most depressed sternal portion. After this osteotomy a wedge resection of the ribs is performed to allow easier displacement of the sternal fragments (Fig. 1).
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Fig. 1. Surgical technique of implantation of seagull wing prosthesis. The body of the prosthesis sustains the sternum and the wings are positioned over the ribs. Note the incomplete transection of the ribs to avoid any malposition of the fragments.
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A stainless steel strut (Sorin Biomedica, Saluggia, Vercelli, Italy) of appropriate size, molded into a seagull wing, is then positioned under the sternum, allocated over the ribs with its lateral wings. Sternal resections act like a hinge mechanism allowing a good correction. Few steel wires are used to stabilize the sternal fragments.
The design of this self-retaining prosthesis allows good support, and the prosthesis can be removed after 8 to 12 months through a small skin incision with local anesthesia in a day hospital (Fig 2).
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Fig. 2. Surgical removal of the prosthesis can be obtained by gentle traction, thanks to the particular composition of the strut (AISI 316 steel), with local anesthesia.
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A recent review of the records of 315 patients operated on with this technique (1958 to 1991) showed a low incidence of complications immediately after the operation and at long-term follow-up (Table I). We did not observe any impairment of chest wall growth when the strut was extracted after 12 months. 3
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Table I. Complications and esthetic results at follow-up in 315 patients with pectus excavatum in whom a self-retaining seagull wing prosthesis was (1958 to 1991)
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We have some reservations about using the bioabsorbable strut as an alternative to the metal strut.
- The use of a bioabsorbable material will always induce undesirable reactions, often impossible to foresee, because different patients have different reactions. By contrast, a metal strut has good biologic tolerance and does not induce rejection.
- To obtain good consolidation after a large resection of the sternum and the ribs for chest deformity, a stabilization period of 6 to 8 months is often desirable because of the tendency for regression. The bioabsorbable strut cannot ensure more than 3 months of stabilization, but a metal strut can remain in place for 1 year with no problems for the patient.
- An external strut, like the bioabsorbable strut proposed by Matsui and associates, requires an extensive dissection of the anatomic planes to allow implantation. Internal fixation by the low-profile seagull wing prosthesis allows a minimal anatomic dissection.
- Cost and availability of the poly-L-lactide bioabsorbable strut are unknown. The seagull wing prosthesis can be crafted in house and the cost is a few dollars for each prosthesis.
We congratulate Matsui and colleagues for their innovative technique, but we will wait for long-term follow-up. Chest wall deformity can recur after several years.
In our experience, the seagull wing prosthesis is safe, economical, easy to implant and remove, and comfortable for the patient, and it does not traumatize the chest tissues. Moreover, it gives good results and recurrence of chest wall deformity is virtually nonexistent.
References
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Matsui T, Kitano M, Nakamura T, Shimizu Y, Hyon S-H, Ikada Y. Bioabsorbable struts made from poly-L-lactide and their application for treatment of chest deformity. J THORAC CARDIOVASC SURG 1994;108:162-8.[Abstract/Free Full Text]
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Actis Dato A, Gentilli R, Calderini P II. Pectus excavatum. Diagnostica e terapia. Turin, Italy: Minerva Medica, 1962.
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Actis Dato GM, De Paulis R, Actis Dato A Jr, et al. Correction of pectus excavatum with a sea gull wing prosthesis: long term follow-up. Chest [In press].
