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J Thorac Cardiovasc Surg 2000;119:176-178
© 2000 Mosby, Inc.

BRIEF COMMUNICATIONS

BIOABSORBABLE WEAVE TECHNIQUE FOR REPAIR OF PECTUS EXCAVATUM

From The Department of Cardiothoracic Surgery, Brooke Army Medical Center, Fort Sam Houston,^b and the Department of General Surgery, Wilford Hall Medical Center, Lackland Air Force Base,^a Tex.

Presented at the Sixty-Fourth Annual International Scientific Assembly of the American College of Chest Physicians, Toronto, November 10, 1998.

Address for reprints: Henry F. Tripp, MD, Lieutenant Colonel, Department of Cardiothoracic Surgery, MCHE-SDC, Building 3600, 3851 Roger Brooke Dr, Fort Sam Houston, TX 78234 (E-mail: HTrippMD{at}aol.com).

The risk of recurrent deformity after repair of pectus excavatum has led many surgeons to use some form of posterior support. Various methods have been developed, including the use of stainless steel struts, Kirschner wires, autologous ribs, and mesh. When metallic supports are used, uncommon yet serious complications may occur. Reported adverse consequences of these devices have included migration into the peritoneal cavity, laceration of the phrenic artery and hemorrhage, and migration through the pericardium causing tamponade, valvular damage, septal perforation, and thrombus formation with systemic embolic events. ^1-5 Most surgeons remove these devices at a later date, thereby necessitating a second operation.

We have developed a bioabsorbable weave technique that is easy to perform and requires no subsequent procedure for implant removal. Polydioxanone (PDS, Ethicon, Inc, Somerville, NJ) is used as horizontal mattress sutures running beneath the sternum for support. The results of this technique were compared with those in a group of patients at our institution who underwent repair during the same period with a metal bar support technique. The patients were not randomized as to the type of repair.

Methods
The surgical technique involves a transverse submammary or vertical midline incision, detachment of the pectoralis muscles, and subperichondrial resection of all involved costal cartilages. The sternal attachments of the perichondrial sheaths and intercostal muscle bundles are preserved. An anterior wedge osteotomy is performed, with sternal elevation and suture fixation at the osteotomy site. Sternal support at our institution historically has consisted of metal bars or autologous rib. The new modification consists of No. 1 polydioxanone suture as a horizontal mattress suture incorporating pectoralis fascia and perichondrium, running beneath the sternum to maintain elevation, and incorporating the contralateral perichondrium and pectoralis fascia at the same level. This suture is then continued in the opposite direction through the same planes of the lower adjacent perichondrial sheath before being tied. Two such mattress sutures are currently used, incorporating the resected perichondrial beds of the third and fourth costal cartilages and of the fifth and sixth costal cartilages, respectively(Fig 1). Flat suction drains are placed subcutaneously before wound closure.

View larger version (25K): [in this window] [in a new window]   Fig. 1. Diagram of the repair technique as described. In the lower part of the diagram the right pectoralis muscle and fascia are cut away. The horizontal mattress sutures are passed through the pectoralis fascia and through the perichondrium of the resected third costal cartilage. The suture is then passed underneath the sternum, with care to avoid the internal thoracic arteries, and back up through the same structures on the contralateral side. The suture is then passed once again through the pectoralis fascia and through the lower adjacent fourth perichondrial sheath on the same side, carried beneath the sternum once again, and brought out in a similar fashion before being tied. The same steps are repeated incorporating the fifth and sixth perichondrial sheaths. As shown in the upper end view, the sternum is supported in an anatomic position by the suture, which passes through the pectoralis fascia and perichondrial sheaths on each side of the sternum. The pectoralis fascia may be approximated in the midline over the sternum at the completion of the repair.

Results
Over the past 4 years, 12 patients underwent repair of pectus excavatum at Wilford Hall Medical Center. (During this time 2 patients underwent repair of pectus carinatum and neither required posterior support.) Cosmetic correction was the major indication for repair in all patients, although many patients did report exercise impairment before the operation. Ages ranged from 4 to 26 years, with a median age of 15 years. Sternal support consisted of 4 metal bars, 1 autologous rib, and in 7 patients a variation of the new technique with polydioxanone suture. Three of 4 metal bars were removed at subsequent procedures.

Follow-up was obtained on 11 of the 12 patients (no follow-up was available on the patient with the autologous rib support). The average length of follow-up was 29 months.

Early cosmetic results were described as excellent in all patients with metal bar support (4/4) and polydioxanone suture support (7/7). One late recurrence occurred in each group. Preoperative exercise impairment was noted in 2 of 4 patients with metal bar support and was improved in both after the operation. Preoperative exercise impairment was noted also in 6 of 7 patients who underwent polydioxanone suture support and was improved in 5 of these 6 patients after the operation.

Discussion
The described technique is easy to perform and its results compare well with rigid fixation, without the need for the subsequent removal or the risk of migration of the metallic device. Polydioxanone suture is readily available, pliable, strong (86% stronger than Prolene suture at the time of implantation), and has a tensile strength half-life of 6 weeks. ⁶ It induces minimal foreign body reaction and is degraded by hydrolysis. With this technique, posterior support is provided during the healing phase, and the entire blood supply of the sternum is preserved. Overcorrection of pectus excavatum, as with a convex posterior support, has been advocated by some but is unnecessary. The "hammock repair" of posterior mesh support has been used successfully by Robicsek ⁷ in a large series of patients. This type of repair supports the entire sternum, particularly the portion near the osteotomy, which is the fulcrum of the repair. Tension is more evenly distributed and the angle of repair need not be exaggerated. It is also believed that preserving the sternal blood supply reduces complications.

Conclusion
Excellent cosmetic results can be achieved in the repair of pectus excavatum with polydioxanone suture used as the posterior support. A single recurrence of deformity has occurred in the early limited use of this technique. This modification may be useful to surgeons who wish to avoid the use of metallic devices for support.

Footnotes

The views expressed in this article are those of the authors and do not represent the policies of the Department of Defense or other US government agencies.

References

1. Stefani A, Morandi U, Lodi R. Migration of pectus excavatum correction metal support into the abdomen. Eur J Cardiothorac Surg 1998;14:434-6.[Abstract/Free Full Text]
   
2. Paret G, Taustein I, Vardi A, Yellin A, Dekel B, Barzilay Z. Laceration of the phrenic artery: a life-threatening complication after repair of pectus excavatum. J Cardiovasc Surg 1996;37:193-4.[Medline]
   
3. Elami A, Lieberman Y. Hemopericardium: a late complication after repair of pectus excavatum. J Cardiovasc Surg 1991;32:539-40.[Medline]
   
4. Dalrymple-Hay MJ, Calver A, Lea RE, Monro JL. Migration of pectus excavatum correction bar into the left ventricle. Eur J Cardiothorac Surg 1997;12:507-9.[Abstract]
   
5. Pircova A, Sekarski-Hunkeler N, Jeanrenaud X, Ruchat P, Sadeghi H, Frey P, et. al. Cardiac perforation after surgical repair of pectus excavatum. J Pediatr Surg 1995;30:1506-8.[Medline]
   
6. Ray JA, Doddi N, Regula D, Williams JA, Melveger A. Polydioxanone (PDS), a novel monofilament synthetic absorbable suture. Surg Gynecol Obstet 1981;153:497-507.[Medline]
   
7. Robicsek F. Pectus excavatum and carinatum. In: Grillo HC, Austen WG, Wilkins EW, Mathisen DJ, Vlahakes GJ. Current therapy in cardiothoracic surgery. Toronto: BC Decker; 1989. p. 87-8.
   

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