Case report-Every thoracic surgeon's nightmare: cardiac and lung perforation during placement of Nuss bar for pectus excavatum

Case Report: Double Pectus Up in severe pectus excavatum, the new frontier of modified taulinoplasty

Introduction

Pectus excavatum, also known as "sunken chest" or "funnel chest," is a congenital condition where the sternum caves inward, creating a noticeable depression in the chest. This deformity can range from mild to severe cases, and can affect appearance and lung and heart function. Treatment options vary depending on the severity of the condition and associated symptoms. A case study was conducted on three patients suffering from severe forms of pectus excavatum using modified taulinoplasty with two Pectus Up bars.

Case description

The patients were males, with an age of 15 years. Preoperatively, they underwent spirometry, an echocardiogram, and allergy tests. The procedure involved inserting two Pectus Up bars into the chest wall at the major sternal defect, allowing the implant to remain completely invisible. The procedure involved placing the sternal plate at the deepest point and anchored to the sternum with five self-tapping screws. The chest plate was then fixed to the bar using two screws.

Discussion

The use of Pectus Up was first reported in 2016 and has been a subject of scientific discussion and research. The double Pectus Up technique offers improved correction, increased stability, and reduced complications. However, it also presents challenges such as increased technical complexity and potential for prolonged operative times. Patient outcomes showed promising results in terms of short-term correction and long-term stability. The use of a double bar technique in the modified Taulinoplasty procedure is a key area of ongoing clinical research and innovation in pectus excavatum repair. Further studies will be needed, including more institutions that use this technique to validate our initial experience.

Recent Advancements in Pectus Surgery: Crane Lifting, Multiple-Bar Approach, Bridge Stabilization, and Sandwich Technique

PURPOSE

The most recent procedure for pectus excavatum repair involves crane-powered entire chest wall remodeling, which employs crane lifting, multiple-bar approach, bridge stabilization, and sandwich techniques. This resulted in a paradigm shift in pectus deformity repair from merely lifting the sunken bone to remodeling the chest wall into normal anatomy.

METHODS

We analyzed 649 patients who underwent surgery for pectus excavatum or complex combined deformities between March 2018 and January 2022. A crane with sternal wiring or screwing was used to lift the chest wall without using the pectus bar turning power. Multiple bars with bridge connections were placed to eliminate bar displacement. Modified sandwich techniques were applied to relieve the lower coastal flare (flare-buster) and focal protuberance (magic string).

RESULTS

The mean age of the patients included in the study was 12.2 years (range: 3-45 years). A single bar was used for 202 patients until 2021. For the multiple-bar technique, parallel bars (n = 142), crossbars (n = 166), and crossbars plus upper horizontal bars (XI pattern; n = 139) were used. The overall complication rate was 6.2 %. There was no cases of bar displacement were observed, but other minor complications such as pneumothorax (n = 20, 3.1 %), pleural effusion (n = 7, 1.1 %), and wound infection (n = 5, 0.8 %) were detected. Three patients required reoperation (infection, two: hemorrhage, one).

CONCLUSIONS

The crane-powered entire chest wall remodeling technique improved the safety and comprehensiveness of the repair procedure. By incorporating bridge stabilization and the use of multiple bars, we effectively resolved the issues related to bar displacement and incomplete repair.

TYPE OF STUDY

Retrospective Cohort Study.

LEVEL OF EVIDENCE: 3