Hyung Joo Park, MD, Kyung Soo Kim, MD, Sungsoo Lee, MD, and Hyun Woo Jeon, MD Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University, and Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, College of Medicine, Yonsei University, Seoul, Korea
Background. When performing pectus excavatum repair using a pectus bar, stabilization of the bar is crucial. However, since 2007, we have been developing new devices to achieve a bar dislocation rate of zero. The purpose of this study is to determine whether our next-generation approach makes it possible to achieve our goal. Methods. We analyzed the results of various bar fixation techniques in a patient cohort of 1,816 consecutive pectus excavatum repairs using a pectus bar between 1999 and 2012. Techniques that have been evolving were a stabilizer (STB, 1999); multipoint pericostal suture fixation (MPF, 2001); and the new devices: claw fixator (CFT, 2007) and hinge plate (HP, 2009). The claw fixator is used for sutureless bar fixation by hooking the rib with blades, whereas the hinge plate prevents intercostal muscle stripping at the hinge points. Patients were divided into groups according to the technique used, and the outcomes were compared.
Results. Early bar dislocation rates were as follows: STB 3.33% (6 of 180), MPF 0.56% (4 of 760), CFT 0.57% (4 of 699), and CFTDHP 0% (0 of 177; p [ 0.002). Reoperation rates were as follows: STB 5% (9 of 180), MPF 1.57% (12 of 760), CFT 2.10% (11 of 699), and CFTDHP 3.38% (6 of 177; p [ 0.042). Total complication rates were also lower in the CFTDHP group (14.1%, 25 of 177) than the STB group (22.7%, 41 of 180; p < 0.01). Conclusions. By using the next-generation approach with the claw fixator plus hinge plate rather than the conventional stabilizer, we were able to reduce the bar dislocation rate and complications. We recommend that the conventional stabilizer be replaced with the claw fixator and hinge plate.
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mechanisms from the patients would enable this goal to be achieved. Our purpose in this study was to compare the various bar fixation techniques we have been using in our practice to determine the best way to fix the pectus bar.
tability of the pectus bar after pectus excavatum repair is a crucial determinant of the success of the repair [1, 2]. Unfortunately, however, the learning curve for this operation is steep. In earlier reports, bar displacement rates ranged from 5% to 20% [3, 4]; we consider these numbers unacceptably high. Inexplicably, however, little effort has been devoted to make this procedure more reproducible since the introduction of this technique a decade ago, and the only device invented is the stabilizer [5]. Although the stabilizer does improve stability, the bar dislocation rate is high (approximately 5%) even in large clinical series [5]. We adopted the stabilizer after its introduction and used it routinely in 180 consecutive patients, but we could not reduce the pectus bar displacement rate to an acceptable level. Thereafter, we have focused on developing novel techniques and devices for reliable pectus bar fixation [6]. Our goal for pectus bar stabilization is a displacement rate of zero. Total elimination of potential bar dislocation Accepted for publication Aug 7, 2014. Presented at the Poster Session of the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26-30, 2013. Address correspondence to Dr Park, Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University, 222 Banpo-Daero, Seocho-Gu, Seoul 137-701, Korea; e-mail:
[email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;99:455–61) Ó 2015 by The Society of Thoracic Surgeons
Patients and Methods We analyzed data from a cohort of 1,816 consecutive pectus excavatum repairs performed using pectus bars between 1999 and 2012. The mean age of the patients was 10.3 years (range, 16 months to 53 years). The male-female ratio was 3.9, and 402 patients were adults (>15 years; 21.4%). A systematic index system calculated from a computed tomography scan [7, 8] and morphologic classification [9] has been used for three-dimensional evaluation of the morphology and for setting up a repair plan. In accordance with those evaluations, we have been dealing with different types of pectus excavatum with specifically designed pectus bars for each type of asymmetric deformity (Fig 1). Particularly, for pectus bar stabilization, we have made great effort on development of techniques and devices. The technique included use of a stabilizer in the early period and then multipoint pericostal suture fixation since 2001. In 2007, we developed a new device, the claw fixator, which enables fixation of the pectus bar to the rib not by suturing but by hooking with a metal blade that prevents bar flipping (type 1 and 2 bar displacement) [10]. In 2009, we developed a hinge plate to prevent intercostal muscle 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.026
GENERAL THORACIC
A Next-Generation Pectus Excavatum Repair Technique: New Devices Make a Difference
GENERAL THORACIC
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Ann Thorac Surg 2015;99:455–61
Fig 1. Repair of asymmetric pectus excavatum with morphology-tailored bar shaping technique. (A) Repair of eccentric asymmetry with asymmetric bar. (B) Repair of unbalanced asymmetry with seagull-shaped bar. (C) Bar shaping method according to terrain contour matching on the patient’s chest wall.
stripping (type 3 bar displacement) [10] by supporting the hinge points. To compare the results of each fixation technique, patients were divided into four groups: a stabilizer group (STB, n ¼ 180); a multipoint pericostal suture fixation group (MPF, n ¼ 760), a claw fixator group (CFT, n ¼ 699); and a claw fixator plus hinge plate group (CFTþHP, n ¼ 177). Demographic characteristics of the patients among groups are presented in Table 1.
Operative Technique The patient is placed in the supine position, and both arms are hung freely to the ether screen with arm slings to avoid
brachial plexus stretch injury. The deepest point of the chest wall depression is marked first, and the bilateral hinge points (points where the pectus bar enters the pleural cavity) are determined. The distance between both midaxillary lines is measured to determine the size of the pectus bar. The skin incision is made on the midaxillary line about 1 cm each side. Subcutaneous tunnels are raised to both hinge points. The intercostal space of the right hinge point is punctured, and a Pectoscope (Hyunju Intech, Seoul, Korea), an internal visualizing device, is inserted. Under visual guidance, the Pectoscope is passed through the mediastinum to the other side of the hinge
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Table 1. Demographic Differences Among Groups Variable
Group STB
Group MPF
Group CFT HP
p Value
No. patients Age (range) Male:female Haller index Depression index Asymmetry Eccentric (2A) Unbalanced (2B) Mixed (2C)
180 14.3 (3–53) 6.0 7.52 18.9 2.54 3.96 118 (64%) 74 16 28
760 10.2 (2–39) 3.9 5.04 3.37 1.86 1.05 303 (40%) 185 85 36
876 (699 þ 177) 8.5 (2–44) 3.4 4.63 2.17 1.74 0.63 237 (27%) 174 58 16
. 0.28 0.12
