Pectus excavatum is sometimes complicated with pulmonary hypoplasia, Marfan syndrome, asthma and other diseases. When these diseases coexist, they often become unbearable deformities for patients, and they often need surgical correction as soon as possible.
How to treat:
1. Surgical indications
If pectus excavatum affects cardiopulmonary function and has mental burden, surgery is needed. All patients with funnel index greater than 0.2 should be operated. The timing of the operation is still controversial. Most experts think it is appropriate to operate at the age of 3 ~ 10. Some people also argue that as long as you see obvious deformity, regardless of age, you should operate immediately, instead of waiting until the clinical symptoms are serious. The younger the age, the better the treatment effect and the smaller the scope of operation. Infants rarely need blood transfusion during surgery, and rarely need to remove parts other than costal cartilage joints. Older patients often need rib stomach resection and blood transfusion. In fact, some symptoms may not be noticed before surgery, but they have disappeared after surgery. When the baby inhales, the chest wall obviously invaginates abnormally, which aggravates the concave deformity. Therefore, some authors believe that when the obvious deformity still exists during forced exhalation, it should be considered as persistent deformity and should be corrected by surgery.
2. Surgical methods
2. 1. One side of funnel chest is deep and does not involve the sternum, so rib plasty can be performed. The method is to make an arc incision from the midline to the affected side, dissect the deformed costal cartilage and ribs under the periosteum and costal membrane, make multiple transverse incisions to correct the deformity, pull the costal cartilage up to the sternum, sew the anterior sternal costal cartilage with suture, then sew the bone, sew the anterior sternal costal cartilage with suture, and then sew the skin. This operation is simple and suitable for lighter funnel chest.
2.2. Sternal lifting is to remove the deformed full-length costal cartilage (3rd-6th costal cartilage) from the periosteum of costal cartilage, so that the sternum is completely free from the lower part of the second costal region. The sternum is raised by cutting the posterior sternal plate at the upper end of the sternum, which is equivalent to the level of the second rib, clamping the costal cartilage piece at the osteotomy and sewing it. Then the second costal cartilage is obliquely cut from front to back, and the inner end of costal cartilage overlaps the outer end of costal cartilage for suture fixation, that is, three-point fixation. Finally, the intercostal muscle and rectus abdominis were sutured to the sternum respectively, and the skin was sutured. After this method, abnormal breathing may occur. Some people use metal needles or metal plates to strengthen the fixation, which can avoid the recurrence of abnormal breathing and sternum collapse after operation. The disadvantage of this method is that it needs to remove the fixed metal material again, so it is not very popular.
2.3. Sternal rib elevation is especially suitable for young patients with flexible costal cartilage and bones. After the skin was cut in the middle, the depressed sternum and costal cartilage were exposed, the ribs were freed under the periosteum of costal cartilage, the 3rd to 7th costal cartilage were cut off near the sternum, and the intercostal muscle was cut sideways, so that the front ends of the ribs and costal cartilage were fully freed. The ventral side of the costal cartilage was cut into many transverse wedges, so that the costal cartilage was lifted and restored to the normal walking position. At the same time, the long costal cartilage was cut off, and the corresponding broken ends of the costal cartilage were stitched with polyester thread to make the chest.
2.4. Thoracoabdominal skin incision with upper and lower vessels, free both pectoralis major muscles to the outside, expose the depressed sternum and deformed ribs and costal cartilage on both sides, free rectus abdominis to umbilical level along the outer edge of rectus abdominis, cut the lower edge of costal arch, free the inner pleura of sternum and costal cartilage to the outside of depressed deformity with fingers, and cut off the 7th ~ 3rd costal cartilage and intercostal muscle from the starting point of deformed costal cartilage on both sides. The internal thoracic arteries and veins on both sides are horizontally separated from the second intercostal space, and the upper and lower parts are 4 ~ 5 cm apart. The depressed sternum and bilateral costal cartilage were completely separated by wire saw, and then the pectoral muscle plate and costal cartilage crossed with the internal thoracic artery and vein and rectus abdominis. Turn over the most depressed part of the sternum to become the most prominent part, which can be trimmed appropriately to make the sternum smooth. Suture the transverse sternal end with stainless steel wire, and suture the corresponding costal cartilage end and intercostal muscle with polyester thread. When sewing, remove the long costal cartilage, so that the inverted sternal costal cartilage plate can be fixed in the original position very properly. After fixation, a closed drainage tube was placed behind the sternum, and then the pectoralis major, subcutaneous tissue and skin were sutured.
2.5. The difference between sternal inversion with rectus abdominis pedicle and sternal inversion with upper and lower blood vessels is that this method cuts off the internal thoracic artery and vein, and only keeps the rectus abdominis pedicle as the source of blood supply. The operation is basically the same as the previous method, except that the arteries and veins in the thoracic cavity are ligated and cut off first, then the sternum is transected, and the sternum is turned over with the internal thoracic muscle and the internal thoracic muscle 180, and the deformed sternum plate is trimmed, stitched and fixed in place.
2.6. Pediceless pectoralis inversion (Hetian method) adopts transverse incision in the middle of sternum or bilateral breasts to free pectoralis major and rectus abdominis muscle, exposing deformed sternum, costal cartilage and ribs, cutting bilateral costal cartilage periosteum from the costal arch from the slightly bony side where the deformity began to sag, cutting off costal cartilage, stripping costal cartilage and pectoralis major from the periosteum, and transecting sternum at the upper intercostal part where the sternum sags downward, completely cutting off some intercostal muscles and ribs that may be attached. After washing with antibiotic solution, turn the sternum plate over 180 and fix it on the sternum handle with steel wire, cut off the long costal cartilage, and then fix it on the corresponding rib position with polyester thread to sew the muscle and skin.
2.7. Patients with partial sternal inversion and overlapping surgery have flat or sunken upper chest. During the operation, after the sternum plate is turned over, the front part of the upper end of the sternum can be cut into an inclined plane and inserted into the periosteum in front of the sternum handle, so that some pectoral muscles overlap and the sternum plate moves. The overlapping sternum was fixed with steel wire suture, the costal cartilage was sutured with polyester thread, and some long costal cartilage was also sutured. The postoperative thoracic correction was more satisfactory.