PECTUS CARINATUM (PIGEON CHEST)
Pectus carinatum is the protruding deformity of the chest wall. It is seen less frequently than pectus excavatum.
Pectus carinatum occurs in the form of unilateral or bilateral involvement of the rib cartilage and structural disruption in the upper or lower projection of the sternum.
Mixed deformities can also be seen. One side of the cartilage ribs collapse, the opposite protrudes with the rotation of the breastbone. The most common clinical presentation of this structural disorder is extroverted of the sternum body and symmetrical protrusion of the lower rib cartilages.
Less frequently, it is an asymmetric deformity caused by unilateral dislocation of rib cartilage and to a lesser extent mixed type deformity. Rarely, upper (chondromanubrium) deformity can be seen. Here, the cartilage of the manubrium hump and the upper ribs are trapped, and the relative collapse of the sternum body seen.
The etiology of the pectus carinatum is unknown. It is seen 3 times more in boys. Unlike pectus excavatum, it occurs in childhood and adolescence.
Pectus carinatum was detected only three at birth. It occurs at the age of patients at the age of puberty when growth begins. Pectus carinatum 26% of them have a family history of chest wall deformity. Scoliosis is accompanied in 15% of patients, and 12% have a family history of scoliosis.
Marfan syndrome with accompanying scoliosis or severe deformity should be suspected.
Heart-Lung effects
According to some sources, “a heart-lung disorder” not directly related to the pectus carinatum has been shown. In other sources, it has been reported that there are more lung complaints in the pectus carinatum than in the pectus excavatum.
Lees and Caldicort also reported a 20% frequency of congenital heart disease in children with pectus carinatum with early sternal closure. However, the only criterion to consider for repairing these lesions is the severity of the deformity. Patients may complain of their sensitivity in the protrusion area as a result of frequent local trauma.
Treatment
A. CORSET (brace) for pectus carinatum works similar to how the braces work on the teeth. The brace is worn around the chest and provides pressure from both the front and back to bring the breastbone back to its normal position.
The patient wears up to 18-20 hours a day for at least 24 months. CORSET can be removed during showers, sports and other activities.
The success rate is very related to compliance with treatment. Success rate is seen in 75-80% of patients at the end of 18-24 months.
B. Invasive method: Pectus carinatum repair methods are developing gradually. The first repair was made in four decades (decade: 10 years). Ravitch reported chondromanubrial protrusion repair in 1952.
He accomplished this by cutting multiple defective rib cartilage and making a double incision in the breastbone.
Subsequent efforts included cutting the anterior part of the sternum and even removing it under the sheath of the breastbone. These were generally optimistic and unsuccessful attempts to correct this structural disorder.
Modern techniques were first introduced in 1963. This method included the incision made under the sheath of the rib cartilage and removal of the lower part of the sternum and strengthening the remaining part of the abdominal muscle and sternum. Subsequently, in 1973, the technique of removing rib cartilage protruding from under the cartilage sheath and preserving it over the entire length of the breastbone, which is still used today, by making a side bone incision through the anterior cortex of the sternum and breaking the posterior cortex, the sternum has been replaced and the protrusion has been corrected.
Consequences and complications
Successful results were generally obtained with the last mentioned method. Blood transfusion is rarely required. Pneumothorax is rare and usually only requires draining of the excess air in the chest cavity.
Recurrence is rare in patients who have undergone surgery before entering the full mature period. Permanent structural impairment can also be rarely seen with inappropriate intervention of the deformity.
C. Non-invasive closed correction of the Pectus Carinatum– Abramson Technique
In the Abramson method, the patient has lied on the back of the surgical table under general anesthesia. A “tunnel” is created for the bar, passing under the muscle over the breastbone. Lorenz Bar, which is selected according to the patient at the beginning of the operation, is given the desired shape and passed through this tunnel and placed directly on the protruded part of the sternum.
It is pressed on the bar with a strong force from the front to the back and the bar and chest wall are pressed by hand until the protrusion flattens. After making sure of the position, the bar is passed on both sides of the fixers, which is firmly fixed on the ribs, on both sides of the chest wall, and the bar is fixed in the desired position. Wire stitches are fastened tightly around the rib so as not to come off.
Again, the bar is tightly stitched around the muscle tissue with thick insoluble sutures to help.
At the last stage, the skin incisions are sutured according to the usual method and the skin is closed.
When the patient comes back to the recovery room, he is transferred to the clinic ward a few hours later.
Pain is controlled by either an epidural catheter or IV-PCA and / or systemic analgesics.
The patient is mobilised as soon as possible to return fast to normal life.
Usually, patients are discharged within 4-5 days.
He can return to school within 2 weeks.
It is recommended to walk only for 1 month. Can do swimming, running, tennis for 1-3 months. He can do professional sports after 6 months.
References
- Cahill JL, Lees GM, Robertson HT. A summary of preoperative and postoperative cardiorespiratory performance in patients undergoing pectus excavatum and carinatum repair. J Pediatr Surg. Aug 1984;19(4):430-3. [Medline].
- Fonkalsrud EW, Bustorff-Silva J. Repair of pectus excavatum and carinatum in adults. Am J Surg. Feb 1999;177(2):121-4. [Medline].
- Marusch F, Gastinger I. [Life-threatening complication of the Nuss-procedure for funnel chest. A case report]. Zentralbl Chir. Nov 2003;128(11):981-4. [Medline].
- Tschirkov A, Baev B, Iliev R. Simultaneous pectus and open-heart surgery. Chest Surg Clin N Am. May 2000;10(2):405-13, viii-ix. [Medline].
- Arch Bronconeumol. 2005;41:349-51
