EDITORIAL
Repair of Pectus Excavatum in Children Under 3 Years of Age: A Twelve-Year Experience Mark M. Ravitch, M.D.
Doctors Randolph, Tunell, and Morton (p 364, this issue) very clearly demonstrate in their 50 patients under 36 months of age that children tolerate the "standard" operation for pectus excavatum very well, even in infancy. The transfusion requirement (26 patients) is unusual. It has been many years since we have had to transfuse any patient with funnel chest except adults or very large adolescents, and even those have needed it infrequently. The outcome-9O0/~ good results-is very good indeed, particularly in view of the fact that 28 patients have been followed six years or more. The literature is replete with references to follow-up of this length being required to identify recurrences. The focus of their paper is upon the ability of infants and small children to undergo an operation that yields exceedingly good results. It is a source of constant wonderment that many papers-particularly those expressing discouragement over the results achieved-state that the younger the patient, the better the long-term results, yet at the same time declare that since small children are usually asymptomatic, operation should be postponed until later in childhood or early adolescence! The fact is that a moderate number of small children are recognized to be symptomatic before operation, while in a much larger group, small children show such a spurt in their activity and appetite after operation as to make it clear that they had, in fact, been symptomatic. There are now abundant angiographic demonstrations of deformation of the heart by funnel chest, particularly the right ventricle or its outflow tract. It is not at all uncommon in the plain posteroanterior roentgenogram of a child with funnel chest to see a circular area of radiolucency corresponding to the right half or so of the heart that has resulted from pancaking of the heart and reduction in the posteroanterior diameter of From the Department of Surgery, Montefiore Hospital, 3459 Fifth Ave, Pittsburgh, PA 15215. 301
the compressed portion. The National Institutes of Health physiological studies [l]in older patients referred to in the paper by Dr.Randolph and his co-workers, which confirmed the previous Swedish studies of Bevegard [21 and colleagues, now demonstrate what has long been suspected: that appropriately designed physiological investigation will show that the heart in pectus excavatum is laboring at some disadvantage. It appears reasonable, therefore, to correct the deformity in infants and children when it is pronounced or progressive, without waiting for recognition of symptoms. A recent opportunity [31 to review the world literature turned up an extraordinary profusion of operative techniques. I conceive the essential features of the operation to be:
1. Subperichondrial resection of all the involved cartilages over the full extent of the deformity. 2. Separation of the xiphoid and the intercostal bundles from the sternum. 3. Oblique division of the lowest normal cartilage, usually the second or third. 4. A transverse sternotomy in the interspace above, stabilizing the reconstruction by the following step. 5. Suturing across the osteotomy (with a bone block if the osteotomy is posterior) and suturing the central stubs of the obliquely divided cartilages over the lateral stubs.
References 1. Beiser GD, Epstein SE, Stampfer M, et al: Impairment of cardiac function in patients with pectus excavatum with improvement after operative correction. N Engl J Med 287:267, 1972 2. Bevegttrd S: Postural circulatory changes at rest and during exercise in patients with funnel chest, with specialreferenceto factors affecting the stroke volume. Acta Med Scand 171:695-713, 1962 3. Ravitch, MM: Congenital Deformities of the Chest Wall and their OperativeCorrection. Philadelphia, W.B. Saunders Company, 1977, chap 2
Repair of Pectus Excavatum in Children Under 3 Years of Age: A Twelve-Year Experience Mark M. Ravitch, M.D.
Doctors Randolph, Tunell, and Morton (p 364, this issue) very clearly demonstrate in their 50 patients under 36 months of age that children tolerate the "standard" operation for pectus excavatum very well, even in infancy. The transfusion requirement (26 patients) is unusual. It has been many years since we have had to transfuse any patient with funnel chest except adults or very large adolescents, and even those have needed it infrequently. The outcome-9O0/~ good results-is very good indeed, particularly in view of the fact that 28 patients have been followed six years or more. The literature is replete with references to follow-up of this length being required to identify recurrences. The focus of their paper is upon the ability of infants and small children to undergo an operation that yields exceedingly good results. It is a source of constant wonderment that many papers-particularly those expressing discouragement over the results achieved-state that the younger the patient, the better the long-term results, yet at the same time declare that since small children are usually asymptomatic, operation should be postponed until later in childhood or early adolescence! The fact is that a moderate number of small children are recognized to be symptomatic before operation, while in a much larger group, small children show such a spurt in their activity and appetite after operation as to make it clear that they had, in fact, been symptomatic. There are now abundant angiographic demonstrations of deformation of the heart by funnel chest, particularly the right ventricle or its outflow tract. It is not at all uncommon in the plain posteroanterior roentgenogram of a child with funnel chest to see a circular area of radiolucency corresponding to the right half or so of the heart that has resulted from pancaking of the heart and reduction in the posteroanterior diameter of From the Department of Surgery, Montefiore Hospital, 3459 Fifth Ave, Pittsburgh, PA 15215. 301
the compressed portion. The National Institutes of Health physiological studies [l]in older patients referred to in the paper by Dr.Randolph and his co-workers, which confirmed the previous Swedish studies of Bevegard [21 and colleagues, now demonstrate what has long been suspected: that appropriately designed physiological investigation will show that the heart in pectus excavatum is laboring at some disadvantage. It appears reasonable, therefore, to correct the deformity in infants and children when it is pronounced or progressive, without waiting for recognition of symptoms. A recent opportunity [31 to review the world literature turned up an extraordinary profusion of operative techniques. I conceive the essential features of the operation to be:
1. Subperichondrial resection of all the involved cartilages over the full extent of the deformity. 2. Separation of the xiphoid and the intercostal bundles from the sternum. 3. Oblique division of the lowest normal cartilage, usually the second or third. 4. A transverse sternotomy in the interspace above, stabilizing the reconstruction by the following step. 5. Suturing across the osteotomy (with a bone block if the osteotomy is posterior) and suturing the central stubs of the obliquely divided cartilages over the lateral stubs.
References 1. Beiser GD, Epstein SE, Stampfer M, et al: Impairment of cardiac function in patients with pectus excavatum with improvement after operative correction. N Engl J Med 287:267, 1972 2. Bevegttrd S: Postural circulatory changes at rest and during exercise in patients with funnel chest, with specialreferenceto factors affecting the stroke volume. Acta Med Scand 171:695-713, 1962 3. Ravitch, MM: Congenital Deformities of the Chest Wall and their OperativeCorrection. Philadelphia, W.B. Saunders Company, 1977, chap 2
