Imagine a world where a simple chest deformity could lead to a lifetime of challenges. This is the reality for individuals with pectus excavatum, a condition that often requires surgical intervention. While the Ravitch and Nuss procedures are effective treatments, they are not without their risks and potential complications. In this article, we delve into the stories of two patients who experienced recurrent pectus excavatum after undergoing the Ravitch procedure during their childhood.
Case 1:
A young woman, now 26, presents with worsening shortness of breath and palpitations. Her journey began with a modified Ravitch procedure at a young age, but over time, her symptoms intensified. Upon examination, a severe chest wall depression was revealed, along with an old surgical scar. Imaging showed a retained stainless-steel strut under the sternum, a potential cause for her deteriorating health.
The surgical team, led by Dr. Hsu, employed a multidisciplinary approach. Under general anesthesia, they carefully navigated the challenges posed by the retained strut. Using thoracoscopic vision, they identified the strut adhering to the lung and mediastinum. With precision, they dissected the mediastinal tunnel and inserted a curved metal bar to correct the deformity. The procedure was a success, and the patient’s postoperative recovery was smooth, with significant improvements in her chest wall and overall quality of life.
Case 2:
A 29-year-old man sought medical attention for persistent discomfort and dyspnea. Like the first patient, he had undergone a modified Ravitch procedure in his youth. Physical examination revealed a persistent depression in the anterior chest wall and a surgical scar. Imaging confirmed a retained stainless-steel strut in the anterior mediastinum.
The surgical team planned a modified Nuss procedure with a multidisciplinary approach. Under general anesthesia, they made incisions and controlled bleeding. Thoracoscopy guided the procedure, allowing them to locate and remove the original strut. Two new bars were inserted horizontally, and the procedure was completed without complications. The patient’s postoperative management included pain control, early mobilization, and regular follow-ups.
Both cases highlight the complexity of recurrent pectus excavatum and the challenges posed by retained struts. The modified Nuss procedure, a minimally invasive technique, proved to be a viable option for these patients. However, the presence of retained struts adds a layer of difficulty, requiring meticulous preoperative planning and surgical expertise.
The debate surrounding the optimal surgical approach for recurrent pectus excavatum continues. Some studies suggest that the Nuss procedure may be more suitable for adult patients with symmetrical defects, while others advocate for a hybrid approach combining thoracoscopic support bars and open osteotomies.
In our cases, the decision to leave the struts in place for an extended period after the Ravitch procedure did not yield the desired results. This underscores the importance of timely strut removal to reduce mediastinal adhesions and simplify future reoperations.
The modified Nuss procedure offers a promising alternative for managing recurrent pectus excavatum, especially after open repair. It provides a shorter operative time and favorable functional and cosmetic outcomes. However, further research is needed to determine the optimal timing for strut removal and guide the management of recurrence.
These cases emphasize the need for a comprehensive approach to treating recurrent pectus excavatum, considering both functional and cosmetic aspects. With proper postoperative management and regular follow-ups, patients can experience significant improvements in their cardiac and pulmonary functions, as well as their overall psychosocial well-being.