Pectus repair after prior sternotomy: clinical practice review and practice recommendations based on a 2,200-patient
Lisa M Kenney1, Robert J Obermeyer1,2
1Department of Surgery, Eastern Virginia Medical School, Norfolk, VA, USA.
Abstract:
The minimally invasive repair of pectus excavatum (MIRPE) is widely accepted as a method of pectus excavatum (PE) repair. Repair is rarely performed in patients with a history of median sternotomy. A feared complication of this procedure is iatrogenic cardiac injury; the risk of injury in patients with prior sternotomy is especially high due to the development of post-surgical retrosternal adhesions, which obscures the "critical view" during MIRPE. A 14-center review reported the incidence to be as high as 7% after analyzing 75 patients with history of sternotomy who underwent MIRPE. Little literature exists on how to best prepare for MIRPE in patients with prior sternotomy. A review of the literature and a retrospective review of over 2,200 patients who underwent MIRPE at our institution was performed to analyze 9 patients who underwent MIRPE after prior sternotomy. Iatrogenic cardiac injury occurred in 2 patients. Given the infrequency in our experience and the low numbers reported in the literature, statistical conclusions cannot be drawn. However, prudent strategies based on this experience include thoracoscopy, routine sternal elevation, direct sub-xiphoid retrosternal dissection, coordination with cardio-thoracic surgeons, preparation for cardio-pulmonary bypass, and massive transfusion protocol availability to optimize surgical outcomes in patients undergoing MIRPE with a history of sternotomy.
Insights
Minimally invasive repair of pectus excavatum (MIRPE) after median sternotomy presents unique risks. Prudent strategies, including thoracoscopy and direct dissection, can optimize surgical outcomes and minimize cardiac injury in these complex cases.
Area of Science:
- Thoracic Surgery
- Pediatric Surgery
- Surgical Innovation
Background:
- Minimally invasive repair of pectus excavatum (MIRPE) is a standard procedure for pectus excavatum (PE).
- Repair in patients with prior median sternotomy is infrequent and carries a high risk of iatrogenic cardiac injury due to retrosternal adhesions.
- Existing literature offers limited guidance for managing MIRPE in patients with a history of sternotomy.
Purpose of the Study:
- To analyze the outcomes of MIRPE in patients with a history of median sternotomy.
- To identify prudent strategies for optimizing surgical outcomes and minimizing complications in this patient population.
Main Methods:
- A retrospective review of 9 patients who underwent MIRPE after prior sternotomy at a single institution.
- Literature review on MIRPE in patients with prior sternotomy.
- Analysis of iatrogenic cardiac injury incidence and contributing factors.
Main Results:
- Two out of 9 patients experienced iatrogenic cardiac injury.
- The incidence in this small cohort was 22%, contrasting with a reported 7% in a multi-center review.
- Statistical conclusions were limited due to small sample size.
Conclusions:
- MIRPE in patients with prior sternotomy is feasible but requires meticulous planning and execution.
- Recommended strategies include thoracoscopy, routine sternal elevation, direct sub-xiphoid retrosternal dissection, and coordination with cardiothoracic surgeons.
- Preparation for cardiopulmonary bypass and availability of massive transfusion protocols are crucial for managing potential complications.
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