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胸郭変形

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Their deformity rendered them hideous to the point they did not dare to show themselves on the beaches.(Guillemined 1964)
Our own supposition has been that the deformity lies primarily in the ribs and that the sternal prominence is entirely secondary.(Ravitch 1977)
The operation for pectus carinatum simply allows the sternum to fall back into its proper place and keeps it there. This is not a particularly difficult task.(Robicsek 1979)

Pectus carinatum is the second most common anomaly of the anterior chest wall (Ravitch 1977) ; Welch 1973 ; Chin 1957 ; Asp 1959-60 ; Howard 1958, Kjaer 1965). The proportion of occurrence between excavatum and carinatum deformities have been reported by different authors to vary between 10:1-to-10:4 (Welch 1973, Chin 1957, Ravitch 1977, Asp 1959, Howard 1955, Kjaer 1965, Sanger 1974). In our own surgical experience, pectus carinatum constituted about 20 percent of 803 patients operated upon with anterior chest deformities (Robicsek 1960, 1963, 1974, 1978, 1979 ; Sanger 1960, 1963, 1968). Males are more commonly affected than females. Pectus carinatum, just like its “sister deformity” pectus excavatum, is a pathological condition in which the exact developmental mechanism is not fully understood, the indication for operative correction is controversial, the surgical technique debatable, and the postoperative results, except for the cosmetic aspects, are difficult of being objectively measured. It is fortunate indeed that at least establishing the diagnosis does not cause undue difficulties.

ANATOMY

The common feature of different forms of pectus carinatum, the prominence of the sternum, was already known in ancient times. Hippocrates already described not only its morphological features but also some of its physiological consequences which may occur, especially in connection with some other anomalies of the rib cage and the spine : “…the chest becomes sharp pointed and not broad, becomes affected with difficulty of breathing and hoarseness ; for the cavities which inspire and expel do not obtain proper capacity (Hippocrates).”
Besides its generally accepted term “pectus carinatum,” protrusion of the anterior chest is also known under several other aliases : chicken breast, pigeon breast, pyramidal chest, thorax cuneiform, sternal kyphosis, etc. Anatomically carinatum deformities may be conveniently divided into four major groups : (1) keel chest, (2) sternum elevatum, (3) pouter pigeon breast, and (4) asymmetrical or lateral pectus carinatum. The identification of these groups is very important because the appropriate surgical procedure is selected according to these individual subtypes.
(a)In keel chest the lower third of the sternum arches more forward, and unlike in the “elevatum”
deformity, the xiphoid process is not an axial continuation of the sternum but joins it in an acute angle with the process pointing in the dorsal direction. Keel chest is commonly associated with bilateral symmetrical depression of the costal cartilages (Howard 1958, Naish 1958) mistakingly identified by some (Brodkin 1949, 1958) as “Harrison grooves.”
(b) In sternum elevatum the breastbone is relatively straight ; however, its lower end rises significantly anterior to the level of the manubrium. This elevation of the sternum is naturally accompanied by bilateral elongation and protrusion of the costal cartilages.
(c) Pouter pigeon breast (Ravitch 1977) or arcuate pectus carinatum (Lester 1953) is an interesting anterior chest wall anomaly in which upper chondromanubrial prominence (Brodkin 1957) is associated with lower chondrosternal depression, creating a situation in which the manubrium protrudes, the mid-portion of the sternum arches posteriorly while the tip of the xiphoid process points anteriorly.
(d) Asymmetrical or lateral pectus carinatum is characterized by unilateral protrusion of the chest wall, hypoplasia or absence of one of the pectoralis major muscles. The anatomy of lateral pectus carinatum is usually dominated by the deformity of the cartilages, thus the malposition of the sternum appears to be less significant. In the most common variety of the disease there is marked unilateral prominence of the cartilages from the second down with 30-45。rotation of the sternum around its longitudinal axis toward the moderately sunken opposite side. A less frequently encountered variety of lateral pectus carinatum is the localized prominence of two or more cartilages with minimal or no sternal involvement.

PATHOGENESIS

The reason why pectus carinatum develops in a particular individual is uncertain. Theories forwarded in the fifties by Brodkin (Brodkin 1949, 1958 ; Chin 1957) attributed pectus carinatum to sternal displacement due to hypoplasia of its attachment to the center of the diaphragm with compensatory hypertrophy of the lateral muscular compartment. As a consequence of this situation, it was believed (Brodkin 1949, 1958) that “changes in the costal cartilages then occur as these have no option but to follow the sternum to its displaced site” (Brodkin 1949).
This theory of CBrodkin which was also elaborated upon by Chin (Chin 1957) a decade later and largely

resembled the reasoning of Brown (Brown 1939) who regarded pectus excavatum as a consequence of abnormal diaphragmatic attachment- a feature which was looked for by later investigators (Ravitch 1977, Lester, Mullard), who like us (Robicsek 1960, 1963, 1974, 1978 ; Sanger 1960, 1963, 1968) were trying unsuccessfuly to identify the changes of the diaphragm described by these authors. Our opinion agrees with those (Ravitch 1977, Lester) who profess that the role of the diaphragm in the development of pectus deformities is very little, if any, and that the position of the sternum is secondary, a consequence of cartilaginous elongation. As we started in 1963 : “To suppose the opposite would be equal to the acceptance of the fact that the reason the neck of the giraffe is so long is that otherwise it would not reach its head. After resecting these elongated, distorted cartilages from more than 200 patients, it is our firm belief that the displacement of the sternum is secondary and due to an overgrowth of the costal cartilages.
If the sternum is pushed inward, pectus excavatum is the result ; if it is pushed outward, pectus carinatum develops” (Sanger 1963). Twenty years and nearly 800 pectus operations later, we are even more convinced about the validity of this view. Faulty osteo and chondrogenesis in the origin of these abnormalities have been emphasized more recently by Mullard (Mullard 1967) and Singh (Singh 1980). This postulate was reemphasized by Pena et al (Pena 1980) that pectus excavatum and carinatum are indeed two different morphological manifestations of the same disease.
One, however, may naturally seek an explanation : What is the cause of this cartilaginous overgrowth? Pectus carinatum has recently become a subject of interest of several genetics. The fact that pectus carinatum often occurs in several members of the same family and that it is not infrequently associated with other genetic defects (Guizar-Vasques 1980, Sanches-Cascos 1983, Steinman 1979, Jones 1979, Urschel 1984, Higashi 1983) also speaks for its congenital origin. Guizar-Vasques et al (GuizarVasques 1980) described a syndrome occurring in siblings, consisting of joint laxity, pectus carinarum and peculiar facial characteristics. Among 21 patients suffering from Noonan syndrome (telecanthus, low set ears, epicantus and facial asymmetry) Sanches-Cascos (Sanches-Cascos 1983) found 10 patients having anterior chest deformities, six of them carinatum. Higashi (Higashi 1983) reported the occurrence of unusual facial features, nasal abnormality, conductive deafness, synphalanogesim and pectus carinatum in four members of a Japanese family. Pectus carinatum is also part of the King-syndrome, consisting of malignant hyperthermia. slowly progressing myopathy, characteristic facial appearance, kyphoscoliosis and short stature and various pectus anomalies (McPherson 1981). Pecuts carinatum also occurs in the so-called “leopard syndrome,” an autosomal dominant trait characterized by lentigo, sensorineural deafness, retarded growth, ocular kypertelorism, prognathia, kyphosis, vinged scapule, valvular pulmonary stenosis and pectus carinatum or excavatum (Howard 1979). The in-depth study of Ravitch (Ravitch 1977) further elaborates on the theory forwarded by Humbard in 1938 in his paper Giantism of the Infantilism Type and its Disclosure in the Pathogenesis of Pigeon Breast and Funnel Chest (Humberd). He called attention to the phenomenon that in non-acromegalic giants “both pigeon breast and funnel chest are common and this is a kind of infantilism in which they retain the infantile chest at the same time the ribs are growing excessively rapidly” (Humberd) and expressed the belief that most anterior chest wall anomalies are consequences of the continued cartilaginous overgrowth which may already be present at birth and could continue after infancy. Interestingly enough, whereas presence of pectus excavatum is usually well recognizable in the very young, pectus carinatum may remain undetected until the child grows older (Ravitch 1977). We believe that the explanation for this is that both anomalies are measured using the most anterior wall and the abdomen as reference points. Whereas, the protruding infantile “potbelly” of

the very young seemingly emphasized the sunken chest of the child with pectus excavatum, at the same time it makes the presence of pectus carinatum less apparent. In the course of the latter years, however, the process reverses ; the recession of the abdominal contour makes pectus carinatum more and pectus excavatum less noticeable. Late recognition of milder forms of anterior chest deformities, however, may also occur because the child has been less conscious of his deformity until the beginning of adolescence or simply the parents have never given a closer scrutiny to the chest of their offspring. An amusing example of this happened to me a few years ago when I was summoned to the emergency room by a tearful mother accompanied by her son with an “acute” pectus carinatum which “was not present during the earlier houors of the day!”

While in some cases there is indeed worsening of the degree of deformity as the juvenile thorax grows, the origin of pectus carinatum is congenital, as the deformity is to some degree always present already at birth. Exceptions to this rule are the rarely occurring traumatic cases and also children suffering from some sort of advanced congenital heart disease which in some instances cause right ventricular enlargement severe enough to “push” the anterior chest forward and create a situation which by definition could be labeled as a carinatum deformity.
There are also some special forms of pectus carinatum where the mechanism of development is probably more complex. In pouter pigeon breast, for example, Currarino and Silverman (Currarino) demonstrated premature obliteration of the sternal sutures and consequential synostosis and nonsegmentation. This fact was also confirmed by Ravitch (Ravitch 1977). Such premature synostosis of the sternum is often associated with congenital heart conditions (Silverman’s disease) (Brunner 1961).

A category by itself in the pathogenesis of pectus carinatum deformities is the keel chest which occurs in hunchbacks. In the etiology of such conditions, forces resulting in the vertical shortening of the chest seems to be acting rather than simple cartilaginous overgrowth.
A unique report of drug-induced pectus carinatum came from the pen of Steinman et al who treated a 2-1/2 year old with seemingly normal body features with D-Penicillamine for cyctinuria. After 18 months of treatment, the patient developed multiple body abnormalities, such as velvety skin, hypoflexible toes and fingers, molluscoid pseudo-tumors, spina bifida occulta, kyphoscoliosis and pectus carinatum, thought to be due to disturbance in stable collagen fibril formation (Steinman 1979).

SYMPTOMS

The symptoms of pectus carinatum are due to its physiological and psychological effects, the latter of which are usually more pronounced and easier to identify.
The physiological shortcomings of the disease is probably the consequence of impaired pulmonary function due to decrease in respiratory excursion of the thorax (Welch 1973, Sitarz 1974). In the recent study of Czerhati et al (Czerhati 1984) out of 381 young adults suffering from severe bronchial asthma, chest deformities were found in 80, in 8 pectus carinatum. In this respect one may even attempt to draw an analogy between pectus carinatum, an anterior thoracic protrusion, and kyphosis which is but a posterior protrusion, both of which can lead to loss of pulmonary elasticity with all of its unwanted sequale (Scoberry). But while respiratory insufficienty, especially the type associated with cor pulmonale, is common in patients with a combination of kyphosis and pectus carinatum, it is rare in those who have carinatum deformity only. We found in our 196 patients operated for pectus carinatum only three who had significant respiratory symptoms. Less severe symptoms, such as moderate dyspnea, fatigue and non-descript chest pain, however, were present in about one-third of our patients. It should be noted, though, that most of our patients operated upon were children, some teenagers, and a few young adults, with the average age of about 12 years. It is possible indeed that some individuals may have developed chronic obstructive pulmonary disease if not operated upon. To our knowledge no such studies were conducted on a larger patient population.
The psychological effects of pigeon breast are more prevalent. Most children and practically all adolescents and young adults were very self-conscious, shy, and usually quite unhappy about their deformity. To conceal the distorted shape of their chest, they sit and walk slightly bent and with dropped shoulders. As large children, they were exposed to mockery, avoided locker room, swimming pools, and outdoor activities. All these led to an abnormal posture which further aggrevated their anomaly.

Treatment

While the posture of these patients, especially after surgery, may indeed be imporoved by appropriate exercise, conservative treatment (Beaujeau, Bianchi, Bianchi) for the carinatum deformity itself is absolutely ineffective. Various non-operative methods, such as physiotherapy, plaster of Paris, external compression, may be dismissed with the words of Howard : “The remedy for the deformity is operation. Physiotherapy is useless without operation and retaining apparatus is worse than useless” (Howard). The nonsense of conservative treatment was revived more recently by Vidal et al (Vidal 1977) who in 1977 reported 55 cases of various forms of carinatum deformities treated with “good results” with application of plaster casts followed by plaster jacket and exercises.
Surgery as the only effective method to treat pectus carinatum was first suggested by Ravitch and Handelsman in 1952 (Ravitch 1952), but it was Lester who performed the first corrective procedure one year later for this disease (Lester 1953). His operation consisted of subperiostal resection of the lower sternum and the sternal ends of the costal cartilages. Lester (Lester 1961) later modified his original procedure by removing the entire sternum subperiostally as well as the cartilages in their entire extent of involvement. In 1960, Ravitch (Ravitch 1960) proposed a new operation consisting of subperiosteal resection of the costal cartilages and shortening the perichondrial strips with reefing sutures – a procedure

he continued to use with considerable success. Brodkin (Brodkin) and Chin (Chin) in the late fifties utilized the pulling effect of the rectus to maintain the sternum in a corrected position. To this method, Howard (Howard) added a transverse sternal osteotomy at the level of maximal protrusion. Essentially the same procedures with minor modifications and with variable success were used by Asp (Asp), Beaujeau (Beaujeau) Lam (Lam), Ashmore (Ashmore), Guillemined (Guilleminet), etc. In 1969, Pataro et al (Pataro 1969) used the sternal turnover procedure with additional osteotomy to correct pectus carinatum. The application of matellic supports for postoperative “stabilization of the chest wall” in pectus carinatum was advocated by Singh (Singh 1980).
During the history of repair of anterior chest deformities, such as different varieties of pectus carinatum, there has also been a trend to “correct” some of these abnormalities by cosmetic means only, such as using muscle flaps or prosthetic implants (Ramsay 1963). Such measures could be occasionally useful indeed if they are applied in conjunction with primary repair of the bony chest wall to put the “finishing touch” on the cosmetic appearance (Urschel 1984) but not in lieu of them because they “do not improve respiratory mechanics or recover the lost intrathoracic space.” (Ravitch 1977) and are therefore physiologically unsound.
We have applied our own techniques in the different types of carinatum deformities since 1957 as follows:The operation, regardless of the type of the carinatum deformity, is performed through a cosmetically suitable upward convex transverse submammary incision in the direction of the Lange lines. The length of the incision is proportional with the degree of the deformity and the planned extent of the procedure. To prevent necrosis of the skin, it is important to carry the incision down to the level of the sternal periosteum in the midline and to the pectoralis fascia on both sides, thus to develop a thick flap of skin and subcutaneous tissue. Using electrocautery, the pectorralis muscles are detached from the sternum and dissected off the bony chest wall on both sides enough to be allowed later on to be pulled and sutured together without undue tension in front of the sternum. A V-shaped transverse osteotomy is now performed on the proximal portion of the sternum at the level of the beginning of the abnormal forward curve and is carried to the depth of but not across the posterior lamina in a line corresponding to an intercostal space rather than to a sternocostal junction.
Caudal to the line of the transverse osteotomy the sternal ends of all costal cartilages are then subperiostally resected. Shorter segments of the upper with progressively longer segments of the lower cartilages are removed. The resection in general is more extensive than is performed in pectus excavatum. If a cartilage is protuberant, elongated or knobby, it is removed in its entire length of involvement because there are instances when postoperative overgrowth of non-resected cartilages (Pena 1980) can indeed jeopardize the otherwise good results (Lam 1971). Resection of the medial ends of the bony ribs may become necessary in advanced cases. The further course of the operation will depend on the anatomical subtype of the deformity.
In cases of kneel chest, also named as “truly kneeled chest” by Ravitch (Ravitch 1977) or “pyramidal chest” by Peters (Peters 1924), the lower end of the the sternum is grabbed with a towel clip, elevated and the xiphoid process is detached. If the xiphoid appears to be rudimentary, its size is augmented by carrying the line of resection somewhat higher to leave a short protion of the distal sternum in continuity with it, thus “creating” a xiphoid of normal size. The xiphoid is mobilized by severing its connections with the diaphragm but not those with the rectus muscle. Breaking the posterior lamina at the level of the transverse osteotomy, the sternum is pressed posteriorly and brought into a corrected position, thus terminating the presence of carinatum deformity. Because the pathologic anatomy of the kneel chest includes not only protrusion but also elongation of the sternum, the operation also includes appropriate shortening of the breastbone by resecting a 2-6 cm length of its distal end. The corrected position of the sternum is now secured by uniting its distal end with the xiphoid process using wire sutures. Care should be taken that the latter maneuver is to be done under tension to assure traction upon the sternum by the rectus muscles via the xiphoid to maintain the sternum permanently in a corrected position. Before the incision is closed, all chondral and bony protuberances are carefully removed with rongeurs and osteotomes.

The edges of the pectoralis muscles are united with chromic catgut sutures in front of the sternum to further secure its corrected position and to provide a smooth, soft contour to the anterior chest wall. After pre-sternal approximation of the edges of the pectoralis muscles, there is usually a triangular-shape3d hiatus in the lower wound which may be disturbing to the surgeon’s eye but is filled readily with subcutaneous tissue after the skin is closed. If this defect appears to be significant, it may easily be corrected by a flap of rectus abdominalis muscle as recommended by Ravitch (Ravitch 1977). The subcutaneous tissue is closed with interrupted catgut and the skin with intracutaneous suture.
In patients who have sternum elevatum, an anomaly with sternal protrusion but without sternal elongation, we perform a similar procedure but omit sternal shortening. In such patients, the corrected sternal position is maintained primarily by the pectoralis muscles sutured together in front of the sternum.
The surgical repair of pouter pigeon breast must include not only the elimination of the chostomanubrial prominence but also raising of the lower sternochondral depression. The initial steps of the operation, i.e., transverse skin incision, retraction of the pectoralis muscles, bilateral resection of the cartilages from the second down and detachment of the xiphoid process are identical with those described for the kneel chest and pectus elevatum. After these steps are accomplished, however, the operation takes a different course :
First of all, the tip of the sternum is lifted with a towel clip, and the breastbone is freed with blunt and sharp dissection of both its intercostal and also of its posterior mediastinal attachments. Attention is then given to eliminate the prominence at the junction of the manubrium and the body of the sternum by chiseling it off using a wide osteotome. After the removal of the protuberant bone, a transverse V-shaped osteotomy is made just below and a second linear osteotomy at the deepest point of the mid-sternal depression. The sternum is fractured at both osteotomy sites and bent appropriately to bring its axis into a slightly over-corrected position. Marlex※1
Mesh is cut into proper size and shape, placed behind the sternum, stretched, and sutured in a “drummed out” position to the distal stump of the resected costal cartilages with heavy nonabsorbable sutures. Such mesh support of the sternum has been recommended for the correction of sternal clefts by Ravitch (Ravitch 1976) who used stainless steel and for the treatment of pectus excavatum and by May (May 1961) who applied mesh of tantalum. The sternum which now rests on and is supported by the mesh is covered with the pectoralis muscles tacked together presternally.※2
When we first operated on patients with different pectus anomalies, special care was taken not to enter either of the pleural cavities. At the same time, however, we also observed a dismayingly large number of wound complications consisting primarily of accumulation of blood or serum under the skin flaps. This was not prevented by draining the wound with a Penrose drain or by Hemovac suction. In a few patients, however, in whom one of the pleural cavities was inadvertently entered, such complications did not occur. Consequently, during the last few years in all cases of pectus excavatum and in most cases of pectus carinatum we have the operative field and drained it through an intercostal water-sealed catheter. This way, even after the chest tube is removed usually on the second day after surgery, the large pleural surface continued to absorb fluid that otherwise might be collected in the wound (Robicsek 1974).
The operation for the repair of lateral or asymmetrical pectus carinatum has to be tailored to the extent and location of the deformity and it may be very simple or quite extensive. If the anomaly consists only of unilateral overgrowth of a few cartilages, an incision is made directly over them and the procedure is limited to subperiosteal removal of the unsightly protuberance. In general, all the involved cartilages
※1C.R. Bard, Inc., Billerica, MA.
※2Angelo May in 1961 recommended Tanalum support to the sternum(May).
We, however, found Marlex mesh more satisfactory.

should be removed from the lateral edge of the prominence all the way to its sternal junction. Even in cases where the deformity is limited, it is advisable to be radical rather than conservative ; otherwise, it may easily happen that after the closure of the skin, or even worse, at the time of the first postoperative visit it will become apparent that part of the deformity is left uncorrected. It is a good practice after correction of the bony anomaly to pull the skin edges temporarily together and to cast a critical look whether additional corrective steps need to be made before permanent closure of the skin is undertaken.
Frequently the extent of lateral pectus carinatum consists only of unilateral protrusion of all costal cartilages below the level of the second rib. If the position of the sternum itself is unaltered, transverse osteotomy is not necessary. Because the cartilages at the sterno-costal junction are frequently overgown, the edge of the sternum on the involved side should be shaved off with an osteotome. If the anomaly involves also the bony portion of the rib, one should not hesitate to remove the bony protrusion as well. It seems paradoxical, but we have larned rather painfully that if a unilateral pectus carinatum is severe enough to necessitate extensive resection of the cartilages on one side, a short parasternal segment of the apparently normal cartilages on the opposite side should be removed too. Otherwise, the unbalanced action of these cartilages will tilt the sternum to its side causing recurrence of the anomaly.

It happens not infrequently that unilateral pectus carinatum is associated with some degree of anterior chest wall depression of the other side which makes the anomaly even more obvious. This combination of unilateral pectus carinatum with some degree of contralateral depression (termed by Ravitch[Ravitch 1977]as “mixed form”). This “mixed” form is especially likely to occur in tall asthenic individuals, such as those with Marfan syndrome. Such combined carinatum-excavatum deformities are invariably accompanied by various degrees of rotation of the sternum toward the depressed side. Interestingly enough, in asymmetrical or lateral pectus carinatum the protrusion is almost always on the left side, ergo propter, the rotation of the sternum occurs toward the right (Ravitch 1977). While Ravitch states this in such cases “the operative attention should always be directed to the depressed side” (Ravitch 1977), we believe that both sides should be treated equally and radically. It is our practice to repair such a combined deformity the following way :
The deformed cartilages – prominent on one side, depressed on the other – are bilaterally removed. Care is taken to end up having the peripheral stumps of the resected cartilages as much as possible on the same level in the antero-posterior plane. Usually in length the resection needs to be more extensive on the prominent than on the depressed side. A transverse, wedge-shaped osteomy is performed high on the sternum, on the sternum, with slightly more bone removed from the lower edge of the osteomy than of the upper.

The sternum is dissected free both laterally and posteriorly. The posterior lamina is fractured and the abnormal plane of the sternum is corrected by manually twisting the sternum around its longitudinal axis toward the opposite (carinatum) direction. The now horizontal anterior plane of the sternum is secured by placing a figure-of-eight heavy wire suture to the previously depressed edge of the transverse osteotomy.
Marlex mesh now spread under the sternum and sutured tight to the peripheral stumps of the resected ribs using 1-0 non-absorbable sutures. The operation is completed by suturing the mobilized pectoralis muscles together pre-sternally.
If pectus carinatum is accompanied with kyphosis, the matter of operative indication as well as the surgery itself should be the common endeavor of the thoracic surgeon and the orthopedist. Simultaneous operations on the anterior chest wall and the spine should be avoided.
We, ourselves, had the most gratifying experience of working closely with other orthopedic colleagues in several cases where pectus carinatum and kyphoscoliosis occurred concomitantly. In most patients the sterno-chondral deformity was repaired first, followed by correction of the spinal deformity – usually through the anqurior approach several weeks later. The principle of the spinal operation was to weaken the vertebra anterior to the cord, remove all or part of the posterior elements, and produce a controlled
compression fracture while observing and protecting the cord. This is followed by a posterior closing wedge osteotomy using the anterior longitudinal ligament as a wedge. In cases of extreme deformity, it might be necessary to perform multiple vertebrectomies to realign and transpose the spine toward the midline (Heining 1984).

Breast augmentation, if needed, could also be much better and safer performed after the carinatum deformity has been corrected and the chest wall has appropriately stabilized.

POSTOPERATIVE CARE

Care of patients after repair of pectus carinatum does not require special measures but in the most advanced cases with respiratory insufficiency. Most of the patients are ambulatory on the first postoperative day and receive unrestricted diet.
Medication for pain is given as necessary. If a foreign body, Marlex mesh or chest tube, is left in the patient, antibiotics are given for a 48-hour period – a measure the value of which we have no definite proof. The patient is usually discharged from the hospital on the fourth day after surgery.
Because of the nature of pectus excavatum repair, where the surgeon virtually has to “suspend the sternum in the air and has to keep it there,” even with proper choice of operation and operator there will probably always be a definite percentage of less than ideal early and late results. By contrast, unsatisfactory results following pectus carinatum repair, where protuberance needs to be corrected, poor results usually indicate unsatisfactory surgical technique (Ottolenghi 1981). Similarly, because the correction of pectus carinatum is less likely to create spaces for fluid accumulation, occurrence of wound complications is less likely.

A serious, however, rare complication of this operation is bleeding which is nearly always due to injury of the mammary artery or one of its major branches and is heralded by voluminous discharge of blood through the chest tube if one has been inserted, or by a rapidly increasing hematoma in the wound. In either case, the patient should be transfused if necessary, and immediately returned to the operating room where the bleeding should be brought under control.

Because the possibility of postoperative bleeding and because extensive pectus carinatum repair may be associated with blood loss which by itself may be significant, especially in smaller children such operation should not be undertaken without group identical blood being held available.
Infection may be also a complication of pectus carinatum operations. The few patients, some of them with Marlex mesh implants, however, who did develop infection in our series, all responded well to smaller drainage procedures and systemic administration of antibiotics.
Non-infected subcutaneous collections of serum may be easily handled with repeated needle aspirations even in small children, the area just below the center of the upward arching skin incision being devoid of sensory innervation for several weeks after surgery. The objective measurement of possible physiological improvement after operation is difficult if not impossible ; however, many patients “seem to feel healthier both physically and mentally after repair” (Heydorn 1977). During the past decade, our cosmetic and functional results in the management of pectus carinatum have been uniformly good. We have had no mortality in our series of 183 pectus carinatum operations are our single serious complication consisted of hemorrhage from the right mammary artery occurring in the immediate postoperative period for which the patient had to be returned to the operating theatre.
Portions of this chapter have been reproduced from Robicsek, F., Cook, J. W., Daugherty, H.K., Selle, J. G.: Thorac Cardiovasc Surg 78:52-61, 1979, published by the C. V. Mosby Company ; and from Robicsek, F., Daugherty, H. K., Mullen, D. C., Harbold, N. B., Jr., Hall, D. G., Jackson, R. D., Masters, T. N., Sanger, P. W.: Ann Thurac Surg 18:549-563, 1974, published by Little, Brown and Company.

By Francis Robisek, M. D.
Chairman, Department of Cardiovascular Surgery,
Charlotte Memorial Hospital and Medical Center
and
Clinical Professor of Surgery,
University of North Carolina Medical School
at Chapel Hill

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