Chest Wall Deformities What about Ravitch? D. Dean Potter, M.D. 12/10/07

Transcription

1 Chest Wall Deformities What about Ravitch? D. Dean Potter, M.D. 12/10/07

2 Outline Background and history Describe 2 Ravitch modifications Compare Ravitch vs Nuss procedure

3 Background 2 types of chest wall deformities Overgrowth of cartilages Aplasia or dysplasia

4 Background Overgrowth Pectus excavatum Pectus carinatum Dysplasia Poland s s syndrome

5 Chest Wall Deformity Anomaly # patients (%) Total 1124 Pectus excavatum 982 (87) Mixed excavatum/carinatum 69 (6) Pectus carinatum 51 (5) Poland s syndrome 8 (0.8) Other 7 (0.6) Nuss et al. Adolecs Med 15 (2004);

6 Pectus Excavatum Funnel chest

7 Mixed Excavatum/Carinatum

8 Mixed Excavatum/Carinatum

9 Pectus Carinatum Pigeon Chest

10 Poland s s Syndrome

11 Severe Poland s s Syndrome

12 Demographics of Pectus Excavatum Shamberger et al. JPS 23 (1988) 615 from Sabiston and Spencer Surgery of Chest, Ed 7

13 Associated Conditions Condition % Scoliosis 30% Marfan s syndrome 3% Marfanoid features 20% Ehlers-Danlos syndrome 2% Family history 45%

14 Presenting Symptoms Respiratory SOB, CP, exercise intolerance Cardiac Compression, displacement, MVP Pulmonary FRC, FEV 1, and FEV 25-75

15 Cardiac Compression / Displacement

16 Haller Index

17 Indications for Repair Haller Index > 3.25 PFT abnormalities Cardiac compression with murmur, MVP, or arrhythmia Progression with physical symptoms Failed prior repair

18 Brief History Dr. Sauerbruch resected ribs and elevated sternum with traction to bed Drs. Ochsner and DeBakey theorized overgrowth of cartilages prevented sternum from moving forward

19 Dr. Mark Ravitch 1949 Described diagnostic features Radical resection of sternal attachments and costocartilages without traction

20 Modified Ravitch - Support Bars Bigger autologus rib graft Daniel internal soft tissue support Adkins rib strut Rehbein flexible steel bands Adkins metal strut Fonkalsrud minimal cartilage resection

21 Nuss Procedure Dr. Donald Nuss 1998 Minimally invasive No cartilage resection

22 Modified Ravitch - Standard

23 Cartilage Resection

24 Osteotomy & Elevation

25 Strut Placement

26 Reefing Sailboat reefing Surgical reefing

27 Closure

28 Modified Ravitch - Minimal Cartilage Resection

29 Modified Ravitch - Minimal Cartilage Resection

30 Results - Excavatum

31 Results - Mixed Deformity

32 The Gloves Come Off!! Bring it on!!

33 The Facts 0 RCT comparing Ravitch vs Nuss Patients, parents, and practitioners request Nuss repairs Nuss repair has increased the referral rates Is the Nuss repair BETTER??

34 Observational study 327 pts Nuss vs 43 open Pre and periop data only No standardized pain managment Awaiting long-term results

35 Complications 286/284 27/43

36 Pain Survey

37 Pain Survey No mortality, but similar morbidity Pain well controlled overall Parents perceived more pain with open vs Nuss than patient experienced

38 Retrospective, single institution 103 patients (5 to 20 yrs) 68 Ravitch 35 Nuss

39 Indiana Results

40 Indiana Result Nuss quicker and better cosmetically Ravitch with fewer readmissions, reoperations,, less pain medicine requirements, and shorter stay Cost data not accurate

41 Retrospective, single institution 112 patients 32 open 80 Nuss

42 Kansas City Results

43 Kansas City Results Satisfaction Excellent 15 of 16 Nuss Excellent 30 of 32 Open

44 Retrospective, two institution review Procedures (ages 5 to 51 yrs) 68 Nuss in SC 139 Mini Ravitch in UCLA Nuss with epidural No epidural with Ravitch

45 SC/UCLA Results

46 SC/UCLA Results Both procedures are safe Open procedure with fewer complications shorter hospital stay less postoperative pain less time with bar in place

47 Bar Complications

48 Cardiac Perforation 2 deaths from introducer bar Unknown pericardial penetrations

49 Conclusions Ravitch and Nuss result in excellent recontouring with high satisfaction Modified Ravitch longer operative times more blood loss less postop pain (without epidural) quicker discharge and recovery decreased time with foreign body

50 Conclusions Ravitch is the procedure for Pectus carinatum Severe mixed excavatum/carinatum carinatum Poland s s syndrome Patients with mature skeleton

51 Conclusions Ravitch for pectus excavatum Shorter hospital stay Less pain