Recurrent Pectus Excavatum: A Surgical Challenge

In contrast too the modified Ravitch procedure, the Nuss procedure is a minimally invasive technique introduced by Dr. Nuss in 1998 as an alternative to the modified Ravitch procedure for the treatment of PE, the most common chest wall malformation [1]. For rigid or mixed excavatum-carinatum deformities, several centers now adopt a “sandwich” strategy in which an external compression bar is combined with one or two internal Nuss bars; the original series of 58 patients reported by Park and Kim achieved significant morphologic correction with a < 5% three-year recurrence rate [8]. A recent extensive review likewise endorses the sandwich construct as a full-remodeling option for complex or very rigid chests [9], but because our two patients exhibited pure recurrent depression without anterior protrusion, the conventional multi-bar minimally invasive technique was deemed sufficient. Correction of PE not only enhances the cosmetic appearance of patients but also expands the thoracic cavity,which improves cardiac and pulmonary function by relieving anterior compression of the heart by the sternum [4]. For open repair, the risk of recurrence can stem from factors such as incomplete initial repair, undergoing the procedure at a young age, excessive dissection, insufficient support structures, inadequate chest wall healing and premature removal. Even though premature strut removal can precipitate early relapse, indefinite retention is not without risk. Case reports describe late strut fracture with cardiac penetration [10] and intrapericardial migration more than 30 years after the index Ravitch repair [11] while biomechanical analyses recommend elective removal within 6-12 months to avoid hardware fatigue and secondary deformity. For patients who undergo primary Nuss repair, issues related to support bars, such as their placement, number, migration, and premature removal, can contribute to failure. Connective tissue disorders such as Marfan syndrome can also complicate this situation and increase the risk of recurrence for both types of PE repair [6]. The approach to the preoperative evaluation for any patient with recurrent PE is similar to that for a patient with primary, uncorrected PE, but with more emphasis on clinical symptoms, including chest pain, respiratory symptoms, palpitations, or exercise intolerance, as well as the patient’s age and psychosocial purpose [12].

Correction of recurrent PE is significantly more challenging and complex than primary repair. In the initial open procedure, irregular fusions and ossifications of the regenerated costal cartilage often create adhesions to the pericardium and lungs, accompanied by dense intrathoracic adhesions between the sternum and mediastinal structures, as evidenced in these patients. Even though the Ravitch approach directly reshapes the chest wall through cartilage resection, the presence of a long-retained bar can contribute to similar complications. there is an ongoing debate regarding the optimal surgical approach for patients who have experienced recurrent PE after initial repair [13].Hebra et al. [14] reported that the Nuss procedure could achieve complete correction of chest deformities only in adult patients with symmetrical pectus defects.Patients with severe asymmetrical deformities and significant calcifications in the re