    View TSDA Curriculum Online for this topic |
View TSDA Curriculum Online for this topic |
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| 1. Pectus Excavatum · Most common congenital sternal deformity, occurring in 1 in 400 children · Excessive growth of lower costal cartilage results in sternal depression · Usually causes a deeper depression on the right, pushing heart to the left · Congenital with progressive worsening over time · Rarely familial |
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| 2. Physiologic Manifestations · Usually asymptomatic · Subjective decrease in respiratory reserve with exercise · Scoliosis and mitral valve prolapse have been associated with pectus excavatum · Decreased maximal voluntary ventilation and a mild restrictive pattern on PFTs has been documented in some studies · Decreased SV and CO during upright exercise has also been demonstrated |
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| 3. Operative Indications · Cosmetic correction is the most common reason · Psycho-social factors, however, may be quite limiting, particularly in older children · Respiratory insufficiency and recurrent pulmonary infections · Best results are obtained in patients between the ages of 3 and 5 |
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| 4. Operative Technique A. Ravitch repair · Midline or transverse inframammary incision · Pectoralis reflected bilaterally to expose costal cartilages · Subperichondrial resection of all deformed costal segments · Elevate sternum from underlying structures and separate from cartilage · Transverse sternal osteotomy and fixation with pin or cartilage support B. Sternal eversion C. Prosthetic implants |
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| 5. Results · Cosmetic results are good in 80-90% · Recurrence occurs in about 10-20% of patients · Return of normal respiratory function and improvement in exercise capacity is possible |
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| 6. Other Deformities A. Pectus Carinatum · More common in males and is associated with scoliosis · Usually presents as anterior sternal displacement with symmetric costal cartilage concavity · Costal cartilage resection gives excellent results B. Poland's syndrome C. Sternal fissure D. Cantrell's Pentalogy |
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| 1. Incidence · Comprise 7-8% of all bony tumors · Most primary chest wall tumors are malignant · 85-90% occur in the ribs (50% malignant) · 10-15% occur in the sternum (95% malignant) · Male:female = 2:1 |
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| 2. Clinical Presentation · Slowly enlarging mass eventually causes pain and presence of mass · Pain is more common in malignant tumors, but 20-25% are asymptomatic · Tumors occur at any age and are more likely to be malignant in older patients · CXR with rib detail films and CT scan are usually adequate and can evaluate associated pulmonary nodules · MRI distinguishes nerve and vascular invasion |
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3. Etiology
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| 4. Principles of Treatment · Excisional rather than incisional biopsy should be peformed if a primary chest wall tumor is suspected · Full thickness excision of the tumor with 1 rib margin is necessary; do not compromise resection to avoid large chest wall defect · Large tumors may warrant incisional biopsy · Needle biopsy is best for suspicious mets or myeloma · Sternal tumors should be treated by sternectomy |
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| 5. Principles of reconstruction · A defect less than 5 cm does not require reconstruction · Posterior defects do not require reconstruction due to scapula · Defects larger than 5 cm will require reconstruction · Skeletal stabilization can be accomplished with a mesh patch or methyl methacrylate · Soft tissue reconstruction can be done in a variety of ways, including myocutaneous flaps (latissimus dorsi, pectoralis major, rectus abdominus) and omental transposition |
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| 6. Results · Low operative mortality and good postoperative pulmonary function · Overall long term survival is about 50-70%, with best rates for chondrosarcoma and rhabdomyosarcoma, and worst rates for malignant fibrous histiocytoma · Survival is better with wide excision · Adjunctive therapy may improve survival |