Chest Wall DeformitiesChest Wall DeformitiesWhat about What about RavitchRavitch??

D. Dean Potter, M.D.D. Dean Potter, M.D.12/10/0712/10/07

OutlineOutline

•• Background and history Background and history

•• Describe 2 Describe 2 RavitchRavitch modificationsmodifications

•• CompareCompare Ravitch vs NussRavitch vs Nuss procedure procedure

BackgroundBackground

2 types of chest wall deformities2 types of chest wall deformities

•• Overgrowth of Overgrowth of cartilagescartilages

•• AplasiaAplasia or or dysplasiadysplasia

BackgroundBackground

Overgrowth Overgrowth

•• Pectus excavatumPectus excavatum

•• Pectus carinatumPectus carinatum

DysplasiaDysplasia

•• PolandPoland’’s syndromes syndrome

Chest Wall DeformityChest Wall Deformity

Anomaly # patients (%)Total 1124Pectus 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); 455-471

Pectus ExcavatumPectus Excavatum ““Funnel chestFunnel chest””

Mixed Mixed ExcavatumExcavatum//CarinatumCarinatum

Mixed Mixed ExcavatumExcavatum//CarinatumCarinatum

Pectus Carinatum Pectus Carinatum ““Pigeon ChestPigeon Chest””

PolandPoland’’s Syndromes Syndrome

Severe PolandSevere Poland’’s Syndromes Syndrome

Demographics ofDemographics of Pectus ExcavatumPectus Excavatum

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

Associated ConditionsAssociated Conditions

Condition %

Scoliosis 30%

Marfan’s syndrome 3%

Marfanoid features 20%

Ehlers-Danlos syndrome 2%

Family history 45%

Presenting SymptomsPresenting SymptomsRespiratoryRespiratory

•• SOB, CP, SOB, CP, exercise intoleranceexercise intolerance

CardiacCardiac•• Compression, displacement, MVPCompression, displacement, MVP

PulmonaryPulmonary

•• FRC, FEVFRC, FEV11, and FEV , and FEV 2525--7575

Cardiac Compression / DisplacementCardiac Compression / Displacement

Haller Haller IndexIndex

Indications for RepairIndications for Repair

•• Haller Haller Index Index >> 3.253.25

•• PFT abnormalitiesPFT abnormalities

•• Cardiac compression with murmur, Cardiac compression with murmur, MVP, or arrhythmiaMVP, or arrhythmia

•• Progression with physical symptomsProgression with physical symptoms

•• Failed prior repairFailed prior repair

Brief HistoryBrief History

1911 1911 -- Dr. Dr. Sauerbruch Sauerbruch resected ribs resected ribs and elevated sternum with traction to and elevated sternum with traction to bedbed

1939 1939 -- Drs. Drs. Ochsner Ochsner and and DeBakey DeBakey theorized overgrowth of theorized overgrowth of cartilages cartilages prevented sternum from moving prevented sternum from moving forwardforward

Dr. Mark Dr. Mark RavitchRavitch

•• 19491949

•• Described diagnostic Described diagnostic featuresfeatures

•• Radical resection of Radical resection of sternal sternal attachments attachments and and costocartilages costocartilages without tractionwithout traction

Modified Modified Ravitch Ravitch -- Support BarsSupport Bars

•• 1952 1952 -- Bigger Bigger autologus autologus rib graftrib graft•• 1958 1958 -- Daniel internal soft tissue Daniel internal soft tissue

supportsupport•• 1958 1958 -- Adkins Adkins rib strutrib strut•• 1959 1959 -- RehbeinRehbein flexible steel bands flexible steel bands •• 1961 1961 -- Adkins Adkins metal strutmetal strut•• 2004 2004 -- Fonkalsrud Fonkalsrud minimal cartilage minimal cartilage

resectionresection

Nuss Nuss ProcedureProcedure

•• Dr. Donald Dr. Donald NussNuss

•• 19981998

•• Minimally invasiveMinimally invasive

•• No cartilage resectionNo cartilage resection

Modified Modified Ravitch Ravitch -- StandardStandard

Cartilage ResectionCartilage Resection

Osteotomy Osteotomy & Elevation& Elevation

Strut PlacementStrut Placement

““ReefingReefing””Sailboat reefingSailboat reefing Surgical reefingSurgical reefing

ClosureClosure

Modified Modified Ravitch Ravitch --Minimal Cartilage ResectionMinimal Cartilage Resection

Modified Modified Ravitch Ravitch --Minimal Cartilage ResectionMinimal Cartilage Resection

Results Results -- ExcavatumExcavatum

Results Results -- Mixed DeformityMixed Deformity

The Gloves Come Off!!The Gloves Come Off!!

Bring it on!!

The FactsThe Facts

•• 0 RCT comparing 0 RCT comparing Ravitch vs NussRavitch vs Nuss

•• Patients, parents, and practitioners Patients, parents, and practitioners request request NussNuss repairsrepairs

•• NussNuss repair has increased the referral repair has increased the referral ratesrates

•• Is the Is the Nuss Nuss repair repair BETTERBETTER????

•• Observational studyObservational study•• 327 327 pts pts -- 284 284 Nuss vs Nuss vs 43 open43 open•• Pre and Pre and periop periop data onlydata only•• No standardized pain No standardized pain managmentmanagment•• Awaiting longAwaiting long--term resultsterm results

ComplicationsComplications

286/284286/284 27/4327/43

Pain SurveyPain Survey

Pain SurveyPain Survey

•• No mortality, but similar morbidityNo mortality, but similar morbidity•• Pain well controlled overallPain well controlled overall•• Parents perceived more pain with open Parents perceived more pain with open

vs Nuss vs Nuss than patient experiencedthan patient experienced

•• Retrospective, single institutionRetrospective, single institution•• 103 patients (5 to 20 103 patients (5 to 20 yrsyrs))

•• 68 68 RavitchRavitch•• 35 35 NussNuss

Indiana ResultsIndiana Results

Indiana ResultIndiana Result

•• Nuss Nuss quicker and better cosmeticallyquicker and better cosmetically

•• Ravitch Ravitch with fewer with fewer readmissionsreadmissions, , reoperationsreoperations, less pain medicine , less pain medicine requirements, and shorter stayrequirements, and shorter stay

•• Cost data not accurateCost data not accurate

•• Retrospective, single institutionRetrospective, single institution•• 112 patients112 patients

•• 32 open32 open•• 80 80 NussNuss

Kansas City ResultsKansas City Results

Kansas City ResultsKansas City Results

•• SatisfactionSatisfaction•• Excellent 15 of 16 Excellent 15 of 16 Nuss Nuss •• Excellent 30 of 32 OpenExcellent 30 of 32 Open

•• Retrospective, two institution reviewRetrospective, two institution review•• Procedures (ages 5 to 51 Procedures (ages 5 to 51 yrsyrs))

•• 68 68 Nuss Nuss in SCin SC•• 139 Mini139 Mini RavitchRavitch in UCLAin UCLA

•• NussNuss with with epiduralepidural•• No No epidural epidural with with RavitchRavitch

SC/UCLA ResultsSC/UCLA Results

SC/UCLA ResultsSC/UCLA Results

•• Both procedures are safeBoth procedures are safe

•• Open procedure with Open procedure with •• fewer complicationsfewer complications•• shorter hospital stayshorter hospital stay•• less postoperative painless postoperative pain•• less time with bar in placeless time with bar in place

Bar ComplicationsBar Complications

Cardiac PerforationCardiac Perforation

•• 2 deaths from introducer bar2 deaths from introducer bar

•• Unknown pericardial penetrationsUnknown pericardial penetrations

ConclusionsConclusions•• Ravitch Ravitch and and Nuss Nuss result in excellent result in excellent

recontouringrecontouring with high satisfactionwith high satisfaction

•• ModifiedModified Ravitch Ravitch •• longer operative timeslonger operative times•• more blood lossmore blood loss•• less less postoppostop pain (without pain (without epiduralepidural) ) •• quicker discharge and recoveryquicker discharge and recovery•• decreased time with foreign bodydecreased time with foreign body

ConclusionsConclusions

Ravitch Ravitch is the procedure foris the procedure for

•• Pectus carinatumPectus carinatum

•• Severe mixed Severe mixed excavatumexcavatum//carinatumcarinatum

•• PolandPoland’’s syndromes syndrome

•• Patients with mature skeletonPatients with mature skeleton

ConclusionsConclusions

Ravitch Ravitch forfor pectus excavatumpectus excavatum

•• Shorter hospital stayShorter hospital stay

•• Less painLess pain