PLEASE POST A COMMENT ONLY IF YOU ARE CURRENTLY ENGAGED IN CLINICAL PRACTICE AND PERFORM SURGERY FOR PECTUS EXCAVATUM.
37 Y male with history of pectus excavatum.
At age 12, patient underwent pectus repair, open Ravitch procedure, excision 8, 9, 10, 11, and 12 th costal cartilages bilaterally, excised of xiphoid process, wedge osteotomy of the sternum, placement of Kirschner wire posterior to the sternum.
As he got older, age 20-30's, his sternal concave gradually increased, with worsened symptoms of SOB, DOE and palpitation.
PFT showed FVC 3.47 L, 0 % predicted, FEV 1 2.96 L, 64 % predicted and DLCO 33 ml/min/mmHg, 94 % predicted.
Chest CT non contrast showed asymmetrical pectus excavatum, with Haller index 3.6, with restricted thoracic dystrophy with calcification of costal cartilages 5-8 bilaterally, sternal wire at sternal osteotomy.
ECHO showed 55-60 %, tricuspid regurgitation and mitral valve regurgitation, normal RV, compressed RA.
He underwent a repair procedure: resection of bilateral costosternal and costalostial junction 3 through 5, anterolateral expansion with bio bridge bars, bilateral rectus and pectoralis major muscle flaps, closure of the lower chest and upper abdomen defect (5 cm x 10 cm) with OVITEX LPR patch (8x 12 cm) and repair xiphoid hernia.
(See uploaded file - operative report).
In the months after the procedure, patient noticed that his post surgical area feels firm, and his symptoms of SOB, DOE, palpitation, and chest pain worsened.
After this procedure, his PFT showed decrease FEV1 and restrictive disease.
After this procedure, 3 D chest CT reconstruction showed there are no cartilages connected to the sternum starting from rib 6 and below with ectopic calcification.
After this procedure, Cardiac MRI and ECHO showed no evidence of right ventricular compression, elevated right ventricular pressures,
Files:
No questions yet!
Do you believe there might have been medical error?
Reoperative pectus repair is quite technically challenging and outcomes are very hard to predict. The surgeon certainly had a long conversation with the patient on the technique, challenges, and expectations after surgery.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The outcome is not unexpected given the surgical history. Patient expectations prior to surgery would have been crucial prior to embarking on this procedure.
What makes you a good expert for this case?
Manage chest wall surgery regularly, including pectus repair and reoperative surgery. Focus on the expectations of patients post-operative my to ensure optimal clinical outcome and patient satisfaction.
How often do you encounter cases similar to this one in your practice?
Pectus excavatum: 1-2 / month Reoperative pectus: 1/yr
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