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Eur J Cardiothorac Surg 1998;14:434-436
© 1998 Elsevier Science NL

Case report

Migration of pectus excavatum correction metal support into the abdomen

Department of Cardio-thoracic Surgery, University Hospital, Largo del Pozzo 71, 41100 Modena, Italy

Received 16 March 1998; received in revised form 3 June 1998; accepted 22 June 1998.

Corresponding author. Tel.: +39 059 422171; fax: +39 059 360159; e-mail: rlodi @ unimo.it

	Abstract

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The authors describe a case of migration of a metal support, used to fix a corrected pectus excavatum deformity, into the peritoneal cavity. The migrated wire caused abdominal pain. A videolaparoscopic removal of the wire was undertaken and the patient made a full recovery. A review of the literature shows that this has not been reported before and that serious complications related to metal struts are very uncommon. We do not believe that a revision of this surgical technique is needed; anyway, foreign body migration should always be considered as a cause for unusual symptoms in patients undergoing this operation.

Key Words: Pectus excavatum correction • Metal support migration

	Introduction

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Pectus excavatum is the most common chest wall deformity referred for surgical correction.

In agreement with many other authors, we use metal supports for internal fixation of the sternum in corrected position [1]. A wide variety of operative procedures for internal stabilization with metal struts has been proposed. They include pre-, trans- and retro-sternal fixation and many different struts have been used for this purpose [2].

Surgical technique: in our procedure [3], the surgical access is through a bi-sub-mammarian incision. To mobilize the sternum, two little cylinders of costal cartilage are resected subperichondrially, one to the chondrosternal junction and the other to the chondrocostal junction. Resection usually extends from the third to the seventh costal cartilages. Xiphoid process is resected. At the site of angulation, a transverse cuneiform osteotomy is made, through the anterior cortex. The sternum is held in position by closing the osteotomy with steel wires and with two metal supports: a Kirschner wire, threaded lengthways into the sternal medullary cavity, through the body until the manubrium and a Rusch pin, placed crosswise, secured with two pericostal sutures laterally and to the caudal end of the Kirschner wire, to prevent migration ( Fig. 1 ). The perichondrium is closed and the muscles are reconstructed.

View larger version (116K): [in this window] [in a new window]   Fig. 1. Postero-anterior chest radiography demonstrating the two struts in situ.

In this report we present a case of migration of a metal wire used to correct this deformity through the rectus abdominal muscles and the peritoneum into the abdominal cavity.

	Case report

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A 20-year-old woman underwent surgical correction of a severe pectus excavatum deformity, in October 1996, at the Department of Cardio-thoracic Surgery of the University of Modena.

We used the reported technique that had provided good results in over 50 patients. Post-operatively, the patient made a good recovery, without any complication and this continued to be so in the early months after discharge. Six months after operation the Rusch pin was removed under local anesthesia and without any difficulty. Two months later the patient began complaining of epigastric pain, at the level of the caudal end of the Kirschner wire. This symptom disappeared after a few days without any specific treatment. During the next month, the patient occasionally complained of pain localized in the left hypochondrium and left iliac fossa. The pain increased with movement. X-ray examinations were performed, which showed migration of the Kirschner wire: it seemed to be placed inside the anterolateral chest wall, at the level of IX–XI left ribs ( Fig. 2 a,b). The patient was admitted to our department. A thoracoabdominal computed tomography was performed, showing the metal wire inside the peritoneal cavity, among the stomach, spleen and left kidney. A videolaparoscopic removal of the wire was undertaken; no drains were placed. Post-operative period was uneventful and the patient was discharged on the second post-operative day.

View larger version (116K): [in this window] [in a new window]   Fig. 2. (a) Postero-anterior and (b) lateral abdominal roengtenograms showing the migration of the Kirschner wire.

	Discussion

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The mechanism of migration of the Kirschner wire, inserted through the sternal medullary cavity, is difficult to understand and remains unknown. To introduce the wire in the sternum a special hand bone drill is needed and some strength is necessary. Anyway, the wire was inserted without any technical difficulty and no post-operative complications were observed. During the first months after the operation, the patient was in good health and recurrence of thoracic deformity was not observed. Chest X-rays performed post-operatively, at 3 and 6 months from the operation, showed that the struts were in the right position. Visiting the patient a few days after she began to have epigastric pain, we could appreciate the correct position of the caudal end of the Kirschner wire. Thus, the migration of the wire happened in the following few weeks. The caudal end of the wire pierced through the rectus abdominal muscles, their fascia and the peritoneum to enter into the peritoneal cavity, where it was free to move. The migration of the wire through the abdominal wall and its moving inside the abdominal cavity might cause the symptoms the patient complained of.

This migration could be due to the fact that the patient did not keep the rules we gave or may have been due to a thoracic trauma. The patient reported that she always strictly kept the rules; there was no history of trauma and chest X-rays did not reveal any sternal or rib fracture.

This case raises interesting considerations about risks and benefits of metal supports. The major area of controversy in settling the optimal surgical technique for repair of pectus excavatum centers on the use of metallic supports or wires for sternal stabilization. Satisfactory results as well as poor results have been reported using either supports or procedures without supports [2] [7]. In our experience in 55 patients, we achieved satisfactory results using struts. We consider it advantageous to place these supports for the following reasons: (1) they stabilize the anterior chest wall in the immediate post-operative period, when it is still weak and not well fixed yet; (2) they keep the sternum in the correct position for the necessary time, so that the growing cartilages may definitively fix it in this position. Moreover, we did not observe an increase of the complication rate or an increase of the discomfort for the patient. No serious complications related to metal struts have been reported in the revised literature, except for the two aforementioned cases. The controversy about metal struts refers to results and not to complications or risks. Thus, we do not believe that the description of these complications may lead to a revision of such a well established surgical technique.

Nevertheless, foreign body migration should always be considered as a cause for unusual symptoms in patients undergoing this operation [5]. Our patients underwent chest roengtenograms at 3, 6 and 12 months after the operation; because migration is very uncommon, we did not change this follow-up procedure. However, we recommend this radiological follow-up and a careful detection of any sign or symptom.

As we do not really know the mechanism of the migration, this experience does not teach us how to avoid this complication. We only can exhort the patient to strictly keep to the rules we usually give and hope the patient co-operates.

	References

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1. Ravitch MM. Congenital deformities of the chest wall and their operative correction. Philadelphia, Saunders, 1977.
2. Morshuis W.J., Mulder H., Wapperom G., Folgering H.T., Assman M., Cox A.L., Van Lier H.J., Vincent J.G., Lacquet L.K. Pectus excavatum. A clinical study with long-term postoperative follow-up. Eur J Cardiothorac Surg 1992;6:318-329.[Abstract]
3. Lodi R., Morandi U., Spagna G., Tazzioli G., Fontana G., Lavini C., Smerieri A., Rumolo A., Marchioni C.F. Correzione chirurgica delle malformazioni della parete toracica anteriore. La Chir Torac 1990;43:73-77.
4. McWilliams R., Hopper T., Lawson R. A late complication of pectus excavatum repair. Postgrad Med J 1992;68:473-474.[Abstract]
5. Dalrymple-Day M.J.R., Calver A., Lea R.E., Monro J.L. Migration of pectus excavatum correction bar into the left ventricle. Eur J Cardiothorac Surg 1997;12:507-509.[Abstract]
6. Gilbert J.C., Zwiren G.T. Repair of pectus excavatum using a substernal metal strut within a Marlex envelope. South Med J 1989;82:1240-1244.[Medline]
7. Shamberger R.C., Welch K.J. Surgical repair of pectus excavatum. J Ped Surg 1988;23:615-622.[Medline]

This article has been cited by other articles:

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				J. P. Brooks and H. F. Tripp BIOABSORBABLE WEAVE TECHNIQUE FOR REPAIR OF PECTUS EXCAVATUM J. Thorac. Cardiovasc. Surg., January 1, 2000; 119(1): 176 - 178. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Uliano Morandi Renzo Lodi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Stefani, A. Articles by Lodi, R. Search for Related Content PubMed PubMed Citation Articles by Stefani, A. Articles by Lodi, R.