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Chest Imaging

E2746. Pectus Excavatum in the Adult Patient, Part II: Assessment of the Postoperative Patient

Czaplicki C,  Jaroszewski D,  Ewais M,  Naqvi T,  Gotway M. Mayo Clinic, Phoenix, AZ

Address correspondence to C. Czaplicki (czaplicki.christopher@mayo.edu)

Background Information: Our objective is to familiarize radiologists with the surgical approaches to pectus excavatum (PE) repair and illustrate the typical early and late imaging findings after surgery, including normal, expected findings as well as common and uncommon complications that may be encountered.

Educational Goals/Teaching Points: The normal and expected chest radiographic and cross-sectional imaging appearances commonly encountered both immediately following and late following surgical repair of PE will be reviewed and illustrated. Uncommon early and late postoperative complications following PE repair, including failed or recurrent PE, will be reviewed and illustrated. An accompanying exhibit has reviewed the pathogenesis, clinical presentation, physiologic impact, and surgical approaches to PE, and the imaging indices used to assess PE severity, with which interpreting radiologists should be familiar.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: There are two main surgical approaches to PE repair, the Nuss procedure (minimally invasive PE repair) and the Ravitch procedure (open procedure). Typically immediately following either surgical repair, atelectasis, small pleural effusions, and pneumothoraces occur; the latter is rarely significant, given prophylactic thoracostomy tubes placement. The pneumothoraces typically resolve quickly, often within 1 week after surgery. Early in the postoperative period, infection, including pneumonia, chest wall abscess, and osteomyelitis may occur, but such events are uncommon. In the late postoperative period, occasionally the bars may induce a well-formed periosteal reaction in the ribs, at the attachment sites, or along the posterior sternal cortex, visible at imaging. Uncommonly, the bars may erode the internal sternal cortex to a variable degree; this finding is visible at lateral chest radiography or cross-sectional imaging. Uncommon late PE repair complications include bar stripping, rotation, and migration; recognition of these findings at imaging is important for correct management. Costosternal malunion, possibly due to a lack of cartilage regeneration, and pseudoarthroses may occur and require repeat operation. PE may recur following repair in 2–37% of patients; this frequency is similar for both Nuss and Ravitch repairs. The reason for recurrent or persistent PE following initial surgical repair includes bar malposition (too long or placed too laterally), inadequate bar stabilization, or failure to elevate the sternum sufficiently. Recurrent PE may prompt imaging for reevaluation prior to repair, necessitating calculation of the severity indices discussed in the accompanying exhibit.

Conclusion: Familiarity with the surgical procedures used to correct PE as well as the expected imaging findings and complications that may be seen during the early and late postoperative periods should enhance the radiologist’s ability to positively contribute to the care of patients