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Neo-sternum reconstruction using costal cartilage approximation and small Permacol® patch repair in the treatment of Cantrell pentalogy: a case report
© Kim et al.; licensee BioMed Central. 2015
Received: 22 October 2014
Accepted: 12 March 2015
Published: 25 March 2015
The ideal treatment for pentalogy of Cantrell is neo-sternum reconstruction by using autologous tissues. Although treatment timing varies depending on the degree of deformity and patient’s condition, the principle is performing the procedure at the earliest, to prevent blunt or piercing trauma to the heart. However, the challenge is performing the procedure on a neonate, because feasibility of the procedure is affected by the size of the defect, and limitations in utilizable autologous tissues. We used a small biocompatible patch (Permacol®) and lower costal cartilage to perform curative neo-sternum reconstruction, which is a simple and safe treatment method.
Patients with pentalogy of Cantrell exhibit the following five characteristics: a midline supraumbilical abdominal wall defect, defect of the lower part of the sternum, deficiency of the anterior diaphragm, defect in the diaphragmatic pericardium, and congenital heart malformation . The ideal treatment for pentalogy of Cantrell is neo-sternum reconstruction by using autologous tissues. Although the treatment timing varies depending on the degree of deformity and patient’s condition, the principle is performing the procedure at the earliest, to prevent blunt or piercing trauma to the heart. However, the challenge is performing the procedure on a neonate, because feasibility of the procedure is affected by the size of the defect and limitations in the amounts of utilizable autologous tissues . We used a small biocompatible patch (Permacol®) and lower costal cartilage to perform curative neo-sternum reconstruction.
In general, two techniques are followed in congenital defect surgical repair: using autologous tissues or artificial materials. Repair by using autologous tissues is preferred to minimize the risk of infection and accommodate the growth during remodeling of the wall . The ideal corrective procedure for a patient with lower sternal cleft, including pentalogy of Cantrell, is sternal reconstruction through approximation of low costal-cartilage by using autologous tissues and covering with the pectoralis major and rectus abdominis muscles . To minimize the tension of the strings during the low costal approximation, sternum resection and lowermost costal cartilage resection should be performed, and tying for the approximation should be performed using encircling suture. However, full approximation of the cartilage is difficult with encircling sutures alone due to risk of amputating the cartilages because of the tension. Additionally, the technique of thoraco-abdominal repair by using autologous tissues is greatly affected by the defect size and corresponding autologous tissue size. Consequently, it is difficult to acquire sufficient amounts of autologous tissues . These disadvantages are why sternal reconstruction by thoraco-abdominal wall repair, typically, is not performed on neonates despite its many advantages.
We improved the existing surgical technique of sternal reconstruction in neonates to facilitate a safer and relatively quicker procedure, thereby overcoming several disadvantages of the technique. In addition to promoting the advantages of using autologous tissues, the new procedure helped minimize the tension of the string during the low costal cartilage approximation by using a small-sized biocompatible patch, which is affixed onto the resected left low costal cartilage by using interrupted stitch. Then, the contra-lateral stitch was performed close to the left stitch to facilitate the approximation of both cartilages. Thus, the tension resulting from approximation of the costal cartilages is distributed evenly on the patch, enabling close approximation with less tension. Further, the gap in the central area was covered using the patch. A minimal amount of the biocompatible agent Permacol® was used for the type and size of the patch, taking into account the risk of infection and mal-growth modeling of the thoraco-abdominal wall. Thus, patients who do not need corrective cardiac surgery could benefit from the safe and relatively quick option of thoraco-abdominal wall reconstruction by using a small patch and low costal cartilage resection and approximation.
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
This study was supported by the Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital.
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