Other than cardiopulmonary impairment, pectus excavatum has been reported as a rare cause of syncope, leg edema, and dysphasia . The Nuss procedure has become a preferred option for correction of pectus excavatum worldwide, due to its excellent functional and cosmetic outcomes [1, 2]. However, the standard Nuss procedure is not applicable in all circumstances, and modification or the Ravitch procedure is necessary in some cases [3, 4].
In the present case, the Eloesser window operation was considered to aggravate pectus excavatum, which caused congestive hepatopathy and bilateral leg edema through compression of the right ventricle and inferior vena cava . Since conservative treatments had been unsuccessful, surgical intervention was planned. The aim of surgical repair was to improve cardiac function and congestive hepatopathy by relieving the compression on the heart and inferior vena cava. The patient’s empyema with the Eloesser window forbade the standard Nuss procedure (through the intrapleural route). Therefore, a modification (through the extrapleural route) was performed, and several previous studies have reported that the extrapleural Nuss procedure is a safe and less traumatic procedure compared to the standard Nuss procedure [3, 4]. Although, there were a few injuries to the right pleura during the procedure, there was no injury or perforation in the left pleura due to its altered nature (thickened due to empyema). In addition, the use of a small subxiphoid incision made the procedure safer and more feasible. We chose the sandwich technique because empyema with the Eloesser window restricted the usage of usual instruments for fixation to the ribs .
Compression on the heart and inferior vena cava was markedly relieved, and congestive hepatopathy was completely resolved. However, the patient required ventilator support due to carbon dioxide retention even though he tolerated no ventilator support for hours. The sandwich technique was considered to impair his respiratory function because the pectus metal bars restricted chest wall movement (8). Since the patient was in very poor condition including severe spinal scoliosis, dextrocardia, and chronic left empyema with the Eloesser window, even mild restriction of chest wall movement by pectus metal bars was assumed to cause respiratory distress. Since ventilator weaning ultimately failed, the modified Ravitch procedure was performed with a short pectus bar, avoiding entry into the empyema space. The patient was weaned off ventilator support completely one month after the Ravitch procedure. The present case report suggests followings. The first, we can repair pectus excavatum through the modification of the Nuss procedure in a patient with an Eloesser thoracostomy window. The second, the sandwich method can restrict chest wall movement in some conditions because the Nuss procedure is usually considered to not cause greater restriction of chest wall movement compared to the Ravitch procedure [1, 8].