ABSTRACT

The Nuss procedure is a minimally invasive repair for pectus excavatum in children and adults. However, it is unclear whether or not the stainless steel bar should be removed before pregnancy. We report on two adult females who had undergone a Nuss repair for pectus excavatum and successfully delivered prior to removal of the pectus bar.

A male, aged 64 years, presented to the Emergency Department with increasing dyspnea over the preceding 3 days. He was known to have alcoholic cirrhosis and had been treated for ascites for 3 years. On examination, he had a rapid respiratory rate (24 per minute) and chest signs consistent with fluid in the right pleural cavity. A chest X-ray confirmed the presence of a right hydrothorax (Fig. 1). Blood tests revealed a mild leucocytosis with an elevated level of C-reactive protein. A contrast-enhanced computed tomography (CT) scan of the abdomen confirmed the presence of cirrhosis with ascites. In addition, there was a defect in the right hemidiaphragm (arrow) and fluid in the right pleural cavity (Fig. 2). Initially, the patient was treated with fluid restriction and diuretics. Subsequently, he underwent video-assisted thoracoscopic surgery with repair of the diaphragm using direct sutures. His postoperative course was uneventful and the hydrothorax did not recur over the subsequent 6 months.Hydrothoraces occur in approximately 5% of patients with cirrhosis and ascites. Most patients have unilateral and right-sided effusions, but a minority have bilateral effusions with larger effusions on the right. Small effusions may be a 'sympathetic' response to diaphragmatic irritation by ascites. Large and unilateral effusions mostly occur because of a small defect in the right hemidiaphragm. These defects are thought to be congenital in origin although this does not necessarily account for the acute development of dyspnea in the patient described above. Conceivably, small congenital defects may dilate if tense ascites results in a further rise in intra-abdominal pressure. The initial treatment of hepatic hydrothorax is optimal medical management of ascites. If this is unsuccessful, one option is the use of a transjugular intrahepatic portosystemic shunt, perhaps followed by liver transplantation. Other options include chest drainage with sclerosis of the pleura and chest drainage followed by direct surgical repair of the diaphragmatic defect. The above patient was notable because of the demonstration of the diaphragmatic defect on a CT scan.