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Dunning J, Burdett C, Child A, Davies C, Eastwood D, Goodacre T, Haecker FM, Kendall S, Kolvekar S, MacMahon L, Marven S, Murray S, Naidu B, Pandya B, Redmond K, Coonar A. The pectus care guidelines: best practice consensus guidelines from the joint specialist societies SCTS/MF/CWIG/BOA/BAPS for the treatment of patients with pectus abnormalities. Eur J Cardiothorac Surg 2024; 66:ezae166. [PMID: 38964837 DOI: 10.1093/ejcts/ezae166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/26/2024] [Accepted: 04/30/2024] [Indexed: 07/06/2024] Open
Abstract
Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back towards the spine (excavatum), protrudes forwards (carinatum) or more rarely is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities (such as swimming, dancing) and from interactions that might 'expose' them (such as sleepovers, dating, going to the beach and wearing fashionable clothes). This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise (such as running) but can also limit moderate activity such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment usually also suffer from low self-esteem and depression. This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and non-surgical techniques including bracing and vacuum bell therapy. We also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants and other rare procedures such as Pectus Up. For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance and long-term support. All the interventions have risks and benefits that the patient, parents and clinicians need to carefully consider and discuss when deciding on the most appropriate course. We hope this evidence review of 'Best Practice for Pectus' will make a significant contribution to those considerations and help all involved, from patients to national policy makers, to deliver the best possible care.
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Affiliation(s)
- Joel Dunning
- Department of Cardiothoracic surgery, James Cook University Hospital, Middlesbrough, UK
| | - Clare Burdett
- Department of Cardiothoracic surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Carl Davies
- Royal College of Physicians and Surgeons of Glasgow, UK
| | | | - Tim Goodacre
- Royal College of Surgeons of England, London, UK
| | - Frank-Martin Haecker
- Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
- Department of Paediatric Surgery, Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Simon Kendall
- Society for Cardiothoracic Surgery in Great Britain and Ireland, London, UK
| | - Shyam Kolvekar
- National Pectus Centre, Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Lisa MacMahon
- Department of Thoracic Surgery, Phoenix Children's Hospital, Phoenix, USA
- Chest Wall International Group (CWIG), Switzerland
| | - Sean Marven
- British Association of Paediatric Surgeons Thoracic and Airway Group, London, UK
| | - Sarah Murray
- Clinical Research Collaborative BHF and Leicester University, National PPI Group, Leicester, UK
| | - Babu Naidu
- Department of Thoracic Surgery, Birmingham Heartlands Hospital, Birmingham, UK
| | - Bejal Pandya
- National Pectus Centre, Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Karen Redmond
- Department of Thoracic Surgery, School of Medicine, University College Dublin, National Thoracic Subcommittee Lead SCTS, The Mater Hospital, Dublin, Dublin, Ireland, UK
| | - Aman Coonar
- Thoracic Lead at NHS England, President of the Society for Cardiothoracic Surgery in Great Britain and Ireland, London, UK
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Janssen N, Daemen JHT, Franssen AJPM, van Polen EJ, van Roozendaal LM, Hulsewé KWE, Vissers Y, de Loos ER. Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive Nuss repair of pectus excavatum: a protocol for a randomised clinical trial (ICE trial). BMJ Open 2024; 14:e081392. [PMID: 38531584 DOI: 10.1136/bmjopen-2023-081392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION Epidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve block) fail in accomplishing adequate prolonged pain management. Furthermore, the continuous use of opioids, often prescribed in addition to all pain management strategies, comes with side effects. Intercostal nerve cryoablation seems a promising novel technique. Hence, the primary objective of this study is to determine the impact of intercostal nerve cryoablation on postoperative length of hospital stay compared with standard pain management of young pectus excavatum patients treated with the minimally invasive Nuss procedure. METHODS AND ANALYSIS This study protocol is designed for a single centre, prospective, unblinded, randomised clinical trial. Intercostal nerve cryoablation will be compared with thoracic epidural analgesia in 50 young pectus excavatum patients (ie, 12-24 years of age) treated with the minimally invasive Nuss procedure. Block randomisation, including stratification based on age (12-16 years and 17-24 years) and sex, with an allocation ratio of 1:1 will be performed.Postoperative length of hospital stay will be recorded as the primary outcome. Secondary outcomes include (1) pain intensity, (2) operative time, (3) opioid usage, (4) complications, including neuropathic pain, (5) creatine kinase activity, (6) intensive care unit admissions, (7) readmissions, (8) postoperative mobility, (9) health-related quality of life, (10) days to return to work/school, (11) number of postoperative outpatient visits and (12) hospital costs. ETHICS AND DISSEMINATION This protocol has been approved by the local Medical Ethics Review Committee, METC Zuyderland and Zuyd University of Applied Sciences. Participation in this study will be voluntary and informed consent will be obtained. Regardless of the outcome, the results will be disseminated through a peer-reviewed international medical journal. TRIAL REGISTRATION NUMBER NCT05731973.
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Affiliation(s)
- Nicky Janssen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Jean H T Daemen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Aimée J P M Franssen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Elise J van Polen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Lori M van Roozendaal
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Yvonne Vissers
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Erik R de Loos
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
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Walsh J, Walsh R, Redmond K. Systematic review of physiological and psychological outcomes of surgery for pectus excavatum supporting commissioning of service in the UK. BMJ Open Respir Res 2023; 10:e001665. [PMID: 37827806 PMCID: PMC10582895 DOI: 10.1136/bmjresp-2023-001665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/28/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Pectus excavatum (PEx) is the most common congenital chest wall abnormality affecting 1 in 400 births in the UK. PEx is associated with significant physiological and psychological impairment. While readily surgically correctable, the benefits that surgery can bring have been debated and proven difficult to objectively measure. In the UK, this has led to the decommissioning of PEx surgery. The aim of this review is to conduct a systematic search of the literature on PEx surgery to assess physiological and psychological outcomes. METHODS A systematic review of the MEDLINE (PubMed), Embase and Cochrane databases was performed. Articles were sought which included patients undergoing surgery for PEx and reported on changes in cardiopulmonary measures, symptoms, quality of life and psychological assessments before and after surgical repair. Last search was performed in July 2022 and relevant findings were synthesised by narrative review. RESULTS Fifty-one articles were included in qualitative synthesis, with 34 studies relating to physiological outcomes and 17 studies relating to psychological and quality of life measures. Twenty-one studies investigated pulmonary function at rest. There was no change in forced vital capacity or forced expiratory volume in 1 second following open repair and transient reductions followed closed repair. In the 11 studies investigating echocardiography, transthoracic rarely demonstrated cardiac compression; however, transoesophageal demonstrated intraoperative relief in cardiac compression in severe cases. Sixteen studies investigated exercise testing (cardiopulmonary exercise testing, CPET), 12 of which demonstrated significant improvement following surgery, both in maximal oxygen consumption and oxygen pulse. Seventeen studies investigated quality of life, all but one of which showed improvement following repair of PEx. All papers that reported on patient satisfaction following surgery found high rates, between 80% and 97%. DISCUSSION While the majority of studies to date have been small and data heterogeneous, the literature shows that for many patients with PEx, there exists a cardiopulmonary limitation that while difficult to objectify, is likely to improve with surgical repair. Resting parameters offer little yield in aiding this except in the most severe cases. CPET therefore offers a better option for dynamic assessment of this limitation and improvements following repair. Surgery significantly improves psychological well-being and quality of life for patients with PEx.
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Affiliation(s)
- Jamie Walsh
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Ross Walsh
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Karen Redmond
- Cardiothoracic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Dreher C, Reinsberg M, Oetzmann von Sochaczewski C, Siebert S, Strohm J, Kurz R, Ziegler AM, Heydweiller A, Yavuz ST. Changes in Pulmonary Functions of Adolescents with Pectus Excavatum Throughout the Nuss Procedure. J Pediatr Surg 2023; 58:1674-1678. [PMID: 36935229 DOI: 10.1016/j.jpedsurg.2023.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND We aimed to determine the longitudinal changes in pulmonary functions of adolescents with Pectus Excavatum who underwent the Nuss procedure, the minimally invasive repair of pectus excavatum (MIRPE). METHODS Lung function measurements were performed before bar implantation (T0), at least six weeks to ten months after implantation (T1a), at least eleven months to sixty-one months after bar implantation (T1b) and at least two weeks after bar explantation (T2). RESULTS Data of 114 patients (83.3% male) whose median age at implantation was 15.6 years and at explantation 18.7 years were analyzed. Shortly after implantation at T1a a significant decline of vital capacity (VC; n = 82), forced vital capacity (FVC; n = 78) and forced expiratory volume in 1 second (FEV1; n = 80) compared to T0 was seen. At T1b a significant decline for the residual volume (RV; n = 83), the residual volume/total lung capacity ratio (RV/TLC; n = 81), the total specific airway resistance (sRaw; n = 80) and the total airway resistance (Raw; n = 84) also compared to T0 was measured. In the comparison of T1b to T2 a significant increase of VC, FVC (n = 67), FEV1 (n = 69), TLC (n = 67) and a significant decrease of Raw (n = 66), sRaw, RV (n = 65) and the RV/TLC (n = 64) ratio could be observed. In the direct analysis between T0 and T2, after the explantation of the bar a significant increase in VC (n = 54), FVC (n = 52), and TLC (n = 55) and a significant decrease of RV (n = 51) and the RV/TLC index (n = 50), and in airway resistance parameters like Raw (n = 52) and sRaw (n = 51) could be detected. CONCLUSIONS Lung function values along with markers of airway resistance improve in patients after the complete procedure of MIRPE. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Charlotte Dreher
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany
| | - Max Reinsberg
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany
| | | | - Stephanie Siebert
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany
| | - Joanna Strohm
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Ralf Kurz
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Anna-Maria Ziegler
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Andreas Heydweiller
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Suleyman Tolga Yavuz
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany.
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Taghizadeh Waghefi A, Petrov A, Wilbring M, Fajfrova Z, Fitze G, Matschke K, Kappert U. Combined Bentall and Modified Ravitch Procedures: A Case Report and Systematic Review of the Evidence. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121774. [PMID: 36556976 PMCID: PMC9788579 DOI: 10.3390/medicina58121774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/05/2022]
Abstract
Background and Objectives: Marfan syndrome (MS) is a genetic disorder with autosomal dominant inheritance that affects the connective tissue and consequently many organ systems. The cardiovascular manifestations of MS are notorious and include aortic root dilatation or acute aortic dissection, which can cause morbidity and early mortality. However, surgical treatment of aortic pathology may be complicated by musculoskeletal deformity of the chest wall, as in pectus excavatum. In this regard, single-stage combined Bentall and Ravitch surgery is an extreme rarity that has also been scarcely reported in the literature. Patients and Methods: We present the medical history and single-stage Bentall and modified Ravitch surgical treatment of an 18-year-old male MS patient with symptomatic and severe pectus excavatum (PEX) in conjunction with a pear-shaped aortic root aneurysm. To discuss our case in the context of a synopsis of similar published cases, we present a systematic review of combined Bentall surgical aortic aneurysm repair and Ravitch correction of PEX. Results: A total of four studies (one case series and three case reports) and a case from our institution describing a single-stage combined Bentall and Ravitch operation were included. Patients were 22 ± 5.9 years of age (median = 22.5 years) and predominantly male (60%). All cases reported a midline vertical skin incision over the sternum. The most common surgical approach was midsternotomy (80%). In all cases metal struts were used to reinforce the corrected chest wall. Postoperative mortality was zero. Conclusions: Single-stage combined Bentall and Ravitch surgery is an underutilized surgical approach. Its use in MS patients with concomitant PEX and ascending aortic aneurysm that require surgical treatment warrants further investigation. Midsternotomy seems to be a viable access route that provides sufficient exposure in the single-stage surgical setting. Although operative time is long, the intraoperative and postoperative risks appear to be low and manageable.
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Affiliation(s)
- Ali Taghizadeh Waghefi
- Department of Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
- Correspondence:
| | - Asen Petrov
- Department of Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Manuel Wilbring
- Department of Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Zuzana Fajfrova
- Department of Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Guido Fitze
- Department of Pediatric Surgery, University Hospital Carl Gustav Carus, 01307 Dresden, Germany
| | - Klaus Matschke
- Department of Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Utz Kappert
- Department of Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
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Bobis Villagrà D, Charlesworth TM. A novel video-assisted thoracoscopic approach for pectus excavatum surgical treatment in a dog. Vet Surg 2022; 51:1009-1015. [PMID: 35723532 DOI: 10.1111/vsu.13843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/09/2022] [Accepted: 05/25/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To describe a novel, video-assisted thoracoscopic surgery (VATS) approach used to treat pectus excavatum (PE) in a dog. ANIMALS A 5 month-old, 5.1 kg, intact, female, Cockapoo. STUDY DESIGN Case report. METHODS Clinical, imaging and surgical records of a dog with severe PE who underwent VATS-assisted sternal cast placement were reviewed and reported. Treatment involved introduction of a mild pneumothorax and use of VATS, allowing direct visualization and therefore safe passage of circumsternal sutures as they were placed to reduce the risk of vascular/cardiac or pulmonary penetration and intraoperative complication in this patient. RESULTS Treatment involved introduction of a mild pneumothorax and use of VATS, allowing direct visualization and therefore safe passage of circumsternal sutures as they were placed to reduce the risk of vascular/cardiac or pulmonary penetration and intraoperative complications in this patient. The patient recovered well and had an excellent long-term outcome with significantly improved vertebral index and frontosagittal index. CONCLUSION This modified technique resulted in an excellent outcome and minimized the risk of intraoperative complications during the surgical procedure in a dog. CLINICAL SIGNIFICANCE This novel VATS approach for PE correction may provide a useful technique to help reduce intraoperative risk during PE correction in dogs.
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Trò R, Martini S, Stagnaro N, Sambuceti V, Torre M, Fato MM. A new tool for assessing Pectus Excavatum by a semi-automatic image processing pipeline calculating the classical severity indexes and a new marker: the Volumetric Correction Index. BMC Med Imaging 2022; 22:30. [PMID: 35184746 PMCID: PMC8859892 DOI: 10.1186/s12880-022-00754-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 02/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background In clinical assessment of Pectus Excavatum (PE), the indication to surgery is based not only on symptoms but also on quantitative markers calculated from Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) scans. According to clinical routine, these indexes are measured manually by radiologists with limited computer support. This process is time consuming and potentially subjected to inaccuracy and individual variability in measurements. Moreover, the existing indexes have limitations, since they are based on linear measurements performed on single slices rather than on volumetric data derived from all the thoracic scans.
Results In this paper we present an image processing pipeline aimed at providing radiologists with a computer-aid tool in support of diagnosis of PE patients developed in MATLAB® and conceived for MRI images. This framework has a dual purpose: (i) to automatize computation of clinical indexes with a view to ease and standardize pre-operative evaluation; (ii) to propose a new marker of pathological severity based on volumetric analysis and overcoming the limitations of existing axial slice-based indexes. Final designed framework is semi-automatic, requiring some user interventions at crucial steps: this is realized through a Graphical User Interface (GUI) that simplifies the interaction between the user and the tools. We tested our pipeline on 50 pediatric patients from Gaslini Children’s Hospital and performed manual computation of indexes, comparing the results between the proposed tool and gold-standard clinical practice. Automatic indexes provided by our algorithm have shown good agreement with manual measurements by two independent readers. Moreover, the new proposed Volumetric Correction Index (VCI) has exhibited good correlation with standardized markers of pathological severity, proving to be a potential innovative tool for diagnosis, treatment, and follow-up. Conclusions Our pipeline represents an innovative image processing in PE evaluation, based on MRI images (radiation-free) and providing the clinician with a quick and accurate tool for automatically calculating the classical PE severity indexes and a new more comprehensive marker: the Volumetric Correction Index. Supplementary Information The online version contains supplementary material available at 10.1186/s12880-022-00754-0.
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Casatori L, Pellegrino A, Messineo A, Ghionzoli M, Facchini F, Modesti A, Modesti PA. Differential Influence of Physical Activity on Cardiopulmonary Performance and Stroke Volume Assessed at Cardiopulmonary Exercise Test in Pectus Excavatum: A Pilot Study. Front Physiol 2022; 13:831504. [PMID: 35185624 PMCID: PMC8850936 DOI: 10.3389/fphys.2022.831504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background Exercise training increases muscle VO2 by increasing O2 transport and O2 uptake while cardiac output increase might be limited by the conformation of the chest in subjects with pectus excavatum (PE). Aims The aim of the present study was to investigate the influence of physical activity (PA) on functional parameters of cardiopulmonary performance and stroke volume obtained at Cardiopulmonary Exercise Test (CPET) in PE. Methods and Procedures A cohort of adolescents (15 with PE and 15 age- and sex-matched healthy controls, HC) underwent Cardiopulmonary Exercise Test (CPET) and administration of the International Physical Activity Questionnaire – Short Form (IPAQ-SF) with estimation of weekly PA (METs h–1⋅week–1). Determinants of CPET parameters were investigated with multivariable linear regression analysis. Results As expected, when compared to HC, PE had lower VO2 max (37.2 ± 6.6 vs. 45.4 ± 6.4 mL⋅kg–1⋅min–1, p < 0.05), and VO2/HR max (O2 pulse, 12.1 ± 2.4 vs. 16.2 ± 3.6 mL⋅min–1⋅bpm–1, p < 0.05). Importantly, physical activity level was a predictor of VO2 max (adjusted for sex, body mass index, FEV1%, and presence of PE, β = 0.085; 95% Cl 0.010 to 0.160, p = 0.029) whereas O2 pulse was independent from PA level (β = 0.035; 95% Cl −0.004 to 0.074). Conclusion Physical activity is a determinant of VO2 max (cardiopulmonary performance), whereas it appears not to affect O2 pulse (a measure of stroke volume at peak exercise) related to constrained diastolic filling in PE.
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Affiliation(s)
- Lorenzo Casatori
- Department of Clinical and Experimental Medicine, School of Medicine, University of Florence, Florence, Italy
- Sports Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Alessio Pellegrino
- Department of Clinical and Experimental Medicine, School of Medicine, University of Florence, Florence, Italy
- Sports Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Antonio Messineo
- Department of Pediatric Surgery, Meyer Children’s University Hospital, University of Florence, Florence, Italy
| | - Marco Ghionzoli
- Department of Pediatric Surgery, Meyer Children’s University Hospital, University of Florence, Florence, Italy
| | - Flavio Facchini
- Department of Pediatric Surgery, Meyer Children’s University Hospital, University of Florence, Florence, Italy
| | - Alessandra Modesti
- Department of Biomedical, Experimental and Clinical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Pietro Amedeo Modesti
- Department of Clinical and Experimental Medicine, School of Medicine, University of Florence, Florence, Italy
- Sports Medicine Unit, Careggi University Hospital, Florence, Italy
- *Correspondence: Pietro Amedeo Modesti,
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Houle MC, Sjulin TJ, McInnis IC, Walter RJ, Morris MJ. Clinical Evaluation of Exertional Dyspnea in Adult Pectus Excavatum Patients. CURRENT RESPIRATORY MEDICINE REVIEWS 2022. [DOI: 10.2174/1573398x18666220128110107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abstract:
Evaluation of patients with pectus excavatum has primarily been focused on the pediatric population who undergo surgical correction of sternal defects mainly for cosmetic reasons combined with exercise-limiting symptoms. The extent of cardiopulmonary improvement in this population based on cardiac imaging, pulmonary function testing, and cardiopulmonary exercise testing may be highly variable. There is no current consensus on the limitations of cardiopulmonary impairment or potential improvement from surgical repair in pediatric patients. Limited data has published in the medical literature on the evaluation of adults with pectus excavatum who may also present with a variety of clinical symptoms. Adult patients with exercise limitation and pectus excavatum may present with exertional dyspnea, chest discomfort, palpitations/tachycardia, exercise-induced wheezing, and use of bronchodilators for asthma-like symptoms. While numerous published review articles outline clinical evaluation and surgical treatment for younger patients, comprehensive evaluation for these adult patients has not been fully elucidated. There is no current consensus on the underlying cause of cardiopulmonary impairment in adult patients or their potential improvement from surgical repair. This review focuses on the recommended evaluation of adult patients to discern the potential cardiopulmonary limitations to exercise due to pectus excavatum, especially in physically fit adults such as active duty military personnel. Two illustrative cases are presented to describe the complexity of the evaluation of adult patients and potential need for surgical correction.
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Affiliation(s)
- Mateo C. Houle
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX , USA
| | - Tyson J. Sjulin
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX , USA
| | - Ian C. McInnis
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX , USA
| | - Robert J. Walter
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX , USA
| | - Michael J. Morris
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX , USA
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Zens TJ, Casar Berazaluce AM, Jenkins TM, Hardie W, Alsaied T, Tretter JT, Moore R, Foster K, Fleck RJ, Hanke RE, Colvin BE, Garrison AP, Kraemer A, Crotty E, Taylor M, Garcia VF, Brown RL. The Severity of Pectus Excavatum Defect Is Associated With Impaired Cardiopulmonary Function. Ann Thorac Surg 2021; 114:1015-1021. [PMID: 34419435 DOI: 10.1016/j.athoracsur.2021.07.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/13/2021] [Accepted: 07/14/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Repair of pectus excavatum has cosmetic benefits, but the physiologic impact remains controversial. The aim of this study was to characterize the relationship between the degree of pectus excavatum and cardiopulmonary dysfunction seen on cardiac magnetic resonance (CMR) imaging, cardiopulmonary exercise testing (CPET), and pulmonary function testing (PFT). METHODS A single-center analysis of CMR, CPET, and PFT was conducted. Regression models evaluated relationships between pectus indices and the clinical end points of cardiopulmonary function. RESULTS Data from 345 CMRs, 261 CPETs, and 281 PFTs were analyzed. Patients were a mean age of 15.2 ± 4 years, and 81% were aged <18 years. The right ventricular ejection fraction (RVEF) was <0.50 in 16% of patients, left ventricular ejection fraction (LVEF) was <0.55 in 22%, RVEF Z-score was < -2 in 32%, and the LVEF Z-score was < -2 in 18%. CPET revealed 33% of patients had reduced aerobic fitness. PFT results were abnormal in 23.1% of patients. Adjusted analyses revealed the Haller index had significant (P < .05) inverse associations with RVEF and LVEF. CONCLUSIONS The severity of pectus excavatum is associated with ventricular systolic dysfunction. Pectus excavatum impacts right and left ventricular systolic function and can also impact exercise tolerance. The Haller index and correction index may be the most useful predictors of impairment.
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Affiliation(s)
- Tiffany J Zens
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Todd M Jenkins
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William Hardie
- Department of Pulmonology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tarek Alsaied
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ryan Moore
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Karla Foster
- Department of Pulmonology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert J Fleck
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rachel E Hanke
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brandon E Colvin
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Aaron P Garrison
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Aimee Kraemer
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eric Crotty
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael Taylor
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Victor F Garcia
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rebeccah L Brown
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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11
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Alqadi GO, Saxena AK. Analysis of Psychological Assessments Affecting Patients Undergoing Treatment for Chest Wall Deformities. Am Surg 2021:31348211038585. [PMID: 34382882 DOI: 10.1177/00031348211038585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM This study aimed to review the literature with regard to the psychological aspects in patients with pectus excavatum (PE) and pectus carinatum (PC). METHODS The literature was reviewed by analyzing articles on PubMed using the search terms "psychology" and "pectus." RESULTS The literature search revealed 22 articles that offered a total of 2214 patients for analysis. Regarding chest wall deformities (CWD), there were 15 articles referring to PE, 4 articles on PC, and 3 pertaining to both PE and PC. Authors used various types of questionnaires and 14 studies which also included a parent questionnaire. There are 14 reports which analyzed both the preoperative and postoperative psychological status and 4 reports in which a control group was used. Treatment of CWD was shown to have consistently positive results. There is no consensus regarding the correlation between severity of CWD and psychological issues. Only 2 studies found no statistically significant results after treatment. CONCLUSIONS The literature reveals a great concern for psychosocial issues in CWD patients. Most articles describe improvement in overall quality of life (QOL) after surgery. An increase in social and physical function, body image, and self-esteem was observed in CWD patients, which is supported by parent responses.
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Affiliation(s)
- Gratiana O Alqadi
- Department of Pediatric Surgery, Chelsea Children's Hospital, 9762Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, London, UK.,Department of Pediatric Surgery, 87267University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Amulya K Saxena
- Department of Pediatric Surgery, Chelsea Children's Hospital, 9762Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, London, UK
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12
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Del Frari B, Blank C, Sigl S, Schwabegger AH, Gassner E, Morawetz D, Schobersberger W. The questionable benefit of pectus excavatum repair on cardiopulmonary function: a prospective study. Eur J Cardiothorac Surg 2021; 61:75-82. [PMID: 34263302 PMCID: PMC8715845 DOI: 10.1093/ejcts/ezab296] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/03/2021] [Accepted: 05/13/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Since the introduction of the minimally invasive technique for repair of pectus excavatum (MIRPE), increasing numbers of patients are presenting for surgery. However, controversy remains regarding cardiopulmonary outcomes of surgical repair. Therefore, the aim of our prospective study was to investigate cardiopulmonary function, at rest and during exercise before surgery, first after MIRPE and then after pectus bar removal.
METHODS Forty-seven patients were enrolled in a prospective, open-label, single-arm, single-centre clinical trial (Impact of Surgical Treatments of Thoracic Deformation on Cardiopulmonary Function) [NCT02163265] between July 2013 and November 2019. All patients underwent a modified MIRPE technique for surgical correction of pectus excavatum (PE), called Minor Open Videoendoscopically Assisted Repair of Pectus Excavatum. The patients underwent pre- and postoperative chest X-ray, three-dimensional volume-rendering computer tomography thorax imaging, cardiopulmonary function tests at rest and during stepwise cycle spiroergometry (sitting and supine position) and Doppler echocardiography. Daily physical activity questionnaires were also completed. RESULTS The study was completed by 19 patients (15 males, 4 females), aged 13.9–19.6 years at the time of surgery. The surgical patient follow-up was 5.7 ± 7.9 months after pectus bar removal. No significant differences in cardiopulmonary and exercise parameters were seen after placement of the intrathoracic bar, or after pectus bar removal, compared to presurgery. CONCLUSIONS Our findings indicate that surgical correction of PE does not impair cardiopulmonary function at rest or during exercise. Therefore, no adverse effects on exercise performance should be expected from surgical treatment of PE via the modified MIRPE technique. Clinical trial registration number clinicaltrials.gov [ClinicalTrials.gov number, NCT02163265].
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Affiliation(s)
- Barbara Del Frari
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Cornelia Blank
- Department of Psychology and Sports Medicine, Institute of Sports Medicine, Alpine Medicine & Health Tourism (ISAG), University for Health Sciences, Medical Informatics and Technology (UMIT TIROL), Hall in Tyrol, Austria
| | - Stephan Sigl
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Anton H Schwabegger
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Eva Gassner
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - David Morawetz
- Department of Psychology and Sports Medicine, Institute of Sports Medicine, Alpine Medicine & Health Tourism (ISAG), University for Health Sciences, Medical Informatics and Technology (UMIT TIROL), Hall in Tyrol, Austria.,Institute for Sports Medicine, Alpine Medicine & Health Tourism (ISAG), Tirol Kliniken GmbH Innsbruck, Innsbruck, Austria
| | - Wolfgang Schobersberger
- Department of Psychology and Sports Medicine, Institute of Sports Medicine, Alpine Medicine & Health Tourism (ISAG), University for Health Sciences, Medical Informatics and Technology (UMIT TIROL), Hall in Tyrol, Austria.,Institute for Sports Medicine, Alpine Medicine & Health Tourism (ISAG), Tirol Kliniken GmbH Innsbruck, Innsbruck, Austria
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13
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ACIPAYAM A, TOKUR M. Minimal İnvaziv Pektus Ekskavatum Ameliyatı: Tek Merkez Deneyimi. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2021. [DOI: 10.17944/mkutfd.833764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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14
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Yu YR, Sola R, Jamal AR, Friske TC, Zhu H, Rosenfeld E, Mazziotti MV, St Peter SD, Shah SR. Preoperative resource utilization prior to minimally invasive repair of pectus excavatum. Am J Surg 2020; 222:650-653. [PMID: 33454026 DOI: 10.1016/j.amjsurg.2020.12.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/22/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Preoperative testing to assess the physiologic impact of pectus excavatum is sometimes ordered to meet third-party payor preauthorization requirements. This study describes the utility of physiologic testing prior to minimally invasive repair of pectus excavatum (MIRPE). METHODS We retrospectively reviewed patients that underwent MIRPE from 1/2012-7/2016 at two academic children's hospitals. Data collected included demographics, insurance, Haller Index (HI), pulmonary function tests (PFTs) and echocardiograms (ECHO) obtained, and preauthorization denials. RESULTS A total of 360 patients (mean age 15.7 ± 2.0 years; mean HI 4.5 ± 1.5) underwent MIRPE (Hospital 1: 189, Hospital 2: 171). Commercial insurers covered 84% of patients. Hospital 1 obtained more frequent preoperative testing (PFTs: 73% vs 6%, p < 0.0001). Overall, 72% of PFTs were normal with abnormal studies limited to mild findings. Similarly, 85% of ECHOs were normal. Third-party payors more frequently denied preauthorization for MIRPE at Hospital 2 (11% vs. 5%, p = 0.03). CONCLUSIONS More frequent preoperative testing may decrease initial preauthorization denials for MIRPE; however, this increased utilization of resources may not be necessary as the majority of test results are normal.
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Affiliation(s)
- Yangyang R Yu
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA; Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX, 77030, USA
| | - Richard Sola
- Children's Mercy Hospital, Division of Pediatric Surgery, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Abdur R Jamal
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA
| | - Tyler C Friske
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA
| | - Huirong Zhu
- Texas Children's Hospital, Division of Outcomes and Impact Service, 6701 Fannin Street, Houston, TX, 77030, USA
| | - Eric Rosenfeld
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA; Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX, 77030, USA
| | - Mark V Mazziotti
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA; Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX, 77030, USA
| | - Shawn D St Peter
- Children's Mercy Hospital, Division of Pediatric Surgery, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Sohail R Shah
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA; Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX, 77030, USA.
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15
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Liu C, Wen Y. Research progress in the effects of pectus excavatum on cardiac functions. WORLD JOURNAL OF PEDIATRIC SURGERY 2020; 3:e000142. [DOI: 10.1136/wjps-2020-000142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/07/2020] [Accepted: 04/21/2020] [Indexed: 11/04/2022] Open
Abstract
BackgroundPectus excavatum, the most common chest wall deformity in children, accounts for nearly 90% of congenital malformations of chest wall. Initially, both parents and doctors paid more attention to the influence of this deformity on patient appearance and psychology. Following deeper studies of pectus excavatum, researchers found that it also affected cardiac functions. The purpose of this review aims to present recent research progress in the effects of pectus excavatum on cardiac functions.Data sourcesBased on aspects of CT, ultrasound cardiography (UCG) and MRI, all the recent literatures on the influence of pectus excavatum on cardiac function were searched and reviewed.ResultsModerate and severe pectus excavatum did have a negative effect on cardiac function. Cardiac rotation angle, cardiac compression index, right atrial and tricuspid annulus size, septal motion and myocardial strain are relatively effective indexes to evaluate cardiac function.ConclusionsPectus excavatum did have a negative effect on cardiac function; so surgeons should actively diagnose and treat such patients in clinical work. However, further research is needed on to explore the measures and indicators that can reflect the changes of cardiac function in patients objectively, accurately, effectively and timely.
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16
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Sonaglioni A, Nicolosi GL, Granato A, Lombardo M, Anzà C, Ambrosio G. Reduced Myocardial Strain Parameters in Subjects With Pectus Excavatum: Impaired Myocardial Function or Methodological Limitations Due to Chest Deformity? Semin Thorac Cardiovasc Surg 2020; 33:251-262. [PMID: 32442666 DOI: 10.1053/j.semtcvs.2020.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 01/28/2023]
Abstract
Pectus excavatum (PE) may cause symptoms and alter cardiopulmonary function. Left ventricular (LV) and right ventricular (RV) function have been reported to be impaired in PE subjects. However, this issue has not been systematically investigated with respect to the degree of chest wall abnormality. We aimed to evaluate the influence of severity of chest shape abnormality on myocardial strain parameters in PE subjects. We studied 30 healthy subjects (55.8 ± 14.0 year/old, 18 males) with PE, assessed by the ratio of chest transverse diameter over the distance between sternum and spine (modified Haller index, MHI, >2.5), and 30 controls (MHI ≤2.5) matched by age, sex, and cardiovascular risk factors. Participants underwent 2-dimensional (2D) transthoracic echocardiography implemented with 2D-speckle tracking echocardiography. Right-heart and left-heart chamber dimensions, and stroke volume, were significantly reduced in PE subjects (all P< 0.0001). While LV ejection fraction, E/A, and E/e', did not significantly differ between the 2 groups, all LV and RV strain and strain rate parameters were severely reduced in subjects with PE (P < 0.0001). Importantly, in PE subjects, but not in controls, LV global longitudinal strain, LV global circumferential strain, LV global radial strain, and RV free wall systolic strain, were all linearly correlated to MHI (all P < 0.0001). In healthy subjects with PE, abnormal chest anatomy progressively impairs myocardial strain. However, this impairment is not due to subclinical myocardial dysfunction; it might reflect intraventricular dyssynchrony due to compressive phenomena, or technical limitations of strain methodology, due to chest wall abnormality.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Milan, Italy.
| | | | - Alberto Granato
- Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
| | - Michele Lombardo
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Milan, Italy
| | - Claudio Anzà
- Cardiovascular Department, MultiMedica IRCCS, Sesto San Giovanni (MI), Italy
| | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Pathophysiology, Azienda Ospedaliero-Universitaria "S. Maria della Misericordia", Perugia, Italy
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Noguchi M, Hoshino Y, Yaguchi K, Hizume E, Yuzuriha S. Does aggressive respiratory rehabilitation after primary nuss procedure improve pulmonary function? J Pediatr Surg 2020; 55:615-618. [PMID: 31272682 DOI: 10.1016/j.jpedsurg.2019.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/20/2019] [Accepted: 05/24/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Here, we present the efficacy of an aggressive respiratory rehabilitation program that was initiated from early postoperative period, expecting to improve inspiratory volume at an early stage after primary Nuss procedure. METHODS The study was performed as a nonrandomized controlled study undergoing primary Nuss procedure at our institute from 2016 to 2018. We evaluated 34 patients and assigned them to two groups based on whether or not they received a respiratory rehabilitation. Group A (between June 2016 and March 2018) includes patients with inspiratory training postoperatively, and group B (between April 2018 and July 2018) includes patients without training. At the time of admission, a physiatrist provided each patient with a training instruction. From day five postoperatively, the patients in group A started training for inspiration with an incentive spirometer (Coach 2®PORTEX) four times a day. Patients were instructed to perform the same training at home after discharge. Using this device, we measured pre- and postoperative inspired volumes in each group. Data were analyzed with Wilcoxon-Mann-Whitney tests and a paired Student t-test. A p-value below 0.05 was considered statistically significant. RESULTS There were no statistically significant differences between the two groups concerning both operative age and the degree of the deformity calculated by Haller index. Preoperative inspiratory volume showed no significant differences. Although there were no statistical differences between two groups in the inspiratory volume at discharge, these two parameters were significantly higher in group A after three months postoperatively (A: 1404 ± 466 ml vs B: 900 ± 314 ml) and the values increased compared to the preoperative stage in group A. CONCLUSIONS These data indicate the aggressive respiratory rehabilitation is an effective regimen to increase inspiratory volume at an early stage after Nuss procedure. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Masahiko Noguchi
- Nagano Children's Hospital Plastic Reconstructive Surgery, Azumino, Japan.
| | - Y Hoshino
- Nagano Children's Hospital Plastic Reconstructive Surgery, Azumino, Japan
| | - K Yaguchi
- Nagano Children's Hospital Plastic Reconstructive Surgery, Azumino, Japan
| | - E Hizume
- Nagano Children's Hospital Physical Medicine and Rehabilitation, Azumino, Japan
| | - S Yuzuriha
- Department of Plastic and Reconstructive Surgery Shinshu University School of Medicine and Graduate School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
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18
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Ben XS, Deng C, Tian D, Tang JM, Xie L, Ye X, Zhou ZH, Zhou HY, Zhang DK, Shi RQ, Qiao GB, Chen G. Multiple-bar Nuss operation: an individualized treatment scheme for patients with significantly asymmetric pectus excavatum. J Thorac Dis 2020; 12:949-955. [PMID: 32274163 PMCID: PMC7139081 DOI: 10.21037/jtd.2019.12.43] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Research into multiple-bar Nuss operations for the treatment of wide-range or significantly asymmetric pectus excavatum is rarely reported. This paper aims to explore the curative effects of multiple-bar Nuss operations on wide-range or significantly asymmetric pectus excavatum. Methods We reviewed the clinical data of 153 patients with pectus excavatum who were treated in our hospital from September 2006 to August 2014. All the patients had wide-range or significantly asymmetric pectus excavatum and underwent multiple-bar Nuss operations performed by the author. Results All 153 patients agreed to undergo the operation. The median age was 17 y (10.2–41 y). The median Haller index was 3.98 (3.2–25). One hundred and fifty-one patients accepted treatment with two bars, and 2 cases accepted treatment with three bars. The median operation time was 123 min (65–500 min), the median blood loss was 20 mL (2–200 mL), and the median postoperative hospital stay was 6 days (3–33 days). The incidence rates of pleural effusion, pneumothorax and hydropneumothorax that required drainage treatment were 0.7% (1/153), 1.3% (2/153) and 3.3% (5/153), respectively. Displacement of a bar occurred in one case, and bar exposure occurred in 7 cases. Therefore, 2 cases had the bars removed early, within 2 years postoperation. One patient with severe depression (Haller index: 8.8) had an unhealed auxiliary incision of the xiphoid process, and although the incision was cured after the early removal of the inferior bar, the deformity recurred. There were no cases of death. Currently, 51.6% (79/153) of the cases have had the bars removed. The most recent follow-up revealed that patients’ median satisfaction score for the surgical correction effect was 9 points (10 points indicated full satisfaction). Conclusions For patients with significantly asymmetric and severely deformed pectus excavatum, the multiple-bar Nuss operation not only is safe and effective but can also achieve a better cosmetic appearance. However, we should continue to explore technical improvements.
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Affiliation(s)
- Xiao Song Ben
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Cheng Deng
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Dan Tian
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Ji Ming Tang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Liang Xie
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiong Ye
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Zi Hao Zhou
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Hai Yu Zhou
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Dong Kun Zhang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Rui Qing Shi
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Gui Bin Qiao
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Gang Chen
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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Taylor JS, Madhavan S, Szafer D, Pei A, Koppolu R, Barnaby K, Wall JK, Chao SD. Three-Dimensional Optical Imaging for Pectus Excavatum Assessment. Ann Thorac Surg 2019; 108:1065-1071. [DOI: 10.1016/j.athoracsur.2019.04.074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 04/03/2019] [Accepted: 04/17/2019] [Indexed: 11/16/2022]
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Das BB, Recto MR, Yeh T. Improvement of cardiopulmonary function after minimally invasive surgical repair of pectus excavatum (Nuss procedure) in children. Ann Pediatr Cardiol 2019; 12:77-82. [PMID: 31143030 PMCID: PMC6521667 DOI: 10.4103/apc.apc_121_18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Severe pectus excavatum in children may result in cardiorespiratory functional impairment; therefore, we evaluated cardiopulmonary response to exercise before and after the Nuss procedure. Methods: Twenty-four physically active pediatric patients aged 9–18 years with severe pectus excavatum (Haller index >3.25) were included in the study. Cardiopulmonary exercise testing using treadmill and modified Bruce protocol was performed before and after the Nuss procedure. Results: Maximal oxygen uptake and oxygen pulse improved by 40.6% (32 ± 13–45 ± 10 ml/kg/min; P = 0.0001) and 44.4% (9 ± 4–13 ± 5 ml/beat; P = 0.03), respectively, after surgical correction of pectus excavatum by Nuss procedure. Significant improvement in maximum voluntary ventilation and minute ventilation after Nuss procedure was also noted. Conclusions: We found that, after repair of pectus excavatum by Nuss procedure, the exercise capacity as measured by maximal oxygen consumption improved significantly primarily due to increase in oxygen pulse, an indirect measurement of stroke volume.
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Affiliation(s)
- Bibhuti B Das
- Division of Pediatric Cardiology, Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Michael R Recto
- Division of Pediatric Cardiology, Children's Hospital of Orange County, Orange, CA, USA
| | - Thomas Yeh
- Department of Cardiac Surgery, Children's Hospital of Richmond, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Wang Q, Fan S, Wu C, Jin X, Pan Z, Hong D. Changes in resting pulmonary function testing over time after the Nuss procedure: A systematic review and meta-analysis. J Pediatr Surg 2018; 53:2299-2306. [PMID: 29550038 DOI: 10.1016/j.jpedsurg.2018.02.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/09/2018] [Accepted: 02/09/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Pectus excavatum, the most common congenital chest wall deformity in pediatric patients, leads to pulmonary dysfunction. There is no consensus regarding the effectiveness of the Nuss procedure for recovering pulmonary function. In this meta- analysis, we focused on the changes that occur in pulmonary function after the Nuss procedure. METHODS We performed a literature search in the MEDLINE, Embase, Cochrane library and PubMed databases. The included studies were required to contain pulmonary function tests with results adjusted to predicted values both before and after the Nuss procedure. The key outcomes of interest in this analysis were pulmonary function measured as forced expiratory volume in 1s (FEV1) and forced vital capacity (FVC). Subgroup analyses were performed based on time since surgery and the mean ages of the patients when they underwent surgery by forest plots and meta-regressions. RESULTS Thirteen studies involving 465 participants were included in this review. The standard mean difference (SMD) observed in FEV1 and FVC after surgery were 0.17 (95% CI, 0.01-0.33, p=0.04) and -0.18 (95% CI, -0.41-0.06, p=0.14), respectively. The overall meta-regression SMD of FEV1 and FVC by time since surgery were 1.21 (95% CI, 1.04-1.41, p=0.020) and 1.38 (95% CI, 1.05-1.83, p=0.027), respectively. We found evidence of a temporal relationship between time at which pulmonary function tests were performed after surgery and predicted FEV1 and FVC values. The SMD of FEV1 (0.26, p=0.012) was slightly higher in group evaluated more than 2year after initial surgery. CONCLUSIONS Abnormal resting pulmonary functions tests performed prior to surgery showed an initial depression after surgery. The FEV1 of patients slightly increased at 2year post surgery compared with the baseline. Further studies with longer term follow-up are still needed to determine if pulmonary function could improve to normal after surgery. LEVELS OF EVIDENCE Level of evidence: 4 (based on lowest level of article analyzed in meta-analysis/systematic review).
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Affiliation(s)
- Quan Wang
- Cardiothoracic surgery of Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China international Science and Technology Cooperation base of Child development and Critical Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China.
| | - Shulei Fan
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
| | - Chun Wu
- Cardiothoracic surgery of Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China international Science and Technology Cooperation base of Child development and Critical Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China.
| | - Xianqing Jin
- Cardiothoracic surgery of Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China international Science and Technology Cooperation base of Child development and Critical Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China.
| | - Zhengxia Pan
- Cardiothoracic surgery of Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China international Science and Technology Cooperation base of Child development and Critical Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China.
| | - Daqing Hong
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
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Rha EY, Kim JH, Yoo G, Ahn S, Lee J, Jeong JY. Changes in thoracic cavity dimensions of pectus excavatum patients following Nuss procedure. J Thorac Dis 2018; 10:4255-4261. [PMID: 30174871 DOI: 10.21037/jtd.2018.06.159] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Using a simple and intuitive method, we evaluated changes in the dimensions of the thoracic cavity of pectus excavatum (PE) patients following the Nuss procedure. Methods We performed a retrospective review of 141 patients who had undergone the Nuss procedure. The thoracic cavity was visualized using computed tomography (CT) scans and its dimensions determined by measuring the anteroposterior (AP) and transverse (T) diameters at three anatomical landmarks (the jugular notch, and manubriosternal and xiphisternal joints). The Wilcoxon signed-rank test was used to compare differences between preoperative and postoperative parameters. Kruskal-Wallis tests were performed to compare differences among groups in patient age, type of PE, and number of inserted bars. Results Of the 141 patients (115 men, 26 women), 87 had symmetric and 54 had asymmetric defects. The postoperative AP diameters at the manubriosternal and xiphisternal joints were significantly higher than their preoperative values, whereas the Haller indices and T diameters at the three anatomical landmarks were significantly lower than their preoperative values. In the multiple bars group, the postoperative AP diameters increased significantly compared with their preoperative values. In the multiple bars group, and in patients aged above 13 years, the postoperative T diameters at all three anatomical landmarks decreased significantly compared with their preoperative values. Conclusions Correction of anterior depression of the sternum and compensatory narrowing of the chest width were observed in PE patients following the Nuss procedure. Further research will be necessary to determine the relationship between these observations and postoperative changes in chest volume.
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Affiliation(s)
- Eun Young Rha
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Hyeok Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gyeol Yoo
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seha Ahn
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Yong Jeong
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Ewais MM, Chaparala S, Uhl R, Jaroszewski DE. Outcomes in adult pectus excavatum patients undergoing Nuss repair. PATIENT-RELATED OUTCOME MEASURES 2018; 9:65-90. [PMID: 29430201 PMCID: PMC5796466 DOI: 10.2147/prom.s117771] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.
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Affiliation(s)
- MennatAllah M Ewais
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Shivani Chaparala
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Rebecca Uhl
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
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Anesthesia for Nuss Procedures (Pectus Deformity). Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chao CJ, Jaroszewski D, Gotway M, Ewais M, Wilansky S, Lester S, Unzek S, Appleton CP, Chaliki HP, Gaitan BD, Mookadam F, Naqvi TZ. Effects of Pectus Excavatum Repair on Right and Left Ventricular Strain. Ann Thorac Surg 2018; 105:294-301. [DOI: 10.1016/j.athoracsur.2017.08.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/07/2017] [Accepted: 08/07/2017] [Indexed: 10/18/2022]
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Abid I, Ewais MM, Marranca J, Jaroszewski DE. Pectus Excavatum: A Review of Diagnosis and Current Treatment Options. J Osteopath Med 2017; 117:106-113. [PMID: 28134952 DOI: 10.7556/jaoa.2017.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Osteopathic medicine places a special emphasis on the musculoskeletal system, and understanding how chest wall structure may influence function is critical. Pectus excavatum is a common congenital chest wall defect in which the sternum is depressed posteriorly. Patients may present with complaints of chest wall discomfort, exercise intolerance, and tachycardia. The medical implications, diagnosis, and treatment options for patients with pectus excavatum are reviewed.
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Maagaard M, Heiberg J. Improved cardiac function and exercise capacity following correction of pectus excavatum: a review of current literature. Ann Cardiothorac Surg 2016; 5:485-492. [PMID: 27747182 DOI: 10.21037/acs.2016.09.03] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients with pectus excavatum (PE) often describe improvements in exercise stamina following corrective surgery. Studies have investigated the surgical effect on physiological parameters; still, no consensus has yet been reached. Therefore, the aim of this literature review was to describe the cardiac outcome after surgical correction, both at rest and during exercise. In February 2016, a detailed search of the databases PubMed, Medline, and EMBASE was performed. We assessed clinical studies that described cardiac outcomes both before and after surgical correction of PE. We only included studies reporting either pre-defined echocardiographic or exercise test parameters. No exclusion criteria or statistical analyses were applied. Twenty-one full-text articles, published between 1972 and 2016, were selected, with cohort-ranges of 3-168 patients, mean age-ranges of 5-33 years, and mean follow-up-ranges from immediately to 4 years after surgery. Twelve studies described resting cardiac parameters. Four studies measured cardiac output, where one described 36% immediate increase after surgery, one reported 15% increase after Nuss-bar removal and two found no difference. Three studies demonstrated improvement in mean stroke volume ranges of 22-34% and two studies found no difference. Fifteen studies investigated exercise capacity, with 11 considering peak O2 pr. kg, where five studies demonstrated improvements with the mean ranging from 8% to 15% after surgery, five studies demonstrated no difference, and one saw a decrease of 19% 3 months after Nuss-bar implantation. A measurable increase in exercise capacity exists following surgery, which may be caused by multiple factors. This may be owed to the relief of compressed cardiac chambers with the increased anterior-posterior thoracic dimensions, which could facilitate an improved filling of the heart. With these results, the positive physiological impact of the surgery is emphasized and the potential gain in cardiac function should be integrated in the clinical assessment of patients with PE.
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Affiliation(s)
- Marie Maagaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark
| | - Johan Heiberg
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark
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Nuss D, Obermeyer RJ, Kelly RE. Pectus excavatum from a pediatric surgeon's perspective. Ann Cardiothorac Surg 2016; 5:493-500. [PMID: 27747183 DOI: 10.21037/acs.2016.06.04] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Historically, pectus excavatum (PE) was reported to be congenital, but in our experience only 22% are noticed in the first decade of life. Thus far, genetic studies support an autosomal recessive heritability, which coincides with only 40% of our patients having some positive family history, but is also contradictory given a constant sex ratio of 4:1 in favor of males. This inconsistency may be explained by the effect of more than one pectus disease-associated allele. Once the deformity is noticed, it tends to progress slowly until puberty, when rapid progression is often seen. We recommend surgical repair at around 12-14 years of age since the chest wall is still typically flexible and because this allows us to keep the bar in place as the patient progresses through puberty which may help decrease growth-related recurrences. Patients with mild to moderate PE are treated with therapeutic deep breathing, posturing, and aerobic exercises, and in appropriately selected patients, the vacuum bell may also be offered. Patients that have severe symptomatic PE are offered Minimally Invasive Repair of Pectus Excavatum (MIRPE). The surgical technique in children is similar to that of adults, except for the higher forces involved that often necessitate sternal elevation and more involved stabilization strategies. Postoperative management includes pain control, deep breathing, and early ambulation. Exercise restriction is mandatory for the first six weeks with slow resumption of normal activity after 12 weeks.
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Affiliation(s)
- Donald Nuss
- Department of Surgery, Eastern Virginia Medical School, 601 Children'S Lane, Norfolk, Virginia 23507, USA
| | - Robert J Obermeyer
- Department of Surgery, Eastern Virginia Medical School, 601 Children'S Lane, Norfolk, Virginia 23507, USA
| | - Robert E Kelly
- Department of Surgery, Eastern Virginia Medical School, 601 Children'S Lane, Norfolk, Virginia 23507, USA
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Jaroszewski DE, Ewais MM, Chao CJ, Gotway MB, Lackey JJ, Myers KM, Merritt MV, Sims SM, McMahon LE, Notrica DM. Success of Minimally Invasive Pectus Excavatum Procedures (Modified Nuss) in Adult Patients (≥30 Years). Ann Thorac Surg 2016; 102:993-1003. [DOI: 10.1016/j.athoracsur.2016.03.105] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 02/17/2016] [Accepted: 03/31/2016] [Indexed: 11/28/2022]
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Nuss D, Obermeyer RJ, Kelly RE. Nuss bar procedure: past, present and future. Ann Cardiothorac Surg 2016; 5:422-433. [PMID: 27747175 PMCID: PMC5056934 DOI: 10.21037/acs.2016.08.05] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 03/16/2016] [Indexed: 11/06/2022]
Abstract
Repair of pectus excavatum began at the beginning of the 20th century before endotracheal intubation was standard practice. Surgeons therefore developed techniques that corrected the deformity using an open procedure via the anterior chest wall. Initial techniques were unsatisfactory, but by the 1930s the partial rib resection and sternal osteotomy technique had been developed and was used in combination with external traction post-operatively to prevent the sternum from sinking back into the chest. In 1949, Ravitch recommended complete resection of the costal cartilages and complete mobilization of the sternum without external traction, and in 1961 Adkins and Blades introduced the concept of a substernal strut for sternal support. The wide resection resulted in a very rigid anterior chest wall, and in some instances, the development of asphyxiating chondrodystrophy. The primary care physicians therefore became reluctant to refer the patients for repair. In 1987, Nuss developed a minimally invasive technique that required no cartilage or sternal resection and relied only on internal bracing by means of a sub-sternal bar, which is inserted into the chest through two lateral thoracic incisions and guided across the mediastinum with the help of thoracoscopy. After publication of the procedure in 1998, it became widely accepted and a flood of new patients suddenly started to appear, which allowed for rapid improvements and modifications of the technique. New instruments were developed specifically for the procedure, complications were recognized, and the steps taken to prevent them included the development of a stabilizer and the use of pericostal sutures to prevent bar displacement. Various options were developed for sternal elevation prior to mediastinal dissection to prevent injury to the mediastinal structures, allergy testing was implemented, and pain management improved. The increased number of patients coming for repair permitted studies of cardiopulmonary function, which showed that patients with a severe degree of pectus excavatum have right- sided cardiac compression, decreased filling, and decreased stroke volume. The degree of pulmonary restriction and obstruction is related to the degree of deformity and degree of cardiac displacement into the left chest. The indications for surgical repair have been clearly outlined, the procedure has been standardized, and post-operative management protocols are now available. A review of our prospective database showed that 98% of patients have a good to excellent outcome. This review of the "Past" outlines the progression of the surgical techniques during the 20th century, the review of the "Present" outlines the important modifications and results of the closed technique, and the review of the "Future" outlines the various new options that are becoming available for the treatment of pectus excavatum.
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Affiliation(s)
- Donald Nuss
- Department of Surgery, Eastern Virginia Medical School, 601 Children'S Lane, Norfolk, Virginia 23507, USA
| | - Robert J Obermeyer
- Department of Surgery, Eastern Virginia Medical School, 601 Children'S Lane, Norfolk, Virginia 23507, USA
| | - Robert E Kelly
- Department of Surgery, Eastern Virginia Medical School, 601 Children'S Lane, Norfolk, Virginia 23507, USA
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Siddiqui A, Tse A, Paul JE, Fitzgerald P, Teh B. Postoperative epidural analgesia for patients undergoing pectus excavatum corrective surgery: a 10-year retrospective analysis. Local Reg Anesth 2016; 9:25-33. [PMID: 27307763 PMCID: PMC4889096 DOI: 10.2147/lra.s80710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Managing postoperative pain in patients undergoing minimally invasive pectus excavatum repair (Nuss procedure) is challenging but essential in facilitating ambulation and minimizing the length of stay. Although multiple epidural regimens with varying opioids are presently used for pain management, there is currently no clinical consensus regarding which epidural regimen provides the best analgesia outcomes with the fewest side effects. This 10-year retrospective cohort study was performed to compare the quality of analgesia and the incidence of side effects associated with the three most common epidural regimens used at a tertiary care children’s hospital, in patients undergoing the Nuss procedure. Methods Seventy-two pediatric patients were identified as having been treated with one of three epidural regimens for postoperative pain management following the Nuss procedure: Group A (n=12) received 0.125% bupivacaine and 5 µg/mL fentanyl, Group B (n=21) received 0.125% bupivacaine and 10 µg/mL hydromorphone, and Group C (n=39) received 0.1% ropivacaine and 20 µg/mL hydromorphone. Our primary outcome was maximal daily pain scores (numerical rating scale 0–10), with an analytical focus on postoperative day 1 scores. The primary outcome was analyzed using linear regression. The secondary outcomes included the length of stay, side-effect profiles as reflected by the number of treatments for nausea and pruritus, pain scores according to epidural site insertion, occurrence of breakthrough pain, and presence of severe pain throughout their hospital stay. Secondary outcomes were analyzed using linear or logistic regression adjusted for pain scores at baseline. The criterion for statistical significance was set a priori at alpha =0.05. Results Group A had significantly higher day-1 pain scores (score 5.42/10) than Group B (4.52/10; P=0.030) and Group C (4.49/10; P=0.015) after adjusting for baseline pain and age. No significant difference in maximum daily pain scores was found between groups during postoperative days 2–5. Among secondary outcomes, Group C had a significantly lower incidence of nausea/vomiting than Group B (P=0.003). There was also significantly more severe pain in Group A than in Group C (P=0.031). No significant difference was found between the three groups for the incidence of pruritus, critical events, breakthrough pain, or patient satisfaction. Conclusion There is no significant difference in managing postoperative pain overall between the three epidural regimens employed at our center. However, in managing day-1 postoperative pain and minimizing nausea/vomiting, our study suggests that a hydromorphone–ropivacaine epidural regimen appears to have more favorable results than a fentanyl–bupivacaine regimen or a hydromorphone–bupivacaine regimen.
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Affiliation(s)
- Asad Siddiqui
- Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Andrew Tse
- Department of Anesthesia, University of Ottawa, Ottawa, Canada
| | - James E Paul
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Peter Fitzgerald
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Bernice Teh
- Canterbury Anesthetic Services, Victoria, Australia
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Jessurun CAC, Bom DAM, Franken R. An update on the pathophysiology, treatment and genetics of Marfan syndrome. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1184083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chao CJ, Jaroszewski DE, Kumar PN, Ewais MM, Appleton CP, Mookadam F, Gotway MB, Naqvi TZ. Surgical repair of pectus excavatum relieves right heart chamber compression and improves cardiac output in adult patients—an intraoperative transesophageal echocardiographic study. Am J Surg 2015; 210:1118-24; discussion 1124-5. [DOI: 10.1016/j.amjsurg.2015.07.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/15/2015] [Accepted: 07/16/2015] [Indexed: 12/24/2022]
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Iwanaka T, Yamataka A, Uemura S, Okuyama H, Segawa O, Nio M, Yoshizawa J, Yagi M, Ieiri S, Uchida H, Koga H, Sato M, Soh H, Take H, Hirose R, Fukuzawa H, Mizuno M, Watanabe T. Pediatric Surgery. Asian J Endosc Surg 2015; 8:390-407. [PMID: 26708583 DOI: 10.1111/ases.12263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 08/21/2015] [Accepted: 08/21/2015] [Indexed: 12/25/2022]
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Kuru P, Dudakli A, Mursaloglu H, Arikan H, Oktay A, Yuksel M. How pulmonary function changes after pectus excavatum correction surgery. Asian Cardiovasc Thorac Ann 2015; 23:945-9. [PMID: 26189888 DOI: 10.1177/0218492315596464] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM We aimed to determine the effects of minimally invasive repair of pectus excavatum on pulmonary function and quality of life. METHODS Minimally invasive pectus excavatum repair was undertaken in 80 patients with a mean age of 16.91 ± 4.37 years (range 7-30 years) and a mean Haller index of 4.07 ± 1.39; 85% of the patients were male. They and their parents completed the Nuss Questionnaire Modified for Adults, and pulmonary function tests were performed on the patients before and 6 months after the operation. RESULTS The mean Nuss score was 31.06 ± 6.78 before the operation and it increased to 37.1 ± 8.31 (p = 0.000) 6 months after the operation. Forced vital capacity decreased from 3.70 ± 1.23 to 3.48 ± 1.03 L (p = 0.05) postoperatively. The percentage of expected forced vital capacity decreased from 83.21% ± 16.97% to 76.52% ± 20.98% (p = 0.01). There was no significant change in forced expiratory volume in 1 s. The mean ratio of forced expiratory volume in 1 s to forced vital capacity was 86% preoperatively and it increased to 91% postoperatively (p = 0.000). CONCLUSIONS Minimally invasive pectus excavatum repair has a positive impact on the quality of life of pectus excavatum patients, but a negative impact on forced vital capacity. Follow-up studies are needed to assess the long-term changes in pulmonary function after this operation.
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Affiliation(s)
- Pinar Kuru
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Asli Dudakli
- Marmara University School of Medicine, Istanbul, Turkey
| | | | - Hazal Arikan
- Marmara University School of Medicine, Istanbul, Turkey
| | - Aysu Oktay
- Marmara University School of Medicine, Istanbul, Turkey
| | - Mustafa Yuksel
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
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Jeong JY, Ahn JH, Kim SY, Chun YH, Han K, Sim SB, Jo KH. Pulmonary function before and after the Nuss procedure in adolescents with pectus excavatum: correlation with morphological subtypes. J Cardiothorac Surg 2015; 10:37. [PMID: 25887607 PMCID: PMC4373000 DOI: 10.1186/s13019-015-0236-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 03/11/2015] [Indexed: 11/26/2022] Open
Abstract
Background Differences in post-Nuss procedure pulmonary function based on the pectus excavatum subtype have not been investigated in adolescents. We evaluated differences in pulmonary function before and after the Nuss procedure according to preoperative morphology. Methods We performed a retrospective review of eighteen male patients who had undergone the Nuss procedures. There were nine patients each with symmetric and asymmetric morphology. Patients were younger than 18 years and had no history of respiratory diseases. Pulmonary function was assessed 2 weeks before and 4–6 months after the surgery. Preoperative and postoperative pulmonary function data were compared between the symmetric and asymmetric types. The paired t-test was used to compare the differences within each group and an analysis of covariance (ANCOVA) was used to access intergroup differences. Results There were no significant demographic differences between patients with symmetric and asymmetric subtypes. Patients with the asymmetric type had a lower preoperative total lung capacity (TLC) (p = 0.018), vital capacity (VC) (p = 0.0308), and inspiratory capacity (IC) (p = 0.0373). In both types, the forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and VC were all significantly decreased postoperatively compared to baseline (all, p < 0.01). The asymmetric type showed further reductions in peak expiratory flow (PEF) (p = 0.0391) and IC (p = 0.0084) postoperatively. The residual volume (RV) (p = 0.0092) and RV/TLC ratio (p = 0.0025) increased significantly in the asymmetric type, but only the postoperative PEF values differed significantly between the two types (p = 0.0151). Conclusions The asymmetric type had poorer preoperative lung volumes and poorer postoperative pulmonary function, with significantly lower PEF compared to the symmetric type cases. Preoperative and postoperative lung function needs more careful evaluation until pectus bar removal in the asymmetric type of pectus excavatum.
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Affiliation(s)
- Jin Yong Jeong
- Department of Thoracic and Cardiovascular Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Joong Hyun Ahn
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Sang Yong Kim
- Department of Pediatrics, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, Republic of Korea.
| | - Yoon Hong Chun
- Department of Pediatrics, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, Republic of Korea.
| | - Kyungdo Han
- Department of Biostatistics, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Sung Bo Sim
- Department of Thoracic and Cardiovascular Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Keon Hyon Jo
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Koumbourlis AC. Pectus deformities and their impact on pulmonary physiology. Paediatr Respir Rev 2015; 16:18-24. [PMID: 25464892 DOI: 10.1016/j.prrv.2014.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 10/29/2014] [Indexed: 11/24/2022]
Abstract
Pectus excavatum (PE) and pectus carinatum (PC) are the most common anomalies of the thoracic cage and they have been recognized since ancient times [1-3]. The two conditions differ in their appearance, and their effect on lung function. There is no direct correlation between the appearance of the deformities and the clinical symptoms. Whether, and when these deformities should be corrected as well as with which method (surgical or conservative) remain controversial. The following article reviews the current concepts regarding the pathophysiology of both conditions as well as the advances in their evaluation and management.
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Affiliation(s)
- Anastassios C Koumbourlis
- Professor of Pediatrics, George Washington University, Chief, Pulmonary & Sleep Medicine, Children's National Medical Center.
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Johnson WR, Fedor D, Singhal S. Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum. J Cardiothorac Surg 2014; 9:25. [PMID: 24506826 PMCID: PMC3922335 DOI: 10.1186/1749-8090-9-25] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 02/04/2014] [Indexed: 11/16/2022] Open
Abstract
This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric=0-21; adult 17-99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.
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Affiliation(s)
- William Rainey Johnson
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
| | - David Fedor
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
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Kelly RE, Mellins RB, Shamberger RC, Mitchell KK, Lawson ML, Oldham KT, Azizkhan RG, Hebra AV, Nuss D, Goretsky MJ, Sharp RJ, Holcomb GW, Shim WKT, Megison SM, Moss RL, Fecteau AH, Colombani PM, Cooper D, Bagley T, Quinn A, Moskowitz AB, Paulson JF. Multicenter study of pectus excavatum, final report: complications, static/exercise pulmonary function, and anatomic outcomes. J Am Coll Surg 2014; 217:1080-9. [PMID: 24246622 DOI: 10.1016/j.jamcollsurg.2013.06.019] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 06/21/2013] [Accepted: 06/24/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND A multicenter study of pectus excavatum was described previously. This report presents our final results. STUDY DESIGN Patients treated surgically at 11 centers were followed prospectively. Each underwent a preoperative evaluation with CT scan, pulmonary function tests, and body image survey. Data were collected about associated conditions, complications, and perioperative pain. One year after treatment, patients underwent repeat chest CT scan, pulmonary function tests, and body image survey. A subset of 50 underwent exercise pulmonary function testing. RESULTS Of 327 patients, 284 underwent Nuss procedure and 43 underwent open procedure without mortality. Of 182 patients with complete follow-up (56%), 18% had late complications, similarly distributed, including substernal bar displacement in 7% and wound infection in 2%. Mean initial CT scan index of 4.4 improved to 3.0 post operation (severe >3.2, normal = 2.5). Computed tomography index improved at the deepest point (xiphoid) and also upper and middle sternum. Pulmonary function tests improved (forced vital capacity from 88% to 93%, forced expiratory volume in 1 second from 87% to 90%, and total lung capacity from 94% to 100% of predicted (p < 0.001 for each). VO2 max during peak exercise increased by 10.1% (p = 0.015) and O2 pulse by 19% (p = 0.007) in 20 subjects who completed both pre- and postoperative exercise tests. CONCLUSIONS There is significant improvement in lung function at rest and in VO2 max and O2 pulse after surgical correction of pectus excavatum, with CT index >3.2. Operative correction significantly reduces CT index and markedly improves the shape of the entire chest, and can be performed safely in a variety of centers.
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Affiliation(s)
- Robert E Kelly
- Department of Surgery, Children's Hospital of The King's Daughters, Norfolk, VA; Department of Surgery, Eastern Virginia Medical School, Norfolk, VA.
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Acosta J, Bradley A, Raja V, Aliverti A, Badiyani S, Motta A, Moriconi S, Parker K, Rajesh P, Naidu B. Exercise improvement after pectus excavatum repair is not related to chest wall function†. Eur J Cardiothorac Surg 2013; 45:544-8. [DOI: 10.1093/ejcts/ezt473] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Tocchioni F, Ghionzoli M, Messineo A, Romagnoli P. Pectus excavatum and heritable disorders of the connective tissue. Pediatr Rep 2013; 5:e15. [PMID: 24198927 PMCID: PMC3812532 DOI: 10.4081/pr.2013.e15] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 06/20/2013] [Accepted: 08/13/2013] [Indexed: 12/03/2022] Open
Abstract
Pectus excavatum, the most frequent congenital chest wall deformity, may be rarely observed as a sole deformity or as a sign of an underlying connective tissue disorder. To date, only few studies have described correlations between this deformity and heritable connective tissue disorders such as Marfan, Ehlers-Danlos, Poland, MASS (Mitral valve prolapse, not progressive Aortic enlargement, Skeletal and Skin alterations) phenotype among others. When concurring with connective tissue disorder, cardiopulmonary and vascular involvement may be associated to the thoracic defect. Ruling out the concomitance of pectus excavatum and connective tissue disorders, therefore, may have a direct implication both on surgical outcome and long term prognosis. In this review we focused on biological bases of connective tissue disorders which may be relevant to the pathogenesis of pectus excavatum, portraying surgical and clinical implication of their concurrence.
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Barua A, Rao VP, Barua B, Majewski A. Patient satisfaction following minimally invasive repair of pectus excavatum: single surgeon experience. J Surg Tech Case Rep 2013; 4:86-8. [PMID: 23741581 PMCID: PMC3673366 DOI: 10.4103/2006-8808.110253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Pectus excavatum (PE) is the most common chest wall deformity in adolescent life. Nuss procedure is a well-established technique for the repair of PE. The indication for correction is mainly medical aesthetic. Advantages of Nuss over conventional methods include reduced length of hospital stay, smaller incisions, and absence of need for osteochondrectomies. Here, we describe our experience with this procedure. Materials and Methods: This was a retrospective study of patients who underwent Nuss procedure by a single surgeon between 2006 and 2010 in a regional center. Indications for surgery included the following: Progressive deformity and psychological stress. All patients underwent chest X-ray and pulmonary function testing. A standard Nuss procedure was performed using a single bar. Patients’ satisfaction was assessed by a questionnaire and follow-up clinic letters. Satisfaction with body image was scored on a scale of 1-10. Results: Eleven patients with PE underwent correction by Nuss procedure. Mean age of the patient was 19 years (range: 15-30). The average hospital stay was 7 days (range: 4-23 days). There was no mortality and no episodes of wound infection. In the immediate post-operative period, three patients (12.5%) were noted to have poor pain control. The post-operative course was uneventful in all cases except one patient who developed lung collapse, pleural effusion, and bar dislocation. Hundred percent of patients were satisfied with the scar. Seven patients scored 7 out of 10 on satisfaction with body image and two patients scored 6 or less. None of the patients complained of chronic pain. Conclusion: Nuss procedure is an effective method for the correction of PE. Most patients were satisfied with the outcome and none experienced chronic pain.
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Affiliation(s)
- Anupama Barua
- Department of Cardiac Surgery, Leeds General Infirmary, Leeds, United Kingdom
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O'Keefe J, Byrne R, Montgomery M, Harder J, Roberts D, Sigalet DL. Longer term effects of closed repair of pectus excavatum on cardiopulmonary status. J Pediatr Surg 2013; 48:1049-54. [PMID: 23701781 DOI: 10.1016/j.jpedsurg.2013.02.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 02/03/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND The "Nuss" repair is done for correction of moderate to severe pectus excavatum (PE). The long term cardiopulmonary and psychosocial effects of repair are uncertain. The objective of this study was to compare cardiopulmonary function and subjective evaluation of appearance and exercise tolerance pre-bar insertion with post-bar removal. METHODS All patients underwent preoperative and post-bar (3 month) removal evaluation with complete pulmonary function tests, exercise stress testing, echocardiogram, and self-rated appearance and exercise tolerance scoring. The protocol was approved by the regional ethics board, and all families gave informed consent. RESULTS Sixty-seven patients underwent pre and post testing. Preoperative CT index was 4.4 ± 1.3. Cardiopulmonary outcomes, standardized for height and weight, showed significant improvements in FEV-1 as (pre) 81.1 ± 17.0 vs post 89.8 ± 20.5*, FVC: 91.2 ± 18.6 vs 98.9 ± 22.9*, O2 pulse: 75.8 ± 14.4 vs 80.5 ± 18.3* (each as % predicted). Both the self-ratings of appearance (2.5 ± 0.8 vs 4.4 ± 0.5) and ability to exercise (3.3 ± 0.7 vs 4.3 ± 0.6, scale 1-5) increased significantly. (All data: mean ± St Dev, *p<0.05) CONCLUSIONS: Closed repair of PE results in improvements in pulmonary and aerobic exercise function and perceived appearance and exercise tolerance. Our data suggest that the impact on appearance and self-perceived well being is greater than the physical effect.
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Affiliation(s)
- Julia O'Keefe
- Department of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada T3B 6A8
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Jayaramakrishnan K, Wotton R, Bradley A, Naidu B. Does repair of pectus excavatum improve cardiopulmonary function? Interact Cardiovasc Thorac Surg 2013; 16:865-70. [PMID: 23449664 DOI: 10.1093/icvts/ivt045] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was 'Does repair of pectus excavatum (PE) improve cardiopulmonary function?' One hundred and sixty-eight papers were found using the reported search, 19 level III evidence papers and three meta-analyses were relevant. Studies were divided into four groups based on the surgical technique applied and pulmonary and cardiac functions in these groups were analysed. The meta-analyses show conflicting results for improvements in pulmonary and cardiac functions when comparing surgical techniques, while four more recent studies show improved long-term results using the Nuss technique. The best evidence of papers studying the PE repair using the minimally invasive Nuss technique demonstrates a decrease in pulmonary function during the early postoperative period, however, there is a small but significant improvement during the late postoperative period and after bar removal. The best evidence for cardiac function in this group suggests an early improvement that is sustained during further follow-up. The best evidence of papers studying the PE repair using the Ravitch technique shows that pulmonary function decreased during the early postoperative period, however, there is a small but significant improvement during the late postoperative period. The best evidence for cardiac function in this group suggests an early improvement that is sustained during further follow-up. The best evidence of papers studying the PE repair using other techniques (modified Daniel's technique, modified Baronofsky's technique, sterno-costal turn-over technique and sterno-costal elevation technique) or where surgical techniques used were not described (preceding year 1985) suggests that there is no improvement in pulmonary function after surgery. There is some evidence that certain aspects of cardiac function improved after surgery in this group.
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Lee RT, Moorman S, Schneider M, Sigalet DL. Bracing is an effective therapy for pectus carinatum: interim results. J Pediatr Surg 2013; 48:184-90. [PMID: 23331813 DOI: 10.1016/j.jpedsurg.2012.10.037] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 10/13/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pectus Carinatum is a common congenital chest wall malformation. Until recently the mainstay of treatment was surgical remodeling of the deformed chest wall. Initial results suggest that non-operative bracing may be an effective therapy, but the optimal strategy for correction is not known. Herein we report the results of a self-adjustable low profile bracing system worn continuously until the defect is corrected (correction phase), then worn at night (8 h/day) until completion of axial growth (maintenance phase)-the Calgary Protocol. METHODS Patients referred to a pediatric surgery chest wall clinic were prospectively asked to join an IRB approved outcomes monitoring study. 124 patients were evaluated from 2007 to 2011, and 98 were prescribed a brace and counseled to follow the protocol. RESULTS 98 patients consented to follow-up at starting bracing age: 14.4 ± 1.9 years, Tanner stage: 3.6 ± 0.5, protrusion: 2.1 ± 1.0 cm, self-rating of appearance: 2.9 ± 1.1, and exercise tolerance: 4.4 ± 1.1 (1-5 with 5 = normal). 10 patients are in correction phase, and 44 patients have completed correction after 7.0 ± 7.3 months: Tanner stage: 3.8 ± 0.1, protrusion: 0.5 ± 0.6 cm*, appearance: 4.3 ± 0.3* and exercise tolerance 4.6 ± 1.0. Correction occurred more quickly in patients prior to achieving Tanner stage IV (4.2 ± 0.9 months) vs. Tanner stage IV (8.0 ± 7.1 months) at the beginning of bracing. 21 patients completed maintenance bracing after 17.9 ± 19.0 months: Tanner stage: 3.9 ± 0.2, protrusion 0.5 ± 0.7 cm*, appearance: 4.3 ± 0.9*, and exercise tolerance: 4.8 ± 1.4. Average follow-up after bracing is 13.9 ± 16.0 months (mean ± S.D., *P < .05). There was one recurrence, likely due to early discontinuation of maintenance. This responded to an additional 6 months of bracing. 42 patients failed therapy secondary to non-compliance or were lost in follow up, while 2 patients did not respond to bracing and required open operation. CONCLUSIONS If patients are compliant, a self- adjusting brace system can give rapid correction of the pectus carinatum protrusion with excellent patient satisfaction. These interim results suggest that continued bracing until skeletal maturity gives long term durability to the correction. Further studies will be required to further refine this promising therapy.
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Affiliation(s)
- Richy T Lee
- Department of Pediatric Surgery, Alberta Children's Hospital, Calgary, Alberta, Canada.
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Chen Z, Amos EB, Luo H, Su C, Zhong B, Zou J, Lei Y. Comparative pulmonary functional recovery after Nuss and Ravitch procedures for pectus excavatum repair: a meta-analysis. J Cardiothorac Surg 2012; 7:101. [PMID: 23020904 PMCID: PMC3504562 DOI: 10.1186/1749-8090-7-101] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 09/23/2012] [Indexed: 12/05/2022] Open
Abstract
Background Pectus excavatum (PE) is a common chest wall malformation, with surgery being the only method known to correct the defect. Although the Nuss and Ravitch procedures are commonly used, there is no consensus as to whether surgical repair improves pulmonary function. We therefore investigated whether pulmonary function recovers after surgical repair, and if recovery is dependent on the type of procedure or time after surgery. Methods Literature searches were performed using PubMed, EMBASE, Health Periodicals Database, and CNKI (Chinese National Knowledge Index) from January 1990 to December 2007. The following keywords were used: pectus excavatum, chest wall deformity, funnel chest, pulmonary function, respiratory, lung function, and pectus severity index. The primary outcome of interest was possible changes in pulmonary function following surgical repair. Results Meta-analysis of 23 studies showed that, although there was evidence of statistically significant heterogeneity among studies (Chi-square, 17.11, p < 0.05), changes in pulmonary functional indices, including forced expiratory volume over 1 s (FEV1), forced vital capacity (FVC), vital capacity (VC), and total lung capacity (TLC), were similar 1 year after the Ravitch and Nuss procedures. Several years after surgery and bar removal, however, the changes in pulmonary functional indices significantly favored the Nuss procedure. Conclusions Pulmonary function tends to improve after the surgical correction of pectus excavatum. Although the Nuss procedure was not significantly better 1 year after surgery, long-term postoperative pulmonary function improvement was significantly better after bar removal.
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Affiliation(s)
- Zhenguang Chen
- Department of Thoracic Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.
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Rokitansky AM, Stanek R. Modified minimally invasive pectus repair in children, adolescents and adults: an analysis of 262 patients. Eur Surg 2012. [DOI: 10.1007/s10353-012-0099-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Effects of the Nuss procedure on chest wall kinematics in adolescents with pectus excavatum. Respir Physiol Neurobiol 2012; 183:122-7. [PMID: 22688019 DOI: 10.1016/j.resp.2012.05.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 05/07/2012] [Accepted: 05/14/2012] [Indexed: 11/21/2022]
Abstract
No data are available on the effects of the Nuss procedure on volumes of chest wall compartments (the upper rib cage, lower rib cage and abdomen) in adolescents with pectus excavatum. We used optoelectronic plethysmography to provide a quantitative description of chest wall kinematics before and 6 months after the Nuss procedure at rest and during maximal voluntary ventilation in 13 subjects with pectus excavatum. An average 11% increase in chest wall volume was accommodated within the upper rib cage (p=0.0001) and to a lesser extent within the abdomen and lower rib cage. Tidal volumes did not significantly change during the study. The repair effect on chest wall kinematics did not correlate with the Haller index of deformity at baseline. Six months of the Nuss procedure do increase chest wall volume without affecting chest wall displacement and rib cage configuration.
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Tang M, Nielsen HHM, Lesbo M, Frokiaer J, Maagaard M, Pilegaard HK, Hjortdal VE. Improved cardiopulmonary exercise function after modified Nuss operation for pectus excavatum. Eur J Cardiothorac Surg 2011; 41:1063-7. [DOI: 10.1093/ejcts/ezr170] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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