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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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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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Stephens EH, Dearani JA, Jaroszewski DE. Pectus Excavatum in Cardiac Surgery Patients. Ann Thorac Surg 2023; 115:1312-1321. [PMID: 36781097 DOI: 10.1016/j.athoracsur.2023.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Pectus excavatum frequently accompanies congenital heart disease and connective tissue diseases requiring cardiac surgery. Sometimes the indication is cardiac repair, with the pectus being incidentally noticed; other times, the pectus subsequently develops or becomes more significant after cardiac surgery. This review arms cardiac and congenital surgeons with background about the physiologic impact of pectus, indications for repair and repair strategies, and outcomes for cardiac surgery patients requiring pectus repair. METHODS A comprehensive literature review was performed using keywords related to pectus excavatum, pectus repair, and cardiac/congenital heart surgery within the PubMed database. RESULTS The risks of complications related to pectus repair, including in the setting of cardiac surgery or after cardiac surgery, are low in experienced hands, and patients demonstrate cardiopulmonary benefits and symptom relief. Concomitant pectus and cardiac surgery should be considered if it is performed in conjunction with those experienced in pectus repair, particularly given the increased cardiopulmonary impact of pectus after bypass. In the setting of potential bleeding or hemodynamic instability, delayed sternal closure is recommended. For those with anticipated pectus repair after cardiac surgery, the pericardium should be reconstructed for cardiac protection. For those undergoing pectus repair after cardiac surgery without a membrane placed, a "hybrid" approach is safe and effective. CONCLUSIONS Patients undergoing cardiac surgery noted to have pectus should be considered for possible concomitant or staged pectus repair. For those who will undergo a staged procedure, a barrier membrane should be placed before chest closure.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dawn E Jaroszewski
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona.
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Jaroszewski DE, Farina JM, Gotway MB, Stearns JD, Peterson MA, Pulivarthi VSKK, Bostoros P, Abdelrazek AS, Gotimukul A, Majdalany DS, Wheatley-Guy CM, Arsanjani R. Cardiopulmonary Outcomes After the Nuss Procedure in Pectus Excavatum. J Am Heart Assoc 2022; 11:e022149. [PMID: 35377159 PMCID: PMC9075480 DOI: 10.1161/jaha.121.022149] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Pectus excavatum is the most common chest wall deformity. There is still controversy about cardiopulmonary limitations of this disease and benefits of surgical repair. This study evaluates the impact of pectus excavatum on the cardiopulmonary function of adult patients before and after a modified minimally invasive repair. Methods and Results In this retrospective cohort study, an electronic database was used to identify consecutive adult (aged ≥18 years) patients who underwent cardiopulmonary exercise testing before and after primary pectus excavatum repair at Mayo Clinic Arizona from 2011 to 2020. In total, 392 patients underwent preoperative cardiopulmonary exercise testing; abnormal oxygen consumption results were present in 68% of patients. Among them, 130 patients (68% men, mean age, 32.4±10.0 years) had post‐repair evaluations. Post‐repair tests were performed immediately before bar removal with a mean time between repair and post‐repair testing of 3.4±0.7 years (range, 2.5–7.0). A significant improvement in cardiopulmonary outcomes (P<0.001 for all the comparisons) was seen in the post‐repair evaluations, including an increase in maximum, and predicted rate of oxygen consumption, oxygen pulse, oxygen consumption at anaerobic threshold, and maximal ventilation. In a subanalysis of 39 patients who also underwent intraoperative transesophageal echocardiography at repair and at bar removal, a significant increase in right ventricle stroke volume was found (P<0.001). Conclusions Consistent improvements in cardiopulmonary function were seen for pectus excavatum adult patients undergoing surgery. These results strongly support the existence of adverse cardiopulmonary consequences from this disease as well as the benefits of surgical repair.
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Affiliation(s)
- Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | | | - Joshua D Stearns
- Department of Anesthesiology and Perioperative Medicine Mayo Clinic Arizona Phoenix AZ
| | - Michelle A Peterson
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | | | - Peter Bostoros
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | - Ahmad S Abdelrazek
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | - Ashwini Gotimukul
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | - David S Majdalany
- Department of Cardiovascular Medicine Mayo Clinic Arizona Phoenix AZ
| | | | - Reza Arsanjani
- Department of Cardiovascular Medicine Mayo Clinic Arizona Phoenix AZ
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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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Rodriguez-Granillo GA, Raggio IM, Deviggiano A, Bellia-Munzon G, Capunay C, Nazar M, Martinez JL, Carrascosa P, Martinez-Ferro M. Impact of pectus excavatum on cardiac morphology and function according to the site of maximum compression: effect of physical exertion and respiratory cycle. Eur Heart J Cardiovasc Imaging 2020; 21:77-84. [DOI: 10.1093/ehjci/jez061] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
Aims
Previous studies have demonstrated diverse cardiac manifestations in patients with pectus excavatum (PEX), although mostly addressing morphological or physiological impact as separate findings. Using multimodality imaging, we evaluated the impact of PEX on cardiac morphology and function according to the site of maximum compression, and the effect of exertion and breathing.
Methods and results
All patients underwent chest computed tomography, cardiac magnetic resonance (CMR), and stress echocardiography (echo) in order to establish surgical candidacy. We evaluated diastolic function and trans-tricuspid gradient during stress (echo); and systolic function and respiratory-related septal wall motion abnormalities (CMR). Patients were classified according to the site of cardiac compression as type 0 (without cardiac compression); type 1 (right ventricle); and type 2 [right ventricle and atrioventricular (AV) groove]. Fifty-nine patients underwent multimodality imaging, with a mean age of 19.5 ± 5.9 years. Compared with a sex and age matched control group, peak exercise capacity was lower in patients with PEX (8.4 ± 2.0 METs vs. 15.1 ± 4.6 METs, P < 0.0001). At stress, significant differences were found between groups regarding left ventricular E/A (P = 0.004) and e/a ratio (P = 0.005), right ventricular E/A ratio (P = 0.03), and trans-tricuspid gradient (P = 0.001). At CMR, only 9 (15%) patients with PEX had normal septal motion, whereas 17 (29%) had septal flattening during inspiration. Septal motion abnormalities were significantly related to the cardiac compression classification (P < 0.0001).
Conclusions
The present study demonstrated that patients with PEX, particularly those with compression affecting the right ventricle and AV groove, manifest diverse cardiac abnormalities that are mostly related to exertion, inspiration, and diastolic function.
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Affiliation(s)
- Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, Diagnostico Maipu, Av. Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Ignacio M Raggio
- Department of Cardiology, Clinica Olivos and CEMIC, Av. Maipú 1660, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Alejandro Deviggiano
- Department of Cardiovascular Imaging, Diagnostico Maipu, Av. Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Gaston Bellia-Munzon
- Department of Surgery, Fundacion Hospitalaria, Private Children's Hospital, Av. Crámer 4601, C1429AKK, Buenos Aires, Argentina
| | - Carlos Capunay
- Department of Cardiovascular Imaging, Diagnostico Maipu, Av. Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Maximiliano Nazar
- Department of Surgery, Fundacion Hospitalaria, Private Children's Hospital, Av. Crámer 4601, C1429AKK, Buenos Aires, Argentina
| | - Jorge Luis Martinez
- Department of Surgery, Fundacion Hospitalaria, Private Children's Hospital, Av. Crámer 4601, C1429AKK, Buenos Aires, Argentina
| | - Patricia Carrascosa
- Department of Cardiovascular Imaging, Diagnostico Maipu, Av. Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Marcelo Martinez-Ferro
- Department of Surgery, Fundacion Hospitalaria, Private Children's Hospital, Av. Crámer 4601, C1429AKK, Buenos Aires, Argentina
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Viña NA, Carrascosa P, Mogensen VC, Deviggiano A, Bellia-Munzon G, Martinez-Ferro M, Rodriguez-Granillo GA. Evaluation of pectus excavatum indexes during standard cardiac magnetic resonance: Potential for single preoperative tool. Clin Imaging 2019; 53:138-142. [DOI: 10.1016/j.clinimag.2018.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/10/2018] [Accepted: 10/12/2018] [Indexed: 11/26/2022]
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Deviggiano A, Carrascosa P, Vallejos J, Bellia-Munzon G, Vina N, Rodríguez-Granillo GA, Martinez-Ferro M. Relationship between cardiac MR compression classification and CT chest wall indexes in patients with pectus excavatum. J Pediatr Surg 2018; 53:2294-2298. [PMID: 29907314 DOI: 10.1016/j.jpedsurg.2018.05.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 04/30/2018] [Accepted: 05/21/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND/PURPOSE In pectus excavatum (PE) patients owing to the location of the heart in the chest cavity, the most affected site of compression by the depressed chest wall is the right heart, and surgical repair has shown to provide a significant relief in the RH cavities compression. Our aim was to explore the relationship between the site of right cardiac compression, chest wall indexes (CT-CWI) and the sternal torsion angle (STA) based on cardiac magnetic resonance (CMR) and computed tomography (CT) among PE patients. METHODS We included PE patients with no previous surgical correction referred to CMR and chest CT imaging as presurgical evaluations. The following CT-CWI were calculated: Haller Index (HI), correction index (CI) and STA. A CMR compression classification (CMR-CC) was implemented based on the analysis (in the horizontal long axis plane at end of diastole) of the right cardiac compression site, caused by the thoracic cage (sternum/ribs): Type 0 (T0): absence of cardiac compression; Type 1 (T1): compression of the lateral wall of the right ventricle (RV) without involvement of the atrioventricular (AV) groove; Type 2 (T2): compression of the RV involving the AV groove. RESULTS Sixty PE patients underwent CMR and chest CT. Fifty (81%) patients were male, and the median age was 17.5 (14.0; 23.0) years. T0, T1 and T2 were found in 14 (23%), 27 (45%) and 19 (32%) patients. There were significant differences between types with regard to the HI (T0 3.9 ± 1.1, T1 4.8 ± 2.0, T2 6.4 ± 3.1, p < 0.009) and to the CI (T0 22.1 ± 10.4%, T1 31.6 ± 16.1%, T2 46.9 ± 16.3% p < 0.0001) and STA (T0 9.1 ± 7.9°, T1 12.7 ± 10.3°, class T2 23.0 ± 13.6°p = 0.001) respectively. CONCLUSION In this study, we established a cardiac magnetic resonance compression classification of patients with pectus excavatum comprising a simple discrimination of cardiac compression sites, which were related to chest wall indexes. TYPE OF STUDY Study of Diagnostic Test. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Alejandro Deviggiano
- Department of Computed Tomography and Magnetic Resonance Imaging, Diagnóstico Maipu, Buenos Aires, Argentina.
| | - Patricia Carrascosa
- Department of Computed Tomography and Magnetic Resonance Imaging, Diagnóstico Maipu, Buenos Aires, Argentina
| | - Javier Vallejos
- Department of Computed Tomography and Magnetic Resonance Imaging, Diagnóstico Maipu, Buenos Aires, Argentina
| | - Gaston Bellia-Munzon
- Department of Pediatric Surgery, Fundacion Hospitalaria, Children's Hospital, Buenos Aires, Argentina
| | - Natalia Vina
- Department of Computed Tomography and Magnetic Resonance Imaging, Diagnóstico Maipu, Buenos Aires, Argentina
| | - Gaston A Rodríguez-Granillo
- Department of Computed Tomography and Magnetic Resonance Imaging, Diagnóstico Maipu, Buenos Aires, Argentina
| | - Marcelo Martinez-Ferro
- Department of Pediatric Surgery, Fundacion Hospitalaria, Children's Hospital, Buenos Aires, Argentina
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Abstract
The adverse physiologic effects of pectus excavatum and subsequent resolution following correction have been a subject of controversy. There are numerous accounts of patients reporting subjective improvement in exercise tolerance after surgery, but studies showing clear and consistent objective data to corroborate this phenomenon physiologically have been elusive. This is partially due to a lack of consistent study methodologies but even more so due to a mere paucity of data. As experts in the repair of pectus excavatum, it is not uncommon for pediatric surgeons to operate on adult patients. For this reason, this review evaluates the contemporary literature to provide an understanding of the physiologic impact of repairing pectus excavatum on pediatric and adult patients separately.
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Affiliation(s)
- Robert J Obermeyer
- Children's Hospital of The King's Daughters, Norfolk, VA, USA ; Eastern Virginia Medical School, Norfolk, VA, USA.
| | - Nina S Cohen
- Eastern Virginia Medical School, Norfolk, VA, USA
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Impact of Pectus Excavatum on Cardiopulmonary Function. Ann Thorac Surg 2018; 105:455-460. [DOI: 10.1016/j.athoracsur.2017.09.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 09/11/2017] [Accepted: 09/18/2017] [Indexed: 11/23/2022]
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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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Exaggerated Interventricular Dependence Among Patients With Pectus Excavatum: Combined Assessment With Cardiac MRI and Chest CT. AJR Am J Roentgenol 2017; 208:854-861. [PMID: 28140622 DOI: 10.2214/ajr.16.17296] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We sought to explore whether patients with pectus excavatum have exaggerated interventricular dependence and to evaluate the impact of the malformation severity (assessed on CT) on both anatomic and functional cardiac parameters (assessed on cardiac MRI). SUBJECTS AND METHODS The current study involved consecutive patients with a diagnosis of pectus excavatum who were referred to undergo cardiac MRI and chest CT to establish surgical candidacy or to define treatment strategies. RESULTS Sixty-two patients with pectus excavatum underwent cardiac MRI and chest CT. Fifty (81%) patients were male, and the median age was 17.5 years (range, 14.0-23.0 years). Forty-seven (76%) patients had evidence of right ventricular compression. The left ventricle showed a significantly decreased end-diastolic volume (inspiration vs expiration: 70.4 ± 11.6 vs 76.1 ± 13.7 mL/m2, respectively; p = 0.01) and a significantly higher eccentricity index (1.52 ± 0.2 vs 1.20 ± 0.1, p < 0.0001) during inspiration than during expiration. The median respiratory-related septal excursion was 8.1% (interquartile range, 5.1-11.7%). Patients with pericardial effusion showed a significantly higher pectus excavatum severity index than patients without pericardial effusion (6.3 ± 3.4 vs 4.4 ± 1.3, respectively; p = 0.003). Patients with a relative septal excursion equal to or larger than 11.8% showed a significantly higher pectus excavatum severity index than patients with a relative septal excursion of less than 11.8% (6.3 ± 2.6 vs 4.7 ± 2.4, respectively; p = 0.05). CONCLUSION In this study, patients with pectus excavatum showed significant alterations of cardiac morphology and function that were related to the deformation severity and that manifest as an exaggerated interventricular dependence.
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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: 25] [Impact Index Per Article: 3.1] [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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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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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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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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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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Dean C, Etienne D, Hindson D, Matusz P, Tubbs RS, Loukas M. Pectus excavatum (funnel chest): a historical and current prospective. Surg Radiol Anat 2012; 34:573-9. [PMID: 22323132 DOI: 10.1007/s00276-012-0938-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 01/24/2012] [Indexed: 11/27/2022]
Abstract
Pectus excavatum (PE) is a relatively common deformity involving the anterior chest wall. It is represented clinically as a conical depression of the sternum and costal cartilages with the apex at the xiphoid process. Associated features and symptoms vary but generally involve respiratory and cardiac abnormalities. Since it's initial description, numerous surgical techniques have been developed to correct PE, with the Ravtich (open) and Nuss (minimally invasive) procedures being the most commonly employed. Although the etiology remains unclear, the pathogenesis of PE is currently thought to involve the overgrowth of the costochondral region of the ribs. In addition, documented case reports of familial pectus excavatum exist, suggesting a heritable form of the defect. Numerous genetic markers have also been discovered, linking PE to various genetic syndromes.
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Affiliation(s)
- Chase Dean
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies
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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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Kim HK, Shim JH, Choi KS, Choi YH. The quality of life after bar removal in patients after the nuss procedure for pectus excavatum. World J Surg 2011; 35:1656-61. [PMID: 21560000 DOI: 10.1007/s00268-011-1111-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The goal of this study was to evaluate the outcome of patients who had the Nuss procedure for repair of pectus excavatum. METHODS Thirty-nine patients (26 male, 13 female) of 61 (63.9%) who had bar removal after the Nuss procedure agreed to participate in an interview. All patients and their parents were asked to complete a questionnaire. RESULTS The mean age of the patients was 6.8±3.23 years at the time of the Nuss procedure, 9.1±3.54 at bar removal, and 12.0±3.28 when the questionnaire was completed. The scores for satisfaction with the procedure, sense of social belonging, and well-being increased after the Nuss procedure according to the responses of the patients and their parents. However, the scores did not significantly differ after bar removal compared to after the Nuss procedure. Patients (4.1±1.08) and parents (4.1±1.02) reported that they were satisfied with the final result and their responses did not significantly differ (P=0.498). However, the surgical team's score for overall satisfaction was 4.5, which was higher than the patients' and/or parents' scores (P=0.019). CONCLUSION The Nuss procedure had a positive impact on the patients' and parents' quality of life. However, the scores before and after bar removal did not differ.
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Affiliation(s)
- Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Guro-dong, Guro-gu, Seoul, 152-703, Korea
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Hadolt B, Wallisch A, Egger JW, Höllwarth ME. Body-image, self-concept and mental exposure in patients with pectus excavatum. Pediatr Surg Int 2011; 27:665-70. [PMID: 21290134 DOI: 10.1007/s00383-011-2854-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pectus excavatum is the most common congenital anomaly of the sternum and anterior chest wall, which occurs about 3-4 times more often in boys than girls [1]. Although most patients do not report physical symptoms as cardiovascular and respiratory problems, they show a loss of self-esteem and a poor self-image. There exist very rare data about psychological state before the OP compared with data afterwards. OBJECTIVE This study was conducted to examine psychological changes in body-image, self-concept and mental exposure in patients with pectus excavatum, who had undergone the Nuss procedure. METHODS Seventeen patients (13 male, 4 female), who underwent 2003 a comprehensive psychological investigation, have been tested again in 2007 by means of the identical questionnaires to get postoperative data: OPE-FB (Wallisch; Operation-Expectation-Questionnaire), FKKS (Deusinger; Frankfurter Body Concept Scales) and SCL-90-R (Derogatis; Symptom Checklist Revised). The mean age at the second time of investigation was 19.6 years (SD = 2.5). The patients were classified into two groups based on a lower (n = 10) and a higher (n = 7) severity index of PE. Parents or a parent person were interviewed about the topics of OPE-FB by a structured interview. Data were analyzed using Mann-Whitney U test and Wilcoxon test. Interview data were evaluated with a content analysis. RESULTS Nearly all patient's expectations in regard to the beneficial effect of the surgical procedure-investigated with the OPE-FB preoperatively-have been confirmed postoperatively. In patients with a lower severity index impairment in general interest in sports and improvements in self-assurance, health, self-acceptance of one's body and acceptance of one's body by others can be reported. Data from SCL-90-R, measuring mental exposure, had normal range. Interviews with relatives showed, that the external attribution could emphasize patient's data from the OPE-FB. CONCLUSIONS The long-time follow-up can make us sure, that the Nuss procedure as a physical treatment has positive effects on physical as well as psychological aspects of young adults. The patient's confidence with the cosmetic result was very high, which reflects the excellent effects of the minimal invasive repair according to Nuss.
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Affiliation(s)
- Barbara Hadolt
- Department of Behavioural Medicine, Psychology of Health and Empirical Psychosomatics, University Clinic of Medical Psychology and Psychotherapy, Graz, Austria.
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