Patient satisfaction and clinical results 10 years after modified open thoracoplasty for pectus deformities

Chest Wall Dermatitis Patterns Following Thoracoscopic Intercostal Nerve Cryoablation for Surgical Correction of Pectus Excavatum

BACKGROUND

Intercostal nerve cryoablation (INC) has been shown to reduce postoperative pain and length of stay following surgical correction of pectus excavatum (SCOPE). Some patients have developed chest wall dermatological symptoms after INC that can be mistaken for metal allergy or infection. The purpose of this study is to report the symptoms, severity, incidence, and treatment of post-cryoablation dermatitis.

METHODS

A retrospective single institution review was performed for patients who underwent SCOPE with and without INC between June 2016 and March 2023 to assess for incidence of postoperative dermatological findings. Characteristics associated with these findings were evaluated.

RESULTS

During study period, 383 patients underwent SCOPE, 165 (43.1%) without INC and 218 (56.9%) with. Twenty-three (10.6%) patients who received INC developed exanthems characteristic of post-cryoablation dermatitis with two distinct phenotypes identified. No patients who underwent SCOPE without INC developed similar manifestations. Early dermatitis, characterized by a painless, erythematous, and blanching rash across the anterior thorax, was observed in 16 patients, presenting on median postoperative day 6.0 [IQR 6.0-8.5], with median time to resolution of 23.0 [IQR 12-71.0] days after symptom onset. Late dermatitis, characterized by hyperpigmentation spanning the anterior thorax, was observed in 7 patients, presenting on median postoperative day 129.0 [IQR 84.5-240.0], with median time to resolution of 114.0 [IQR 48.0-314.3] days.

CONCLUSION

This is the first report of dermatological manifestations following SCOPE with INC, a phenomenon of unknown etiology and no known long-term sequela. In our experience, it is self-resolving and lacks systemic symptoms suggesting observation alone is sufficient for resolution.

LEVEL OF EVIDENCE

IV.

Effectiveness of one minute per level intercostal nerve cryoablation for postoperative analgesia after surgical correction of pectus excavatum

PURPOSE

Intraoperative intercostal nerve cryoablation has emerged as a promising modality for postoperative analgesia following Surgical Correction of Pectus Excavatum (SCOPE). Most centers use two-minute cryoablation per level, although data from histologic and adult studies suggest the effectiveness of one-minute freezes. We aimed to describe our center's experience with one minute per level cryoablation.

METHODS

A retrospective single institution review of patients undergoing SCOPE was performed to compare patients pre- and post-intercostal nerve cryoablation implementation. Cryoablation was performed as one minute for each of the thoracic intercostal nerves T3-T7. Multivariable regression analyses were conducted to compare the outcomes and cost between pre- and post-implementation groups.

RESULTS

During the study period, 198 patients underwent SCOPE with one Nuss bar, receiving either intraoperative intercostal nerve cryoablation (Cryo, n = 100) or preoperative thoracic paravertebral catheters (NoCryo, n = 98). Surgical time was on average 9 min longer for the Cryo group (p<0.01). Median length of stay for the Cryo group was 3 days shorter compared to the NoCryo group (p<0.01). The Cryo group had a 19-fold and 5.6-fold reduction in average inpatient and total postoperative opioid usage, respectively (p<0.01). Total hospital costs were significantly lower in the Cryo group (p<0.01). Overall complication rate was not statistically significant different between the two groups.

CONCLUSIONS

Intraoperative one minute per level cryoablation is a potent approach to postoperative analgesia for SCOPE patients that led to a shorter hospital length of stay, lower hospital costs, and decreased opioid use compared to conventional analgesia at our institution. Pediatric surgeons performing correction of chest wall deformities should consider offering this technique.

[Correction of pectus excavatum and long-term outcome in adult]

Pectus excavatum is the most common congenital chest malformation characterized by symmetrical or asymmetric depression of the chest with deformation of the sternocostal complex. Pectus excavatum is often associated with other dysplastic diseases of connective tissue. Ravitch thoracoplasty and Nuss minimally invasive correction are the most common today. The authors report surgical correction of PE in a 50-years-old male who underwent Ravitch modified thoracoplasty with implantation of shape memory plate. Long-term treatment outcomes and technical properties of the plate after removing are analyzed.

A Modfied Nuss Procedure for Recurrent Pectus Excavatum of Adults

Background

Limited data exist for adults with recurrent pectus excavatum (PE) treated with minimally invasive surgical repair.

Methods

Between July 2008 and December 2020, forty-two adult patients with recurrent PE underwent a modified Nuss procedure with a newly designed bar in our center. A small vertical subxiphoid incision was used to separate severe adhesions when necessary. Multiple steel wires were sutured, and the rib space was narrowed to firmly fix the bar. The primary end point was Haller index change after operation. The secondary end points included length of stay after operation, short-term and long-term complications.

Results

The mean patient age was 22.02 ± 3.49 years. The mean Haller index was 4.59 ± 1.09. A subxiphoid incision was performed in 12 patients. Thirty-nine patients had one bar placed, and 3 patients required two bars. Sixteen patients had 3 or more wires fixation, and 4 patients needed to have their intercostal space narrowed. There was no perioperative death, and the mean hospitalization was 5.57 ± 2.47 days. The Haller index reduced to 3.03 ± 0.41 after the operation (t = 11.85, p < 0.001). During the follow-up, there were 3 patients who developed non-infective wound effusion; bar rotations occurred in 3 patients. Twenty patients had the bar removed, post-bar removal Haller index was significantly reduced compared to the preoperative Haller index (2.89 ± 0.37 vs. 4.72 ± 1.05, t = 8.96, p < 0.001).

Conclusions

The modified Nuss procedure with a new titanium alloy bar can achieve good results for adult patients with recurrent PE.

Standardization of clinical care pathway leads to sustained decreased length of stay following Nuss pectus repair: A multidisciplinary quality improvement initiative

BACKGROUND AND PURPOSE

Postoperatively, standardized clinical care pathways (SCCPs) help patients reach necessary milestones for discharge. The objective of this study was to achieve 90% compliance with a pectus specific SCCP within 9 months of implementation. We hypothesized that adherence to a pectus SCCP following the Nuss procedure would decrease postsurgical length of stay (LOS).

METHODS

A multidisciplinary team implemented the pectus SCCP, including goals for mobility, lung recruitment, pain control, intake, and output. The full protocol included 42 components, tracked using chart reviews and a patient-directed checklist. The primary process measure was compliance with the pectus SCCP. The primary outcome measure was LOS; secondary outcomes were patient charges, patient satisfaction, and hospital readmission.

RESULTS

Total study patients were n = 509: 159 patients pre-intervention, 350 patients post-intervention (80 implementation group; 270 sustain group). SCCP compliance data were collected on 164 patients post-intervention - 80 implementation, 84 sustain. LOS, ED visits, and hospital readmissions were recorded for all 509 patients. Mean LOS decreased from 4.5 days to 3.4 days, with >90% adherence to the pectus SCCP postintervention. There were no readmissions owing to pain despite earlier termination of epidural analgesia. Total patient charges decreased by 30% and patient satisfaction was high.

CONCLUSION

Using quality improvement methodology with strict adherence to a pectus SCCP, we had significant reduction in LOS and patient charge without compromising effective postoperative pain management or patient satisfaction.

TYPE OF STUDY

Clinical research; quality improvement.

LEVEL OF EVIDENCE

V.

The impact of an enhanced recovery perioperative pathway for pediatric pectus deformity repair

PURPOSE

Pediatric repair of chest wall deformities is associated with significant pain, morbidity, and resource utilization. We sought to determine outcomes of a perioperative enhanced recovery after surgery (ERAS) pathway for patients undergoing minimally invasive (Nuss) and traditional (Ravitch) corrective procedures.

METHODS

Our ERAS protocol was implemented in 2015. We performed a retrospective review of patients for Nuss or Ravitch procedures before and after ERAS implementation. Combined and procedure segregated bivariate analyses were conducted on postoperative outcomes and resource utilization.

RESULTS

There are 17 patients in the pre-intervention group (Nuss = 13 and Ravitch = 4) compared to 38 patients in the post-intervention group (Nuss = 28 and Ravitch = 10). Protocol implementation increased utilization of pre-operative non-narcotic medication. The combined and Nuss post-intervention groups had a significant decrease in epidural duration and time to enteral medications, but had increased total postoperative opioid usage. The Ravitch post-intervention group had a significant decrease in intra-operative narcotics and discharge pain scores. There were no differences in length of stay or complications.

CONCLUSION

Implementation of our ERAS protocol standardized pectus perioperative care, but did not improve postoperative opioid usage, complications, or resource utilization. Alterations in the protocol may lead to achieving desired goals of better pain management and decreased resource utilization.

Pectoralis Muscle Transposition in Association with the Ravitch Procedure in the Management of Severe Pectus Excavatum

Pectus excavatum (PE) is the most common congenital chest wall deformity. PE is sometimes associated with cardiorespiratory impairment, but is often associated with psychological distress, especially for patients in their teenage years. Surgical repair of pectus deformities has been shown to improve both physical limitations and psychosocial well-being in children. The most common surgical approaches for PE treatment are the modified Ravitch technique and the minimally invasive Nuss technique. A technical modification of the Ravitch procedure, which includes bilateral mobilization and midline transposition of the pectoralis muscle flap, is presented here.

Methods

From 2010 to 2016, 12 patients were treated by a modified Ravitch procedure with bilateral mobilization and midline transposition of the pectoralis muscle flap for severe PE. Outcomes, morphological results, and complications were analyzed with respect to this new combined surgical approach.

Results

There was a statistically significant difference between pre- and postoperative values (P = 0.0025) of the Haller index at the 18-month follow-up, showing a significant morphological improvement for all treated patients. After surgery, no morbidity and mortality were noted. The mean hospital stay was 7 days, and all patients were discharged without major complications.

Conclusion

This technique significantly improved patients' postoperative morphological outcomes and significantly reduced long-term complications, such as wound dehiscence, skin thinning, and hardware exposure.

Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis

BACKGROUND/PURPOSE

To evaluate surgical outcomes of Nuss versus Ravitch repair of pectus excavatum via a systematic review and meta-analysis.

METHODS

Medline, PubMed, Cochrane, EMBASE, and Google Scholar databases were searched up to September 5, 2016 using the following search terms: pectus excavatum, funnel chest, Nuss; Ravitch, minimally invasive, and open surgery. Randomized controlled trials, two-arm prospective, and two-arm retrospective studies were eligible for inclusion.

RESULTS

Nineteen studies were included with a total of 1731 patients: 989 treated with Nuss and 742 treated with Ravitch. The overall analysis revealed that patients in the Nuss group had significantly shorter operation time (pooled SMD=-2.83, 95% CI=-3.76 to -1.90, p<0.001) and less blood loss (pooled SMD=-1.68, 95% CI=-2.28 to -1.09, P<0.001) than the Ravitch group. However, the length of hospital stay was similar between groups (pooled SMD=-0.55, 95% CI=-1.44 to 0.35, p=0.230). These findings were similar in the subgroup analysis for randomized and non-randomized controlled studies. Complications were not assessed due to inconsistent reporting across the included studies.

CONCLUSIONS

Our meta-analysis demonstrate that the Nuss procedure has a shorter operative time and less operative blood loss than the Ravitch procedure while the postoperative length of stay was similar.

LEVELS OF EVIDENCE

Level III.

Ravitch versus Nuss procedure for pectus excavatum: systematic review and meta-analysis

BACKGROUND

Pectus excavatum is the most common congenital chest wall deformity. The two most common surgical techniques for its correction are the modified Ravitch technique and the minimally invasive Nuss technique. Despite both procedures being used widely, data comparing them are scarce.

METHODS

We conducted a systematic review and meta-analysis of comparative studies to evaluate these procedures. A systematic search of the literature was performed from six electronic databases. Pooled meta-analysis was conducted using odds ratio (OR) and weighted mean difference (WMD).

RESULTS

A total of 13 studies comprising 1,432 pediatric (79.3%) and adult (20.7%) patients were identified, including 912 patients undergoing the Nuss procedure compared to 520 patients undergoing the Ravitch procedure. There was no significant difference found between the Nuss group versus Ravitch group in pediatric patients with regard to overall complications (OR =1.16; 95% CI: 0.61-2.19; I²=56%; P=0.65), reoperations (6.1% vs. 6.4%; OR =1.00; 95% CI: 0.40-2.50; I²=0%; P=1.00), wound infections (OR =0.58; 95% CI: 0.23-1.46; I²=0%; P=0.25), hemothorax (1.6% vs. 1.3%; OR =0.74; 95% CI: 0.21-2.65; I²=12%; P=0.64), pneumothorax (3.4% vs. 1.5%; OR =1.11; 95% CI: 0.42-2.93; I²=0%; P=0.83) or pneumonia (OR =0.15; 95% CI: 0.02-1.48; I²=0%; P=0.10). Adult patients undergoing the Nuss procedure had a higher incidence of overall complications (OR =3.26; 95% CI: 1.01-10.46; I²=0%; P=0.05), though there were far fewer studies that reported data.

CONCLUSIONS

These results suggest no difference between the Nuss and Ravitch procedures for pediatric patients, while in adults the Ravitch procedure resulted in fewer complications.

Surgical correction of pectus carinatum improves perceived body image, mental health and self-esteem

PURPOSE

The purpose of this study was to assess the effects of surgical correction of pectus carinatum on health-related quality of life and self-esteem.

METHODS

Between May 2012 and May 2013, a prospective observational single-center cohort study was conducted on consecutive patients undergoing surgical correction of pectus carinatum at our institution. Patients filled in questionnaires on health-related quality of life and self-esteem before and six months after surgery.

RESULTS

Disease-specific health-related quality of life was improved by 33% (95% CI: 23; 44%) according to responses to the Nuss Questionnaire modified for Adults. The improvement for generic mental health-related quality of life was 7% (95% CI: 3; 12%) in responses to the Short Form-36 Questionnaire. The improvement in self-esteem was 9% (95% CI: 2; 17%) as assessed with the Rosenberg Self-Esteem Scale. A Single Step Questionnaire supported the improvements in health-related quality of life and self-esteem six months postsurgery.

CONCLUSION

This study confirms positive effects of surgical correction of pectus carinatum on health-related quality of life and self-esteem. Patients were to a greater extent self-satisfied about chest appearance following surgery, indicating this to be a step in the right direction toward improved body image, mental health and self-esteem.

Fate of allogenic bone graft for sternal support in pectus excavatum repair

BACKGROUND

Techniques for pectus excavatum repair are based on sternal support using various implants that have been reported to cause complications including migration and perforation of adjacent vital organs. Thus the search for an ideal sternal support is ongoing. This study aimed to assess the feasibility and fate of allogenic bone grafts as a durable sternal support for pectus excavatum repair.

METHODS

Pectus excavatum deformities in 3 men were corrected by modified Ravitch repair using allogeneic bone grafts for sternal support. Postoperatively, the patients were followed up for 3 years. Chest computed tomography and bone scans were performed to identify radiological features relevant to the stability, viability, and fate of the bone grafts.

RESULTS

The postoperative course was uneventful in all patients. Cosmetic correction was rated as very good with patient satisfaction. Bone scans showed progressively increasing activity in the graft, indicating an ongoing process of neovascularization. Chest computed tomography showed not only bone resorption, new bone formation, and remodeling but also incorporation of the graft into the sternum and corresponding ribs through newly generated, normally configured sternocostal segments.

CONCLUSIONS

As seen radiologically, this technique offers a model for sternal support that has the potential to incorporate into the host tissue through newly generated, normally configured sternocostal segments, without restriction of chest wall expansion, features that have not been previously reported.

Evaluation of sternochondroplasty efficacy in treatment of pectus deformities

PURPOSE

This study aimed to evaluate the efficacy of sternochondroplasty for repair of pectus deformities.

METHODS

Thirty-three patients underwent repair of pectus deformity with a sternochondroplasty technique between 1989 and 2009. Studied variables were age, sex, symptoms, pulmonary function tests before and after surgery, Haller index, complications, recurrence, and cosmetic results.

RESULTS

The median age at operation was 13.27 years. Twenty patients (13 male and 7 female) had pectus excavatum, and 13 (11 male and 2 female) had pectus carinatum. Congenital anomalies associated with pectus excavatum included a skeletal anomaly in 6 (30%) patients and a cardiac anomaly in 4 (20%); only 1 patient with pectus carinatum had cardiac anomaly. Inspiratory vital capacity and forced expiratory volume in 1 s were significantly different before and after surgery in patients with pectus excavatum, but there was no significant difference in functional residual capacity. Pulmonary function tests showed no significant differences before and after surgery in patients with pectus carinatum. Complications after surgery were seroma in 2 cases and 1 case each of pneumothorax and atelectasis. Recurrence was observed in 2 cases of pectus excavatum. The cosmetic result was excellent in 93.9% of cases. Hospital mortality was zero.

CONCLUSION

Sternochondroplasty is a desirable procedure for repairing pectus deformities. This procedure has minimal complications and the cosmetic and physiologic results are excellent.

Modified Robicsek procedure for pectus excavatum in adult patients

OBJECTIVES

The aim of this study was to clarify the short-term and mid-term outcomes of the modified Robicsek procedure using polypropylene mesh for adult pectus excavatum patients.

METHODS

Retrospective chart review was performed. Between 2001 and 2012, 46 consecutive adult patients underwent modified Ravitch repair using polypropylene mesh for pectus excavatum at our institution. There were 30 males and 16 females, with a median age of 25.5 (range: from 17 to 60). Potential risk factors for perioperative complications and early failure in pectus repair were analysed with χ(2) test or Fisher's exact test and Mann-Whitney test. Potential risk factors for postoperative mid-term recurrence were analysed using Cox proportional hazard regression model.

RESULTS

The postoperative follow-up interval was 7.0 ± 15.1 months (mean ± standard deviation). No mortality and 11 patients (24.0%) of morbidity, including 2 patients with temporary mesh infection, were noted. A lower preoperative %FEV1.0 predicted was a significant factor (P = 0.0088) of morbidity in multivariate analysis. Regarding chest morphology, early failure in 1 patient (2.2%) and mid-term recurrence in 1 patient (2.2%) were seen. Previous pectus repair (P = 0.0324) and severe asymmetry (P = 0.04) were significant factors of early failure in multivariate analysis, while no significant factor for mid-term recurrence was found.

CONCLUSIONS

Modified Robicsek procedure with a polypropylene mesh is associated with low incidences of early failure and mid-term recurrence. The procedure is recommended for adult pectus excavatum patients, including those with asymmetric or combined deformity as an initial or reoperative procedure.

Longer term effects of closed repair of pectus excavatum on cardiopulmonary status

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.