Surgical repair of pectus excavatum

Incidence of chest wall deformity in 15,862 students in the province of Sivas, Türkiye

Background

This study aims to investigate the prevalence of chest deformity in middle- and high-school students in Sivas province of Turkey, to identify the risk factors associated with the psychological and physical disorders caused by the deformity, and to facilitate early diagnosis and treatment guidance by increasing awareness of this problem.

Methods

Between October 2011 and May 2012, a total of 15,862 students (8,508 males, 7,354 females; mean age: 15.9±1.3 years; range, 12 to 19 years) from public schools were included. A number of schools were randomly selected for study, and the students were screened by physical examination. A study protocol was developed in which patients with deformities were questioned about family history and symptoms.

Results

Chest wall deformity was detected in a total of 250 students (1.6%). The prevalence rates of pectus carinatum and pectus excavatum in the children were 0.7% and 0.6%, respectively. The overall prevalence of chest wall deformity was 1.6%.

Conclusion

Chest wall deformity is more common in boys and pectus carinatum is the most common deformity type. Chest wall deformity is more common in the 15-16 age group and female sex is a risk factor for psychological discomfort.

Utility of routine patch testing prior to surgical repair of pectus excavatum: A multidisciplinary experience via retrospective review at a single tertiary care center

BACKGROUND

The Nuss procedure is the only implant procedure in which routine, rather than selective, preoperative patch testing is recommended. This practice has recently been called into question.

OBJECTIVE

To evaluate an updated experience of pre-implant patch testing in patients undergoing the Nuss procedure.

METHODS

A retrospective chart review of Nuss procedures from 2012 through 2020.

RESULTS

Forty-five patients were identified for data collection. From 2012 to 2014, none of the 14 patients were patch tested. From 2015 to 2020, 26 of 31 (83.9%) were patch tested. Of those tested, only 2 had a positive patch test. A hypoallergenic titanium bar was inserted in each case. In total, there were zero bar reactions.

CONCLUSION

The risks of patch testing are extremely small and should be weighed against the serious implications of even one bar allergy when deciding on future guidelines.

Pectus excavatum and scoliosis: a review about the patient's surgical management

Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine. This review article aims to perform an updated overview of the literature about the effect of pectus excavatum correction at the spine and the management of patients with both pectus excavatum and scoliosis. Although acquired scoliosis has been rarely reported after a Nuss procedure, studies show that the Nuss procedure can have a beneficial effect in mild coexisting scoliosis especially when it is performed during the adolescence. The management of cases presented with both pectus excavatum and scoliosis depends on the severity of pre-operative scoliosis and demands detailed evaluation of the spine pre and postoperatively. In the rare condition of post-operative scoliosis following a Nuss procedure, the removal of the metallic bar and conservative measures may have satisfactory results on the spine.

Esophageal cancer with severe funnel chest treated by simultaneous funnel chest surgery and thoracoscopic esophagectomy: a case report

BACKGROUND

Funnel chest is the most common chest deformity, occurring in 0.06-0.3% of the general population. When it occurs concomitantly with esophageal cancer, it hinders intrathoracic surgery that is necessary for treatment. Although there are a few reports of esophagectomy performed in patients with funnel chest, simultaneous treatment of esophageal cancer and funnel chest with funnel chest surgery (Nuss method) and esophagectomy has not been reported. We report the first case of advanced esophageal cancer complicated by severe funnel chest that was treated using the Nuss method and radical thoracoscopic esophagectomy.

CASE PRESENTATION

A 59-year-old man was diagnosed with advanced thoracic esophageal cancer and severe funnel chest. Because his sternum was almost attached to the vertebral bone, thereby creating a narrow space in the mediastinum, esophageal surgery was expected to be complicated. After the patient underwent neoadjuvant chemotherapy, we used the Nuss method to reconstruct the chest and widen the mediastinum. Subsequently, radical thoracoscopic esophagectomy was performed with the patient in the left decubitus position without any difficulty, and the postoperative course was uneventful.

CONCLUSION

Simultaneous funnel chest surgery (Nuss method) and thoracoscopic esophagectomy with the patient in the left decubitus position are recommended for esophageal cancer patients with severe funnel chest.

Video-assisted thoracoscopic esophagectomy in the left lateral decubitus position in an esophageal cancer patient with pectus excavatum

During thoracic cavity operations, it is difficult to obtain sufficient working space and good operative field visibility in patients with pectus excavatum because the space between the vertebral bodies and sternum is very narrow. Here, we report the successful treatment of esophageal cancer in a patient with pectus excavatum. A 77-year-old man with esophageal cancer was referred to our hospital for further treatment. He was diagnosed with multiple early esophageal squamous cell carcinomas. The patient had pectus excavatum, but because it was asymptomatic, a video-assisted thoracoscopic radical esophagectomy in the left lateral decubitus position without pectus excavatum repair was selected. Despite the patient's unusual anatomy, video-assisted thoracoscopic esophagectomy in the left decubitus position allowed for good operative field visibility, as the videoscope was inserted from the side of the diaphragm. This operative procedure is useful in patients with esophageal cancer who also have pectus excavatum. To the best of our knowledge, this is the second report of video-assisted thoracoscopic esophagectomy in an esophageal cancer patient with pectus excavatum.

Cardiac stem cells: translation to human studies

The discovery of multiple classes of cardiac progenitor cells in the adult mammalian heart has generated hope for their use as a therapeutic in heart failure. However, successful results from animal models have not always yielded similar findings in human studies. Recent Phase I/II trials of c-Kit (SCIPIO) and cardiosphere-based (CADUCEUS) cardiac progenitor cells have demonstrated safety and some therapeutic efficacy. Gaps remain in our understanding of the origins, function and relationships between the different progenitor cell families, many of which are heterogeneous populations with overlapping definitions. Another challenge lies in the limitations of small animal models in replicating the human heart. Cryopreserved human cardiac tissue provides a readily available source of cardiac progenitor cells and may help address these questions. We review important findings and relative unknowns of the main classes of cardiac progenitor cells, highlighting differences between animal and human studies.

Pectus excavatum (funnel chest): a historical and current prospective

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.

Imaging diagnosis--acquired pectus excavatum secondary to laryngeal paralysis in a dog

A 13-year-old neutered female Labrador retriever had inspiratory dyspnea secondary to bilateral laryngeal paralysis. Radiographically, there was pectus excavatum with a mediastinal shift to the right. Arytenoid lateralization was performed, relieving the upper respiratory obstruction, and the sternal deformity also resolved. Chronic upper respiratory obstruction should be considered in dogs with pectus excavatum. Furthermore, correction of upper respiratory obstruction has the potential to result in resolution of pectus excavatum.

Dermatitis in patients undergoing the Nuss procedure for correction of pectus excavatum

BACKGROUND

The Nuss procedure was introduced in 1987 for the correction of pectus excavatum. In this procedure, a stainless steel bar is placed underneath the sternum.

OBJECTIVES

To report cutaneous reactions associated with Nuss bar placement.

METHODS

Over a period of 30 months, 50 patients underwent the Nuss procedure. The study population was limited to those who developed clinically significant cutaneous reactions postoperatively. Patient information was obtained from electronic medical records. All patients had been patch tested preoperatively with stainless steel discs supplied by the bar manufacturer. When performed, expanded patch testing was carried out in accordance with the North American Contact Dermatitis Group guidelines.

RESULTS

Postoperatively, 3 patients developed areas of protuberant granulation tissue at one or more incision sites. One patient developed localized oedema, dermatitis, and lymphadenopathy. Two of these 4 patients underwent further patch testing. Of these 2, 1 with dermatitis had a positive reaction to nickel and the other, with granulation tissue, tested negative for metal allergy.

CONCLUSIONS

Despite clinical evidence of cutaneous reactions or putative allergy, no patient required early removal of the bar(s). Cutaneous testing with stainless steel discs supplied by the bar manufacturer does not provide accurate screening for allergy to the implant used in the Nuss procedure.

Indications and guidelines for pectus excavatum repair

PURPOSE OF REVIEW

The introduction of the Nuss procedure in 1997 for treatment of pectus excavatum, in conjunction with the ever-expanding body of medical information available on the internet, significantly raised the level of awareness for this deformity as both an anatomic and a functional problem. The subsequent increase in referrals for pectus excavatum repair provided large patient series for clinical analyses to better define underlying physiologic impairments and stimulated surgeons to develop technical improvements to enhance the safety and effectiveness of pectus excavatum repair.

RECENT FINDINGS

Clinical assessment, diagnostic imaging, and cardiorespiratory testing of patients with pectus excavatum have helped to characterize physiologic impairments associated with severe pectus excavatum and to define inclusion criteria for surgical repair. Appropriate timing of repair is important to minimize complications, especially recurrence. Evidence of improved cardiorespiratory function after pectus excavatum repair has been presented. As a result of numerous technical improvements, safe and effective operative correction of pectus excavatum has been reported for both the Nuss procedure and open repair.

SUMMARY

The findings presented in this review provide objective evidence of the cardiorespiratory impairment associated with severe pectus excavatum. Clinical identification of affected patients should prompt timely work-up and referral for pectus excavatum repair if inclusion criteria are met. Regular follow-up through pubertal growth is recommended.