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Piro L, Lena F, Roggero A, Stagnaro N, Mattioli G, Torre M. Sternal cleft and pectus excavatum: an overlooked congenital association? Pediatr Surg Int 2024; 40:105. [PMID: 38602580 DOI: 10.1007/s00383-024-05686-0] [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] [Accepted: 04/02/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Sternal cleft (SC), a rare thoracic malformation, is associated with pectus excavatum (PE) in 2.6-5% of cases. It remains unclear if these conditions are congenitally linked or if SC repair triggers PE. To investigate the potential higher frequency of PE in SC cases, we conducted a retrospective study of our SC patients. METHODS We assessed PE incidence, progression, and management in SC patients treated at our institute from 2006 to 2022. When available, we collected pre-SC repair CT scan data, calculating the Haller Index (HI) and Correction Index (CI) and compared them to a selected control group. RESULTS Among 8 SC patients, 7 had concomitant PE (87.5%), varying in severity. PE management ranged from observation to thoracoplasty, depending on its degree. We observed a significant pre-operative CI difference between SC and control group patients (p < 0.00001). In the last two SC repair cases, we attempted concurrent PE prevention or treatment. CONCLUSION Our findings suggest an underestimated association between PE and SC in the existing literature. SC patients may exhibit a predisposition to PE from birth, which may become more apparent with growth after SC repair. Consequently, PE prevention or treatment should be considered during SC repair procedures.
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Affiliation(s)
- Liliana Piro
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy.
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science, University of Genoa, Genoa, Italy.
| | - Federica Lena
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science, University of Genoa, Genoa, Italy
| | - Arianna Roggero
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science, University of Genoa, Genoa, Italy
| | - Nicola Stagnaro
- Department of Radiology, IRCCS Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
| | - Girolamo Mattioli
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science, University of Genoa, Genoa, Italy
| | - Michele Torre
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
- Pediatric Thoracic and Airway Surgery Unit, IRCCS Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
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A hybrid approach to maximize safety with thoracoscopic Nuss procedure after prior sternotomy. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Liu S, Wang L, Zhang H, Zeng W, Hu F, Xiao H, Li G, Mei J, Zhu J. Modified Nuss procedure with a novel steel bar in patients with pectus excavatum post-congenital heart surgery. Interact Cardiovasc Thorac Surg 2021; 34:424-430. [PMID: 34661678 PMCID: PMC8860435 DOI: 10.1093/icvts/ivab284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/29/2021] [Accepted: 09/20/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Pectus excavatum (PE) can be secondary in patients who underwent sternotomy for cardiac surgery. Retrosternal adhesions increase the complexity and risk of traditional Nuss repair. Thus, we summarized the outcomes of our modified Nuss procedure using a newly designed bar. METHODS A retrospective analysis was performed on 35 patients who underwent modified PE repair after open heart surgery from January 2011 to July 2019. The surgery was performed using a novel bar with no need for intraoperative reshaping and rotation, assisted by thoracoscopy and subxiphoid incision when necessary. RESULTS There were 19 males and 16 females with a median age of 5.3 years (interquartile range, 4.1–10.9) at PE repair. All patients underwent the modified procedure uneventfully with no death. The median operating time was 70 min. Twenty-nine (82.9%) patients required subxiphoid incision assistance. There was 1 case (2.8%) with unexpected sternotomy due to intraoperative bleeding. The median length of postoperative hospital stay was 4 days. During the median 3.5 years of follow-up, no bar dislocation was found and 30 (85.7%) patients had their bars removed with no recurrence recorded. After PE repair, the Haller index improved significantly (2.6 ± 0.4 vs 4.9 ± 1.3, P < 0.05) and further decreased till the time of bar removal (2.5 ± 0.4 vs 2.6 ± 0.4, P < 0.05). All patients were satisfied with the cosmetic outcome. CONCLUSIONS The novel bar can be placed and removed easily with a low rate of adverse events. This modified Nuss procedure seems to be a safe, effective and convenient approach for the management of PE after cardiac surgery.
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Affiliation(s)
- Siming Liu
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Wang
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hongkun Zhang
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wenhui Zeng
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fengqing Hu
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haibo Xiao
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Guoqing Li
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ju Mei
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiaquan Zhu
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Wang L, Liu J, Li Y, Feng T, Cao B, Xiao H, Hu F, Li G. Modified Nuss operation using introducer-bar complex for pectus excavatum in adults: a retrospective study. J Cardiothorac Surg 2021; 16:267. [PMID: 34551817 PMCID: PMC8456631 DOI: 10.1186/s13019-021-01624-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 08/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background Shortcoming of traditional Nuss operation on adults is gradually found in the clinical practice. A new kind of introducer-bar complex was introduced. However, there is limited evidence regarding its safety and efficacy. Therefore, a single center, retrospective study was conducted to address this issue. Methods Patients with pectus excavatum who underwent surgery between January 2015 and June 2017 were consecutively enrolled in this study. In all, 52 patients underwent the modified procedure using the introducer-bar complex (new procedure group), whereas 48 underwent the traditional anti-Nuss procedure (traditional procedure group). Outcomes analysis of balanced baseline was performed to compare the intraoperative and postoperative short-term outcomes. Results All patients in the new procedure group had shorter operation duration (51.54 ± 20.32 vs. 79.45 ± 13.88 min, p = 0.017), postoperative hospitalizations (4.77 ± 1.62 vs. 6.86 ± 2.18 days, p = 0.028), plate removal surgery durations (39.30 ± 8.97 vs. 60.30 ± 10.49 min, p < 0.001), and less blood loss during operation (6.25 ± 4.88 vs. 10.90 ± 5.75 ml, p = 0.003) than patients in the traditional procedure group. There was no significant difference in the length of incision, postoperative Haller index, cost, number of steel bars, postoperative surgical outcome and incidence of complications between the two groups. Conclusion Through the main clinical outcome were similar, our results shown that modified procedure may have the shorter operation time, postoperative hospital stay, and operation time for plate removal and less blood loss, which may bring potential clinical benefits to patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01624-6.
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Affiliation(s)
- Lei Wang
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Juan Liu
- Department of Cardiovascular Medicine, Baoshan Branch of Shanghai Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 201900, China
| | - Yao Li
- Department of Disaster and Emergency Medicine, Shanghai East Hospital, Tongji University, 1239 Siping Road, Shanghai, 200120, China
| | - Tienan Feng
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.,Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation, 416 hospital, Chengdu, 610051, Sichuan, China
| | - Beibei Cao
- Department of Printing Equipment Engineering, Shanghai Publishing and Printing College, Shanghai, 200093, China
| | - Haibo Xiao
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China.
| | - Fengqing Hu
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China.
| | - Guoqing Li
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
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Feingold PL, Marshall MB. Commentary: One Plus One Does Not Equal Two: Combined Pectus Repair With Open Cardiac Surgery. Semin Thorac Cardiovasc Surg 2021; 33:1154-1155. [PMID: 33691192 DOI: 10.1053/j.semtcvs.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/16/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Paul L Feingold
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Margaret Blair Marshall
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Chen C, Li X, Zhang N, Yu J, Yan D, Xu C, Zeng Q, Li Z. Different Nuss procedures and risk management for pectus excavatum after surgery for congenital heart disease. J Pediatr Surg 2018; 53:1964-1969. [PMID: 29716732 DOI: 10.1016/j.jpedsurg.2018.04.006] [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: 08/12/2017] [Revised: 03/31/2018] [Accepted: 04/02/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE In Nuss procedure for pectus excavatum (PE) after surgery for congenital heart disease (CHD), retrosternal adhesion may increase the risk of cardiac injury. This study aimed to explore different Nuss procedures and their implications for reducing the incidence of serious complications and improving surgical safety. METHODS We retrospectively reviewed 49 cases (29 male and 20 female) of Nuss procedures for PE after surgery for CHD that were performed between April 2003 and December 2016. The median age was 5.8 years (range, 3.0-17.9), and the median Haller index was 4.6 (3.2-17.7). All patients were evaluated on their cardiac function and severity of PE by echocardiography and computed tomography scan, respectively. Three surgical procedures were used. Perioperative conditions were analyzed, including CHD type, interval between two operations, blood loss, operation time, hospital stay, complications, and postoperative results. RESULTS All 49 cases were completed successfully. Fourteen cases (28.6%) involved the standard three-incision thoracoscopic Nuss procedure, 30 cases (61.2%) involved the Nuss procedure assisted by a median sternum incision, and 5 cases (10.2%) involved the Nuss procedure with sternal suspension. The median interval between the CHD surgery and Nuss procedure was 4.0 years (0.5-12.0). The median blood loss was 2.0 mL (1.0-150.0 mL). The median operation time was 45.0 min (27.0-230.0), and the median hospital stay was 6.0 days (5.0-9.0). Three patients (6.1%) experienced severe surgical complications: 2 experienced a rupture of the right atrium and 1 had pericardial injury. Patients were followed up for 7-120 months after surgery. The postoperative results were excellent in 46 cases (93.9%) and good in 3 (6.1%). Twenty-four of the 49 patients have had their bars removed. The median time for bar removal was 36.0 months (24.0-47.0). The outcome after bar removal surgery was excellent in 20 cases and good in 4. CONCLUSIONS Patients may develop PE or worsening of preexisting PE after open heart surgery for CHD. Surgery for PE can still be performed by the standard Nuss technique without increasing the risk of cardiac injury for the patients that have had interventional cardiology procedures for CHD previously. However, the risk of cardiac injury during the Nuss procedure dramatically increases due to retrosternal adhesions that develop after open heart surgery for CHD. In our experience, the Nuss procedure is safe and feasible after open heart surgery for CHD when performed by an experienced pectus surgeon using an individualized surgical plan for each patient. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Chenghao Chen
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Xiaofeng Li
- Department of Cardiac Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Na Zhang
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Jie Yu
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Dong Yan
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Changqi Xu
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Qi Zeng
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China.
| | - Zhongzhi Li
- Department of Cardiac Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China.
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De Wolf J, Brian E, Wurtz A. Letter to the Editor. J Pediatr Surg 2018; 53:857-858. [PMID: 29366505 DOI: 10.1016/j.jpedsurg.2017.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 12/17/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Julien De Wolf
- CHU Lille, Department of Thoracic Surgery, F-59000 Lille, France
| | | | - Alain Wurtz
- CHU Lille, Department of Thoracic Surgery, F-59000 Lille, France.
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Wang J, Wang Q, Pan Z. Simultaneous repair of congenital heart defects and pectus excavatum in young children. Pediatr Surg Int 2018; 34:269-275. [PMID: 29302749 DOI: 10.1007/s00383-017-4223-z] [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] [Accepted: 12/18/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE The present study was undertaken to summarize our experience with the concurrent repair of pectus excavatum (PE) and congenital heart defects in young children over the past 15 years. METHODS A retrospective study was conducted that included patients who underwent combined repair of PE and a congenital heart defect in a large clinical center between 2002 and 2017. Intraoperative and postoperative patient characteristics, postoperative complications and surgical outcomes were recorded. RESULTS Twenty-one patients met the inclusion criteria. An open heart surgery and a modified sternal elevation with anterior sternal suspension were performed. No intraoperative complications occurred. Postoperatively, three patients developed pneumonia, two patients developed subcutaneous effusions, one patient sustained an asymptomatic pneumothorax, and one other patient had a transitory fever. In all cases, postoperative recovery was uneventful, and no perioperative mortality occurred. Bar removal was performed in 19 patients at an average of 2.55 years postoperatively: 18 of them achieved an excellent outcome, and 1 patient had a good final result. CONCLUSION A combined procedure of modified sternal elevation and cardiac repair may be performed safely in young children. Early repair of PE is feasible and effective in these patients.
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Affiliation(s)
- Junke Wang
- Department of Cardiovascular and Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China.,Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China
| | - Quan Wang
- Pediatric Research Institute, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China.,Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China
| | - Zhengxia Pan
- Department of Cardiovascular and Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China. .,Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China.
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Reply. Ann Thorac Surg 2017; 104:1759-1760. [PMID: 29054223 DOI: 10.1016/j.athoracsur.2017.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 03/26/2017] [Indexed: 11/22/2022]
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Brian E, Wurtz A. The Nuss Procedure After Prior Cardiac Surgery: Friend or Foe? Ann Thorac Surg 2017; 104:1759. [PMID: 29054222 DOI: 10.1016/j.athoracsur.2017.01.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 01/15/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Emmanuel Brian
- Thoracic Department, Institut Mutualiste Montsouris, Paris, France
| | - Alain Wurtz
- CHU Lille, Department of Thoracic Surgery, F-59000 Lille, France.
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Jaroszewski DE, Gustin PJ, Haecker FM, Pilegaard H, Park HJ, Tang ST, Li S, Yang L, Uemura S, De Campos JRM, Obermeyer R, Frantz FW, Torre M, McMahon L, Hebra A, Chu CC, Phillips JD, Notrica DM, Messineo A, Kelly R, Yüksel M. Pectus excavatum repair after sternotomy: the Chest Wall International Group experience with substernal Nuss bars. Eur J Cardiothorac Surg 2017; 52:710-717. [DOI: 10.1093/ejcts/ezx221] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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