Standardized Haller and Asymmetry Index Combined for a More Accurate Assessment of Pectus Excavatum

Quality of life, psychological states, and personality traits in patients with pectus excavatum

Objective

The quality of life (QOL) and psychological states of patients with pectus excavatum (PE) have yet to be well understood. This study aimed to evaluate the health-related QOL (HRQOL), psychological states, and personality traits of patients with PE, alongside the associations of these factors with the severity of PE.

Methods

A cross-sectional evaluation was prospectively performed in patients scheduled to undergo PE repair surgery between July 2019 and April 2021. The primary outcome was the patients' HRQOL, and the secondary outcomes were depression, social anxiety, self-efficacy, and personality traits.

Results

In total, 129 patients were subjected to analyses. Patients' HRQOL had a lower role component summary score (mean ± standard deviation: 41.8 ± 12.8, P < .001) than the general population controls. Patients' HRQOL had a significantly better physical component summary (54.0 ± 10.4, P < .001) and mental component summary (53.3 ± 8.8, P < .001) than that of the general population. Fourteen patients' (10.9%) and 56 patients' (43.4%) scores indicated the presence of depression and social anxiety disorder, respectively. Patients' self-efficacy (46.1 ± 11.4, P, .001) and level of extraversion (46.5 ± 11.8, P < .001) were lower than those of the general population. No significant correlation was found between the severity of PE and these scores.

Conclusions

Our study revealed that patients with PE had decreased social-role QOL, depressive tendencies, increased social anxiety, lower self-efficacy, and introversion. No correlation between the severity of PE and the patients' psychological outcomes leads us to conclude that surgical implications of PE should not be decided solely by a physical index.

Biomechanical validation of novel Nuss procedure simulations for patients with various morphological types of pectus excavatum

A novel Nuss procedure simulation was developed for patients with pectus excavatum considering the displacement of a metal bar and a chest wall model, including the intercostal muscles. However, this simulation was developed for a typical symmetrical patient among the various morphological types of pectus excavatum. Accordingly, this study aimed to validate and confirm the novel simulation for patients with eccentric and imbalanced types, which are severe types of pectus excavatum, considering factors such as depression depth and eccentricity among others. Three-dimensional models of chest walls and metal bars were created for three different types of patients. The rotation-equilibrium displacement and chest wall with intercostal muscles were set according to the methods and conditions of the novel Nuss procedure simulation. The anterior sternal translation and the Haller index derived from the simulation results were compared and verified using medical data from actual postoperative patients. Additionally, maximum equivalent stresses and strains were derived to confirm the suitability of the novel Nuss procedure for each patient type. The severe types had similar precision to the typical type when compared to the actual postoperative patient. Relatively high maximum equivalent stresses and strains were observed on the metal bars and sternum in the severe type, thereby predicting and confirming the biomechanical characteristics of these types. In conclusion, a novel Nuss procedure simulation for severe types was numerically validated. This underscores the importance of biomechanical evaluation through a novel Nuss procedure simulation when planning actual surgeries for severe types of cases.

Analysis of Factors Affecting Postoperative Opioid Requirement in Pediatric Patients Undergoing Pectus Excavatum Repair with Multimodal Analgesic Management

Children with pectus excavatum are treated with surgical repair in a procedure known as minimally invasive repair of pectus excavatum (MIRPE). MIRPE causes considerable postoperative pain, resulting in the administration of a substantial dose of opioids. This study aimed to identify perioperative factors that influence the requirement for opioids in children undergoing MIRPE. Retrospective data from children who underwent MIRPE were analyzed. A multimodal analgesic protocol was implemented with a continuous wound infiltration system and administration of non-opioid analgesics. Intravenous opioid analgesics were administered if the pain score was greater than 4. The cumulative opioid use was assessed by calculating the morphine equivalent dose at 6, 24, and 48 h after surgery. Perioperative factors affecting the postoperative opioid use were identified with multiple linear regression analyses. This study included 527 children aged 3-6 years, with a mean age of 3.9 years. Symmetrically depressed chest walls, a lower Haller index, and a lower revised depression index were found to be associated with decreased postoperative opioids. Boys required higher opioid doses than girls. Longer pectus bars (10 inches versus 9 inches) were associated with increased opioid use. Severity indices, gender, and the length of pectus bars influence postoperative opioid requirement in children undergoing MIRPE surgery with multimodal analgesia.

Liposomal bupivacaine reduces opioid requirements following Ravitch repair for pectus excavatum

Background and Aims

The management of post-operative pain after surgical repair of pectus excavatum with the Ravitch procedure is challenging. Although previous studies have compared various methods of pain control in these patients, few have compared different local anesthetics. This retrospective analysis compares the use of bupivacaine to its longer-acting form, liposomal bupivacaine, in patients who had undergone pectus excavatum repair with the Ravitch method.

Material and Methods

Eleven patients who received local infiltration with liposomal bupivacaine were matched to 11 patients who received local infiltration utilizing bupivacaine with epinephrine. The primary outcome was total morphine milligram equivalents per kilogram body weight (MME/kg) over the complete length of hospital stay. Secondary outcomes included total cumulative diazepam, acetaminophen, ondansetron, and NSAID dose per kilogram body weight (mg/kg) over the course of the hospital stay, chest tube drainage (ml/kg body weight), number of post-operative hours until the first bowel movement, Haller Index, patient request for magnesium hydroxide, average pain scores from post-operative day 1 to post-operative day 5, and length of hospital stay. Continuous variables were reported as medians with inter-quartile ranges, and categorical values were reported as percentages and frequencies.

Results

The total MME/kg [1.7 (1.2-2.4) vs 2.9 (2.0-3.9), P = 0.007] and hydromorphone (mg/kg) [0.1 (0.0-0.2) vs 0.3 (0.1-0.4), P = 0.006] use in the liposomal bupivacaine group versus bupivacaine with epinephrine was significantly reduced over total length of hospital stay. Similarly, there was a reduction in diazepam use in the liposomal bupivacaine group versus the bupivacaine group [0.4 (0.1-0.8) vs 0.6 (0.4-0.7), P = 0.249], but this did not reach statistical significance. The total dose of ondansetron (mg/kg) was not statistically different when comparing the liposomal bupivacaine group to the bupivacaine group [0.3 (0.0-0.5) vs 0.3 (0.2-0.6), P = 0.332]. Interestingly, the total dose of acetaminophen (mg/kg) was statistically increased in the liposomal bupivacaine group compared to the bupivacaine with epinephrine group [172 (138-183) vs 74 (55-111), P = 0.007]. Additionally, the total chest tube drainage (ml/kg) was significantly reduced in the liposomal bupivacaine group [9.3 (7.5-10.6) vs 12.8 (11.3-18.5), P = 0.027]. Finally, the percentage of patients without requests for magnesium hydroxide to promote laxation was significantly higher in the liposomal bupivacaine group than in the bupivacaine group (63.6% vs 18.2%, P = 0.027).

Conclusion

The use of liposomal bupivacaine for local infiltration in patients who undergo the Ravitch procedure for pectus repair offers advantages over plain bupivacaine, including reduced opioid consumption and opioid-related side effects. However, more data are needed to understand the significance of these findings.

Computed tomographic evaluation of pectus excavatum in 14 cats

Pectus excavatum (PE) is one of the most frequently reported chest deformities. However, limited studies are available with regard to its CT scan findings in cats. In the present research computed tomographic images of the thoraxes of 14 cats diagnosed with PE has been reviewed. This is one of the first studies exploring the use of CT to characterise PE in animals. The aim of this study was to present characteristic CT features of PE in cats. The introduction of new criteria for better assessing thoracic wall deformity–a correction index (CI) and an asymmetry index (AI)–was also proposed. The study revealed a high variety of morphological features of PE in cats. It was demonstrated that among the 14 cats: cranial PE (an atypical location) occurred in seven cats while seven cats had typical (caudal) PE, long PE occurred in five cats, while short PE had nine cats. Of the 14 cats included in the study eight showed symmetric PE, and asymmetric PE was found insix. Thoracic asymmetry was found in six cats. Six cats had sternal torsion. Based on the Vertebral Index moderate or severe PE was revealed in 11 animals. In the group of cats studied the CI ranged from 12.20 to 32.11. The magnitude of AI did not exceed 10% in any of the cats studied. The study confirmed statistically significant differences in the CI values between groups of cats with different degrees of PE severity (p = 0.02). CT examination showed many PE features that have not been discussed so far. The main benefit of CT examination is its ability to reveal asymmetric PE, thoracic asymmetry and sternal torsion. CI and AI provided a clinically useful tool to quantify thoracic wall deformity in order to obtain comparable results between cats with PE.

Stiffness reduction of the rib cage to perform a minimally invasive pectus excavatum repair: biomechanical evaluation

OBJECTIVES

To study the influence of sternal transection and costal chondrotomies on the stiffness and stresses in the rib cage of adult patients undergoing Nuss pectus excavatum procedure.

METHODS

Four pectus excavatum models with different Haller indexes were created by parameterizing a 3D model of a rib cage obtained based on a computed tomography scan of a patient with no pectus deformity. Using the finite element method, insertion of intrathoracic bars into all models was simulated in 3 conditions, namely, non-intervened, transverse sternal section and costal chondrotomies. Stiffness, stress distribution and maximum stresses for each case were obtained and compared.

RESULTS

Transverse sternotomy provided a reduction of 44% to 54% in the stiffness of the rib cage, depending on the Haller index analysed, while chondrotomies promoted a stiffness reduction of 70%. Stress distribution in the rib cage followed similar pattern for all the tested Haller index, but the maximum stress decreased by 36% when performing a transverse sternotomy, whereas when performing costal chondrotomies, it decreased by 47%.

CONCLUSIONS

Computational results report that transverse sternotomy reduces appreciably the stiffness of the rib cage, while costal chondrotomies promote even a higher stiffness reduction. Thus, these surgical procedures could improve the clinical outcomes of adult patients undergoing a pectus excavatum repair.

Prevalence and prognosis of pericardial effusion in patients affected by pectus excavatum: A case-control study

BACKGROUND

The presence of pectus excavatum(PEX) has been occasionally associated with pericardial effusion. Aim of the present study was to compare incidence and prognosis of pericardial effusion in a group of unselected patients with PEX vs a control group.

METHODS

From a prospective registry of consecutive patients who underwent chest CT for cardiovascular disease, subjects with a radiological diagnosis of PEX were retrospectively identified (cases); from the same registry patients (controls) without rib cage abnormalities were randomly selected, until a 1:2 ratio was reached. The presence of pericardial effusion at CT was quantified. Follow-up was obtained for a composite end-point: cardiac tamponade, need for pericardiocentesis, need for cardiac surgery for relapsing pericardial effusion.

RESULTS

A total of 43 patients with PEX (20 females) and a control group of 86 cases (31 females) without rib cage abnormalities were identified. Pericardial effusion evaluated at CT was significatively more prevalent in patients with PEX vs control group, 37.2% vs 13.9% (p < 0.001), respectively; four patients with PEX (9.3%) had at least moderate pericardial effusion vs no subjects among the controls (p = 0.004). PEX diagnosis was significantly associated to pericardial effusion at multi-variate analysis (OR95%CI 10.91[3.47-34.29], p < 0.001). At a mean follow-up of 6.5 ± 3.4 years no pericardial events were recorded.

CONCLUSION

Our findings support the higher prevalence of pericardial effusion in patients with PEX when compared to a control group. The absence of adverse pericardial events at follow-up suggest the good prognosis of these effusions, that in the appropriate clinical setting might not be considered "idiopathic".

Modified Nuss procedure with a novel steel bar in patients with pectus excavatum post-congenital heart surgery

 

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.

Factors influencing negative surgical outcomes in adult pectus excavatum patients undergoing Nuss procedure

BACKGROUND

This study aimed to examine the factors associated with the negative outcomes of Nuss procedure in adult pectus excavatum (PE) patients.

METHODS

Forty-seven adult PE patients were enrolled in this study. Mimics 21.0 software (Materialise) was used to reconstruct the preoperative and postoperative three-dimensional (3D) thoracic model. The preoperative and postoperative pulmonary volumes and function parameters were compared. The diaphragm positions were localized, and the anteroposterior diameter (APD) of the thoracic cavity was calculated using neoteric methods. Binary logistic regression was used to reveal the association between clinical factors and altered pulmonary parameters.

RESULTS

Postoperative lung volumes in adult PE patients decreased significantly (P<0.001). The mean preoperative lung volume was 4,592.82±946.54 cm³, which reduced to 3,976.26±867.35 cm³ postoperatively. The rate of postoperative lung volume reduction was approximately 12.1%. Physiologically, forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF) significantly decreased after Nuss procedure, and a near 10% reduction in FVC was observed. Diaphragm elevation was positively associated with decrease in lung volumes [odds ratio (OR) =40.51; P=0.011; 95% confidence interval (CI), 2.37-692.59]. The presence of reduced thoracic APDs was significantly associated with negative pulmonary function results (OR =1.21; P=0.008; 95% CI, 1.050-1.388).

CONCLUSIONS

This study reveals that thoracic APD reduction and diaphragm elevation are associated with decreased postoperative pulmonary volumes and function in adult PE patients. Nuss procedure for adult patients with PE must be considered cautiously by thoracic surgeons, especially in patients who expect to improve their cardiopulmonary function.

Thoracoscopic Costal Cartilage Excision Combined with the Nuss Procedure for Patients with Asymmetrical Pectus Excavatum

Background and Aims: We performed thoracoscopic costal cartilage excision (TCCE) combined with the Nuss procedure to correct asymmetrical pectus excavatum (PE). We reviewed the efficacy of combined TCCE and Nuss procedure for asymmetric PE. Patients and Methods: Overall, 8 patients with asymmetrical PE underwent TCCE with the Nuss procedure. The Haller index, asymmetry index, and angle of sternal rotation were calculated using preoperative computed tomography. The procedure was performed using bilateral 2.5-cm incisions at the same level of the deepest chest wall depression. The most depressed three to four costal cartilages were partially resected through a right mini-thoracotomy. Subsequently, one or two titanium bars were implanted and secured with stabilizers. The cosmetic outcome was evaluated on the following four ratings: excellent, good, fair, and failure ( = recurrence). Results: The median age at surgery was 14.5 years (8-20 years). The number of bars was one in 3 cases and two in 5 cases. The preoperative Haller index, asymmetry index, and angle of sternal rotation were 4.3 (3.5-5.9), 1.15 (1.04-1.26), and 21.5° (15°-31°), respectively; 2 patients had scoliosis before the Nuss procedure. Complications included surgical site infection and hemothorax. Median follow-up time was 25.5 months (3-63). Bars were removed in 3 patients, 3 years postoperatively. Cosmetic results were excellent, 4; good, 2; fair, 1; failure, 1. Both patients with scoliosis had poor outcomes (fair, 1; failure, 1). Conclusions: Combined TCCE with Nuss procedure is considered safe and effective for patients with asymmetrical PE. Careful long-term follow-up is required, especially in cases with scoliosis.

The effectiveness of double-bar correction for pectus excavatum: A comparison between the parallel bar and cross-bar techniques

Purpose

To compare the effectiveness between parallel bar and cross-bar techniques for treating pectus excavatum.

Methods

A total of 80 patients who underwent parallel bar insertion (group 1) or cross-bar insertion (group 2) were evaluated retrospectively. From the pre- and post-operative chest CT images, vertebral-level-specific pectus indices were defined as the ratio of the maximum transverse diameter to the anteroposterior diameter of the thoracic cavity at a specific vertebral level and measured at 3 levels up (3Up-PI, 2Up-PI, 1Up-PI) and 1 vertebral level down (1Down-PI) from the narrowest point. The effectiveness of double-bar correction was compared between the 2 groups using postoperative vertebral level-specific pectus index changes.

Results

A total of 44 patients were enrolled in group 1, and 36 patients were enrolled in group 2. Preoperative pectus index values were not different between the 2 groups (4.5 ± 1.0 vs. 4.9 ± 1.5, P = 0.135). After double-bar correction, pectus index significantly decreased in both groups. There were no differences in postoperative pectus indices between the 2 groups (2.7 ± 0.4 vs. 2.6 ± 0.3, P = 0.197). Postoperative changes in 3Up-PI, 2Up-PI, and 1Up-PI were not significantly different between the 2 groups (P > 0.05). However, postoperative changes at the narrowest level and at 1Down-PI were significantly greater in group 2 than in group 1 (1.78 ± 0.85 vs. 2.32 ± 1.44, P = 0.009; 1.21 ± 0.70 vs. 1.70 ± 1.20, P = 0.009, respectively).

Conclusions

Double-bar correction appears to be effective for treating pectus excavatum. The cross-bar insertion technique might be superior to the parallel bar insertion technique for correcting a wider range of deformities, especially at the lower part of the depression.

Serum lactate dehydrogenase activity and its isoenzyme patterns in patients with pectus excavatum

Background

In previous study, we found elevated serum total lactate dehydrogenase (LDH) before correction of pectus excavatum and a decrease in total LDH after the deformity correction. In the present study, we analyzed total LDH activity and its isoenzyme patterns to investigate the causes of these laboratory findings in patients with pectus excavatum.

Methods

Between March 2014 to December 2018, 85 patients with pectus excavatum who had undergone the Nuss procedure (NP) and bar removal (BR) were included into this study. We analyzed (I) total LDH and its isoenzyme patterns before the correction, (II) relationships of total LDH and its isoenzymes with age at time of NP, sex, severity of pectus excavatum, and pectus morphology types, and (III) post-corrective changes.

Results

The mean age of the patients was 13.6 (±6.5) years at the age of NP and the mean interval between NP and BR was 2.2 (±0.42) years. Seventy-one males and 14 females were included. The pectus types included 54 symmetric and 31 asymmetric cases. The mean Haller index before NP and BR were 3.8±1.45 and 2.7±0.4, respectively. The mean of total LDH before NP (pre-correction) and BR (post-correction) were 404.2±80.8 and 369.2±79.3 IU/L, respectively. Before correction, total LDH was significantly higher than normal values, irrespective of age [the young group (<10 years old), P=0.006, and the old group (≥10 years old), P<0.001]. The proportion of LDH5 was significantly higher than that of LDH4 (P<0.001). Total serum LDH was significantly associated with age at time of NP and Haller index (P<0.001 and P=0.030). There was no significant correlation between severity and total LDH. However, the value of only LDH5 among all isoenzymes had a significant positive correlation with severity (P=0.006) and the proportion of only LDH5 in the severe group was significantly higher (P=0.003). After correction, proportions of each isoenzyme were all within the reference range, however, there were significant decreases in values of LDH1-LDH4, except LDH5 (P=0.020, P<0.001, P<0.001, and P=0.029).

Conclusions

This study shows that pectus excavatum is a muscular disease entity and that laboratory findings are associated with compression of internal organs, which was explained by post-corrective changes in LDH activity and its isoenzyme patterns. This study will provide a deeper and wider comprehension of pectus excavatum.