Extreme eccentric canal type pectus excavatum: morphological study and repair techniques

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.

Recent Advancements in Pectus Surgery: Crane Lifting, Multiple-Bar Approach, Bridge Stabilization, and Sandwich Technique

PURPOSE

The most recent procedure for pectus excavatum repair involves crane-powered entire chest wall remodeling, which employs crane lifting, multiple-bar approach, bridge stabilization, and sandwich techniques. This resulted in a paradigm shift in pectus deformity repair from merely lifting the sunken bone to remodeling the chest wall into normal anatomy.

METHODS

We analyzed 649 patients who underwent surgery for pectus excavatum or complex combined deformities between March 2018 and January 2022. A crane with sternal wiring or screwing was used to lift the chest wall without using the pectus bar turning power. Multiple bars with bridge connections were placed to eliminate bar displacement. Modified sandwich techniques were applied to relieve the lower coastal flare (flare-buster) and focal protuberance (magic string).

RESULTS

The mean age of the patients included in the study was 12.2 years (range: 3-45 years). A single bar was used for 202 patients until 2021. For the multiple-bar technique, parallel bars (n = 142), crossbars (n = 166), and crossbars plus upper horizontal bars (XI pattern; n = 139) were used. The overall complication rate was 6.2 %. There was no cases of bar displacement were observed, but other minor complications such as pneumothorax (n = 20, 3.1 %), pleural effusion (n = 7, 1.1 %), and wound infection (n = 5, 0.8 %) were detected. Three patients required reoperation (infection, two: hemorrhage, one).

CONCLUSIONS

The crane-powered entire chest wall remodeling technique improved the safety and comprehensiveness of the repair procedure. By incorporating bridge stabilization and the use of multiple bars, we effectively resolved the issues related to bar displacement and incomplete repair.

TYPE OF STUDY

Retrospective Cohort Study.

LEVEL OF EVIDENCE: 3

The Cross-Bar Technique for Pectus Excavatum Repair: A Key Element for Remodeling of the Entire Chest Wall

INTRODUCTION

 The multiple bar approach was developed to cover broader and heavier teenager/adult chest wall deformities. We designed the cross-bar technique to achieve remodeling of the entire chest wall. This study aimed to demonstrate the role of cross-bar and its benefits over the parallel bar.

MATERIALS AND METHODS

 The cross-bar technique involves placing two bars diagonally and then cross on the target. The primary purposes are to double the lifting forces by making two bars converge on a single target to lift inflexible heavy chest wall depressions or cover lower lateral areas. The results of the cross-bar and parallel bar are compared for the indications, postrepair outcomes, and complications.

RESULTS

 From 2016 to 2019, 247 patients who underwent multiple bar pectus excavatum (PE) repair were enrolled in the study: 157 with cross-bar and 90 with parallel bar. In the cross-bar group, 33% (51/157) received three bars in XI fashion to cover the upper depression. The cross-bar group was older (18.0 ± 6.1 vs. 15.7 ± 5.0), had higher depression index (1.9 ± 0.7 vs. 1.8 ± 0.3), and was less asymmetric (45% vs. 71%) than those in the parallel bar group. The overall complication rates were not different between the two groups (9.6% vs. 10%, p = 1.0), although the cross-bar group was more rigid and complex. There was no bar displacement or reoperation in both groups.

CONCLUSION

 The cross-bar technique is as safe and effective as the parallel-bar technique, even though it was selected to correct more complexities. The cross-bar technique could be a method for complex PE deformities for remodeling of the entire chest wall.

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.

Three-Dimensional Simulation for Breast Augmentation of Female Asymmetric Pectus Excavatum: A Case Report

Breast augmentation for women with asymmetric pectus excavatum (PE) has a characteristic problem in that surgeons need to select implants while considering the left-right difference in breast volume, contour, and position. We herein report a 33-year-old woman with severe asymmetric PE who presented with residual breast asymmetry after chest wall correction using the Nuss procedure. Her right breast appeared hypoplastic and the right anterior chest wall remained depressed. Augmentation of the right breast with a silicone implant was performed, selecting the inserted implant preoperatively with the assistance of three-dimensional (3D) simulation. The breast asymmetry and anterior chest wall depression were improved to a natural appearance. Three-dimensional simulation represents an advantageous way to preoperatively select optimal implants for breast augmentation in asymmetric PE women with breast asymmetry.

Level of Evidence: 5

Effect of the Nuss Procedure on the Physical Development of Patients with Pectus Excavatum

PURPOSE

This study assessed physical development of patients with pectus excavatum and evaluated the effect of the Nuss procedure on physical development.

METHODS

A total of 146 patients underwent the Nuss procedure; of these, at the time of the study, the bar had been removed from 123 patients (84.9%; male 93, female 30) who were eligible for participation in this study. Heights and body weights of patients were measured prior to surgery and immediately before bar removal. Chest computed tomography (CT) was performed preoperatively and immediately before bar removal. The associations between physical development and chest CT indices were evaluated.

RESULTS

The height standard deviation score (SDS) was - 0.66 ± 2.23 preoperatively and 0.04 ± 1.34 immediately before bar removal (p <0.01). The weight SDS was - 0.02 ± 2.59 preoperatively; it increased significantly to 0.56 ± 1.56 immediately before bar removal (p <0.01). The Haller index (3.85 ± 1.18 to 2.99 ± 0.54; p <0.01) and asymmetric index (9.75 ± 6.63 to 7.01 ± 4.77; p <0.01) also showed improvements.

CONCLUSIONS

The Nuss procedure may contribute positively to the physical development of patients with pectus excavatum.

Radiologic factors related to double-bar insertion in minimal invasive repair of pectus excavatum

BACKGROUND

Pectus excavatum is the most common congenital chest wall deformity, with a high incidence in live births. This study aimed to evaluate the measured factors on CT images related to the number of pectus bars for surgical correction.

METHODS

A total of 497 patients who had undergone minimally invasive repair between April 2007 and July 2011 were classified into single-bar (n=358) and double-bar (n=139) insertion groups. We measured eight distinct distances and one angle on CT scans to reflect quantitative assessment. Univariate analysis and multivariate logistic regression analysis were performed to detect statistically significant association between radiologic measurements and the pectus bars required.

RESULTS

After adjusting for age and gender, the transverse distance (T), the transverse distance of the depression area (A), the inclined distance of the depression area (B), the AP distance of the depression area (C), the depression angle (G), and the eccentric distance of deformity (E) were significantly correlated with double-bar insertion. The regression model showed that age (P<0.0001), gender (P<0.0001), depression angle (G) (P<0.0001), direction of the depression (DD) (P<0.0001) and depression depth (D) (P<0.0001) were significantly associated with double-bar insertion.

CONCLUSION

CT scan provides useful factors which can be of assistance in predicting the number of pectus bars for the surgical correction of pectus excavatum.

Correction of pectus excavatum with breast hypoplasia using simultaneous pectus bar procedure and augmentation mammoplasty

Most women with asymmetric pectus excavatum suffer from hypoplastic breasts. Hence, aesthetic correction of pectus excavatum has to address thoracic wall deformity, breast hypoplasia, and asymmetry.In retrospective series, 21 patients with a diagnosis of pectus excavatum with hypoplastic breasts were corrected using the pectus bar procedure and subpectoral augmentation mammoplasty. Results were assessed by analyzing prospectively collected data and calculating pectus indices from computed tomographic scans. At 12 months postoperatively, cosmetic evaluations were performed by the patients and by an independent, board-certified plastic surgeon using score from 0 (very poor) to 4 (very good).Cosmetic results evaluated by plastic surgeon were good (3.33 ± 0.03) and patient satisfaction was high (3.52 ± 0.03). Furthermore, indices of pectus excavatum were corrected to near normal.The authors consider that the pectus bar procedure with subpectoral augmentation mammoplasty is useful for the aesthetic correction of pectus excavatum with hypoplastic breasts.

Thoracic outlet syndrome after the Nuss procedure for the correction of extreme pectus excavatum

Since the Nuss procedure was introduced in 1998, many complications have been reported, but not thoracic outlet syndrome. Here we report a 13-year-old boy with pectus excavatum who had thoracic outlet syndrome develop after a modified Nuss procedure. The major modification from the original technique was the use of an additional bar to resolve his long, asymmetric deformity. The patient showed clinical features of brachial plexus compression. The abrupt structural and spatial changes induced by the marked elevation of the upper depressed chest might have given rise to this condition. Thoracic outlet syndrome is a possible complication of the Nuss procedure.

The search for stability: bar displacement in three series of pectus excavatum patients treated with the Nuss technique

OBJECTIVES

To compare bar displacement and complication rates in three retrospective series of patients operated on by the same surgical team.

METHOD

A retrospective medical chart analysis of the three patient series was performed. In the first series, the original, unmodified Nuss technique was performed. In the second, we used the ''third point fixation'' technique,and in the last series, the correction was performed with modifications to the stabilizer and stabilizer position.

RESULTS

There were no deaths in any of the series. Minor complications occurred in six (4.9%) patients: pneumothorax with spontaneous resolution (2), suture site infection (2), and bar displacement without the reoperation need (2). Major complications were observed in eight (6.5%) patients: pleural effusion requiring drainage (1), foreign body reaction to the bar (1), pneumonia and shock septic (1), cardiac perforation (1), skin erosion/seroma (1), and displacement that necessitated a second operation to remove the bar within the 30 days of implantation (3). All major complications occurred in the first and second series.

CONCLUSION

The elimination of fixation wires, the use of shorter bars and redesigned stabilizers placed in a more medial position results in a better outcome for pectus excavatum patients treated with the Nuss technique. With bar displacement and instability no longer significant postoperative risks, the Nuss technique should be considered among the available options for the surgical correction of pectus excavatum in pediatric patients.

Minimally invasive repair of pectus excavatum: a novel morphology-tailored, patient-specific approach

OBJECTIVE

Minimally invasive repair of pectus excavatum, introduced by Nuss in 1998, has undergone a serious learning curve because of a lack of understanding on morphologies and repair techniques. To summarize the current status of minimally invasive repair of pectus excavatum, we reviewed and appraised our 10-year experience with a novel approach, a morphology-tailored technique, including diverse bar shaping, bar fixation, and techniques for adults.

METHODS

We analyzed the data of 1170 consecutive patients with pectus excavatum who underwent minimally invasive repair between August 1999 and September 2008. All pectus repairs were performed by the primary author (H.J.P.) with our modified technique.

RESULTS

The mean age was 10.3 years (range, 16 months to 51 years). There were 331 adult patients (>15 years) (28.3%). A total of 576 patients (49.2%) had bar removal after a mean of 2.5 years (range, 10 days to 7 years). The asymmetry index change (1.10-1.02, P < .001) demonstrated post-repair symmetry. Complication rates decreased through the 3 time periods (1999-2002 [n = 335]; 2003-2005 [n = 441]; 2006-2008 [n = 394]) as follows: pneumothorax rate (7.5% vs 4.3% vs 0.8%; P < .001) and bar displacement rate (3.8% vs 2.3% vs 0.5%; P = .002). Reoperation rate also decreased (4.8% vs 2.5% vs 0.8%; P = .002). Satisfaction outcomes were excellent in 92.7%, good in 5.9%, and fair in 1.4% of patients. After bar removal, 3 patients (0.6%) had minor recurrences.

CONCLUSION

Minimally invasive repair of pectus excavatum based on a novel morphology-tailored, patient-specific approach is effective for quality repair of the full spectrum of pectus excavatum, including asymmetry and adult patients. Continuous technical refinements have significantly decreased the complication rates and postoperative morbidity.