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Chen T, Xu Y, Chen Y, Chen S, Zhang Y. Analgesic Effectiveness of Truncal Plane Blocks in Patients Undergoing the Nuss Procedure: A Randomized Controlled Trial. Pain Ther 2024; 13:909-917. [PMID: 38888719 PMCID: PMC11255141 DOI: 10.1007/s40122-024-00627-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 06/05/2024] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION Most patients undergoing the Nuss procedure reported moderate to severe pain after surgery. This study aimed to investigate the efficacy and safety of ultrasound-guided serratus anterior plane block (SAPB) combined with transversus thoracic muscle plane (TTMP) block for relieving acute pain in patients undergoing the Nuss procedure. METHODS The enrolled patients in our study were allocated to either receive combined nerve blocks with ropivacaine (NB group) or saline (CON group). The primary outcome of this study was postoperative pain at 2, 4, 8, 16, 24, 36, and 48 h during rest and movement (coughing). Secondary outcomes included intraoperative dosage of remifentanil, the time to extubation and the length of stay in the post-anesthesia care unit (PACU), the total acetaminophen and codeine tablet consumption, time to first bowel movement, time to first flatus, opioid-related adverse events, and the length of hospital stay. RESULTS Patients in the NB group had significantly lower Numerical Rating Scale (NRS) pain scores compared with the CON group. The NB group required significantly less postoperative acetaminophen consumption and lower dosages of perioperative sufentanyl and remifentanil compared with the CON group. The length of stay in the PACU and time to extubation were significantly increased in the CON group compared with the NE group. Time to first bowel movement and time to first flatus were earlier in the NB group. But there were no significant differences between the groups in terms of the length of hospital stay and codeine tablet consumption. CONCLUSION Ultrasound-guided SAPB and TTMP blocks in patients undergoing the Nuss procedure could provide effective analgesia. TRIAL REGISTRATION This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000038506).
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Affiliation(s)
- Tao Chen
- Department of Anesthesiology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China
| | - Yu Xu
- Department of Anesthesiology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China
| | - Yu Chen
- Department of Anesthesiology, Jiangxi Provincial Children's Hospital, 122 Yang Ming Road, Nanchang, 330006, Jiangxi, China
| | - Shibiao Chen
- Department of Anesthesiology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China
| | - Yang Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China.
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What Is the Appropriate Timing for Bar Removal After the Nuss Repair for Pectus Excavatum? J Surg Res 2023; 285:136-141. [PMID: 36669392 DOI: 10.1016/j.jss.2022.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 12/07/2022] [Accepted: 12/24/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The Nuss procedure for pectus excavatum requires that the sternal elevation be maintained by indwelling metal bars that are traditionally removed approximately 3 y after the repair. METHODS A retrospective cohort study was conducted of all patients who underwent primary Nuss repair from 2007 to 2018 in two institutions and had a follow-up of at least 24 mo. Pectus bars had been left in place beyond 3 y in patients concerned over possible recurrence after bar removal. Structured interviews were held to assess pain, chest tightness, or other discomfort, and any adverse events related to pectus bars. Results were compared between patients in whom pectus bars were removed after 3 y (standard group) and those in whom bars were left in place longer (extended bar duration group). RESULTS Two hundred and thirty-one patients (91% males, mean age 23.9 ± 8.3, mean Haller index 4.9 ± 2.3) were included. Bar duration was 30.6 ± 6.6 mo in the standard group (51 patients) versus 69.1 ± 26.3 mo in the extended group (180 patients). Some discomfort was reported by 81.6% in the standard group versus 62.9% in the extended group (P = 0.033), and discomfort occurring at least monthly or more often was only reported by 30% in the standard versus 30.3% in the extended group (P = 1.000). Quality of life improved in 92.6% of the standard group versus 94.7% of the extended group (P = 1.000). No significant adverse events were reported in either group. CONCLUSIONS Our data suggest that an extended bar duration after the Nuss repair may not cause any adverse event nor negatively affect quality of life.
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Viggiano D, Bongiolatti S, Borgianni S, Lo Piccolo R, Voltolini L, Gonfiotti A. Nuss Technique for Pectus Excavatum in Adult Patients: Cosmetic Satisfaction and Improvement of Quality of Life in a Single-Center Experience. Front Surg 2022; 9:903791. [PMID: 35722532 PMCID: PMC9198457 DOI: 10.3389/fsurg.2022.903791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/27/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives Since its introduction, the Nuss minimally invasive procedure for pectus excavatum (PE) repair (MIRPE) has become the method of choice. The current study describes our experience of PE correction in adults, with particular focus on postoperative outcomes, pain, quality of life, and patients’ satisfaction. Methods We enrolled for this observational study n = 93 adult patients from 2011 to 2018. The Haller index was used to quantify PE severity. Pulmonary function tests and cardiac examinations were performed preoperatively; we developed a standardized surgical technique and postoperative treatment, including follow-up at 3, 12, and 24 months after surgery and 6 months after bar removal. We also evaluated the quality of life and the satisfaction with the cosmetic result after the procedure with standardized questionnaires. Results No operative or perioperative deaths occurred nor life-treating complications. Thirteen complications occurred in 12 patients, with a total complication rate of 14% (n = 13/93). Pain intensity decreased in the follow-up [pain score visual analog scale at 3 months: median 1 (0–8); 12 months: median 1 (0–5); and 24 months: median 1 (0–4)]. Better or much better quality of life after the Nuss procedure was observed: n = 79 (84.1%) at 3 months, n = 80 (86%) at 12 months, and n = 85 (91.4%) at 24 months. After 2 years of observation, more than 90% of patients described improvement in their quality of life and satisfaction with the cosmetic results. Only a very small group of patients suffered from pain in the follow-up. Conclusion Our results demonstrate that the MIRPE procedure is safe and can be performed with excellent results in adults both for improvement of quality of life and for satisfaction with cosmetic results.
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Affiliation(s)
- Domenico Viggiano
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
- Correspondence: Domenico Viggiano
| | | | - Sara Borgianni
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Roberto Lo Piccolo
- Department of Pediatric Surgery, University of Florence and Children’s University Hospital A. Meyer, Florence, Italy
| | - Luca Voltolini
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
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Ho CWG, Tan BK, Ong BH, Nakao M, Lim CH. Customized Two-Dimensional Computed Tomography-Guided Preoperative Pectus Bar Shaping. Ann Plast Surg 2021; 87:676-680. [PMID: 34176895 DOI: 10.1097/sap.0000000000002892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Successful minimally invasive repair of pectus excavatum relies on a pectus bar that closely conforms to the desired shape of the sternum and ribs to produce optimal elevation and remodeling. However, the present method of empirical intraoperative bar shaping is tedious and risks trauma to surrounding structures. To overcome this, we devised a technique using a life-sized computed tomography (CT) printout of the patient's chest wall to guide preoperative bar bending. METHODS A 5-cm-wide polymethylmethacrylate block placed on the sternum as the patient underwent chest CT was used as a marker to guide scaling of an axial screenshot of the patient's chest to life-size. This life-size image was printed and the planned correction of the patient's chest wall was traced onto it. The pectus bar was bent according to this template. Patient demographics, Haller index, surgical indications, operative technique, complications, aesthetic and functional improvements, and overall satisfaction were assessed. RESULTS Thirty patients (4 women) underwent primary minimally invasive repair of pectus excavatum with a single pectus bar shaped preoperatively over an 8-year period. The average age and Haller index was 20.6 years and 5.4, respectively. The mean operative time was 66.4 minutes. Satisfactory sternal elevation was attained with a single attempt at bar insertion in all cases. Two patients had pneumothoraxes that resolved without intervention. The mean follow-up period was 50.1 months. There were no cases of bar migration or recurrence of deformity after bar removal. On a 5-point Likert scale, all patients indicated an improvement in aesthetic appearance (4.6), and patients with physical symptoms (10) reported an improvement in function (4.4). The overall satisfaction score was 4.7. CONCLUSIONS This technique of CT-guided preoperative pectus bar shaping is straightforward, eliminates the need for intraoperative revisions to bar shape, and achieves effective correction of the pectus excavatum deformity. All patients were satisfied with the aesthetic, functional, and overall outcomes.
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Affiliation(s)
- Christopher Wei Guang Ho
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital
| | - Bien-Keem Tan
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital
| | - Boon Hean Ong
- Department of Cardiothoracic Surgery, National Heart Centre
| | | | - Chong-Hee Lim
- Department of Cardiothoracic Surgery, National Heart Centre
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Park WJ, Son JW, Park KH, Kim YM, Nam JH, Choi KU, Kim JH. Late complication of the Nuss procedure: recurrent cardiac tamponade. Yeungnam Univ J Med 2019; 36:260-264. [PMID: 31620642 PMCID: PMC6784654 DOI: 10.12701/yujm.2019.00241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 11/05/2022] Open
Abstract
Pectus excavatum (PE) is known as one of the most common congenital deformities of the anterior chest wall. The Nuss procedure is an effective surgical therapy to correct PE. Here, we report a case of recurrent cardiac tamponade due to hemopericardium that occurred after 16 months following the Nuss procedure. The cause of recurrent hemopericardium was thought to be local, repetitive irritation of the pericardium by the Nuss steel bar. We should keep in mind that this serious complication can occur after the Nuss procedure, even in the late phase.
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Affiliation(s)
- Won Jong Park
- Division of Cardiology, Department of Internal Medicine, Dong-Eui Medical Center, Busan, Korea
| | - Jang Won Son
- Division of Cardiology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyu Hwan Park
- Division of Cardiology, Department of Internal Medicine, Daegu Veterans Hospital, Daegu, Korea
| | - You Min Kim
- Division of Cardiology, Department of Internal Medicine, Pohang SM Christianity Hospital, Pohang, Korea
| | - Jong Ho Nam
- Division of Cardiology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kang Un Choi
- Division of Cardiology, Department of Internal Medicine, Dongguk University Gyeongju Hospital, Gyeongju, Korea
| | - Jung Ho Kim
- Department of Emergency Medicine, Yeungnam University Medical Center, Daegu, Korea
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Hedén P, Sinna R. An Open, Prospective Study to Evaluate the Effectiveness and Safety of Hyaluronic Acid for Pectus Excavatum Treatment. Aesthet Surg J 2019; 39:NP189-NP201. [PMID: 30388191 PMCID: PMC6520969 DOI: 10.1093/asj/sjy303] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Pectus excavatum (PE) is sometimes associated with psychological and physiological difficulties influencing a patient’s quality of life. Treatment with a hyaluronic acid (HA)-based gel may benefit patients and be an alternative to other more invasive treatments. Objectives The authors sought to evaluate the effectiveness in terms of satisfaction, duration, and safety of HA gel treatment for PE including impact on quality of life. Methods Males ≥18 years having PE without functional problems received HA gel injections (50 – 150 mL) at the site of deformity and in some cases at the medial pectoralis muscle borders to optimize the aesthetic result. Follow-up visits were performed after 1, 3, 6, 12, and 24 months with optional retreatment at the 24-month visit including a 1-month follow-up. Evaluations included Pectus Excavatum Evaluation Questionnaire, patient satisfaction, magnetic resonance imaging, and safety assessments. Results The treatment significantly improved patients’ self-esteem (P < 0.001) and psychosocial function (P ≤ 0.038) throughout the study, as assessed by Pectus Excavatum Evaluation Questionnaire. Patients were satisfied with the aesthetic outcome and considered the treatment mild in terms of level of pain during injection. Treatment effects were maintained up to 24 months and 58% of the HA gel remained at this visit, shown by Magnetic Resonance Imaging measurements. The treatment was well tolerated. Conclusions Treatment of PE with HA gel improved patient quality of life related to self-esteem and psychosocial functioning including aesthetically pleasing results. The treatment may also offer benefits in terms of safety and tolerability compared with other treatments. Level of Evidence: 4
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Affiliation(s)
| | - Raphael Sinna
- Department of Plastic Reconstructive and Aesthetic Surgery, University Hospital Amiens, Amiens, France
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Pulmonary function in children with Pectus excavatum and post-operative changes after nuss procedure. Pediatr Surg Int 2018; 34:1099-1103. [PMID: 30084024 DOI: 10.1007/s00383-018-4319-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The aim of this study was to show the difference between the pulmonary function of children with mild or severe types of pectus excavatum (PE) and post-operative changes in their predicted vital capacity (%VC) following Nuss procedure. PATIENTS AND METHODS One hundred and twenty-four of the 208 children who underwent Nuss procedure for PE between January 2007 and March 2016 were deemed eligible for this study and evaluated retrospectively. A spirometry was performed on these children on four occasions: before operation; pre-bar removal; and 1 month and 1 year after bar removal. Ninety-seven of the children who were more than 7 years of age were divided using the Haller Index (HI) into a mild group (n = 54) and a severe group (n = 43) and compared. The children were also divided into three groups based on their age and their %VC was compared at each follow-up occasion. RESULTS The severe group showed a significantly lower %VC and peak expiratory flow rate than the mild group. %VC change after bar removal showed significantly lower in group aged 11 or over. 43 of the children had spirometry data recorded 1 year after bar removal which, compared with 1 month after bar removal, showed a significant higher %VC in groups aged of 10 or under. CONCLUSION Nuss procedure in children aged of 10 or under proved to be an advantage in the post-operative pulmonary function.
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Comparison of Ultrasonography-guided Bilateral Intercostal Nerve Blocks and Conventional Patient-controlled Intravenous Analgesia for Pain Control After the Nuss Procedure in Children: A Prospective Randomized Study. Clin J Pain 2018; 33:604-610. [PMID: 27841838 PMCID: PMC5462349 DOI: 10.1097/ajp.0000000000000449] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objectives: Patients experience severe pain after pectus excavatum (PE) surgery. The aim of this prospective, randomized study was to compare analgesic effects of ultrasonography-guided bilateral intercostal nerve blocks (UG-ICNBs) with those of conventional patient-controlled intravenous analgesia (PCIA) on acute pain after the Nuss procedure for PE repair in children. Methods: A prospective randomized study was performed in children with PE who were scheduled for the Nuss procedure. Participants were randomly assigned to receive either UG-ICNBs or PCIA for postoperative analgesia. Faces Pain Scale-Revised scores, opioid consumption, analgesia-associated side effects (respiratory depression, pruritus, nausea, vomiting) during the first 24 hours, and lengths of stay in the postanesthesia care unit (PACU) and hospital were recorded after the surgery. Results: Sixty-two children undergoing the Nuss procedure were enrolled in the trial. Faces Pain Scale-Revised scores were significantly decreased in the UG-ICNBs group compared with the PCIA group for up to 6 hours after surgery. The opioid doses required in the PACU and during the first 24 hours after surgery were significantly greater in the PCIA group compared with the UG-ICNBs group. Accordingly, patients in the UG-ICNBs group showed a lower incidence of analgesia-associated side effects and faster PACU discharge compared with the PCIA group. Conclusions: Our study suggests that UG-ICNBs might be more effective than PCIA for postoperative analgesia in children who undergo the Nuss procedure for PE.
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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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Ewais MM, Chaparala S, Uhl R, Jaroszewski DE. Outcomes in adult pectus excavatum patients undergoing Nuss repair. PATIENT-RELATED OUTCOME MEASURES 2018; 9:65-90. [PMID: 29430201 PMCID: PMC5796466 DOI: 10.2147/prom.s117771] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.
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Affiliation(s)
- MennatAllah M Ewais
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Shivani Chaparala
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Rebecca Uhl
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
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Pilegaard H, Licht PB. Minimal Invasive Repair of Pectus Excavatum and Carinatum. Thorac Surg Clin 2017; 27:123-131. [DOI: 10.1016/j.thorsurg.2017.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lomholt JJ, Jacobsen EB, Thastum M, Pilegaard H. A prospective study on quality of life in youths after pectus excavatum correction. Ann Cardiothorac Surg 2016; 5:456-465. [PMID: 27747179 DOI: 10.21037/acs.2016.08.02] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The impact of correction of pectus excavatum (PE) on adolescents' health-related quality of life (HRQL) has only been investigated in prospective designs using disease-specific measures and without controls. The aim of this prospective study was to evaluate the HRQL before and after surgical correction of PE using a generic HRQL measure, and to compare the reported level of HRQL before surgery with an age-comparable control group. METHODS Patients (n=107) and one of their parents (n=106) completed the generic HRQL measure: the Child Health Questionnaire before, 3 months, and 6 months after correction for PE. A control group (n=183) consisting of school children comparable in age completed the same measure on one occasion. RESULTS The patients' level of HRQL before surgery was comparable to the level of the controls except for physical functioning; here boys reported impaired function compared to controls (P<0.0001, d=0.72). Both patients and parents reported improved emotional wellbeing and self-esteem, as well as an increase in physical and social activities from pre- to post-surgery. These improvements were statistically significant (P≤0.001-0.03) and yielded moderate to high effect sizes (ƞ2=0.04-0.22). CONCLUSIONS The improvement of physical and psychosocial HRQL reported by both patients and their parents as proxy indicates the psychological implications of the deformity. Patients reported impaired physical function compared to controls. Further, pre-surgery differences in HRQL between the patients and the controls were lacking. However, the improvement in the patients' HRQL following surgery may justify the correction of pectus excavatum. The effect of the deformity on patients wellbeing compared with controls' needs to be addressed in further studies.
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Affiliation(s)
| | | | - Mikael Thastum
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Hans Pilegaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark;; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Hoksch B, Kocher G, Vollmar P, Praz F, Schmid RA. Nuss procedure for pectus excavatum in adults: long-term results in a prospective observational study. Eur J Cardiothorac Surg 2016; 50:934-939. [DOI: 10.1093/ejcts/ezw130] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 03/18/2016] [Indexed: 11/13/2022] Open
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Fibla JJ, Molins L, Moradiellos J, Rodríguez P, Heras F, Canalis E, Bolufer S, Martínez P, Aragón J, Arroyo A, Pérez J, León P, Canela M. Experience with the Nuss technique for the treatment of Pectus Excavatum in Spanish Thoracic Surgery Departments. Cir Esp 2015; 94:38-43. [PMID: 26546550 DOI: 10.1016/j.ciresp.2015.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/18/2015] [Accepted: 08/07/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Although the Nuss technique revolutionized the surgical treatment of pectus excavatum, its use has not become widespread in our country. The aim of this study was to analyze the current use of this technique in a sample of Thoracic Surgery Departments in Spain. METHODS Observational rectrospective multicentric study analyzing the main epidemiological aspects and clinical results of ten years experience using the Nuss technique. RESULTS Between 2001 and 2010 a total of 149 patients were operated on (mean age 21.2 years), 74% male. Initial aesthetic results were excellent or good in 93.2%, mild in 4.1% and bad in 2.7%. After initial surgery there were complications in 45 patients (30.6%). The most frequent were wound seroma, bar displacement, stabilizer break, pneumothorax, haemothorax, wound infection, pneumonia, pericarditis and cardiac tamponade that required urgent bar removal. Postoperative pain appeared in all patients. In 3 cases (2%) it was so intense that it required bar removal. After a mean follow-up of 39.2 months, bar removal had been performed in 72 patients (49%), being difficult in 5 cases (7%). After a 1.6 year follow-up period good results persisted in 145 patients (98.7%). CONCLUSION Nuss technique in adults has had good results in Spanish Thoracic Surgery Departments, however its use has not been generalized. The risk of complications must be taken into account and its indication must be properly evaluated. The possibility of previous conservative treatment is being analyzed in several departments at present.
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Affiliation(s)
- Juan J Fibla
- Cirugía Torácica, Hospital Universitari Sagrat Cor, Barcelona, España.
| | - Laureano Molins
- Cirugía Torácica, Hospital Universitari Sagrat Cor, Barcelona, España; Cirugía Torácica, Hospital Clinic, Barcelona, España
| | - Javier Moradiellos
- Cirugía Torácica, Hospital Puerta de Hierro, Majadahonda (Madrid), España
| | - Pedro Rodríguez
- Cirugía Torácica, Hospital Insular de Las Palmas de Gran Canaria, Las Palmas, España
| | - Félix Heras
- Cirugía Torácica, Hospital Clínico Universitario, Valladolid, España
| | - Emili Canalis
- Cirugía Torácica, Hospital Universitari Joan XXIII, Tarragona, España
| | - Sergio Bolufer
- Cirugía Torácica, Hospital General Universitario de Alicante, Alicante, España
| | - Pablo Martínez
- Cirugía Torácica, Hospital Miguel Servet, Zaragoza, España
| | - Javier Aragón
- Cirugía Torácica, Hospital Universitario Central de Asturias, Oviedo, España
| | - Andrés Arroyo
- Cirugía Torácica, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Javier Pérez
- Cirugía Torácica, Hospital Germans Trias i Pujol, Badalona, España
| | - Pablo León
- Cirugía Torácica, Complejo Hospitalario Universitario, Albacete, España
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Iwanaka T, Yamataka A, Uemura S, Okuyama H, Segawa O, Nio M, Yoshizawa J, Yagi M, Ieiri S, Uchida H, Koga H, Sato M, Soh H, Take H, Hirose R, Fukuzawa H, Mizuno M, Watanabe T. Pediatric Surgery. Asian J Endosc Surg 2015; 8:390-407. [PMID: 26708583 DOI: 10.1111/ases.12263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 08/21/2015] [Accepted: 08/21/2015] [Indexed: 12/25/2022]
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Pilegaard HK. Nuss technique in pectus excavatum: a mono-institutional experience. J Thorac Dis 2015; 7:S172-6. [PMID: 25984364 DOI: 10.3978/j.issn.2072-1439.2015.04.07] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/27/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND Pectus excavatum (PE) is the most common anomaly of the anterior chest wall. Prior PE was corrected by a modified Ravitch operation, but since Nuss published his minimal technique in 1998, most surgeons have preferred this technique. METHODS Since 2001 the modified Nuss procedure has routinely been used for correction of more than 1,500 patients at Aarhus University Hospital. In the time period between January 1, 2011 and January 31, 2015, 675 patients have been corrected. The median age was 16 years (range, 11-58 years). All patients had preoperatively an epidural catheter and the operations were done in general anaesthesia. The postoperative pain treatment was planned for 4-5 weeks and the patients were routinely seen in the outpatient clinic 6 weeks after surgery and the bars removed after 3 years. RESULTS Four hundred-and-fifty patients had one bar, 216 patients with two bars and nine patients with three bars inserted. The median length of the bar was 10 inch. The median duration of the operation was 29 minutes. The median postoperative stay was 3 days. No death, cardiac perforation or deep infection occurred and only 5% of the patients experienced a complication. CONCLUSIONS The Nuss procedure should still be considered in the treatment of PE. To my opinion, it should be the choice for correction of PE. The short bar should be used to achieve the best stability of the system, to obtain a good cosmetic result, a reduced dysfunction motion of the chest wall and an increased cardiac performance.
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Affiliation(s)
- Hans K Pilegaard
- Department of Cardiothoracic and Vascular Surgery, Institute of Clinical Medicine, Aarhus University Hospital, Denmark
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Lukosiene L, Macas A, Trepenaitis D, Kalibatiene L, Malcius D, Barauskas V. Single shot intercostal block for pain management in pediatric patients undergoing the Nuss procedure: a double-blind, randomized, controlled study. J Pediatr Surg 2014; 49:1753-7. [PMID: 25487477 DOI: 10.1016/j.jpedsurg.2014.09.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 09/05/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE The aim of this study was to investigate the efficacy of a single shot intercostal block for pain control in pediatric patients undergoing the Nuss procedure. METHODS A double-blind, randomized, controlled study was performed. Thirty patients received a single shot bilateral intercostal block with levobupivacaine (L group) and 30 patients with 0.9 % saline (S group). Standardized baseline analgesia was applied for all patients. Morphine consumption, pain scores, respiratory depression, nausea and vomiting, and urinary retention were recorded every 3h for 48h after surgery. RESULTS The loading dose of morphine was lower (p<0.00001) in the L group. There were significantly lower morphine doses up to 6h after surgery and VAS scores up to 3h after surgery in the L group (p<0.001 and p=0.0003, respectively). The incidence of nausea and vomiting was lower in the L group (<0.00001). The incidence of urinary retention was lower in the L group (p=0.019). CONCLUSIONS A single shot IB is an effective additional treatment for pediatric patients undergoing the Nuss procedure and results in the reduced consumption of morphine, less postoperative pain, and fewer opioid-related adverse effects.
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Affiliation(s)
- Laura Lukosiene
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
| | - Andrius Macas
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
| | | | - Lina Kalibatiene
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
| | - Dalius Malcius
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
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Johnson WR, Fedor D, Singhal S. Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum. J Cardiothorac Surg 2014; 9:25. [PMID: 24506826 PMCID: PMC3922335 DOI: 10.1186/1749-8090-9-25] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 02/04/2014] [Indexed: 11/16/2022] Open
Abstract
This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric=0-21; adult 17-99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.
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Affiliation(s)
- William Rainey Johnson
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
| | - David Fedor
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
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Rodrigues PL, Direito-Santos B, Moreira AHJ, Fonseca JC, Pinho ACM, Rodrigues NF, Henriques-Coelho T, Correia-Pinto J, Vilaça JL. Variations of the soft tissue thicknesses external to the ribs in pectus excavatum patients. J Pediatr Surg 2013; 48:1878-86. [PMID: 24074661 DOI: 10.1016/j.jpedsurg.2013.01.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 01/02/2013] [Accepted: 01/20/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Surgical repair of pectus excavatum (PE) has become more popular due to improvements in the minimally invasive Nuss procedure. The pre-surgical assessment of PE patients requires Computerized Tomography (CT), as the malformation characteristics vary from patient to patient. OBJECTIVE This work aims to characterize soft tissue thickness (STT) external to the ribs among PE patients. It also presents a comparative analysis between the anterior chest wall surface before and after surgical correction. METHODS Through surrounding tissue segmentation in CT data, STT values were calculated at different lines along the thoracic wall, with a reference point in the intersection of coronal and median planes. The comparative analysis between the two 3D anterior chest surfaces sets a surgical correction influence area (SCIA) and a volume of interest (VOI) based on image processing algorithms, 3D surface algorithms, and registration methods. RESULTS There are always variations between left and right side STTs (2.54 ± 2.05 mm and 2.95 ± 2.97 mm for female and male patients, respectively). STTs are dependent on age, sex, and body mass index of each patient. On female patients, breast tissue induces additional errors in bar manual conception. The distances starting at the deformity's largest depression point at the SCIA are similar in all directions. Some diverging measures and outliers were found, being difficult to find similar characteristics between them, especially in asymmetric patients. CONCLUSION The Nuss procedure metal bar must be modeled according to each patient's special characteristics. The studied relationships between STT and chest surface could represent a step forward to eliminate the CT scan from PE pre-surgical evaluation.
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Affiliation(s)
- Pedro L Rodrigues
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal; DIGARC-Polytechnic Institute of Cávado and Ave, Barcelos, Portugal.
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Knudsen MR, Nyboe C, Hjortdal VE, Pilegaard HK. Routine postoperative chest X-ray is unnecessary following the Nuss procedure for pectus excavatum. Interact Cardiovasc Thorac Surg 2013; 16:830-3. [PMID: 23439441 DOI: 10.1093/icvts/ivt052] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Pneumothorax is the most common complication after the Nuss procedure for pectus excavatum. The majority of pneumothoraces are small, and the patients have no symptoms. The aim of this study was to evaluate the necessity for routine chest X-ray immediately after surgery. METHODS Group I consists of 644 patients who were operated on with a Nuss procedure for pectus excavatum between 2001 and 2009 (85% male, median age 16 [range 7-48 years]) at Aarhus University Hospital. The standard procedure included chest X-ray immediately after surgery and before discharge. Group II consists of 294 patients (88% male, median age 16 [range 11-54 years]) who had a Nuss procedure in the period January 2011 to October 2012, where the standard procedure only included chest X-ray before discharge. RESULTS In Group I, pneumothorax was found on the chest X-ray obtained immediately after surgery in 333 (52%) patients. Fifteen (4.5%) were treated with chest-tube drainage. Six of these patients had no symptoms, but a 2- to 3-cm pneumothorax, 2 had progression of the pneumothorax and 7 had respiratory symptoms. The median size of those drained was 3 (range 2-6 cm). At the normal 6-week control, no pneumothorax remained. Group II: Among the 294 patients, 1 (0.3%) had a chest tube. CONCLUSIONS Only patients with respiratory symptoms after the Nuss procedure need a chest X-ray. A routine chest X-ray can be limited to the time of discharge where the position of the bar(s) is also checked.
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Affiliation(s)
- Mette Reinholdt Knudsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
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Wu TH, Huang TW, Hsu HH, Lee SC, Tzao C, Chang H, Cheng YL. Usefulness of chest images for the assessment of pectus excavatum before and after a Nuss repair in adults. Eur J Cardiothorac Surg 2012; 43:283-7. [PMID: 22588031 DOI: 10.1093/ejcts/ezs253] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate whether chest radiographs could offer useful information for the assessment of pectus excavatum (PE) before and after Nuss repair in adults. METHODS A total of 154 adults, with a mean age of 24.0 ± 5.0 years (range, 18-44 years), who underwent a Nuss repair of PE, with a mean follow-up of 42 months (range, 14-71 months), were included in this retrospective study. Sixty-two of these patients were also evaluated after the pectus bar removal, with a mean follow-up of 13 months (range, 6-44 months). The preoperative and postoperative imaging modalities were compared. RESULTS The preoperative mean Haller indices measured on computed tomography (CT) and chest radiographs were 4.61 ± 1.58 (range, 2.6-11.9) and 3.82 ± 1.17 (range, 2.0-10.2), respectively. The Pearson correlation coefficient between the two parameters was 0.757. The postoperative mean Haller index measured on chest radiographs was 2.86 ± 0.56 (range, 1.7-5.4) and showed statistically significant improvement compared with the preoperative index (P < 0.001). The mean sternovertebral (SV) distances detected on preoperative and postoperative (>6 months after surgery) lateral chest radiographs were 7.67 ± 1.89 cm (range, 2.5-12.9 cm) and 9.89 ± 1.80 cm (range, 4.6-15.0 cm), respectively, showing statistically significant improvement (P < 0.001). The mean sternovertebral (SV) distance in patients after the bar removal detected on lateral chest radiographs was 9.25 ± 2.14 cm, also showing statistically significant improvement compared with the preoperative value (P < 0.001). CONCLUSIONS Haller indices measured using chest radiographs and CT showed a strong correlation. Therefore, chest radiographs can be used as an alternative tool for the preoperative evaluation of PE. The Nuss operation significantly improved SV distances detected on lateral chest radiographs. Lateral chest radiographs can be used as a simple modality for the objective quantitative assessment of the anatomic results and follow-up of the Nuss operation in adults.
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Affiliation(s)
- Ti-Hei Wu
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Krasopoulos G, Goldstraw P. Reply to Actis Dato et al. (I). Eur J Cardiothorac Surg 2012. [DOI: 10.1093/ejcts/ezr088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Actis Dato GM, Sansone F, Flocco R, Zingarelli E. Nuss procedure for all? But all are not equal! Eur J Cardiothorac Surg 2012; 41:724; author reply 725-6. [PMID: 22345209 DOI: 10.1093/ejcts/ezr085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Neviere R, Montaigne D, Benhamed L, Catto M, Edme JL, Matran R, Wurtz A. Cardiopulmonary response following surgical repair of pectus excavatum in adult patients. Eur J Cardiothorac Surg 2011; 40:e77-82. [PMID: 21570313 DOI: 10.1016/j.ejcts.2011.03.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 03/23/2011] [Accepted: 03/28/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Severe pectus excavatum are common in adult patients, often causing psychological complaints and physiological impairments. Although lung function at rest may minimally deteriorate after surgical correction, it remains unclear if surgery improves exercise capacity. The objective of present study is to assess whether the surgical repair of pectus excavatum in adults would improve exercise tolerance. METHODS A prospective study was performed to compare pulmonary and cardiovascular function at rest and at maximal exercise, before, and at 1 year after pectus excavatum repair. RESULTS From December 2005 to May 2009, 120 adult patients underwent pectus excavatum repair. Of these patients, 70 (nine women, 61 men) underwent thorough preoperative, 6-, and 12-month postoperative assessments, and were included in the present study. Age ranged from 18 to 62 years (mean 27 years). The pectus index (Haller index) was 4.5 ± 1.1. Lung function tests at rest were within the normal range, whereas maximal oxygen uptake (peak VO₂) was only 77 ± 2% of the predicted value. At 1-year follow-up, the pectus excavatum repair was associated with minor changes in lung function tests and significant increase (p=0.0005) in VO₂ (87 ± 2% of the predicted value). Postoperative O₂ pulse increase at maximal exercise suggested that aerobic capacity improvement was the result of better cardiovascular adaptation at maximal workload. CONCLUSION These results demonstrate sustained improvement in exercise cardiopulmonary function at 1-year follow-up of pectus excavatum surgical repair in adult patients.
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Affiliation(s)
- Remi Neviere
- Service d'explorations fonctionnelles respiratoires EFR Hôpital Calmette CHU Lille, Lille, France.
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Robicsek F. Editorial comment: The Nuss procedure: not so fast! Eur J Cardiothorac Surg 2010; 39:159. [PMID: 20884216 DOI: 10.1016/j.ejcts.2010.08.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 08/16/2010] [Accepted: 08/16/2010] [Indexed: 10/19/2022] Open
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