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Gonzalez GC, Berazaluce AMC, Jenkins TM, Hardie WD, Foster KE, Moore RA, Powell AW, Garcia VF, Brown RL. (F)utility of preoperative pulmonary function testing in pectus excavatum to assess severity. Pediatr Surg Int 2024; 40:102. [PMID: 38589706 PMCID: PMC11001679 DOI: 10.1007/s00383-024-05675-3] [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: 03/14/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE The utility of pulmonary function testing (PFT) in pectus excavatum (PE) has been subject to debate. Although some evidence shows improvement from preoperative to postoperative values, the clinical significance is uncertain. A high failure-to-completion rate for operative PFT (48%) was identified in our large institutional cohort. With such a high non-completion rate, we questioned the overall utility of PFT in the preoperative assessment of PE and sought to evaluate if other measures of PE severity or cardiopulmonary function could explain this finding. METHODS Demographics, clinical findings, and results from cardiac MRI, PFT (spirometry and plethysmography), and cardiopulmonary exercise tests (CPET) were reviewed in 270 patients with PE evaluated preoperatively between 2015 and 2018. Regression modeling was used to measure associations between PFT completion and cardiopulmonary function. RESULTS There were no differences in demographics, symptoms, connective tissue disorders, or multiple indices of pectus severity and cardiac deformation in PFT completers versus non-completers. While regression analysis revealed higher RVEF, LVEF, and LVEF-Z scores, lower RV-ESV/BSA, LV-ESV/BSA, and LV-ESV/BSA-Z scores, and abnormal breathing reserve in PFT completers vs. non-completers, these findings were not consistent across continuous and binary analyses. CONCLUSIONS We found that PFT completers were not significantly different from non-completers in most structural and functional measures of pectus deformity and cardiopulmonary function. Inability to complete PFT is not an indicator of pectus severity.
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Affiliation(s)
- Gabriel C Gonzalez
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio, USA.
| | - Alejandra M Casar Berazaluce
- Division of Pediatric Surgery, Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio, USA
| | - Todd M Jenkins
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio, USA
| | - William D Hardie
- Department of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Karla E Foster
- Department of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ryan A Moore
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Cincinnati Children's Hospital Medical Center Heart Institute, Cincinnati, Ohio, USA
| | - Adam W Powell
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Cincinnati Children's Hospital Medical Center Heart Institute, Cincinnati, Ohio, USA
| | - Victor F Garcia
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio, USA
| | - Rebeccah L Brown
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio, USA
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Suehs CM, Molinari N, Bourdin A, Solovei L. Change in cardiorespiratory parameters following surgical correction of pectus excavatum: protocol for the historical-prospective HeartSoar cohort. BMJ Open 2023; 13:e070891. [PMID: 37321811 PMCID: PMC10277089 DOI: 10.1136/bmjopen-2022-070891] [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] [Received: 12/07/2022] [Accepted: 05/23/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION How cardiorespiratory function changes following the surgical correction of pectus excavatum (PE) often gives mixed results, with meta-analyses demonstrating no benefit in terms of pulmonary function but improvement in cardiac function. Functional responses may depend on type of surgery, follow-up time and/or the patient's presurgical functional status, and debate persists on the purely aesthetic nature of such surgery. The aim of this protocol is to analyse data describing lung function and incremental exercise testing before vs after the surgical correction of PE. METHODS AND ANALYSIS A historical-prospective before-after surgical correction of PE cohort will be constituted. Historical inclusions are recruited during follow-up visits at approximately 12, 24, 36 or 48 months following a prior surgery (with presurgical data mined from patient records). Prospective inclusions are recruited during presurgical work-ups and followed for 1 year following surgery. The data collected include spirometry, incremental exercise testing, body mass index, body composition, questionnaires targeting general health status, self-esteem and body image. Any complications due to surgery are also described.The primary outcome is oxygen pulse during incremental exercise testing, and 44 data points are required to demonstrate a moderate postsurgical change (ie, a Cohen's effect of d=0.5). Wilcoxon signed-rank tests or t-tests for paired data will be used for before-after comparisons (with false discovery rate corrections for secondary analyses). ETHICS AND DISSEMINATION This study will be conducted according to the principles of the Declaration of Helsinki (as revised in 2013) and was approved by a randomly assigned, independent, ethics committee (Comité de Protection des Personnes Sud-Méditerranée II, reference number: 218 B21) as per French law on 6 July 2018. Informed, written consent for study participation is required of all study candidates prior to enrolment. Results will be published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT03770390; Clinicaltrials.gov.
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Affiliation(s)
- Carey Meredith Suehs
- Respiratory Diseases, Medical Information, Univ Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, France
| | - Nicolas Molinari
- Medical Information, IMAG; CNRS, Univ Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, France
| | - A Bourdin
- Respiratory Diseases, PhyMedExp, CNRS, INSERM, Univ Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, France
| | - Laurence Solovei
- Thoracic Surgery, Univ Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, France
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Stephens EH, Dearani JA, Jaroszewski DE. Pectus Excavatum in Cardiac Surgery Patients. Ann Thorac Surg 2023; 115:1312-1321. [PMID: 36781097 DOI: 10.1016/j.athoracsur.2023.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Pectus excavatum frequently accompanies congenital heart disease and connective tissue diseases requiring cardiac surgery. Sometimes the indication is cardiac repair, with the pectus being incidentally noticed; other times, the pectus subsequently develops or becomes more significant after cardiac surgery. This review arms cardiac and congenital surgeons with background about the physiologic impact of pectus, indications for repair and repair strategies, and outcomes for cardiac surgery patients requiring pectus repair. METHODS A comprehensive literature review was performed using keywords related to pectus excavatum, pectus repair, and cardiac/congenital heart surgery within the PubMed database. RESULTS The risks of complications related to pectus repair, including in the setting of cardiac surgery or after cardiac surgery, are low in experienced hands, and patients demonstrate cardiopulmonary benefits and symptom relief. Concomitant pectus and cardiac surgery should be considered if it is performed in conjunction with those experienced in pectus repair, particularly given the increased cardiopulmonary impact of pectus after bypass. In the setting of potential bleeding or hemodynamic instability, delayed sternal closure is recommended. For those with anticipated pectus repair after cardiac surgery, the pericardium should be reconstructed for cardiac protection. For those undergoing pectus repair after cardiac surgery without a membrane placed, a "hybrid" approach is safe and effective. CONCLUSIONS Patients undergoing cardiac surgery noted to have pectus should be considered for possible concomitant or staged pectus repair. For those who will undergo a staged procedure, a barrier membrane should be placed before chest closure.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dawn E Jaroszewski
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona.
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Sollie ZW, Gleason F, Donahue JM, Wei B. Evolution of Technique and Results Following Permanent Open Repair for Pectus Deformities. JTCVS Tech 2022; 12:212-219. [PMID: 35403047 PMCID: PMC8987321 DOI: 10.1016/j.xjtc.2021.12.008] [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: 06/15/2021] [Accepted: 12/04/2021] [Indexed: 11/29/2022] Open
Abstract
Objective Open correction of pectus deformities has evolved since its origin. We performed a Ravitch type repair using a permanent titanium plate fixed with screws and describe the procedure with outcomes after our modifications. Methods A retrospective review of 61 pectus excavatum and pectus carinatum cases from August 2013 to April 2021 was performed. Data were extracted from medical records and reported. In January 2016, we began administering satisfaction surveys at the 6-month postoperative visit; results are reported. Results The mean age of our cohort was 24.5 years; 43 (70%) were male. Fifty-four underwent pectus excavatum repair, 6 pectus carinatum repair, and 1 mixed repair. Median Haller index was 3.8. Mean operative duration was 98 minutes; mean blood loss was 116.4 mL. Median chest tube duration was 5.0 days; median hospital stay was 4 days. Reexploration for bleeding was 30% in the first 10 patients. Protocol changes including postponing chemical deep vein thrombosis prophylaxis, using intraoperative hemostatic agents, and using shorter implantation screws decreased this to 0% for the remaining cases. The most frequent complication was urinary retention (21.3%). Postoperative surveys were completed for 37 of 50 patients. Seventy-five percent reported health improved, 65% reported exercise capacity improved, 75% reported breathing improved, and 59% reported chest pain improved. Self-esteem improved from 6.6 ± 2.5 (of 10) before surgery to 8.2 ± 2.1 after surgery. Ninety percent were satisfied and 86% would have the operation again. Conclusions Ravitch type repair with permanent titanium plate fixation is a safe and effective procedure for correction of pectus excavatum and carinatum. Most patients experience improvement in preoperative symptoms.
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Yu YR, Sola R, Jamal AR, Friske TC, Zhu H, Rosenfeld E, Mazziotti MV, St Peter SD, Shah SR. Preoperative resource utilization prior to minimally invasive repair of pectus excavatum. Am J Surg 2020; 222:650-653. [PMID: 33454026 DOI: 10.1016/j.amjsurg.2020.12.053] [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: 07/27/2020] [Revised: 11/22/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Preoperative testing to assess the physiologic impact of pectus excavatum is sometimes ordered to meet third-party payor preauthorization requirements. This study describes the utility of physiologic testing prior to minimally invasive repair of pectus excavatum (MIRPE). METHODS We retrospectively reviewed patients that underwent MIRPE from 1/2012-7/2016 at two academic children's hospitals. Data collected included demographics, insurance, Haller Index (HI), pulmonary function tests (PFTs) and echocardiograms (ECHO) obtained, and preauthorization denials. RESULTS A total of 360 patients (mean age 15.7 ± 2.0 years; mean HI 4.5 ± 1.5) underwent MIRPE (Hospital 1: 189, Hospital 2: 171). Commercial insurers covered 84% of patients. Hospital 1 obtained more frequent preoperative testing (PFTs: 73% vs 6%, p < 0.0001). Overall, 72% of PFTs were normal with abnormal studies limited to mild findings. Similarly, 85% of ECHOs were normal. Third-party payors more frequently denied preauthorization for MIRPE at Hospital 2 (11% vs. 5%, p = 0.03). CONCLUSIONS More frequent preoperative testing may decrease initial preauthorization denials for MIRPE; however, this increased utilization of resources may not be necessary as the majority of test results are normal.
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Affiliation(s)
- Yangyang R Yu
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA; Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX, 77030, USA
| | - Richard Sola
- Children's Mercy Hospital, Division of Pediatric Surgery, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Abdur R Jamal
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA
| | - Tyler C Friske
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA
| | - Huirong Zhu
- Texas Children's Hospital, Division of Outcomes and Impact Service, 6701 Fannin Street, Houston, TX, 77030, USA
| | - Eric Rosenfeld
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA; Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX, 77030, USA
| | - Mark V Mazziotti
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA; Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX, 77030, USA
| | - Shawn D St Peter
- Children's Mercy Hospital, Division of Pediatric Surgery, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Sohail R Shah
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA; Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX, 77030, USA.
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Beltsios ET, Mitsos SL, Panagiotopoulos NT. Pectus excavatum and scoliosis: a review about the patient's surgical management. Gen Thorac Cardiovasc Surg 2020; 68:1225-1233. [PMID: 32990868 DOI: 10.1007/s11748-020-01496-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine. This review article aims to perform an updated overview of the literature about the effect of pectus excavatum correction at the spine and the management of patients with both pectus excavatum and scoliosis. Although acquired scoliosis has been rarely reported after a Nuss procedure, studies show that the Nuss procedure can have a beneficial effect in mild coexisting scoliosis especially when it is performed during the adolescence. The management of cases presented with both pectus excavatum and scoliosis depends on the severity of pre-operative scoliosis and demands detailed evaluation of the spine pre and postoperatively. In the rare condition of post-operative scoliosis following a Nuss procedure, the removal of the metallic bar and conservative measures may have satisfactory results on the spine.
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Affiliation(s)
- Eleftherios T Beltsios
- Department of Thoracic Surgery, University College London Hospitals (UCLH), London, UK. .,Department of Medicine, Faculty of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece.
| | - Sofoklis L Mitsos
- Department of Thoracic Surgery, University College London Hospitals (UCLH), London, UK
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Jaroszewski D, Eldeib A, Gotimukul A, Lackey J, Gaitan B, DeValeria P, Lanza L, Steidley DE, LeMond L, Notrica D. Cardiac Transplantation and Consecutive Minimally Invasive Pectus Excavatum Repair. Ann Thorac Surg 2020; 111:e11-e14. [PMID: 32544457 DOI: 10.1016/j.athoracsur.2020.04.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/23/2020] [Accepted: 04/11/2020] [Indexed: 10/24/2022]
Abstract
Pectus excavatum is a common chest wall deformity with inward deviation of sternum and accompanying ribs. The depression can cause symptomatic cardiac compression, although the cardiopulmonary impact remains controversial. We present 2 cases of cardiac transplantation followed by modified minimally invasive pectus excavatum repair due to the hemodynamic consequences of the pectus deformity.
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Affiliation(s)
- Dawn Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona; Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona.
| | - Ahmed Eldeib
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Ashwini Gotimukul
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jesse Lackey
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Brantley Gaitan
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Patrick DeValeria
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Louis Lanza
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - D Eric Steidley
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Lisa LeMond
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - David Notrica
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona; Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
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Liu C, Wen Y. Research progress in the effects of pectus excavatum on cardiac functions. WORLD JOURNAL OF PEDIATRIC SURGERY 2020; 3:e000142. [DOI: 10.1136/wjps-2020-000142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/07/2020] [Accepted: 04/21/2020] [Indexed: 11/04/2022] Open
Abstract
BackgroundPectus excavatum, the most common chest wall deformity in children, accounts for nearly 90% of congenital malformations of chest wall. Initially, both parents and doctors paid more attention to the influence of this deformity on patient appearance and psychology. Following deeper studies of pectus excavatum, researchers found that it also affected cardiac functions. The purpose of this review aims to present recent research progress in the effects of pectus excavatum on cardiac functions.Data sourcesBased on aspects of CT, ultrasound cardiography (UCG) and MRI, all the recent literatures on the influence of pectus excavatum on cardiac function were searched and reviewed.ResultsModerate and severe pectus excavatum did have a negative effect on cardiac function. Cardiac rotation angle, cardiac compression index, right atrial and tricuspid annulus size, septal motion and myocardial strain are relatively effective indexes to evaluate cardiac function.ConclusionsPectus excavatum did have a negative effect on cardiac function; so surgeons should actively diagnose and treat such patients in clinical work. However, further research is needed on to explore the measures and indicators that can reflect the changes of cardiac function in patients objectively, accurately, effectively and timely.
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Murphy BL, Naik ND, Roskos PL, Glasgow AE, Moir CR, Habermann EB, Klinkner DB. Minimal cosmetic revision required after minimally invasive pectus repair. Pediatr Surg Int 2018; 34:775-780. [PMID: 29744653 DOI: 10.1007/s00383-018-4275-8] [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: 04/30/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite surgical correction procedures for pectus deformities, remaining cosmetic asymmetry may have significant psychological effects. We sought to evaluate factors associated with plastic surgery (PS) consultation and procedures for these deformities at an academic institution. METHODS We reviewed patients aged 0-21 diagnosed with a pectus excavatum or carinatum deformity at our institution between January 2001 and October 2016. Pectus diagnoses were identified by ICD-9/ICD-10 codes and surgical repair by CPT codes; patients receiving PS consultation were identified by clinical note service codes. Student's t tests, Fisher's exact tests, and Chi-squared tests were utilized. RESULTS 2158 patients were diagnosed with a pectus deformity; 442 (20.4%) underwent surgical correction. 19/442 (4.3%) sought PS consultation, either for pectus excavatum [14/19 (73.7%)], carinatum [4/19 (21.0%)], and both [1/19 (5.3%)], (p = 0.02). Patients seeking PS consultation were more likely to be female (p < 0.01), have scoliosis (p = 0.02), or undergo an open repair (p < 0.01). The need for PS consultation did not correlate with Haller index, p = 0.78. CONCLUSION PS consultation associated with pectus deformity repair was rare, occurring in < 5% of patients undergoing repair. Patients who consulted PS more commonly included females, patients with scoliosis, and those undergoing open repair. These patients would likely benefit most from multidisciplinary pre-operative discussions regarding repair of the global deformity.
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Affiliation(s)
- Brittany L Murphy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.,The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Nimesh D Naik
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Penny L Roskos
- Division of Pediatric Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Amy E Glasgow
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Christopher R Moir
- Division of Pediatric Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Elizabeth B Habermann
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Denise B Klinkner
- Division of Pediatric Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
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Anesthesia for Nuss Procedures (Pectus Deformity). Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Mao YZ, Tang S, Li S. Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis. J Pediatr Surg 2017; 52:1545-1552. [PMID: 28606386 DOI: 10.1016/j.jpedsurg.2017.05.028] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/16/2017] [Accepted: 05/29/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE To evaluate surgical outcomes of Nuss versus Ravitch repair of pectus excavatum via a systematic review and meta-analysis. METHODS Medline, PubMed, Cochrane, EMBASE, and Google Scholar databases were searched up to September 5, 2016 using the following search terms: pectus excavatum, funnel chest, Nuss; Ravitch, minimally invasive, and open surgery. Randomized controlled trials, two-arm prospective, and two-arm retrospective studies were eligible for inclusion. RESULTS Nineteen studies were included with a total of 1731 patients: 989 treated with Nuss and 742 treated with Ravitch. The overall analysis revealed that patients in the Nuss group had significantly shorter operation time (pooled SMD=-2.83, 95% CI=-3.76 to -1.90, p<0.001) and less blood loss (pooled SMD=-1.68, 95% CI=-2.28 to -1.09, P<0.001) than the Ravitch group. However, the length of hospital stay was similar between groups (pooled SMD=-0.55, 95% CI=-1.44 to 0.35, p=0.230). These findings were similar in the subgroup analysis for randomized and non-randomized controlled studies. Complications were not assessed due to inconsistent reporting across the included studies. CONCLUSIONS Our meta-analysis demonstrate that the Nuss procedure has a shorter operative time and less operative blood loss than the Ravitch procedure while the postoperative length of stay was similar. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Yong Zhong Mao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China..
| | - ShaoTao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Bojanić K, Grizelj R, Dilber D, Šarić D, Vuković J, Pianosi PT, Driscoll DJ, Weingarten TN, Pritišanac E, Schroeder DR, Sprung J. Cardiopulmonary exercise performance is reduced in congenital diaphragmatic hernia survivors. Pediatr Pulmonol 2016; 51:1320-1329. [PMID: 27228382 DOI: 10.1002/ppul.23481] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 04/28/2016] [Accepted: 05/06/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is associated with lung hypoplasia. CDH survivors may have pulmonary morbidity that can decrease cardiopulmonary exercise. We aimed to examine whether cardiopulmonary exercise testing (CPET) results differ in CDH survivors versus healthy age-matched controls and whether CPET results among CDH survivors differ according to self-reported daily activity. METHODS In one medical center in Croatia, CDH survivors-patients with surgically corrected CDH who were alive at age 5 years-were invited to participate in spirometry and CPET. Values were compared with those of controls matched 2:1 by age and sex for each CDH survivor aged 7 years or older. RESULTS Among 27 CDH survivors aged 5-20 years, 13 (48%) had continued symptoms or spirometric evidence of pulmonary disease. Compared with controls (n = 44), survivors (n = 22) had lower peak oxygen consumption (V˙O2 mean [SD], 35.7 [6.9] vs. 45.3 [8.2] ml/kg per min; P < 0.001). At peak exercise, V˙O2/heart rate (P < 0.001), tidal volume (P = 0.005), and minute ventilation (P < 0.001) were lower in survivors, but the maximal respiratory rate was not different (P = 0.72). Among survivors, mean (SD) V˙O2peak (ml/kg per min) differed by self-reported activity level: athletic, 40.3 (5.0); normal, 35.8 (6.5); and sedentary, 32.1 (6.8) (by ANOVA, P = 0.10 across three groups and P = 0.04 athletic vs. sedentary). CONCLUSION More than half of CDH survivors continue to have chronic pulmonary disease. CDH survivors had lower aerobic exercise capacity than controls. Self-reporting information on daily activities may identify CDH patients with low V˙O2max who may benefit from physical training. Pediatr Pulmonol. 2016;51:1320-1329. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Katarina Bojanić
- Division of Neonatology, Department of Obstetrics and Gynecology, University Hospital Merkur, Zagreb, Croatia
| | - Ruža Grizelj
- Department of Paediatrics, University of Zagreb, School of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Daniel Dilber
- Division of Pediatric Cardiology, University of Zagreb, School of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Dalibor Šarić
- Division of Pediatric Cardiology, University of Zagreb, School of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Jurica Vuković
- Department of Paediatrics, University of Zagreb, School of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Paolo T Pianosi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - David J Driscoll
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Toby N Weingarten
- Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester 55905, Minnesota
| | - Ena Pritišanac
- Department of Paediatrics, University of Zagreb, School of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester 55905, Minnesota
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Kim HK, Yoon JY, Han KN, Choi YH. Effect of the Nuss Procedure on the Physical Development of Patients with Pectus Excavatum. Ann Thorac Cardiovasc Surg 2016; 22:327-332. [PMID: 27629820 DOI: 10.5761/atcs.oa.16-00012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Maagaard M, Heiberg J. Improved cardiac function and exercise capacity following correction of pectus excavatum: a review of current literature. Ann Cardiothorac Surg 2016; 5:485-492. [PMID: 27747182 DOI: 10.21037/acs.2016.09.03] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients with pectus excavatum (PE) often describe improvements in exercise stamina following corrective surgery. Studies have investigated the surgical effect on physiological parameters; still, no consensus has yet been reached. Therefore, the aim of this literature review was to describe the cardiac outcome after surgical correction, both at rest and during exercise. In February 2016, a detailed search of the databases PubMed, Medline, and EMBASE was performed. We assessed clinical studies that described cardiac outcomes both before and after surgical correction of PE. We only included studies reporting either pre-defined echocardiographic or exercise test parameters. No exclusion criteria or statistical analyses were applied. Twenty-one full-text articles, published between 1972 and 2016, were selected, with cohort-ranges of 3-168 patients, mean age-ranges of 5-33 years, and mean follow-up-ranges from immediately to 4 years after surgery. Twelve studies described resting cardiac parameters. Four studies measured cardiac output, where one described 36% immediate increase after surgery, one reported 15% increase after Nuss-bar removal and two found no difference. Three studies demonstrated improvement in mean stroke volume ranges of 22-34% and two studies found no difference. Fifteen studies investigated exercise capacity, with 11 considering peak O2 pr. kg, where five studies demonstrated improvements with the mean ranging from 8% to 15% after surgery, five studies demonstrated no difference, and one saw a decrease of 19% 3 months after Nuss-bar implantation. A measurable increase in exercise capacity exists following surgery, which may be caused by multiple factors. This may be owed to the relief of compressed cardiac chambers with the increased anterior-posterior thoracic dimensions, which could facilitate an improved filling of the heart. With these results, the positive physiological impact of the surgery is emphasized and the potential gain in cardiac function should be integrated in the clinical assessment of patients with PE.
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Affiliation(s)
- Marie Maagaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark
| | - Johan Heiberg
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark
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Abstract
Informed consent should be seen as an essential part of health care practice; parental permission and childhood assent is an active process that engages patients, both adults and children, in their health care. Pediatric practice is unique in that developmental maturation allows, over time, for increasing inclusion of the child's and adolescent's opinion in medical decision-making in clinical practice and research. This technical report, which accompanies the policy statement "Informed Consent in Decision-Making in Pediatric Practice" was written to provide a broader background on the nature of informed consent, surrogate decision-making in pediatric practice, information on child and adolescent decision-making, and special issues in adolescent informed consent, assent, and refusal. It is anticipated that this information will help provide support for the recommendations included in the policy statement.
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Sesia SB, Obermeyer RJ, Mayr J, Haecker FM. Pulmonary function in pectus excavatum patients before repair with the Nuss procedure. Postgrad Med 2016; 128:598-602. [PMID: 27352619 DOI: 10.1080/00325481.2016.1205454] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Whether the origin of symptoms in pectus excavatum patients (Pex) is related to reduced pulmonary function or impaired cardiovascular performance is debatable. However, pulmonary function testing (PFT) is still part of the evaluation prior to surgical repair in Pex. The purpose of this study was to corroborate our hypothesis that the majority of Pex that qualified for surgery present preoperatively with normal or close to normal PFT. METHODS After institutional review board approval, preoperative PFT data of Pex who underwent surgical repair were analyzed retrospectively: total lung capacity (TLC), vital capacity (VC), functional residual capacity, forced expiratory volume in 1 second (FEV1) and maximal expiratory flow at 25% of FVC (MEF25). RESULTS 82 patients aged from 9 to 27 years (average, 15 years) underwent PFT. A restrictive pattern (VC<80%) was observed in 45%, an obstructive pattern (FEV1 < 75 %) in 35%, and a normal total lung capacity in 62% of the Pex. No significant correlation was noted between the increasing severity of the Haller index and the PFT. CONCLUSION Adolescent Pex without relevant respiratory symptoms have nearly a normal lung function. We suggest to skip PFT from the routine preoperative assessment in asymptomatic Pex.
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Affiliation(s)
- Sergio B Sesia
- a Department of Pediatric Surgery , Children's Hospital of Basel (UKBB) , Basel , Switzerland
| | - Robert J Obermeyer
- b Department of Pediatric Surgery , Eastern Virginia Medical School (EVMS), Children's Hospital of The King's Daughters (CHKD) , Norfolk , VA , USA
| | - Johannes Mayr
- a Department of Pediatric Surgery , Children's Hospital of Basel (UKBB) , Basel , Switzerland
| | - Frank-Martin Haecker
- a Department of Pediatric Surgery , Children's Hospital of Basel (UKBB) , Basel , Switzerland
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Patvardhan C, Martinez G. Anaesthetic considerations for pectus repair surgery. J Vis Surg 2016; 2:76. [PMID: 29078504 DOI: 10.21037/jovs.2016.02.31] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/04/2016] [Indexed: 11/06/2022]
Abstract
Repair of pectus is one of the most common congenital abnormality for which patient presents for thoracic surgery. In recent years, innovative minimally invasive techniques involving video assisted thoracoscopy for pectus repair have become the norm. Similarly, anaesthetic techniques have evolved to include principles of enhanced recovery, multimodal analgesia and innovative ultrasound guided neuraxial and nerve blocks. Adequate anaesthetic set up and monitoring including the use of real time intraoperative monitoring with transesophageal echocardiography (TOE) has enabled the anaesthetist to enhance patient safety by providing instantaneous imaging of cardiac compression and complications during surgery. In this review article we aim to provide non-systematic review and institutional experience of our anaesthetic strategy to provide effective peri-operative care in this patient group.
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Affiliation(s)
- Chinmay Patvardhan
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Guillermo Martinez
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Kuru P, Dudakli A, Mursaloglu H, Arikan H, Oktay A, Yuksel M. How pulmonary function changes after pectus excavatum correction surgery. Asian Cardiovasc Thorac Ann 2015; 23:945-9. [PMID: 26189888 DOI: 10.1177/0218492315596464] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM We aimed to determine the effects of minimally invasive repair of pectus excavatum on pulmonary function and quality of life. METHODS Minimally invasive pectus excavatum repair was undertaken in 80 patients with a mean age of 16.91 ± 4.37 years (range 7-30 years) and a mean Haller index of 4.07 ± 1.39; 85% of the patients were male. They and their parents completed the Nuss Questionnaire Modified for Adults, and pulmonary function tests were performed on the patients before and 6 months after the operation. RESULTS The mean Nuss score was 31.06 ± 6.78 before the operation and it increased to 37.1 ± 8.31 (p = 0.000) 6 months after the operation. Forced vital capacity decreased from 3.70 ± 1.23 to 3.48 ± 1.03 L (p = 0.05) postoperatively. The percentage of expected forced vital capacity decreased from 83.21% ± 16.97% to 76.52% ± 20.98% (p = 0.01). There was no significant change in forced expiratory volume in 1 s. The mean ratio of forced expiratory volume in 1 s to forced vital capacity was 86% preoperatively and it increased to 91% postoperatively (p = 0.000). CONCLUSIONS Minimally invasive pectus excavatum repair has a positive impact on the quality of life of pectus excavatum patients, but a negative impact on forced vital capacity. Follow-up studies are needed to assess the long-term changes in pulmonary function after this operation.
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Affiliation(s)
- Pinar Kuru
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Asli Dudakli
- Marmara University School of Medicine, Istanbul, Turkey
| | | | - Hazal Arikan
- Marmara University School of Medicine, Istanbul, Turkey
| | - Aysu Oktay
- Marmara University School of Medicine, Istanbul, Turkey
| | - Mustafa Yuksel
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
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Neuville M, Jondeau G, Crestani B, Taillé C. [Respiratory manifestations of Marfan's syndrome]. Rev Mal Respir 2014; 32:173-81. [PMID: 25765122 DOI: 10.1016/j.rmr.2014.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/24/2014] [Indexed: 11/19/2022]
Abstract
Marfan's syndrome is a rare genetic disorder caused by a mutation of the gene FBN1, coding for the protein fibrillin-1. Cardiovascular, musculoskeletal and ophthalmic manifestations are the most commonly observed, but minor diagnostic criteria also include pulmonary manifestations. Pneumothorax, frequently relapsing, affects 5 to 11% of patients. Rib cage abnormalities (pectus excavatum or pectus carinatum) and apical blebs may contribute to their occurrence. Treatment does not require any specific procedure but there is an increased risk of recurrence. Pectus excavatum affects up to 60% of the patients, without any functional impairment in most cases. Surgery may be required (using the Nuss procedure) in case of cardiovascular or psychological symptoms. Marfan's syndrome is frequently associated with obstructive sleep apnoea, which may itself contribute to aortic dilatation. Some studies suggest a potential role of craniofacial abnormalities in the pathogenesis of sleep apnea in these patients. Pulmonologists should consider Marfan's syndrome when treating patients for recurrent spontaneous pneumothorax or rib cage abnormalities, since early detection of cardiac abnormalities improves the prognosis significantly.
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Affiliation(s)
- M Neuville
- Service de pneumologie, département hospitalo-universitaire FIRE, centre de compétence pour les maladies pulmonaires rares, hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - G Jondeau
- Service de cardiologie, département hospitalo-universitaire FIRE, centre national de référence pour le syndrome de Marfan et apparentés, hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - B Crestani
- Service de pneumologie, département hospitalo-universitaire FIRE, centre de compétence pour les maladies pulmonaires rares, hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - C Taillé
- Service de pneumologie, département hospitalo-universitaire FIRE, centre de compétence pour les maladies pulmonaires rares, hôpital Bichat-Claude-Bernard, 75018 Paris, France.
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Identifying pectus excavatum in the primary care setting. Nurse Pract 2014; 39:25-8. [PMID: 24841462 DOI: 10.1097/01.npr.0000446870.69156.ea] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article reviews pectus excavatum and the role of the primary care provider in correct identification. Historically, pectus excavatum was viewed as a cosmetic concern. Research indicates that severe cases result in cardiopulmonary impairment and physiologic limitations. Evidence demonstrates that surgical repair improves cardiovascular function, exercise tolerance, and body image.
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Acosta J, Bradley A, Raja V, Aliverti A, Badiyani S, Motta A, Moriconi S, Parker K, Rajesh P, Naidu B. Exercise improvement after pectus excavatum repair is not related to chest wall function†. Eur J Cardiothorac Surg 2013; 45:544-8. [DOI: 10.1093/ejcts/ezt473] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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O'Keefe J, Byrne R, Montgomery M, Harder J, Roberts D, Sigalet DL. Longer term effects of closed repair of pectus excavatum on cardiopulmonary status. J Pediatr Surg 2013; 48:1049-54. [PMID: 23701781 DOI: 10.1016/j.jpedsurg.2013.02.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 02/03/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND The "Nuss" repair is done for correction of moderate to severe pectus excavatum (PE). The long term cardiopulmonary and psychosocial effects of repair are uncertain. The objective of this study was to compare cardiopulmonary function and subjective evaluation of appearance and exercise tolerance pre-bar insertion with post-bar removal. METHODS All patients underwent preoperative and post-bar (3 month) removal evaluation with complete pulmonary function tests, exercise stress testing, echocardiogram, and self-rated appearance and exercise tolerance scoring. The protocol was approved by the regional ethics board, and all families gave informed consent. RESULTS Sixty-seven patients underwent pre and post testing. Preoperative CT index was 4.4 ± 1.3. Cardiopulmonary outcomes, standardized for height and weight, showed significant improvements in FEV-1 as (pre) 81.1 ± 17.0 vs post 89.8 ± 20.5*, FVC: 91.2 ± 18.6 vs 98.9 ± 22.9*, O2 pulse: 75.8 ± 14.4 vs 80.5 ± 18.3* (each as % predicted). Both the self-ratings of appearance (2.5 ± 0.8 vs 4.4 ± 0.5) and ability to exercise (3.3 ± 0.7 vs 4.3 ± 0.6, scale 1-5) increased significantly. (All data: mean ± St Dev, *p<0.05) CONCLUSIONS: Closed repair of PE results in improvements in pulmonary and aerobic exercise function and perceived appearance and exercise tolerance. Our data suggest that the impact on appearance and self-perceived well being is greater than the physical effect.
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Affiliation(s)
- Julia O'Keefe
- Department of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada T3B 6A8
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Jayaramakrishnan K, Wotton R, Bradley A, Naidu B. Does repair of pectus excavatum improve cardiopulmonary function? Interact Cardiovasc Thorac Surg 2013; 16:865-70. [PMID: 23449664 DOI: 10.1093/icvts/ivt045] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was 'Does repair of pectus excavatum (PE) improve cardiopulmonary function?' One hundred and sixty-eight papers were found using the reported search, 19 level III evidence papers and three meta-analyses were relevant. Studies were divided into four groups based on the surgical technique applied and pulmonary and cardiac functions in these groups were analysed. The meta-analyses show conflicting results for improvements in pulmonary and cardiac functions when comparing surgical techniques, while four more recent studies show improved long-term results using the Nuss technique. The best evidence of papers studying the PE repair using the minimally invasive Nuss technique demonstrates a decrease in pulmonary function during the early postoperative period, however, there is a small but significant improvement during the late postoperative period and after bar removal. The best evidence for cardiac function in this group suggests an early improvement that is sustained during further follow-up. The best evidence of papers studying the PE repair using the Ravitch technique shows that pulmonary function decreased during the early postoperative period, however, there is a small but significant improvement during the late postoperative period. The best evidence for cardiac function in this group suggests an early improvement that is sustained during further follow-up. The best evidence of papers studying the PE repair using other techniques (modified Daniel's technique, modified Baronofsky's technique, sterno-costal turn-over technique and sterno-costal elevation technique) or where surgical techniques used were not described (preceding year 1985) suggests that there is no improvement in pulmonary function after surgery. There is some evidence that certain aspects of cardiac function improved after surgery in this group.
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25
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Lakoma A, Kim ES. Current readings: surgical repair experience of congenital chest wall deformities. Semin Thorac Cardiovasc Surg 2013; 25:317-22. [PMID: 24673961 DOI: 10.1053/j.semtcvs.2013.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2013] [Indexed: 11/11/2022]
Abstract
Major advancements have been made in the surgical repair of congential chest wall deformities. This review highlights selected readings of the experience in correction of pectus excavatum and pectus carinatum. In particular, it summarizes the current standard of care and outcomes of new and modified procedures for patients with chest wall deformities.
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Affiliation(s)
- Anna Lakoma
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Eugene S Kim
- Department of Surgery, Baylor College of Medicine, Houston, Texas..
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26
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Kang CH, Park S, Park IK, Kim YT, Kim JH. Long-term Surveillance Comparing Satisfaction between the Early Experience of Nuss Procedure vs. Ravitch Procedure. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:308-15. [PMID: 23130304 PMCID: PMC3487014 DOI: 10.5090/kjtcs.2012.45.5.308] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 04/12/2012] [Accepted: 04/28/2012] [Indexed: 11/16/2022]
Abstract
Background Long-term surveillance comparing satisfaction between the early experience of Nuss procedure vs. Ravitch procedure. Materials and Methods A total of 100 patients that underwent surgical correction of a pectus excavatum between 2001 and 2004 and were followed for ≥2 years were included. Surveillance on the degree of satisfaction was performed using five-levels of the Likert scale and self-assessment scoring. Results Nuss or Ravitch surgery was performed in 63 and 37 patients, respectively. The Nuss procedure required a shorter operation time and shorter hospital stay than the Ravitch procedure (p<0.001). The surveillance demonstrated that 17.6% of the Nuss group and 35.7% of the Ravitch group were not satisfied with the outcome of the surgery (p=0.072). The most common causes of dissatisfaction were redepression in the Nuss group (n=5) and incomplete correction in the Ravitch group (n=7). The multivariate analysis showed that reoperation and a high postoperative pectus index were significant risk factors for a low satisfaction score. Conclusion The Nuss procedure had several advantages over the Ravitch procedure in the immediate postoperative period. However, the long-term satisfaction was determined by a complete correction without recurrence or need for re-intervention rather than by the operation type.
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Affiliation(s)
- Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Korea
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Swanson JW, Avansino JR, Phillips GS, Yung D, Whitlock KB, Redding GJ, Sawin RS. Correlating Haller Index and cardiopulmonary disease in pectus excavatum. Am J Surg 2012; 203:660-664. [DOI: 10.1016/j.amjsurg.2011.12.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Revised: 12/14/2011] [Accepted: 12/14/2011] [Indexed: 11/29/2022]
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Brochhausen C, Turial S, Müller FKP, Schmitt VH, Coerdt W, Wihlm JM, Schier F, Kirkpatrick CJ. Pectus excavatum: history, hypotheses and treatment options. Interact Cardiovasc Thorac Surg 2012; 14:801-6. [PMID: 22394989 DOI: 10.1093/icvts/ivs045] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Pectus excavatum and pectus carinatum represent the most frequent chest wall deformations. However, the pathogenesis is still poorly understood and research results remain inconsistent. To focus on the recent state of knowledge, we summarize and critically discuss the pathological concepts based on the history of these entities, beginning with the first description in the sixteenth century. Based on the early clinical descriptions, we review and discuss the different pathogenetic hypotheses. To open new perspectives for the potential pathomechanisms, the embryonic and foetal development of the ribs and the sternum is highlighted following the understanding that the origin of these deformities is given by the disruption in the maturation of the parasternal region. In the second, different therapeutical techniques are highlighted and based on the pathogenetic hypotheses and the embryological knowledge potential new biomaterial-based perspectives with interesting insights for tissue engineering-based treatment options are presented.
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29
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Campo-Cañaveral de la Cruz JL, Herrero Collantes J, Sánchez Lorente D, Torres Lanzas J. [Chest wall surgery]. Arch Bronconeumol 2011; 47 Suppl 3:15-24. [PMID: 21640288 DOI: 10.1016/s0300-2896(11)70024-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite the numerous differences among the distinct diseases of the chest wall, the surgery of this area shows certain common features. Treatment has progressively changed in the last few years due to advances in diagnostic techniques, minimally invasive procedures and reconstruction materials, and especially due to the multidisciplinary management of many diseases. Nuss' minimally invasive correction of pectus excavatum has gained devotees, although open approaches are performed with increasingly small incisions, almost comparable to the lateral incisions in Nuss' technique. Surgeons supporting the open approach also cite the evident disadvantages of the need for a steel implant for 2 or 3 years and for a second intervention to remove this implant. En-bloc resections with reconstruction using materials, which are increasingly better and covered by myocutaneous grafts in collaboration with plastic surgery departments, constitute a major advance in the treatment of chest wall tumors. Trimodal therapy for Pancoast tumors, consisting of induction chemotherapy and radiotherapy and subsequent surgical treatment of the tumor, currently provides the best results in terms of resectability and survival.
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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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Densmore JC, Peterson DB, Stahovic LL, Czarnecki ML, Hainsworth KR, Davies HW, Cassidy LD, Weisman SJ, Oldham KT. Initial surgical and pain management outcomes after Nuss procedure. J Pediatr Surg 2010; 45:1767-71. [PMID: 20850618 DOI: 10.1016/j.jpedsurg.2010.01.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Revised: 01/26/2010] [Accepted: 01/27/2010] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this article was to report surgical and pain management outcomes of the initial Nuss procedure experience at the Children's Hospital of Wisconsin (Milwaukee) and to place this experience in the context of the published literature. METHODS The initial 118 consecutive Nuss procedures in 117 patients were retrospectively reviewed with approval of the Children's Hospital of Wisconsin human rights review board. Patient, surgical, complication, and pain descriptors were collected for each case. Statistical methods for comparison of pain strategies included the Kolmogorov-Smirnov test for normality, 1-way repeated measures analysis of variance, and paired t tests. RESULTS Patient, surgical, and complication descriptors were comparable to other large series. Complication rates were 7% early and 25% late. Epidural success rate was 96.4%. There was 1 episode of recurrence 2 years postbar removal (n = 114). CONCLUSIONS The institution of the Nuss procedure provides a highly desired result with significant complication rates. The ideal approach would deliver this result with lower risk. A pain service-driven epidural administration of morphine or hydromorphone with local anesthetic provides excellent analgesia for patients after Nuss procedure. The success of epidural analgesia is independent of catheter site and adjunctive medications. Ketorolac was an effective breakthrough medication.
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Castellani C, Windhaber J, Schober PH, Hoellwarth ME. Exercise performance testing in patients with pectus excavatum before and after Nuss procedure. Pediatr Surg Int 2010; 26:659-63. [PMID: 20532529 DOI: 10.1007/s00383-010-2627-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the changes in lung function and exercise performance due to minimal invasive pectus repair. METHODS Fifty-nine patients with an average age of 16 years were included in this prospective investigation. After determination of body mass index (BMI) and body fat patients were subjected to pre-OP, post-OP and post-implant removal spirometry and bicycle ergospirometry. Forced vital capacity (FVC), performance capacity (PC) and relative oxygen uptake were determined. RESULTS Post-OP FVC significantly decreased from 91% of normal value to 79%, but again increased to 88% after implant removal. PC showed a significant reduction (105-97% of normal value). Likewise, the relative oxygen uptake showed a significant decrease (43.8-42.2 ml/kg per min). These findings correlated to a significant increase of BMI and body fat. When calculating oxygen uptake per kilogram lean body weight, there were no significant changes (49.8 to 49.8 ml/kg per min). CONCLUSIONS Pectus repair resulted in a temporary reduction of FVC, which resolved after implant removal. The drop in oxygen uptake and PC could be related to a significant increase of BMI and body fat. According to our data pectus repair is not followed by improvements in lung function and exercise performance.
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Affiliation(s)
- Christoph Castellani
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria.
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Fokin AA, Steuerwald NM, Ahrens WA, Allen KE. Anatomical, histologic, and genetic characteristics of congenital chest wall deformities. Semin Thorac Cardiovasc Surg 2009; 21:44-57. [PMID: 19632563 DOI: 10.1053/j.semtcvs.2009.03.001] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2009] [Indexed: 11/11/2022]
Abstract
There is a large and diverse group of congenital abnormalities of the thorax that manifest as deformities and/or defects of the anterior chest wall and, depending on the severity and concomitant anomalies, may have cardiopulmonary implications. Pectus excavatum, the most common anterior chest deformity, is characterized by sternal depression with corresponding leftward displacement and rotation of the heart. Pectus carinatum, the second most common, exhibits a variety of chest wall protrusions and very diverse clinical manifestations. The cause of these conditions is thought to be abnormal elongation of the costal cartilages. Collagen, as a major structural component of rib cartilage, is implicated by genetic and histologic analysis. Poland syndrome is a unique unilateral chest/hand deficiency that may include rib defects, pectoral muscle deficit, and syndactyly. Cleft sternum is a rare congenital defect resulting from nonfusion of the sternal halves, which leaves the heart unprotected and requires early surgical intervention.
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Affiliation(s)
- Alexander A Fokin
- Heineman Medical Research Laboratories, Carolinas Medical Center, Charlotte, NC 28203, USA.
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Affiliation(s)
- Anastassios C Koumbourlis
- Pulmonary Medicine, Schneider Children's Hospital, Clinical Pediatrics, Albert Einstein College of Medicine, Great Neck, NY 11021, USA.
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