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Dunning J, Burdett C, Child A, Davies C, Eastwood D, Goodacre T, Haecker FM, Kendall S, Kolvekar S, MacMahon L, Marven S, Murray S, Naidu B, Pandya B, Redmond K, Coonar A. The pectus care guidelines: best practice consensus guidelines from the joint specialist societies SCTS/MF/CWIG/BOA/BAPS for the treatment of patients with pectus abnormalities. Eur J Cardiothorac Surg 2024; 66:ezae166. [PMID: 38964837 DOI: 10.1093/ejcts/ezae166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/26/2024] [Accepted: 04/30/2024] [Indexed: 07/06/2024] Open
Abstract
Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back towards the spine (excavatum), protrudes forwards (carinatum) or more rarely is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities (such as swimming, dancing) and from interactions that might 'expose' them (such as sleepovers, dating, going to the beach and wearing fashionable clothes). This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise (such as running) but can also limit moderate activity such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment usually also suffer from low self-esteem and depression. This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and non-surgical techniques including bracing and vacuum bell therapy. We also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants and other rare procedures such as Pectus Up. For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance and long-term support. All the interventions have risks and benefits that the patient, parents and clinicians need to carefully consider and discuss when deciding on the most appropriate course. We hope this evidence review of 'Best Practice for Pectus' will make a significant contribution to those considerations and help all involved, from patients to national policy makers, to deliver the best possible care.
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Affiliation(s)
- Joel Dunning
- Department of Cardiothoracic surgery, James Cook University Hospital, Middlesbrough, UK
| | - Clare Burdett
- Department of Cardiothoracic surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Carl Davies
- Royal College of Physicians and Surgeons of Glasgow, UK
| | | | - Tim Goodacre
- Royal College of Surgeons of England, London, UK
| | - Frank-Martin Haecker
- Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
- Department of Paediatric Surgery, Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Simon Kendall
- Society for Cardiothoracic Surgery in Great Britain and Ireland, London, UK
| | - Shyam Kolvekar
- National Pectus Centre, Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Lisa MacMahon
- Department of Thoracic Surgery, Phoenix Children's Hospital, Phoenix, USA
- Chest Wall International Group (CWIG), Switzerland
| | - Sean Marven
- British Association of Paediatric Surgeons Thoracic and Airway Group, London, UK
| | - Sarah Murray
- Clinical Research Collaborative BHF and Leicester University, National PPI Group, Leicester, UK
| | - Babu Naidu
- Department of Thoracic Surgery, Birmingham Heartlands Hospital, Birmingham, UK
| | - Bejal Pandya
- National Pectus Centre, Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Karen Redmond
- Department of Thoracic Surgery, School of Medicine, University College Dublin, National Thoracic Subcommittee Lead SCTS, The Mater Hospital, Dublin, Dublin, Ireland, UK
| | - Aman Coonar
- Thoracic Lead at NHS England, President of the Society for Cardiothoracic Surgery in Great Britain and Ireland, London, UK
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Dupuis M, Daussy L, Noel-Savina E, Dahan M, Didier A, Chavoin JP, Guibert N. Impact of pectus excavatum on pulmonary function and exercise capacity in patients treated with 3D custom-made silicone implants. ANN CHIR PLAST ESTH 2024; 69:53-58. [PMID: 36737354 DOI: 10.1016/j.anplas.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pectus excavatum (PE) is the most common congenital chest wall deformity, whose cardiopulmonary consequences are controversial. PE surgery is in our experience usually performed for aesthetic reasons. OBJECTIVES The aim of this study was to evaluate the impact of PE on respiratory function and exercise capacity in patients with PE before patient-specific silicone implant correction. METHODS This monocentric prospective study conducted at Toulouse University Hospital included sixty patients scheduled for custom-made silicone implants correction. Respiratory function (pulmonary function tests (FPTs)) and exercise capacity (VO2 max) were measured before surgery. RESULTS Before surgery, no (0/60) restrictive lung disease was detected, with a mean total lung capacity (TLC) of 98.5% of predicted value (IC 95%; 80.4-137). Median VO2 max (n=56) was normal (89% predicted), with no cardiac limitation. CONCLUSION In this cohort, PE had no impact on respiratory function nor exercise capacity. In patients without cardiac or respiratory effects of PE, silicone implants should be considered the preferred approach as it adequately addressed patients' main complaint of low self-esteem.
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Affiliation(s)
- M Dupuis
- Pulmonology Department, University Hospital of Toulouse, 24, chemin de Pouvourville, 31059 Toulouse, France
| | - L Daussy
- Pulmonology Department, Albi Hospital, Albi, France
| | - E Noel-Savina
- Pulmonology Department, University Hospital of Toulouse, 24, chemin de Pouvourville, 31059 Toulouse, France
| | - M Dahan
- Thoracic surgery Department, Toulouse University Hospital, Toulouse, France
| | - A Didier
- Pulmonology Department, University Hospital of Toulouse, 24, chemin de Pouvourville, 31059 Toulouse, France
| | - J P Chavoin
- Plastic surgery Department, Toulouse University Hospital, Toulouse, France
| | - N Guibert
- Pulmonology Department, University Hospital of Toulouse, 24, chemin de Pouvourville, 31059 Toulouse, France.
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Dreher C, Reinsberg M, Oetzmann von Sochaczewski C, Siebert S, Strohm J, Kurz R, Ziegler AM, Heydweiller A, Yavuz ST. Changes in Pulmonary Functions of Adolescents with Pectus Excavatum Throughout the Nuss Procedure. J Pediatr Surg 2023; 58:1674-1678. [PMID: 36935229 DOI: 10.1016/j.jpedsurg.2023.02.057] [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: 10/16/2022] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND We aimed to determine the longitudinal changes in pulmonary functions of adolescents with Pectus Excavatum who underwent the Nuss procedure, the minimally invasive repair of pectus excavatum (MIRPE). METHODS Lung function measurements were performed before bar implantation (T0), at least six weeks to ten months after implantation (T1a), at least eleven months to sixty-one months after bar implantation (T1b) and at least two weeks after bar explantation (T2). RESULTS Data of 114 patients (83.3% male) whose median age at implantation was 15.6 years and at explantation 18.7 years were analyzed. Shortly after implantation at T1a a significant decline of vital capacity (VC; n = 82), forced vital capacity (FVC; n = 78) and forced expiratory volume in 1 second (FEV1; n = 80) compared to T0 was seen. At T1b a significant decline for the residual volume (RV; n = 83), the residual volume/total lung capacity ratio (RV/TLC; n = 81), the total specific airway resistance (sRaw; n = 80) and the total airway resistance (Raw; n = 84) also compared to T0 was measured. In the comparison of T1b to T2 a significant increase of VC, FVC (n = 67), FEV1 (n = 69), TLC (n = 67) and a significant decrease of Raw (n = 66), sRaw, RV (n = 65) and the RV/TLC (n = 64) ratio could be observed. In the direct analysis between T0 and T2, after the explantation of the bar a significant increase in VC (n = 54), FVC (n = 52), and TLC (n = 55) and a significant decrease of RV (n = 51) and the RV/TLC index (n = 50), and in airway resistance parameters like Raw (n = 52) and sRaw (n = 51) could be detected. CONCLUSIONS Lung function values along with markers of airway resistance improve in patients after the complete procedure of MIRPE. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Charlotte Dreher
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany
| | - Max Reinsberg
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany
| | | | - Stephanie Siebert
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany
| | - Joanna Strohm
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Ralf Kurz
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Anna-Maria Ziegler
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Andreas Heydweiller
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Suleyman Tolga Yavuz
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany.
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Acipayam A, Güllü UU, Güngör Ş. Cardiac anomalies in pediatric patients with pectus excavatum. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20221301. [PMID: 37466586 DOI: 10.1590/1806-9282.20221301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/28/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVE Pectus excavatum is the most prevalently encountered deformity of the thoracic wall. It can be accompanied by congenital anomalies. METHODS The cardiac findings of 36 children who were diagnosed at the Thoracic surgery outpatient clinic of our university between 10 February 2021 and 1 October 2021 and 57 healthy children in a similar age group were analyzed. RESULTS We determined that the pectus excavatum patients in our study had a higher risk of having mitral insufficiency, mitral valve prolapse, tricuspid valve prolapse, cardiac malposition, and congenital heart disease. CONCLUSION Our study showed that the prevalence of cardiac pathologies was higher in pediatric pectus excavatum patients than in healthy children in the control group. Thus, we recommend clinicians to refer pediatric pectus excavatum patients to pediatric cardiology outpatient clinics for the early diagnosis of potential cardiac pathologies.
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Affiliation(s)
- Ahmet Acipayam
- Kahramanmaraş Sütçü İmam University, Faculty of Medicine, Department of Thoracic Surgery - Kahramanmaras, Turkey
| | - Utku Ufuk Güllü
- Hatay Mustafa Kemal University, Faculty of Medicine, Department of Pediatric Cardiology - Antakya, Turkey
| | - Şükrü Güngör
- Kahramanmaraş Sütçü İmam University, Faculty of Medicine, Department of Pediatric Gastroenterology, Hepatology and Nutrition - Kahramanmaras, Turkey
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Caro C, Freude W, Florek A, Morgenstern S, Boeer B, Roehm C, Hahn M, Marx M. Simultaneous correction of a pectus excavatum with tubular breast deformity using a custom-made silicone implant. Arch Gynecol Obstet 2021; 303:1025-1037. [PMID: 33389096 DOI: 10.1007/s00404-020-05898-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
Pectus excavatum (PE) is one of the most common congenital deformities of the thorax and is characterized by a depressed sternum with reduction of the antero-posterior thoracic diameter. Although the majority of patients with PE have no physiologic limitations, it is often associated with psychological problems influencing the patients' quality of life. Surgical treatment options show particular variation with regard to invasiveness and morbidity of the respective procedures. Surgical treatment using a custom-made silicone implant represents a less invasive alternative for patients without further accompanying physical symptoms. This article describes the simultaneous correction of a PE combined with tubular breast deformity using this minimally invasive technique.
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Affiliation(s)
- C Caro
- Department of Plastic, Reconstructive and Breast Surgery, Elbland Hospital Radebeul, Radebeul, Germany
| | - W Freude
- Department of Plastic, Reconstructive and Breast Surgery, Elbland Hospital Radebeul, Radebeul, Germany
| | - A Florek
- Department of Plastic, Reconstructive and Breast Surgery, Elbland Hospital Radebeul, Radebeul, Germany
| | - S Morgenstern
- Department of Plastic, Reconstructive and Breast Surgery, Elbland Hospital Radebeul, Radebeul, Germany
| | - B Boeer
- Department of Women's Health, University of Tübingen, Tübingen, Germany
| | - C Roehm
- Department of Women's Health, University of Tübingen, Tübingen, Germany
| | - M Hahn
- Department of Women's Health, University of Tübingen, Tübingen, Germany
| | - M Marx
- Department of Plastic, Reconstructive and Breast Surgery, Elbland Hospital Radebeul, Radebeul, Germany.
- Department of Women's Health, University of Tübingen, Tübingen, Germany.
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ACIPAYAM A, TOKUR M. Minimal İnvaziv Pektus Ekskavatum Ameliyatı: Tek Merkez Deneyimi. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2021. [DOI: 10.17944/mkutfd.833764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Wang Q, Fan S, Wu C, Jin X, Pan Z, Hong D. Changes in resting pulmonary function testing over time after the Nuss procedure: A systematic review and meta-analysis. J Pediatr Surg 2018; 53:2299-2306. [PMID: 29550038 DOI: 10.1016/j.jpedsurg.2018.02.052] [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] [Received: 12/20/2017] [Revised: 02/09/2018] [Accepted: 02/09/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Pectus excavatum, the most common congenital chest wall deformity in pediatric patients, leads to pulmonary dysfunction. There is no consensus regarding the effectiveness of the Nuss procedure for recovering pulmonary function. In this meta- analysis, we focused on the changes that occur in pulmonary function after the Nuss procedure. METHODS We performed a literature search in the MEDLINE, Embase, Cochrane library and PubMed databases. The included studies were required to contain pulmonary function tests with results adjusted to predicted values both before and after the Nuss procedure. The key outcomes of interest in this analysis were pulmonary function measured as forced expiratory volume in 1s (FEV1) and forced vital capacity (FVC). Subgroup analyses were performed based on time since surgery and the mean ages of the patients when they underwent surgery by forest plots and meta-regressions. RESULTS Thirteen studies involving 465 participants were included in this review. The standard mean difference (SMD) observed in FEV1 and FVC after surgery were 0.17 (95% CI, 0.01-0.33, p=0.04) and -0.18 (95% CI, -0.41-0.06, p=0.14), respectively. The overall meta-regression SMD of FEV1 and FVC by time since surgery were 1.21 (95% CI, 1.04-1.41, p=0.020) and 1.38 (95% CI, 1.05-1.83, p=0.027), respectively. We found evidence of a temporal relationship between time at which pulmonary function tests were performed after surgery and predicted FEV1 and FVC values. The SMD of FEV1 (0.26, p=0.012) was slightly higher in group evaluated more than 2year after initial surgery. CONCLUSIONS Abnormal resting pulmonary functions tests performed prior to surgery showed an initial depression after surgery. The FEV1 of patients slightly increased at 2year post surgery compared with the baseline. Further studies with longer term follow-up are still needed to determine if pulmonary function could improve to normal after surgery. LEVELS OF EVIDENCE Level of evidence: 4 (based on lowest level of article analyzed in meta-analysis/systematic review).
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Affiliation(s)
- Quan Wang
- Cardiothoracic surgery of Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China international Science and Technology Cooperation base of Child development and Critical Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China.
| | - Shulei Fan
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
| | - Chun Wu
- Cardiothoracic surgery of Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China international Science and Technology Cooperation base of Child development and Critical Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China.
| | - Xianqing Jin
- Cardiothoracic surgery of Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China international Science and Technology Cooperation base of Child development and Critical Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China.
| | - Zhengxia Pan
- Cardiothoracic surgery of Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China international Science and Technology Cooperation base of Child development and Critical Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China.
| | - Daqing Hong
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
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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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Velazco CS, Arsanjani R, Jaroszewski DE. Nuss procedure in the adult population for correction of pectus excavatum. Semin Pediatr Surg 2018; 27:161-169. [PMID: 30078487 DOI: 10.1053/j.sempedsurg.2018.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.
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Affiliation(s)
- Cristine S Velazco
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States.
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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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Chao CJ, Jaroszewski D, Gotway M, Ewais M, Wilansky S, Lester S, Unzek S, Appleton CP, Chaliki HP, Gaitan BD, Mookadam F, Naqvi TZ. Effects of Pectus Excavatum Repair on Right and Left Ventricular Strain. Ann Thorac Surg 2018; 105:294-301. [DOI: 10.1016/j.athoracsur.2017.08.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/07/2017] [Accepted: 08/07/2017] [Indexed: 10/18/2022]
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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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Akyüz Özkan E, Khosrashahi HE, Serin Hİ, Metin B, Kılıç M, Geçit UA. Cardiac and arterial elastance and myocardial wall stress in children with pectus excavatum. Interact Cardiovasc Thorac Surg 2016; 23:4-8. [PMID: 26993478 PMCID: PMC4986733 DOI: 10.1093/icvts/ivw054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/08/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Pectus excavatum (PE) is one of the most common skeletal deformities of childhood. The study was undertaken to assess cardiac functions in children with PE. METHODS Echocardiography was performed on 32 children with PE and 40 age-matched healthy controls. The following parameters were monitored: meridional left ventricular (LV) wall stress (WSM), arterial elastance (Ea), LV elastance at end-systole derived by single beat (Ees(sb)), LV circumferential end-systolic wall stress (ESWSc), midwall shortening fraction (SFmid), predicted midwall fiber shortening for a measured fiber stress (midwall VCFc), myocardial fiber stress (MFS), LV end-systolic dimension (LVES), LV end-diastolic dimension (LVED) and end-systolic blood pressure (Pes), LV wall thickness at end-systole (hes). To assess the severity of PE, Haller index (HI) was calculated by computed tomography of the thorax. RESULTS SFmid, ESWSc, midwall VCFc and MFS were lower in PE children than in controls. The degree to which the parameters SFmid, ESWSc, midwall VCFc and MFS were altered in PE children was 14.9, 27.5, 20.3 and 20.3%, respectively. The minimum HI value of children with PE was 2.00, the maximum value was 4.93 and the arithmetic mean was 2.62 ± 0.56. Of the 32 children, 14 (43.75%) demonstrated mild deformity, 15 (46.88%) showed moderate and only 3 (9.37%) had severe deformity. In children with PE, there was no statistically significant correlation between the cardiac data (ESWSc, midwall VCFc, MFS, Ea, Ees(sb), LVES, LVED, Pes, hes) and HI. CONCLUSION We found ESWSc, MFS, midwall VCFc and SFmid to be lower in children with PE than in controls. We concluded that the myocardial contractility and afterload is affected in children with PE.
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Affiliation(s)
- Esra Akyüz Özkan
- Department of Pediatrics, Bozok University Medical Faculty, Yozgat, Turkey
| | - Hashem E Khosrashahi
- Department of Pediatric Cardiology, Bozok University Medical Faculty, Yozgat, Turkey
| | | | - Bayram Metin
- Department of Thoracic Surgery, Bozok University Medical Faculty, Yozgat, Turkey
| | - Mahmut Kılıç
- Department of Public Health, Bozok University Medical Faculty, Yozgat, Turkey
| | - U Aliye Geçit
- Department of Pediatrics, Bozok University Medical Faculty, Yozgat, Turkey
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Udholm S, Maagaard M, Pilegaard H, Hjortdal V. Cardiac function in adults following minimally invasive repair of pectus excavatum. Interact Cardiovasc Thorac Surg 2016; 22:525-9. [PMID: 26860899 DOI: 10.1093/icvts/ivw007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 11/12/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To study if minimally invasive repair of pectus excavatum (PE) in adult patients would improve cardiopulmonary function at rest and during exercise as we have found previously in young and adolescent patients with PE. METHODS Nineteen adult patients (>21 year of age) were studied at rest and during bicycle exercise before surgery and 1 year postoperatively. Lung spirometry was performed at rest. Cardiac output, heart rate and aerobic exercise capacity were measured using a photo-acoustic gas-rebreathing technique during rest and exercise. Data are shown as mean ± standard deviation. RESULTS Fifteen patients completed the 1-year follow-up. No significant differences were found in neither cardiac output (14.0 ± 0.9 l min at baseline vs 14.8 ± 1.1 l min after surgery; P = 0.2029), nor maximum oxygen uptake (30.4 ± 1.9 and 33.3 ± 1.6 ml/kg/min; P = 0.0940 postoperatively). The lung spirometry was also unchanged, with no difference in forced expiratory capacity during the first second. CONCLUSIONS Correction of PE in adult patients does not improve the cardiopulmonary function 1 year after surgery as seen in children and adolescents.
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Affiliation(s)
- Sebastian Udholm
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Denmark
| | - Marie Maagaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Denmark
| | - Hans Pilegaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Denmark
| | - Vibeke Hjortdal
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Denmark
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Chao CJ, Jaroszewski DE, Kumar PN, Ewais MM, Appleton CP, Mookadam F, Gotway MB, Naqvi TZ. Surgical repair of pectus excavatum relieves right heart chamber compression and improves cardiac output in adult patients—an intraoperative transesophageal echocardiographic study. Am J Surg 2015; 210:1118-24; discussion 1124-5. [DOI: 10.1016/j.amjsurg.2015.07.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/15/2015] [Accepted: 07/16/2015] [Indexed: 12/24/2022]
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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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Lee RT, Moorman S, Schneider M, Sigalet DL. Bracing is an effective therapy for pectus carinatum: interim results. J Pediatr Surg 2013; 48:184-90. [PMID: 23331813 DOI: 10.1016/j.jpedsurg.2012.10.037] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 10/13/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pectus Carinatum is a common congenital chest wall malformation. Until recently the mainstay of treatment was surgical remodeling of the deformed chest wall. Initial results suggest that non-operative bracing may be an effective therapy, but the optimal strategy for correction is not known. Herein we report the results of a self-adjustable low profile bracing system worn continuously until the defect is corrected (correction phase), then worn at night (8 h/day) until completion of axial growth (maintenance phase)-the Calgary Protocol. METHODS Patients referred to a pediatric surgery chest wall clinic were prospectively asked to join an IRB approved outcomes monitoring study. 124 patients were evaluated from 2007 to 2011, and 98 were prescribed a brace and counseled to follow the protocol. RESULTS 98 patients consented to follow-up at starting bracing age: 14.4 ± 1.9 years, Tanner stage: 3.6 ± 0.5, protrusion: 2.1 ± 1.0 cm, self-rating of appearance: 2.9 ± 1.1, and exercise tolerance: 4.4 ± 1.1 (1-5 with 5 = normal). 10 patients are in correction phase, and 44 patients have completed correction after 7.0 ± 7.3 months: Tanner stage: 3.8 ± 0.1, protrusion: 0.5 ± 0.6 cm*, appearance: 4.3 ± 0.3* and exercise tolerance 4.6 ± 1.0. Correction occurred more quickly in patients prior to achieving Tanner stage IV (4.2 ± 0.9 months) vs. Tanner stage IV (8.0 ± 7.1 months) at the beginning of bracing. 21 patients completed maintenance bracing after 17.9 ± 19.0 months: Tanner stage: 3.9 ± 0.2, protrusion 0.5 ± 0.7 cm*, appearance: 4.3 ± 0.9*, and exercise tolerance: 4.8 ± 1.4. Average follow-up after bracing is 13.9 ± 16.0 months (mean ± S.D., *P < .05). There was one recurrence, likely due to early discontinuation of maintenance. This responded to an additional 6 months of bracing. 42 patients failed therapy secondary to non-compliance or were lost in follow up, while 2 patients did not respond to bracing and required open operation. CONCLUSIONS If patients are compliant, a self- adjusting brace system can give rapid correction of the pectus carinatum protrusion with excellent patient satisfaction. These interim results suggest that continued bracing until skeletal maturity gives long term durability to the correction. Further studies will be required to further refine this promising therapy.
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Affiliation(s)
- Richy T Lee
- Department of Pediatric Surgery, Alberta Children's Hospital, Calgary, Alberta, Canada.
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21
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Chen Z, Amos EB, Luo H, Su C, Zhong B, Zou J, Lei Y. Comparative pulmonary functional recovery after Nuss and Ravitch procedures for pectus excavatum repair: a meta-analysis. J Cardiothorac Surg 2012; 7:101. [PMID: 23020904 PMCID: PMC3504562 DOI: 10.1186/1749-8090-7-101] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 09/23/2012] [Indexed: 12/05/2022] Open
Abstract
Background Pectus excavatum (PE) is a common chest wall malformation, with surgery being the only method known to correct the defect. Although the Nuss and Ravitch procedures are commonly used, there is no consensus as to whether surgical repair improves pulmonary function. We therefore investigated whether pulmonary function recovers after surgical repair, and if recovery is dependent on the type of procedure or time after surgery. Methods Literature searches were performed using PubMed, EMBASE, Health Periodicals Database, and CNKI (Chinese National Knowledge Index) from January 1990 to December 2007. The following keywords were used: pectus excavatum, chest wall deformity, funnel chest, pulmonary function, respiratory, lung function, and pectus severity index. The primary outcome of interest was possible changes in pulmonary function following surgical repair. Results Meta-analysis of 23 studies showed that, although there was evidence of statistically significant heterogeneity among studies (Chi-square, 17.11, p < 0.05), changes in pulmonary functional indices, including forced expiratory volume over 1 s (FEV1), forced vital capacity (FVC), vital capacity (VC), and total lung capacity (TLC), were similar 1 year after the Ravitch and Nuss procedures. Several years after surgery and bar removal, however, the changes in pulmonary functional indices significantly favored the Nuss procedure. Conclusions Pulmonary function tends to improve after the surgical correction of pectus excavatum. Although the Nuss procedure was not significantly better 1 year after surgery, long-term postoperative pulmonary function improvement was significantly better after bar removal.
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Affiliation(s)
- Zhenguang Chen
- Department of Thoracic Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.
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22
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Tang M, Nielsen HHM, Lesbo M, Frokiaer J, Maagaard M, Pilegaard HK, Hjortdal VE. Improved cardiopulmonary exercise function after modified Nuss operation for pectus excavatum. Eur J Cardiothorac Surg 2011; 41:1063-7. [DOI: 10.1093/ejcts/ezr170] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Minimally invasive repair of pectus excavatum deformity. Eur J Cardiothorac Surg 2010; 39:149-58. [PMID: 20739187 DOI: 10.1016/j.ejcts.2010.07.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 07/15/2010] [Accepted: 07/19/2010] [Indexed: 11/21/2022] Open
Abstract
This review is trying to address the effectiveness and sustainability of results following minimally invasive repair of pectus excavatum (MIRPE). The aim is to present these results for the benefit of clinicians and the patients. Literature search has revealed 179 hits, which were independently assessed and led to 80 publications being formally reviewed. Studies reporting results from less than 10 patients were excluded. Thirty-five studies were found to be reporting results from patients' and/or surgeons' perspective and they were included in this review. Data from the United Kingdom registry for MIRPE were also included. Results from over 2997 patients (age: <1-85 years) who had MIRPE and 1393 patients who had their metallic bar removed were assessed. The most common indication for surgery was cosmesis. There was a net gain with regard to self-esteem for 96-100% of the individuals. A percentage of procedures (0-20%) was assessed by surgeons as having an 'unsatisfactory outcome' and a number of patients (0-25%) reported an 'unsatisfactory end result.' However, these percentages are not necessarily referring to the same patients and an unsatisfactory result does not seem to affect the positive effect on self-esteem. The reported changes in social life, lung capacity, cardiovascular capacity, exercise capacity and general health are based on weak data and significant improvements, if any, are probably seen in a limited number of patients. The metallic bars were removed after 1.5-4.5 years and there is an overall 0-4.5% reported recurrence post-bar removal. In conclusion, MIRPE may improve cosmesis and self-esteem of patients with pectus excavatum deformity. Direct or indirect improvement in other physiological parameters may also help the 'well-being' of these patients and their social integration. There is a clear need for standardisation in the way results are reported in the literature and a socioeconomic analysis with regard to gains, benefits and costs related to MIRPE.
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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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25
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Cardiac Function Assessed by Transesophageal Echocardiography During Pectus Excavatum Repair. Ann Thorac Surg 2010; 89:240-3. [DOI: 10.1016/j.athoracsur.2009.06.126] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 05/30/2009] [Accepted: 06/04/2009] [Indexed: 11/23/2022]
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Kim M, Lee KY, Park HJ, Kim HY, Kang EY, Oh YW, Seo BK, Je BK, Choi EJ. Development of new cardiac deformity indexes for pectus excavatum on computed tomography: feasibility for pre- and post-operative evaluation. Yonsei Med J 2009; 50:385-90. [PMID: 19568601 PMCID: PMC2703762 DOI: 10.3349/ymj.2009.50.3.385] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 10/29/2008] [Accepted: 10/29/2008] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim of this study was to evaluate new cardiac deformity indexes (CDIs) for diagnosis of pectus excavatum as well as morphological assessment of heart on computed tomography (CT). MATERIALS AND METHODS We retrospectively evaluated the CT images of the control group (n=200), and the pectus excavatum before and after correction groups (n=178), and calculated the CDIs; cardiac compression index (CCI), and cardiac asymmetry index (CAI). We also calculated chest wall compression index (CWCI) and asymmetry index (CWAI) on the axial images. We performed logistic regression analysis using each index and age as predictor variables. RESULTS The CDIs (CCI and CAI) were significant (p < 0.05) in the diagnosis of pectus excavatum, regardless of age (p = 0.4033, p = 0.8113). The CWCI and CWAI were significant (p < 0.05) and significantly affected by age (p < 0.05). If we selected 1.82 as the cutoff of the CCI, the sensitivity and specificity were 99.4% and 98%, respectively. The following cutoffs and the sensitivity and specificity were obtained: 1.15 for the CAI gave 94.4% and 94.5%, 3.05 for the CWCI gave 92.1% and 92%, and 1 for the CWAI gave 62.4% and 65%, respectively. The CCI after repair improved from 2.83 +/- 0.84 to 1.84 +/- 0.33, while the CWCI improved from 4.49 +/- 1.61 to 2.57 +/- 0.44. CONCLUSION CDIs such as the CCI and CAI may be potentially useful to detect and estimate repair for pectus excavatum.
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Affiliation(s)
- Miyoung Kim
- Department of Diagnostic Radiology, Korea University Hospital, Ansan, Korea
| | - Ki Yeol Lee
- Department of Diagnostic Radiology, Korea University Hospital, Ansan, Korea
| | - Hyung Joo Park
- Department of Thoracic Surgery, Korea University Hospital, Ansan, Korea
| | - Hee-Young Kim
- Department of Biostatistics, Korea University Hospital, Ansan, Korea
| | - Eun-Young Kang
- Department of Diagnostic Radiology, Korea University Hospital, Ansan, Korea
| | - Yu Whan Oh
- Department of Diagnostic Radiology, Korea University Hospital, Ansan, Korea
| | - Bo Kyung Seo
- Department of Diagnostic Radiology, Korea University Hospital, Ansan, Korea
| | - Bo Kyung Je
- Department of Diagnostic Radiology, Korea University Hospital, Ansan, Korea
| | - Eun Jung Choi
- Department of Diagnostic Radiology, Korea University Hospital, Ansan, Korea
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Al-Assiri A, Kravarusic D, Wong V, Dicken B, Milbrandt K, Sigalet DL. Operative innovation to the "Nuss" procedure for pectus excavatum: operative and functional effects. J Pediatr Surg 2009; 44:888-92. [PMID: 19433163 DOI: 10.1016/j.jpedsurg.2009.01.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Accepted: 01/15/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The "Nuss" procedure for repair of pectus excavatum is performed with increasing frequency worldwide. We describe a technique of performing relaxing or "kerf" incisions along the cartilaginous ribs at the point of maximal chest wall concavity to facilitate retrosternal dissection and to reduce chest wall tension. The effects on operative parameters and long-term changes in cardiopulmonary function and appearance were evaluated prospectively. METHODS Thirty patients underwent a Nuss procedure for the period from 2001 to 2004. Fifteen patients underwent a modified Nuss (MN) with sternocostal "relaxing" incisions, and these were compared to 15 patients undergoing a standard Nuss (SN). Data were prospectively gathered and included the number of relaxing incisions, bar number, blood loss, duration of epidural analgesia, number of days to discharge, and preoperative and postoperative cardiopulmonary function measures. RESULTS The average Haller index of the SN group was 3.9 +/- 0.7 vs MN group index of 4.6 +/- 1.6 (P < .05). The median number of relaxing incisions in the study group was 4.0 +/- 0.7 (range 3 - 8). There were no significant differences between the study groups in any of the operative parameters analyzed, including blood loss, days of epidural requirements or days to reach functional independence. Nor were there differences in the improvement in subjective appearance, complications, pulmonary function, cardiac output at rest, oxygen transport or minute ventilation at maximal exercise. Subjectively, bar positioning and the intraoperative visualization was easier with the relaxing incisions. CONCLUSIONS The addition of sternocostal relaxing incisions to the standard Nuss procedure appears to facilitate retrosternal dissection and bar placement, but no changes in long-term function or cosmesis were noted. The use of relaxing incisions appears to be safe and may facilitate operative visualization of retrosternal structures.
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Affiliation(s)
- Ali Al-Assiri
- Division of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
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Durkin ET, Shaaban AF. Recent advances and controversies in pediatric laparoscopic surgery. Surg Clin North Am 2008; 88:1101-19, viii. [PMID: 18790157 DOI: 10.1016/j.suc.2008.05.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Children represent a unique group of patients who are likely to greatly benefit from minimally invasive surgery (MIS). The promise of less postoperative pain, smaller scars, shorter hospital stays, and a faster return to school continues to drive growth in this area. The development of pediatric-specific techniques and documentation of improved outcomes form a critical gateway to widespread application of pediatric MIS. A brief perspective on current approaches to MIS for pediatric congenital and acquired disease is provided in this report. Technical departures from standardized adult MIS and the rationale for their modification are highlighted.
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Affiliation(s)
- Emily T Durkin
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA
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Johnson JN, Hartman TK, Pianosi PT, Driscoll DJ. Cardiorespiratory function after operation for pectus excavatum. J Pediatr 2008; 153:359-64. [PMID: 18534622 DOI: 10.1016/j.jpeds.2008.03.037] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 01/17/2008] [Accepted: 03/17/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We performed a review of current data to determine the effect that operation has on pulmonary function, aerobic capacity, and stroke volume in patients with pectus excavatum. STUDY DESIGN Two reviewers independently assessed clinical trials and collected data on interventions and outcomes. To qualify for inclusion, a study had to include preoperative and postoperative assessment, provide outcomes in either a published percentile or qualified matched control form to control for interval growth, and include only original patient groups. RESULTS Postoperative total lung capacity for patients who had Ravitch repair was significantly lower (SMD, 0.71 [CI -1.06, -0.36]; I(2) = 19.6%) than preoperative. Based on 2 studies after removal of the Nuss bar, FEV(1) was significantly increased from preoperative values (SMD, 0.39 [CI, 0.03, 0.74]; I(2) = 0%). Stroke volume increased after surgery (SMD, 0.40 [CI, 0.10, 0.70]; I(2) = 0%) after Ravitch repair. There was a trend toward improved exercise tolerance, but it was not statistically significant. CONCLUSIONS Total lung capacity was decreased after Ravitch repair, and FEV(1) was increased after Nuss bar removal. Stroke volume may be increased after Ravitch repair. Exercise tolerance was not improved after either type of surgical repair.
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Affiliation(s)
- Jonathan N Johnson
- Department of Pediatrics, Mayo Clinic College of Medicine, Rochester, MN, USA
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Nakagawa Y, Uemura S, Nakaoka T, Yano T, Tanaka N. Evaluation of the Nuss procedure using pre- and postoperative computed tomographic index. J Pediatr Surg 2008; 43:518-21. [PMID: 18358292 DOI: 10.1016/j.jpedsurg.2007.10.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Objective assessment of the chest in patients with pectus excavatum after the Nuss procedure has not been published. This study evaluated the results of the Nuss procedure using computed tomographic (CT) index (CTi). METHODS We have performed the Nuss procedure in 382 patients since 1998, and 150 patients who underwent bar removal were included in this study. Computed tomographic scans were obtained before the Nuss procedure and after bar removal, and then preoperative CTi (pre-CTi) and postoperative CTi (post-CTi) were calculated. Computed tomographic scans of 62 age-matched patients without chest deformity were collected as controls. Patients were divided at 10 years of age into the younger and older groups, and groups with mild and severe deformity were defined using a pre-CTi value of 5 as border. These CT indices were compared and statistically analyzed. RESULTS Mean pre-CTi in all cases was 5.97 +/- 3.31 and improved to 3.08 +/- 0.64. Postoperative CTi was not significantly different from that of the control (2.47 +/- 0.32, P = .17). In the group with mild depression, pre-CTi was 4.15 +/- 0.62, and post-CTi was 2.88 +/- 0.50. Preoperative CTi in the group with severe deformity (7.44 +/- 3.82) improved to 3.25 +/- 0.69. Postoperative CTi values between the severe and mild groups were not significantly different (P = .75). Computed tomographic index of the young group improved from 6.20 +/- 3.58 to 2.93 +/- 0.49 and in older group from 5.50 +/- 2.64 to 3.40 +/- 0.79. These 2 post-CTi values were not significantly different (P = .73). CONCLUSION Postoperative CT scan could provide objective evaluation of sternal elevation. Mean CTi after the Nuss procedure was statically equivalent to that of the control cohort. Good sternal elevation can be achieved with the Nuss procedure regardless of the severity of chest depression or age.
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Affiliation(s)
- Yoshikiyo Nakagawa
- Department of Pediatric Surgery, Kawasaki Medical School, Kurashiki, Okayama 701-0192, Japan.
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Malek MH, Berger DE, Marelich WD, Coburn JW. On the application of meta-analysis in pectus excavatum research. Am J Cardiol 2008; 101:415-7. [PMID: 18237612 DOI: 10.1016/j.amjcard.2007.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Revised: 07/18/2007] [Accepted: 07/18/2007] [Indexed: 11/27/2022]
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Guntheroth WG, Spiers PS. Cardiac function before and after surgery for pectus excavatum. Am J Cardiol 2007; 99:1762-4. [PMID: 17560891 DOI: 10.1016/j.amjcard.2007.01.064] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Revised: 01/22/2007] [Accepted: 01/22/2007] [Indexed: 11/19/2022]
Abstract
A 2006 meta-analysis concluded that thoracic surgery for pectus excavatum (PE) significantly improves cardiovascular function. However, that analysis was flawed by a high level of heterogeneity in the outcomes and inappropriate methods in 5 of the 8 publications analyzed. Therefore, a search of the published research from 1965 to the present was conducted, and only 5 publications were found that reported studies of cardiac function before and after operation, including 118 patients and 82 unoperated controls. Cardiac function was studied most frequently by echocardiography, despite the limitations imposed by the abnormal anatomy of pectus excavatum, but only studies that did not report cardiac or left ventricular dimensions or output were excluded. Studies using indirect estimates on the basis of oxygen pulse, which depends on several other variables, were not included. No improvements were found in left ventricular size, stroke volume, and cardiac output after surgery in 4 of 5 studies, using radionuclides, 2-dimensional echocardiography, radiographic planimetry, and cardiac output by the Fick method. Only a single study, with volumes calculated by squaring the diameter of the left ventricle from M-mode echocardiography, reported an increase (22%) in left ventricular stroke volume after operation, but that increased (17%) in the investigators' unoperated controls. This and 2 other studies used in this meta-analysis were also included in a meta-analysis conducted by Malek et al. In a fourth study, Malek et al included only the first study that found an improvement, but the final study reported no improvement. In conclusion, there is no reliable documentation of improved cardiac function from thoracic surgery for pectus excavatum.
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Affiliation(s)
- Warren G Guntheroth
- Department of Pediatrics, Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA.
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Sigalet DL, Montgomery M, Harder J, Wong V, Kravarusic D, Alassiri A. Long term cardiopulmonary effects of closed repair of pectus excavatum. Pediatr Surg Int 2007; 23:493-7. [PMID: 17252283 DOI: 10.1007/s00383-006-1861-y] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The closed or "Nuss" repair of pectus excavatum is widely accepted for correction of moderate to severe deformities. Patients typically report significant subjective improvements in pulmonary symptoms, and short and medium term evaluations (up to 2 years with the bar in place) suggest modest improvement to cardiac function but a decrease in pulmonary function. This study examined the effects at 3 months post-bar removal of closed repair of pectus on pulmonary function, exercise tolerance and cardiac function. Patients were followed prospectively after initial evaluation for operation. All patients underwent preoperative and post-bar removal evaluation with CT scan, complete pulmonary function and exercise testing to anaerobic threshold, as well as echocardiogram. Twenty-six patients have completed the follow up protocol. Preoperative CT index was 4.5 +/- 1.3, average age at operation was 13.2 years, and average tanner stage was 3.5 +/- 0.5. At 3 months or greater follow-up post-bar removal, patients reported an improvement in subjective ability to exercise and appearance (P < 0.05 by wilcoxin matched pairs). Objective measures of FEV1, total lung capacity, diffusing lung capacity, O(2) pulse, VO(2max), and respiratory quotient all showed significant improvement compared to preoperative values, while normalized values of cardiac index at rest did not (All values normalized for height and age, comparisons P < 0.05 by student's paired t test). These results demonstrate a sustained improvement in cardiopulmonary function after bar removal following closed repair of pectus excavatum. These findings contrast with results from previous studies following the open procedure, or with the closed procedure at earlier time points; the long term physiological effects of closed repair of pectus excavatum include improved aerobic capacity, likely through a combination of pulmonary and cardiac effects.
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Affiliation(s)
- David L Sigalet
- Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, Canada.
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Schalamon J, Pokall S, Windhaber J, Hoellwarth ME. Minimally invasive correction of pectus excavatum in adult patients. J Thorac Cardiovasc Surg 2006; 132:524-9. [PMID: 16935105 DOI: 10.1016/j.jtcvs.2006.04.038] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Revised: 03/29/2006] [Accepted: 04/20/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The repair of pectus excavatum by minimally invasive surgery (Nuss procedure) is well established among pediatric surgeons. Studies on adult patients are rare. We analyzed the efficacy of minimally invasive pectus repair in a series of adult patients. METHODS We prospectively included all adult patients with minimally invasive repair of funnel chest treated from 2000 to 2005. The pectus bar was inserted under thoracoscopic control. On the right side a stabilizer was used to prevent bar displacement. Postoperative pain control was provided by epidural catheters. Clinical checks were performed 2 weeks, 3 months, and then annually after discharge. RESULTS Forty-three adult patients (39 men, 4 women) with a mean age of 22 years (range 18-39 years) were included. Mean duration of the operative procedures was 70 minutes (range 29-125 minutes); mean length of hospital stay was 9.3 days. Bars were removed from 15 patients 3 years after implantation. Minor complications occurred in 8 patients (19%), with intrapleural effusions being most frequent (n = 5). Three patients (7%) had major complications: drainage of a pneumothorax (n = 2) and bar displacement (n = 1). The cosmetic results were excellent and patient satisfaction was high. CONCLUSIONS We conclude that the Nuss procedure was beneficial in adult patients. Dislocation of the pectus bar can be prevented by submuscular placement. The use of corticosteroids may be helpful in case of repeated, uncontaminated pleural effusions. Patient satisfaction and the acceptable number and kind of complications are encouraging.
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Malek MH, Berger DE, Housh TJ, Marelich WD, Coburn JW, Beck TW. Cardiovascular Function Following Surgical Repair of Pectus Excavatum. Chest 2006; 130:506-16. [PMID: 16899852 DOI: 10.1378/chest.130.2.506] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Despite numerous published reports, there is no consensus in the literature as to whether the surgical repair of the pectus excavatum improves cardiovascular function. As a result, it has been suggested that correction should be considered a cosmetic procedure, and therefore, many health insurance companies have questioned whether the repair of the pectus excavatum improves cardiovascular function and thus are reluctant to authorize the procedure. The purpose of this study was to apply metaanalysis methodology to generate a quantitative synthesis of the effects of surgical repair on cardiovascular function and to test the hypothesis that surgical repair of the pectus excavatum results in significant improvements in cardiovascular function. METHODS Studies were retrieved via computerized literature searches, cross-referencing from original and review articles, and a review of the reference list by a recognized authority in the area of pectus excavatum repair. The inclusion criteria were as follows: (1) reporting quantitative measures of preoperative and postoperative cardiovascular function; (2) published in the English language; (3) indexed between January 1960 and May 2005; (4) reporting the duration between which preoperative and postoperative assessments were conducted; and (5) describing the cardiovascular assessment procedures. RESULTS A comprehensive search of the literature identified eight studies that met all of the inclusion criteria. These studies, representing 169 pectus excavatum patients, were used for the metaanalysis. Random-effects modeling yielded a mean weighted effect size (ES) for cardiovascular function that was statistically significant (ES, 0.59; 95% confidence interval, 0.25 to 0.92; p = 0.0006). CONCLUSIONS The findings of the present study indicated that surgical repair of the pectus excavatum significantly improves cardiovascular function and contradicts arguments that surgical repair is primarily cosmetic yielding minimal physiologic improvement.
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Affiliation(s)
- Moh H Malek
- Human Performance Laboratory, Department of Nutrition and Health Sciences, University of Nebraska-Lincoln, Lincoln, 68583-0806, USA.
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Abstract
PURPOSE OF REVIEW The management of pediatric lung and chest wall diseases has changed dramatically in the last decade because of the application of minimally invasive surgical techniques. This review will try to highlight some of the more significant recent contributions. RECENT FINDINGS Most of the papers quoted will show that the application of minimally invasive surgery to the treatment of common problems such as empyema, pneumothorax, and lung biopsy has significantly altered our treatment algorithms, because of decreased morbidity and improved outcomes compared to standard surgical or medical treatment plans. This has also been true for pediatric chest wall deformities, which previously were treated in only the most severe cases and thought to be mostly cosmetic in nature. More recent reports now show statistically significant improvements in cardio-pulmonary physiology as well as quality of life. SUMMARY The application of less invasive surgical procedures for lung and chest wall diseases has warranted earlier intervention, with better outcomes, and less morbidity than previously used techniques. A clear understanding of these techniques and their benefits is important for the referring and treating physician as previously used treatment protocols may no longer provide the best patient care.
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Abstract
Marfan's syndrome is a systemic disorder of connective tissue caused by mutations in the extracellular matrix protein fibrillin 1. Cardinal manifestations include proximal aortic aneurysm, dislocation of the ocular lens, and long-bone overgrowth. Important advances have been made in the diagnosis and medical and surgical care of affected individuals, yet substantial morbidity and premature mortality remain associated with this disorder. Progress has been made with genetically defined mouse models to elucidate the pathogenetic sequence that is initiated by fibrillin-1 deficiency. The new understanding is that many aspects of the disease are caused by altered regulation of transforming growth factor beta (TGFbeta), a family of cytokines that affect cellular performance, highlighting the potential therapeutic application of TGFbeta antagonists. Insights derived from studying this mendelian disorder are anticipated to have relevance for more common and non-syndromic presentations of selected aspects of the Marfan phenotype.
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Affiliation(s)
- Daniel P Judge
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
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