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Kwong JZ, Gulack BC. Non-surgical approaches to the management of chest wall deformities. Semin Pediatr Surg 2024; 33:151388. [PMID: 38219537 DOI: 10.1016/j.sempedsurg.2024.151388] [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: 01/16/2024]
Abstract
Chest wall deformities in children encompass a broad spectrum of disorders but pectus excavatum and carinatum are by far the most common. Treatment varies substantially by center, and depends on patient symptoms, severity of disease, and surgeon preference. Historically, surgical approaches were the mainstay of treatment for these disease processes but new advances in non-surgical approaches have demonstrated reasonable results in select patients. These non-surgical approaches include vacuum bell therapy, autologous fat grafting and hyaluronic acid injections for pectus excavatum, and orthotic brace therapy for pectus carinatum. There is debate with regards to optimal patient selection for these non-surgical approaches, as well as other barriers including reimbursement issues. This paper will review the current non-surgical approaches to chest wall deformities available, including optimal patient selection, treatment protocols, indications, contraindications, and outcomes.
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Affiliation(s)
- Jacky Z Kwong
- General Surgery Resident, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Brian Ch Gulack
- General Surgery Resident, Department of Surgery, Rush University Medical Center, Chicago, IL, USA.
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2
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van Braak H, de Beer SA, Zwaveling S, Oomen MWN, de Jong JR. Ravitch Surgery or Dynamic Compression Bracing for Pectus Carinatum: A Retrospective Cohort Study. Ann Thorac Surg 2024; 117:144-150. [PMID: 36395878 DOI: 10.1016/j.athoracsur.2022.10.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pectus carinatum is a pediatric condition that can be treated by dynamic compression system (DCS) bracing or surgery. Several publications on DCS bracing or surgery are available; however, they do not compare both treatments. METHODS Over a 10-year period, 738 patients with pectus carinatum were treated at the Amsterdam Pectus Center (Amsterdam, The Netherlands). This study describes this 10-year experience and the results of both treatments. RESULTS Of the 631 patients who underwent DCS bracing treatment, 553 finished treatment, and 78 patients are still under treatment. A total of 73.8% (n = 408) of these patients finished treatment successfully, 13.6% (n = 75) experienced treatment failure, and 12.7% (n = 70) were lost to follow-up. The success rate decreased with an increasing pressure of initial compression (84.2%-67.3%). Marfan syndrome and Poland syndrome were associated with unfavorable results. Ravitch surgery was performed in 105 patients, with a success rate of 92.4%. Complications occurred in 32.4% of patients, and 6.7% of patients had complications for which surgery was needed. No relationship was found between osteotomy or sternal fixation and outcomes or complications. The Abramson procedure was performed in 2 patients. CONCLUSIONS DCS bracing should be the treatment of choice in patients with pectus carinatum because of its noninvasiveness, good results, and lower complication rate compared with surgery. Besides pressure of initial correction, motivation is an important factor influencing outcomes, and compliance remains a major challenge in treating pectus carinatum using DCS bracing. Bracing patients before their growth spurt should be discouraged. Patients with a higher pressure of initial compression (>8.0-8.5 psi) and Marfan syndrome or Poland syndrome have poorer outcomes. In those patients, surgery may be considered.
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Affiliation(s)
- Hendrik van Braak
- Department of Pediatric Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Sjoerd A de Beer
- Department of Pediatric Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Sander Zwaveling
- Department of Pediatric Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Matthijs W N Oomen
- Department of Pediatric Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Justin R de Jong
- Department of Pediatric Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Alaca N, Arslan DÇ, Alaca İ, Yüksel M. Psychometric properties of the Turkish version of the Pectus Carinatum Evaluation Questionnaire used in patients with pectus carinatum treated with compression orthosis. Prosthet Orthot Int 2023; 47:313-320. [PMID: 36037280 DOI: 10.1097/pxr.0000000000000173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/01/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Pectus Carinatum Evaluation Questionnaire (PCEQ) was developed for use in patients with pectus carinatum (PC) treated with compression orthosis. The questionnaire can be used to develop a strict program in the early follow-up period or to improve patients' compliance with the treatment after treatment initiation and to improve the quality of life. OBJECTIVE This study aimed to evaluate the psychometric properties of the Turkish version of the PCEQ in patients with PC treated with compression orthosis. STUDY DESIGN Validity and reliability study. METHODS This study included 52 volunteer patients with PC, aged 10-18 years. The Cronbach α coefficient, a measure of internal consistency, was used to check questionnaire reliability, and test-retest reliability (intraclass correlation coefficient) was used to check consistency over time. Construct validity was analyzed (correlation analysis) with the days/hours of orthosis use. RESULTS The reliability of the Turkish version of the PCEQ was found to have acceptable-to-sufficient-to-excellent internal consistency (Cronbach α coefficient = 0.701-915). Test-retest reliability calculated for investigating the reliability of the questionnaire over time was found to be excellent (intraclass correlation coefficient = 0.880-0.941). Furthermore, treatment compliance hours (r = 0.280, P = 0.044) and days (r = 0.299, P = 0.032) were found to be associated with parents' influence at a low level and with time to compliance at a moderate level (r = -0.449-457, P = 0.001). CONCLUSION The Turkish version of the PCEQ used in patients with PC treated with compression orthosis was found to have sufficient-to-excellent validity and reliability and could be used to develop a strict program for patients with PC using the orthosis or to improve patients' treatment compliance after treatment initiation. Using this questionnaire may be important to assist the team members in the clinical decision-making process.
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Affiliation(s)
- Nuray Alaca
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Dilek Çağrı Arslan
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - İhsan Alaca
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
- Chest Wall Deformities and Pectus Association, Istanbul, Turkey
| | - Mustafa Yüksel
- Chest Wall Deformities and Pectus Association, Istanbul, Turkey
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Geraedts TCM, Daemen JHT, Vissers YLJ, Hulsewé KWE, Van Veer HGL, Abramson H, de Loos ER. Minimally invasive repair of pectus carinatum by the Abramson method: A systematic review. J Pediatr Surg 2022; 57:325-332. [PMID: 34969524 DOI: 10.1016/j.jpedsurg.2021.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this review is to provide an overview of the outcomes after minimally invasive pectus cartinatum repair (MIRPC) by the Abramson method to determine its effectiveness. METHODS The PubMed and Embase databases were systematically searched. Data concerning subjective postoperative esthetic outcomes after initial surgery and bar removal were extracted. In addition, data on recurrence, complications, operative times, blood loss, post-operative pain, length of hospital stay, planned time to bar removal and reasons for early bar removal were extracted. The postoperative esthetic result, was selected as primary outcome since the primary indication for repair in pectus carinatum is of cosmetic nature. RESULTS Six cohort studies were included based on eligibility criteria, enrolling a total of 396 patients. Qualitative synthesis showed excellent to satisfactory esthetic results in nearly all patients after correctional bar placement (99.5%, n = 183/184). A high satisfaction rate of 91.0% (n = 190/209) was found in patients after bar removal. Recurrence rates were low with an incidence of 3.0% (n = 5/168). The cumulative postoperative complication rate was 26.5% (n = 105/396), of whom 25% required surgical re-intervention. There were no cases of mortality. CONCLUSIONS Minimally invasive repair of pectus carinatum through the Abramson method is effective and safe. Its efficacy is demonstrated by the excellent to satisfactory esthetic results in 99.5% and 91.0% of patients after respectively correctional bar placement and implant removal. Future studies should aim to compare different treatment options for pectus carinatum in order to elucidate the approach of choice for different patient groups.
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Affiliation(s)
- Tessa C M Geraedts
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Jean H T Daemen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands; Faculty of Health, Medicine and Life Sciences (FHML), School for Oncology and Developmental Biology (GROW), Maastricht, the Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Hans G L Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium; BREATHE Laboratory, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Horacio Abramson
- Surgical Thoracic Service, Hospital Antonio Cetrángolo, Vicente Lopez, Buenos Aires, Argentina
| | - Erik R de Loos
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands.
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Duncan Phillips J, Hoover JD. Chest Wall Deformities and Congenital Lung Lesions. Surg Clin North Am 2022; 102:883-911. [DOI: 10.1016/j.suc.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bergmann F, Muensterer OJ. [Chest Wall Deformities in Children and Adolescents]. Zentralbl Chir 2021; 147:74-82. [PMID: 34963176 DOI: 10.1055/a-1657-0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Chest wall deformities as a whole are relatively common in children and adolescents, although they comprise a wide spectrum of entities, some of them rare. Pectus excavatum has the highest prevalence. While some patients are asymptomatic, others suffer from substantial limitations. All symptomatic patients should be offered treatment. Minimally invasive surgical correction is the more effective option of treatment, besides the alternative application of a suction bell. Pectus carinatum and combined manifestations of chest wall deformities can also lead to physiological and psychosocial impairment and require treatment tailored to the individual patient in such cases. Syndromal chest wall deformities, such as Jeune syndrome, comprise a separate group of rare diseases that are associated with considerable, occasionally life-threatening comorbidities. These patients should be cared for in centres with appropriate expertise in an interdisciplinary and multimodal manner. This review discusses the different chest wall deformities encountered in paediatric surgical practice, along with their significance and possible therapeutic approaches.
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Affiliation(s)
- Florian Bergmann
- Kinderchirurgische Klinik und Poliklinik, Dr. von Haunersches Kinderspital, LMU Klinikum, München, Deutschland
| | - Oliver J Muensterer
- Kinderchirurgische Klinik und Poliklinik, Dr. von Haunersches Kinderspital, LMU Klinikum, München, Deutschland
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Pollock L, Ridout A, Teh J, Nnadi C, Stavroulias D, Pitcher A, Blair E, Wordsworth P, Vincent TL. The Musculoskeletal Manifestations of Marfan Syndrome: Diagnosis, Impact, and Management. Curr Rheumatol Rep 2021; 23:81. [PMID: 34825999 PMCID: PMC8626407 DOI: 10.1007/s11926-021-01045-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 11/29/2022]
Abstract
Purpose of Review
Marfan syndrome (MFS) is an autosomal dominant heritable disorder of fibrillin-1 (FBN1) with predominantly ocular, cardiovascular, and musculoskeletal manifestations that has a population prevalence of approximately 1 in 5–10,000 (Chiu et al. Mayo Clin Proc. 89(1):34–42, 146, Dietz 3, Loeys et al. J Med Genet. 47(7):476–85, 4). Recent Findings The vascular complications of MFS still pose the greatest threat, but effective management options, such as regular cardiac monitoring and elective surgical intervention, have reduced the risk of life-threatening cardiovascular events, such as aortic dissection. Although cardiovascular morbidity and mortality remains high, these improvements in cardiovascular management have extended the life expectancy of those with MFS by perhaps 30–50 years from an estimated mean of 32 years in 1972 (Dietz 3, Gott et al. Eur J Cardio-thoracic Surg. 10(3):149–58, 147, Murdoch et al. N Engl J Med. 286(15):804–8, 148). The musculoskeletal manifestations of MFS, which to date have received less attention, can also have a significant impact on the quality of life and are likely to become more important as the age of the Marfan syndrome population increases (Hasan et al. Int J Clin Pract. 61(8):1308–1320, 127). In addition, musculoskeletal manifestations are often critically important in the diagnosis of MFS. Summary Here, we review the main clinically relevant and diagnostically useful musculoskeletal features of MFS, which together contribute to the “systemic features score” (referred to hereafter as systemic score), part of the revised Ghent nosology for MFS. We discuss current treatment strategies and highlight the need for a multidisciplinary approach to diagnosis and management. Finally, we review new pharmacological approaches that may be disease modifying and could help to improve the outcome for individuals with this syndrome.
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Affiliation(s)
- Lily Pollock
- Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
| | - Ashley Ridout
- Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James Teh
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, England, UK
| | - Colin Nnadi
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Alex Pitcher
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Edward Blair
- Department of Clinical Genetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Wordsworth
- Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Tonia L Vincent
- Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK. .,Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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A new minimally invasive technique for correction of pectus carinatum. J Cardiothorac Surg 2021; 16:280. [PMID: 34583717 PMCID: PMC8480000 DOI: 10.1186/s13019-021-01663-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 09/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background The Abramson technique for the correction of pectus carinatum (PC) is commonly performed worldwide. However, the postoperative complications of this technique related to bar fixation, including wire breakage and bar displacement, are relatively high. In this study, a new minimally invasive technique for correction of PC is described, in which the pectus bar is secured by bilateral selected ribs, and for which no special fixation to the rib is needed. Methods The procedure was performed by placing the pectus bar subcutaneously over the sternum with both ends of the bar passing through the intercostal space of the selected rib at the anterior axillary line. The protruding sternum was depressed by the bar positioned in this 2 intra- and 2 extra-thorax manners. Between October 2011 and September 2019, 42 patients with PC underwent this procedure. Results Satisfactory cosmetic results were obtained in all the patients. The mean operation time was 87.14 min, and the mean postoperative stay was 4.05 days. Wound infection occurred in 3 patients, 2 were cured by antibiotics, and 1 received bar removal 4 months after the initial operation due to the exposure of the implant resulting from uncontrolled infection. Mild pneumothorax was found in 3 patients and cured by conservative treatment. One patient suffered from hydropneumothorax, which was treated with chest drainage. The bars were removed at a mean duration of 24.4 months since primary repair in 20 patients without recurrence. Conclusions This new technique for minimally invasive correction of PC deformity is a safe and feasible procedure yielding good results and minimal complications.
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Giray E, Ermerak NO, Bahar-Ozdemir Y, Kalkandelen M, Yuksel M, Gunduz OH, Akyuz G. A Comparative Study on Short-Term Effects of Compression Orthosis and Exercises in the Treatment of Pectus Carinatum: A Randomized Controlled Pilot Feasibility Trial. Eur J Pediatr Surg 2021; 31:147-156. [PMID: 32146715 DOI: 10.1055/s-0040-1701699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Pectus carinatum (PC) is a congenital chest wall deformity which is characterized by the protrusion of the sternum and costal cartilages. Although orthotic and exercise therapies are commonly offered by physicians for PC treatment, there is a lack of evidence on the benefits of exercises and how long the orthosis should be worn. The aim of this study is to investigate the effects and feasibility of custom-made compression orthosis and exercises in the treatment of PC. MATERIALS AND METHODS Patients with PC aged 7 to 17 years old were randomized into three groups: compression orthosis 23 hours, compression orthosis 8 hours, and control group. All groups received exercises for 1 hour a day for 3 weeks. Additionally, compression orthosis 23 hours group wore the orthosis for 23 hours a day, while compression orthosis 8 hours group wore the orthosis for 8 hours a day. PC protrusion, pressure of correction, thorax lateral and anteroposterior parameters, external chest wall measurements, and Nuss Questionnaire were evaluated before and after the treatment. Also, adverse effects, retention, and compliance were assessed. Feasibility was evaluated by calculating the percentages of recruitment, retention, and safety. RESULTS The compression orthosis 23 hours group showed greater improvements than the other groups. After treatment, all groups showed significant changes in protrusion, pressure of correction, and external chest wall measurements. Adverse events occurred with similar frequency across groups. Retention percentages did not differ among groups. CONCLUSION Compression orthosis use for 23 hours can be recommended rather than its use for 8 hours because 23 hours of orthosis use has better correction and similar adverse effects.
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Affiliation(s)
- Esra Giray
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
| | - Nezih Onur Ermerak
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Yeliz Bahar-Ozdemir
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
| | - Melihat Kalkandelen
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
| | - Mustafa Yuksel
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Osman Hakan Gunduz
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
| | - Gulseren Akyuz
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
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Does physiotherapy applied in conjunction with compression brace treatment in patients with pectus carinatum have efficacy? A preliminary randomized-controlled study. Pediatr Surg Int 2020; 36:789-797. [PMID: 32424499 DOI: 10.1007/s00383-020-04675-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Non-invasive treatment of pectus carinatum (PC) deformity includes the use of a compression brace and exercises. In this study, we aimed to examine the effect of a physiotherapy protocol applied as adjunct to compression brace treatment in patients with PC. METHODS The study included 30 male patients between 11 and 18 years of age. Patients were randomly assigned into two groups: a brace treatment only group (Group 1) and a brace and physiotherapy group (Group 2). Patient demographics and disease-related properties, protrusion measurements, postural evaluations, deformity perceptions, life quality, and treatment satisfaction were evaluated. RESULTS Although both groups showed improvements based on external chest measurements related to PC protrusion following treatment (p < 0.001), Group 2 had more benefit from the treatment (effect size > 0.36) and displayed greater improvement in maximum protrusion degree and lateral length values (p < 0.05). Additionally, we found that patient perception of deformity, posture, psychological life quality, and treatment satisfaction scores were significantly better in Group 2 (p < 0.05). CONCLUSION Owing to the satisfaction and additional benefits observed in the physiotherapy group, we think that a proper cardiopulmonary and musculoskeletal exercise program should be applied concurrently with brace treatment for patients with PC deformity. Nevertheless, long-term outcomes need to be clarified in future studies.
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Fraser S, Harling L, Patel A, Richards T, Hunt I. External Compressive Bracing With Initial Reduction of Pectus Carinatum: Compliance Is the Key. Ann Thorac Surg 2019; 109:413-419. [PMID: 31557482 DOI: 10.1016/j.athoracsur.2019.08.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 07/01/2019] [Accepted: 08/08/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND To assess the impact of manipulation and a tailored program for compressive bracing on the quality of life of patients with flexible pectus carinatum. METHODS Two hundred forty-nine sequential patients attending a clinic for assessment of pectus carinatum deformities underwent outpatient manipulation and then followed a prescribed schedule of continuous external compressive bracing but without significant progressive tightening. RESULTS There was successful sustained reduction of the deformity in 244 patients with high reported rates of concordance (98%) and satisfaction (94%). Patients experienced a reduction in symptoms of anxiety and depression (P < .001) and had improved body satisfaction (P < .001). Mild skin irritation occurred in 18% of patients (n = 44), and there were 2 severe cases of skin irritation, 1 of which resulted in abandonment of bracing. CONCLUSIONS Manipulation and nontightening compressive bracing was associated with complete concordance, high levels of successful bracing, improved confidence, and reduced psychological morbidity.
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Affiliation(s)
- Stephanie Fraser
- Department of Thoracic Surgery, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Leanne Harling
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Akshay Patel
- Department of Thoracic Surgery, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Tom Richards
- Department of Thoracic Surgery, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Ian Hunt
- Department of Thoracic Surgery, St George's Hospital NHS Foundation Trust, London, United Kingdom.
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Abstract
Awareness of pectus carinatum has increased among the medical community over the last several decades, as innovative options for nonsurgical treatments have become more widely known. Management alternatives have shifted from open resective to minimally invasive
strategies, and finally, to reshaping the chest using both surgical and non-surgical modalities. We aim to review the evolution of the diagnosis
and treatment of pectus carinatum up to its current management.
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Dekonenko C, Dorman RM, Pierce A, Orrick BA, Juang D, Aguayo P, Fraser JD, Oyetunji TA, Snyder CL, St Peter SD, Holcomb GW. Outcomes Following Dynamic Compression Bracing for Pectus Carinatum. J Laparoendosc Adv Surg Tech A 2019; 29:1223-1227. [PMID: 31241400 DOI: 10.1089/lap.2019.0171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Children with pectus carinatum (PC) are particularly vulnerable to psychosocial effects of poor body image, even though they may not experience physical symptoms. Nonoperative treatment with orthotic bracing is effective in PC correction. We describe our experience with dynamic compression bracing (DCB) for PC patients and their satisfaction with bracing. Materials and Methods: Prospective institutional data of patients undergoing DCB from July 2011 to June 2018 were reviewed and analyzed for those who entered the retainer mode after correction, defined by a correction pressure of <1 psi. A telephone survey was conducted regarding their bracing experience and satisfaction with the outcome on a scale of 1-10. Results: Of 460 PC patients, 144 reached the retainer mode. Median time to retainer mode was 5.5 months. There was no statistically significant relationship between initial correction pressure or carinatum height and time to retainer mode (P = .08 and P = .10, respectively). Fifty-seven percent were compliant with brace use, and median time to retainer mode in this subset was significantly shorter than noncompliant patients (3.5 months versus 10 months, P < .001). Fifty-three percent responded to the survey 13 months [interquartile ratios 3, 33] after the last clinic visit. The main barrier to compliance with wearing the brace was discomfort (37%), while the main motivation for compliance was appearance (58%). All endorsed bracing as worthwhile, with 94% reporting a satisfaction rating of 8 or greater for the correction outcome. Conclusion: DCB is effective in achieving correction of PC in compliant patients. Regardless of time to retainer mode, patients reported high satisfaction with bracing.
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Affiliation(s)
| | - Robert M Dorman
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Amy Pierce
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Beth A Orrick
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - David Juang
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | | | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - George W Holcomb
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
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Port E, Hebal F, Hunter CJ, Malas B, Reynolds M. Measuring the impact of brace intervention on pediatric pectus carinatum using white light scanning. J Pediatr Surg 2018; 53:2491-2494. [PMID: 30257811 DOI: 10.1016/j.jpedsurg.2018.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/25/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evaluation of Pectus Carinatum (PC) deformity in patients undergoing bracing is limited to subjective assessment of the chest through physical exam and photography. White Light Scanning (WLS) is a novel 3D imaging modality and offers an objective alternative that is quick, inexpensive, and safe. We previously demonstrated the feasibility of using a WLS-derived proxy for Haller index, called the Hebal-Malas Index (HMI), in measuring the surgical correction of Pectus Excavatum. The purpose of this study was to demonstrate the use of WLS to measure the severity of pre- and postbracing intervention of PC deformities and assess corrected difference between the two scans. METHODS We conducted a prospective review of preintervention WLS scans in pediatric patients with PC from 2015 to 2017. HMI was obtained from the preintervention and postintervention WLS scans. Analysis assessed the differences of pre- and postbracing intervention of measurements. RESULTS Of 32 patients with both pre- and postbracing scans, 13 (34%) showed improvement of more than 10%, 21 (55%) showed slight improvement of 1%-10%, and 4 (11%) did not improve at follow-up. The average postbracing change in the WLS-derived HMI was 0.10 (SD:0.11). The average length of bracing days was 331.4 (SD: 127.3) with an average of 6.8 h worn per day. Compliance was defined as patient reported utilization of the brace. Patients who were compliant showed a significant improvement (p = 0.004) compared to those who were not compliant (Table 2). However, even patients with moderate compliance still improved in many instances. Change in height was a significant factor correlating with improvement. Children who grew more while wearing a brace showed greater improvement in their deformity. CONCLUSION Using this technique, we have the ability to objectively quantify the impact of bracing on the severity of PC deformity and measure change in deformity over time. TYPE OF STUDY Prospective study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Elissa Port
- Ann and Robert H. Lurie Children's Hospital of Chicago.
| | | | | | - Bryan Malas
- Ann and Robert H. Lurie Children's Hospital of Chicago
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Muntean A, Stoica I, Saxena AK. Pigeon chest: comparative analysis of surgical techniques in minimal access repair of pectus carinatum (MARPC). World J Pediatr 2018; 14:18-25. [PMID: 29500788 DOI: 10.1007/s12519-018-0121-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/08/2017] [Accepted: 07/17/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND After minimally invasive repair for pectus excavatum (MIRPE), similar procedures for pectus carinatum were developed. This study aimed to analyse the various published techniques of minimal access repair for pectus carinatum (MARPC) and compare the outcomes. DATA SOURCES Literature was reviewed on PubMed with the terms "pectus carinatum", "minimal access repair", "thoracoscopy" and "children". RESULTS Twelve MARPC techniques that included 13 articles and 140 patients with mean age 15.46 years met the inclusion criteria. Success rate of corrections was n = 125, about 89% in cumulative reports, with seven articles reporting 100%. The complication rate was 39.28%. Since the pectus bar is placed over the sternum and has a large contact area, skin irritation was the most frequent morbidity (n = 20, 14.28%). However, within the complication group (n = 55), wire breakage (n = 21, 38.18%) and bar displacement (n = 10, 18.18%) were the most frequent complications. Twenty-two (15.71%) patients required a second procedure. Recurrences have been reported in four of twelve techniques. There were no lethal outcomes. CONCLUSIONS MARPC techniques are not standardized, as MIRPE are, so comparative analysis is difficult as the only common denominator is minimal access. Surgical morbidity is high in MARPC and affects > 2/3rd patients with about 15% requiring surgery for complication management.
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Affiliation(s)
- Ancuta Muntean
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, 369 Fulham Road, London, SW109NH, UK
- Department of Paediatric Surgery, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Ionica Stoica
- Department of Paediatric Surgery, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Amulya K Saxena
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, 369 Fulham Road, London, SW109NH, UK.
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16
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Wahba G, Nasr A, Bettolli M. A less intensive bracing protocol for pectus carinatum. J Pediatr Surg 2017; 52:1795-1799. [PMID: 28196662 DOI: 10.1016/j.jpedsurg.2017.01.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/16/2017] [Accepted: 01/21/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Despite the widespread use of bracing to correct Pectus carinatum (PC) there is no consensus in the number of hours per day patients are instructed to wear the brace. In our practice, we use a less rigorous protocol of 8-12h/day. We sought to evaluate our results and those in the literature to determine whether more intensive usage is necessary. STUDY DESIGN We reviewed the outcomes of patients with PC treated at our institution between 2012 and 2015. We searched MEDLINE, EMBASE and Web of Science for studies describing the use of bracing to correct PC. RESULTS Seventy-five patients presented with PC at our institution. Among those who were offered bracing and had adequate follow-up (n=32), the success rate (full correction or improvement) was 90.6%. The compliance rate was 93.8%. Fifteen studies met our inclusion criteria. Our pooled data combining our results with those of other published data showed that less intensive brace usage (<12h/day), when compared to more intensive usage (≥12h/day), is associated with higher patient compliance (89.6% vs. 81.1%) with a similar time to correction (7.3 vs 7.1months) and success rate (85.3% vs. 83.5%). CONCLUSIONS Implementing a less intensive bracing protocol for PC is successful, efficient and improves compliance. TYPE OF STUDY Clinical Research. LEVELS OF EVIDENCE Oxford Centre for Evidence-Based Medicine Level-of-Evidence rating: Level IV.
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Affiliation(s)
- George Wahba
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5
| | - Ahmed Nasr
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5; Department of Pediatric Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada K1H 8L1
| | - Marcos Bettolli
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5; Department of Pediatric Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada K1H 8L1.
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de Beer SA, Gritter M, de Jong JR, van Heurn ELW. The Dynamic Compression Brace for Pectus Carinatum: Intermediate Results in 286 Patients. Ann Thorac Surg 2017; 103:1742-1749. [PMID: 28274516 DOI: 10.1016/j.athoracsur.2016.12.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/29/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Dynamic brace compression is a novel treatment for patients with pectus carinatum. The dynamic compression system contains a device to measure the flexibility of the thoracic wall and regulate the pressure of the brace. METHODS Patients referred to our pediatric surgical center were screened for treatment with the dynamic compression brace. Patients with a pressure of initial correction (PIC) of 10.0 pounds per square inch or less were offered treatment with the brace. Patients with a PIC above 10.0 pounds per square inch were offered surgical correction. Between March 2013 and April 2016, 286 patients were treated with the brace; 260 were male (91%) and 26 were female (9%). Their mean age was 14 years (range, 4 to 21 years). RESULTS Seventy-eight patients completed brace treatment; the mean treatment time was 14 months. Twenty-seven patients abandoned treatment because of lack of motivation, loss to follow-up, persistent protrusion of the sternal bone or flaring that required surgical correction, failure of treatment because of a bifid rib, fear of locking the brace, and delayed correction. One hundred eighty-one patients are still wearing the brace, either in the active or in the retainer phase. Patients with a high PIC also showed improvement when they were compliant. Adverse events were minor and included skin lesions (n = 4, 1%) and vasovagal reactions at the start of therapy (n = 3, 1%). CONCLUSIONS These data show that brace therapy can be considered a valuable treatment option to correct pectus carinatum in patients with a flexible thorax.
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Affiliation(s)
- Sjoerd A de Beer
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC and VU University Medical Center, Amsterdam, The Netherlands.
| | - Martin Gritter
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC and VU University Medical Center, Amsterdam, The Netherlands
| | - Justin R de Jong
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC and VU University Medical Center, Amsterdam, The Netherlands
| | - Ernst L W van Heurn
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC and VU University Medical Center, Amsterdam, The Netherlands
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18
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Emil S, Sévigny M, Montpetit K, Baird R, Laberge JM, Goyette J, Finlay I, Courchesne G. Success and duration of dynamic bracing for pectus carinatum: A four-year prospective study. J Pediatr Surg 2017; 52:124-129. [PMID: 27836367 DOI: 10.1016/j.jpedsurg.2016.10.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 10/20/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study sought to establish factors that can prognosticate outcomes of bracing for pectus carinatum (PC). METHODS Prospective data were collected on all patients enrolled in a dynamic bracing protocol from July 2011 to July 2015. Pressure of correction (POC) was measured at initiation of treatment, and pressure of treatment (POT) was measured pre- and post-adjustment at every follow-up visit. Univariate and Cox regression analysis tested the following possible determinants of success and bracing duration: age, sex, symmetry, POC, and POT drop during the first two follow-up visits. RESULTS Of 114 patients, 64 (56%) succeeded, 33 (29%) were still in active bracing, and 17 (15%) failed or were lost to follow-up. In successful patients, active and maintenance bracing was 5.66±3.81 and 8.80±3.94months, respectively. Asymmetry and older age were significantly associated with failure. Multivariable Cox proportional hazard analysis of time-to-maintenance showed that asymmetry (p=0.01) and smaller first drop in POT (p=0.02) were associated with longer time to reach maintenance. CONCLUSIONS Pressure of correction does not predict failure of bracing, but older age, asymmetry, and smaller first drop in pressure of treatment are associated with failure and longer bracing duration. LEVEL OF EVIDENCE Prospective Study/Level of Evidence IV.
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Affiliation(s)
- Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre; Chest Wall Anomaly Center, Shriners Hospital for Children, Montreal, Canada.
| | - Marika Sévigny
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre; Chest Wall Anomaly Center, Shriners Hospital for Children, Montreal, Canada
| | - Kathleen Montpetit
- Chest Wall Anomaly Center, Shriners Hospital for Children, Montreal, Canada
| | - Robert Baird
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre; Chest Wall Anomaly Center, Shriners Hospital for Children, Montreal, Canada
| | - Jean-Martin Laberge
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre; Chest Wall Anomaly Center, Shriners Hospital for Children, Montreal, Canada
| | - Jade Goyette
- Chest Wall Anomaly Center, Shriners Hospital for Children, Montreal, Canada
| | - Ian Finlay
- Chest Wall Anomaly Center, Shriners Hospital for Children, Montreal, Canada
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19
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20
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Gonzalez KW, Dalton BGA, Poola AS, Marty Knott E, Kurtz B, Snyder CL, St Peter SD, Holcomb GW. The impact of developing a pectus center for chest wall deformities. Pediatr Surg Int 2016; 32:701-4. [PMID: 27278391 DOI: 10.1007/s00383-016-3904-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE In 2011, we established a dedicated center for patients with chest wall deformities. Here, we evaluate the center's effect on patient volume and management. METHODS A retrospective review of 699 patients with chest wall anomalies was performed. Patients were compared, based on the date of initial consultation, before the pectus center opened (July 2009-June 2011, Group 1) versus after (July 2011-June 2013, Group 2). Analysis was performed utilizing Chi-square and Mann-Whitney U tests. RESULTS 320 patients were in Group 1 and 379 in Group 2, an 18.4 % increase in patient volume. Excavatum patients increased from 172 (Group 1) to 189 (Group 2). Carinatum patients increased from 125 (Group 1) to 165 (Group 2). Patients undergoing operative repair of carinatum/mixed defects dropped significantly from 15 % (Group 1) to 1 % (Group 2) (p < 0.01), whereas those undergoing nonoperative bracing for carinatum/mixed defects rose significantly from 19 % (Group 1) to 63 % (Group 2) (p < 0.01). Patients traveled 3-1249 miles for a single visit. CONCLUSION Initiating a dedicated pectus center increased patient volume and provided an effective transition to nonoperative bracing for carinatum patients. The concentrated focus of medical staff dedicated to chest wall deformities has allowed us to treat patients on a local and regional level.
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Affiliation(s)
- Katherine W Gonzalez
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Brian G A Dalton
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Ashwini S Poola
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - E Marty Knott
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Brendan Kurtz
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - George W Holcomb
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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21
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Suh JW, Joo S, Lee GD, Haam SJ, Lee S. Minimally Invasive Repair of Pectus Carinatum in Patients Unsuited to Bracing Therapy. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:92-8. [PMID: 27066432 PMCID: PMC4825909 DOI: 10.5090/kjtcs.2016.49.2.92] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/27/2015] [Accepted: 09/30/2015] [Indexed: 11/16/2022]
Abstract
Background We used an Abramson technique for minimally invasive repair of pectus carinatum in patients who preferred surgery to brace therapy, had been unsuccessfully treated via brace therapy, or were unsuitable for brace therapy because of a rigid chest wall. Methods Between July 2011 and May 2015, 16 patients with pectus carinatum underwent minimally invasive surgery. Results The mean age of the patients was 24.35±13.20 years (range, 14–57 years), and all patients were male. The percentage of excellent aesthetic results, as rated by the patients, was 37.5%, and the percentage of good results was 56.25%. The preoperative and postoperative Haller Index values were 2.01±0.19 (range, 1.60–2.31), and 2.22±0.19 (range, 1.87–2.50), respectively (p-value=0.01), and the median hospital stay was 7.09±2.91 days (range, 5–15 days). Only one patient experienced postoperative complications. Conclusion Minimally invasive repair is effective for the treatment of pectus carinatum, even in adult patients.
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Affiliation(s)
- Jee-Won Suh
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine
| | - Seok Joo
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine
| | - Seok Jin Haam
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine
| | - Sungsoo Lee
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine
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Harrison B, Stern L, Chung P, Etemadi M, Kwiat D, Roy S, Harrison MR, Martinez-Ferro M. MyPectus: First-in-human pilot study of remote compliance monitoring of teens using dynamic compression bracing to correct pectus carinatum. J Pediatr Surg 2016; 51:608-11. [PMID: 26700692 DOI: 10.1016/j.jpedsurg.2015.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 10/13/2015] [Accepted: 11/10/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patient compliance is a crucial determinant of outcomes in treatments involving medical braces, such as dynamic compression therapy for pectus carinatum (PC). We performed a pilot study to assess a novel, wireless, real-time monitoring system (MyPectus) to address noncompliance. METHODS Eight patients (10-16years old) with moderately severe PC deformities underwent bracing. Each patient received a data logger device inserted in the compression brace to sense temperature and pressure. The data were transmitted via Bluetooth 4.0 to an iOS smartphone app, then synced to cloud-based storage, and presented to the clinician on a web-based dashboard. Patients received points for brace usage on the app throughout the 4-week study, and completed a survey to capture patient-reported usage patterns. RESULTS In all 8 patients, the data logger sensed and recorded data, which connected through all MyPectus system components. There were occasional lapses in data collection because of technical difficulties, such as limited storage capacity. Patients reported positive feedback regarding points. CONCLUSIONS The components of the MyPectus system recorded, stored, and provided data to patients and clinicians. The MyPectus system will inform clinicians about issues related to noncompliance: discrepancy between patient-reported and sensor-reported data regarding brace usage; real-time, actionable information; and patient motivation.
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Affiliation(s)
- Brittany Harrison
- University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, United States.
| | - Lily Stern
- University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, United States
| | - Philip Chung
- University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, United States
| | - Mozziyar Etemadi
- University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, United States
| | - Dillon Kwiat
- University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, United States
| | - Shuvo Roy
- University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, United States
| | - Michael R Harrison
- University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, United States
| | - Marcelo Martinez-Ferro
- Hospital Privado de Niños Fundación Hospitalaria, Cramer 4601, Capital Federal (C1429AKK), Buenos Aires, Argentina
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Martinez-Ferro M, Bellia Munzon G, Fraire C, Abdenur C, Chinni E, Strappa B, Ardigo L. Non-surgical treatment of pectus carinatum with the FMF ® Dynamic Compressor System. J Vis Surg 2016; 2:57. [PMID: 29078485 DOI: 10.21037/jovs.2016.02.20] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 02/04/2016] [Indexed: 11/06/2022]
Abstract
Pectus carinatum is a chest wall deformity, sometimes associated with physical signs and symptoms, but always associated to significant psychological distress. Surgical correction used to be the only solution, and was therefore only indicated for the most severe cases. Non-surgical approaches have been developed and improved during the last 15-20 years. A paradigm shift occured when the medical community realized that, despite the wall deformity, the chest wall was not completely rigid, but flexible and capable of remodeling. Several bracing devices and protocols are available as of today. This article will focus specifically in the FMF® Dynamic Compressor System (DCS), which was developed in Argentina in 2001 and is currently used worldwide.
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Affiliation(s)
- Marcelo Martinez-Ferro
- Department of Pediatric Surgery, Fundación Hospitalaria Private Children's Hospital, Buenos Aires, Argentina
| | - Gaston Bellia Munzon
- Department of Pediatric Surgery, Fundación Hospitalaria Private Children's Hospital, Buenos Aires, Argentina
| | - Carlos Fraire
- Department of Pediatric Surgery, Fundación Hospitalaria Private Children's Hospital, Buenos Aires, Argentina
| | - Constanza Abdenur
- Department of Pediatric Surgery, Fundación Hospitalaria Private Children's Hospital, Buenos Aires, Argentina
| | - Emilio Chinni
- Department of Pediatric Surgery, Fundación Hospitalaria Private Children's Hospital, Buenos Aires, Argentina
| | | | - Laura Ardigo
- Department of Pediatric Surgery, Fundación Hospitalaria Private Children's Hospital, Buenos Aires, Argentina
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Abstract
BACKGROUND Pectus carinatum is a congenital chest wall deformity characterized by protrusion of the sternum and adjacent costal cartilages. Multiple treatment options are available for correction of pectus carinatum. OBJECTIVE We report our initial experience with first-line treatment using a custom fitted dynamic compression orthosis. DESIGN Prospective evaluation of all patients seen between November 2013 and December 2014. SETTING University hospital. PATIENTS AND METHODS The treatment protocol for patients who had pressure for initial correction.
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Affiliation(s)
- Iskander S Al-Githmi
- Dr. iskander Soliman Al-Githmi, King Abdulaziz Unversity Hospital-Surgery, Division of Cardiothoracic Surgery, Adullah Al Suliman Street, Jeddah 21589 Saudi Arabia, T: 966 12 640 8346, F: +966 12 640 8347,
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25
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Abstract
The authors summarize a 32-year experience in the study and in the non-operative approach of pectus carinatum and pectus excavatum. Data of 4,012 patients with pectus deformities were collected from 1977 to January 2009, allowing evaluation on the etiology, pathogenesis and treatment of these deformities. Growth disturbances of anterior chest wall bones and cartilages were detected in imaging studies. Heredity, and biomechanical factors, like respiratory disturbances and scoliosis were noticed in more than 40% of the patients. The method of dynamic remodeling of the thorax – compressive orthoses simultaneously to exercises practice – was indicated in 2453 patients. Concomitant treatment with bending brace was provided in patients with 20° to 52° scoliosis. Of pectus patients with treatment indication, 1717 returned for re-evaluation: 1632 children and adolescents and 85 adults. Good results were seen in 60.6% of children and adolescents and in 27% of adults treated. No scoliosis patient presented curve worsening, and a case of 52° presented an improvement of 20° in the scoliosis with the treatment. Disturbances in the growth of the sternum and costal arches, as well as biomechanical factors related to the pathogenesis of pectus deformities, demonstrate how these deformities are correlated to orthopaedics. Appropriate evaluation of the anterior chest wall and concomitant treatment with bending brace are recommended in the presence of scoliosis. The dynamic remodeling method of the thorax requires a protocol of medical actions for a successful treatment.
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Affiliation(s)
- Sydney Abrão Haje
- Pediatric Orthopedist and Physiatrist, Orthopectus Clinical Center and Asa Norte Regional Hospital
| | - Davi de Podestá Haje
- Doctor in Orthopedics, School of Medicine, University de Sāo Paulo, Ribeirāo Preto, SP. Pediatric Orthopedist, Orthopectus Clinical Center. Preceptor, Adult Foot and Pediatric Orthopedics, Federal District Hospital, Brasilia, DF
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Pessanha I, Severo M, Correia-Pinto J, Estevão-Costa J, Henriques-Coelho T. Pectus Carinatum Evaluation Questionnaire (PCEQ): a novel tool to improve the follow-up in patients treated with brace compression. Eur J Cardiothorac Surg 2015; 49:877-82. [PMID: 26059874 DOI: 10.1093/ejcts/ezv198] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 05/04/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES A questionnaire (Pectus Carinatum Evaluation Questionnaire, PCEQ) was developed to be applied in follow-up of patients with Pectus Carinatum (PC). After validation of the PCEQ, we aimed to quantify the compliance to brace compression and to assess factors that could influence this treatment in patients with PC. METHODS From July 2008 to July 2014, 56 patients with PC were treated with the Calgary Protocol of compressive bracing at Paediatric Surgery Department of Hospital São João. Forty patients (71%) completed the questionnaire. The PCEQ was divided into four sections: (i) compliance; (ii) symptoms; (iii) social influence; (iv) activities. For the validation process of the PCEQ, principal components analysis (PCA), orthogonal varimax or oblimin rotation and Cronbach's α coefficient were used. To evaluate the association between compliance and other sections of the questionnaire, we estimated the Pearson's correlation between compliance factor scores ('Compliance Days' and 'Compliance Hours') and the final score of each new questionnaire component identified by PCA ('Chest Pain', 'Dyspnoea', 'Back Pain', 'Parents' Influence', 'Friends' Influence', 'Activities', 'Time To Compliance'). For the sections 'Symptoms', 'Social Influence' and 'Activities', we estimated final scores as the sum of the questions that constitute each component. For the section 'Compliance', the factor scores were estimated by the regression method. RESULTS After PCA analysis, the PCEQ found nine different components with high reliability. When analysing the compliance of our study group, the final score for 'Activities' revealed a significant correlation with the factor score for 'Compliance Hours' (r = 0.382, P = 0.015). The final score for 'Time To Compliance' showed a significant correlation with both factor scores for 'Compliance Hours' (r = -0.765, P < 0.001) and 'Compliance Days' (r = -0.345, P < 0.029). CONCLUSIONS The PCEQ seems to be an important tool to follow up patients with PC treated by brace compression. Practical steps, such as developing a tight schedule in the early follow-up period or applying the PCEQ in first visits after initiating brace therapy, can be taken in order to increase compliance with brace therapy and improve the quality of life.
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Affiliation(s)
- Inês Pessanha
- Department of Paediatric Surgery, Faculty of Medicine and Hospital S. João, Porto, Portugal
| | - Milton Severo
- Department of Medical Education and Simulation, Faculty of Medicine, Porto, Portugal
| | - Jorge Correia-Pinto
- Surgical Sciences, Life and Health Sciences Research Institute, University of Minho, Braga, Portugal
| | - José Estevão-Costa
- Department of Paediatric Surgery, Faculty of Medicine and Hospital S. João, Porto, Portugal
| | - Tiago Henriques-Coelho
- Department of Paediatric Surgery, Faculty of Medicine and Hospital S. João, Porto, Portugal
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27
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Kang DY, Jung J, Chung S, Cho J, Lee S. Factors affecting patient compliance with compressive brace therapy for pectus carinatum. Interact Cardiovasc Thorac Surg 2014; 19:900-3. [DOI: 10.1093/icvts/ivu280] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Wong KE, Gorton GE, Tashjian DB, Tirabassi MV, Moriarty KP. Evaluation of the treatment of pectus carinatum with compressive orthotic bracing using three dimensional body scans. J Pediatr Surg 2014; 49:924-7. [PMID: 24888836 DOI: 10.1016/j.jpedsurg.2014.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/27/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study is to measure the effectiveness of compressive orthotic brace therapy for the treatment of pectus carinatum using an adjusted Haller Index (HI) measurement calculated from 3D body scan (BS) images. METHODS Pediatric patients with pectus carinatum were treated with either compressive orthotic bracing or observation. An adjusted BS Haller index (HI) was calculated from serial 3D BS images obtained on all patients. Medical records were evaluated to determine treatment with bracing and brace compliance more than 12hours daily. Compliant patient measurements were compared to non-compliant and non-brace groups. RESULTS Forty patients underwent compressive orthotic bracing, while ten were observed. Twenty-three patients were compliant with bracing, and seventeen patients were non-compliant. Compliant patients exhibited an 8.2% increase, non-compliant patients had a 1.5% increase, and non-brace patients exhibited a 2.5% increase in BS HI. The change in BS HI of compliant patients was significantly different compared to non-brace patients (p=0.004) and non-compliant patients (p<0.001). CONCLUSIONS Three dimensional BS is an effective, radiation free, and objective means to evaluate patients treated with compressive orthotic bracing.
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Affiliation(s)
- Kaitlyn E Wong
- Baystate Children's Hospital, Springfield, MA; Shriners Hospitals for Children, Springfield, MA.
| | | | - David B Tashjian
- Baystate Children's Hospital, Springfield, MA; Shriners Hospitals for Children, Springfield, MA
| | - Michael V Tirabassi
- Baystate Children's Hospital, Springfield, MA; Shriners Hospitals for Children, Springfield, MA
| | - Kevin P Moriarty
- Baystate Children's Hospital, Springfield, MA; Shriners Hospitals for Children, Springfield, MA
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Lopez M, Patoir A, Varlet F, Perez-Etchepare E, Tiffet T, Villard A, Tiffet O. Preliminary study of efficacy of dynamic compression system in the correction of typical pectus carinatum. Eur J Cardiothorac Surg 2013; 44:e316-e319. [DOI: 10.1093/ejcts/ezt425] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Ateş O, Karakuş OZ, Hakgüder G, Olguner M, Akgür FM. Pectus carinatum: the effects of orthotic bracing on pulmonary function and gradual compression on patient compliance. Eur J Cardiothorac Surg 2013; 44:e228-e232. [DOI: 10.1093/ejcts/ezt345] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Abstract
PURPOSE OF REVIEW Pectus carinatum has been termed the undertreated chest wall deformity. Recent advances in patient evaluation and management, including the development of nonoperative bracing protocols, have improved the care of children with this condition. RECENT FINDINGS Recent evidence confirms that children with pectus carinatum have a disturbed body image and a reduced quality of life. Treatment has been shown to improve the psychosocial outcome of these patients. SUMMARY Patients with pectus carinatum are at risk for a disturbed body image and reduced quality of life. Until recently, treatment required surgical reconstruction. A growing body of literature, however, now supports the use of orthotic bracing as a nonoperative alternative in select patients. This article reviews the current literature and describes the evaluation and management of children with pectus carinatum deformity.
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Colozza S, Bütter A. Bracing in pediatric patients with pectus carinatum is effective and improves quality of life. J Pediatr Surg 2013; 48:1055-9. [PMID: 23701782 DOI: 10.1016/j.jpedsurg.2013.02.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 02/03/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to examine the effectiveness and patient satisfaction with bracing for pectus carinatum (PC). MATERIALS AND METHODS Twenty-five PC patients were treated between August 2007 and October 2011. Most patients were male (21/25,84%) with a mean age of 14.4 ± 2.0 yrs. A lightweight, patient controlled, external brace (Braceworks, Calgary, AB) was used. Monthly follow-up with anterior-posterior (AP) width measurements occurred until bracing was completed. Three quality of life (QOL) questionnaires were used: SF-36, SSQ, and PEEQ. RESULTS Group 1 involved twenty patients who successfully completed bracing (12/25,56%) or who are still bracing (8/25,32%). Group 2 comprised five patients who failed bracing (2/25,8%) or who were noncompliant (3/25,12%). One patient who failed bracing underwent successful Ravitch repair. AP width decreased more in those with successful bracing (2.31 vs 0.64 cm, p=0.05). Questionnaires were completed by 19/25 (76%) patients. Pre-bracing, the SF-36, and PEEQ revealed that few patients were symptomatic, although most still avoided activities which showed their chest. The SSQ revealed that the majority of patients were very satisfied with their post-bracing appearance, experienced minimal discomfort while bracing, and would use the brace again. Self-esteem increased significantly after bracing (7.5 vs 8.7, p=0.01). CONCLUSIONS Bracing in PC patients is very effective in a compliant patient with close follow-up. Surgical repair remains feasible if bracing fails.
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Affiliation(s)
- Sara Colozza
- Division of Pediatric Surgery, Children's Hospital, The University of Western Ontario, London, Ontario, Canada, N6A 4G5
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Cohee AS, Lin JR, Frantz FW, Kelly RE. Staged management of pectus carinatum. J Pediatr Surg 2013; 48:315-20. [PMID: 23414858 DOI: 10.1016/j.jpedsurg.2012.11.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 11/12/2012] [Indexed: 11/16/2022]
Abstract
AIM The aim was to report the treatment of pectus carinatum with a novel Argentine brace and operation. METHODS The bracing and clinical data of 137 consenting pectus carinatum patients treated between October 2008 and December 2011 were reviewed for outcome. Institutional approval was obtained. Data are reported as median (range). RESULTS Median age 122 bracing patients was 14 (10-28)years with 67 (55%) progressing under active treatment. Five patients (4%) were lost to follow-up, and thirteen (11%) failed treatment. Thirty-seven patients (30%) exhibited flattening of the sternum after 6 (1-24)months without surgery. After flattening, patients then wore the brace for progressively fewer hours each day as a "retainer" for 5 (3-19)months. Five patients (4%) experienced recurrence 5 (3-7)months after brace treatment was discontinued. Complications were limited to transient skin breakdown in nine patients. Three of the 13 Argentine brace failures and 15 other pectus carinatum patients were treated surgically. Thirteen underwent Abramson's minimally invasive operation and five an open repair, all with good initial correction. For Abramson repairs, seven patients have had bars removed, with results rated as excellent (n=4), good (n=2), and failure (n=1, converted to open with excellent result later). In three patients with stiff chests, costal cartilage was resected thoracoscopically during the Abramson repair with measurably improving compliance. CONCLUSION Staged treatment of pectus carinatum allows most teenagers to be managed non-operatively. For patients who fail bracing or are not amenable to bracing, minimally invasive surgical treatment for pectus carinatum is a viable option.
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Affiliation(s)
- Amy S Cohee
- Children's Hospital of The King's Daughters, Norfolk, VA 23507, USA
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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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Jung J, Chung SH, Cho JK, Park SJ, Choi H, Lee S. Brace compression for treatment of pectus carinatum. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:396-400. [PMID: 23275922 PMCID: PMC3530724 DOI: 10.5090/kjtcs.2012.45.6.396] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 08/09/2012] [Accepted: 08/16/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Surgery has been the classical treatment of pectus carinatum (PC), though compressive orthotic braces have shown successful results in recent years. We propose a non-operative approach using a lightweight, patient-controlled dynamic chest-bracing device. MATERIALS AND METHODS Eighteen patients with PC were treated between July 2008 and June 2009. The treatment involved fitting of the brace, which was worn for at least 20 hours per day for 6 months. Their degree of satisfaction (1, no correction; 4, remarkable correction) was measured at 12 months after the initiation of the treatment. RESULTS Thirteen (72.2%) patients completed the treatment (mean time, 4.9±1.4 months). In patients who completed the treatment, the mean overall satisfaction score was 3.73±0.39. The mean satisfaction score was 4, and there was no recurrence of pectus carinatum in patients who underwent the treatment for at least 6 months. Minimal recurrence of pectus carinatum after removal of the compressive brace occurred in 5 (38.5%) patients who stopped wearing the compressive brace at 4 months. CONCLUSION Compressive bracing results in a significant improvement in PC appearance in patients with an immature skeleton. However, patient compliance and diligent follow-up appear to be paramount for the success of this method of treatment. We currently offer this approach as a first-line treatment for PC.
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Affiliation(s)
- Joonho Jung
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Korea
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Repair of a floating sternum with autologous rib grafts and polylactide bioabsorbable struts in an 18-year-old male. J Pediatr Surg 2012; 47:e27-30. [PMID: 23217912 DOI: 10.1016/j.jpedsurg.2012.08.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 08/24/2012] [Accepted: 08/27/2012] [Indexed: 11/21/2022]
Abstract
Failed regeneration of costal cartilage after open repair of pectus chest wall deformities can result in a floating sternum. A floating sternum can be repaired by insertion of a rib graft between the rib and sternum, and stabilization with a metal strut. The metal implant is usually removed with a second operation. We report use of bioabsorbable struts to stabilize rib grafts during repair of a floating sternum in an 18-year-old male with a failed open repair of pectus carinatum. He had an uncomplicated peri-operative course. One year later, the sternum had a normal appearance and was sturdy. A second operation for removal of hardware was not necessary.
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Andreetti C, D'Andrilli A, Venuta F, Rendina EA. Sub-axillary access with the use of costal cartilages articulated bars for correction of pectus carinatum. Interact Cardiovasc Thorac Surg 2012; 16:209-10. [PMID: 23111343 DOI: 10.1093/icvts/ivs452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We describe an original technique for correction of pectus carinatum (PC) through a limited sub-axillary incision by chondrectomy and the use of costal cartilages articulated bars to stabilize the chest wall. We have developed this technique in order to improve the cosmetic results in the surgical treatment of even complex sterno-chondral deformities. The surgical incision is made along the lateral edge of the pectoralis major muscle in the sub-axillary region and its length is related to the number of costal cartilages to be treated. This technique is principally indicated for asymmetric PC with unilateral deformities of the costal cartilages, but its application can be extended to bilateral alteration of the parasternal cartilages by performing the sub-axillary incision bilaterally. When more than four cartilages are removed, the chest is stabilized by articulated bars made using cylindrical fragments obtained by the division of the removed costal cartilages. This thoracoplasty technique performed with a minimally invasive sub-axillary access is simple and safe. It allows the effective treatment of severe PC with either unilateral asymmetric or bilateral costal cartilages deformities, avoiding the median sternal incision and the use of the metallic bar.
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Affiliation(s)
- Claudio Andreetti
- Department of Thoracic Surgery, University of Rome La Sapienza, Sant'Andrea Hospital, Rome, Italy
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Bell R, Idowu O, Kim S. Minimally invasive repair of symmetric pectus carinatum: bilateral thoracoscopic chondrotomies and suprasternal compression bar placement. J Laparoendosc Adv Surg Tech A 2012; 22:921-4. [PMID: 23072407 DOI: 10.1089/lap.2012.0086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE We previously reported a novel minimally invasive repair for unilateral pectus carinatum. We have now modified this approach for the repair of symmetric bilateral pectus carinatum. MATERIALS AND METHODS Using thoracoscopy, parasternal chondrotomies were performed at multiple rib levels at points of maximal sternal protrusion. The sternum was depressed to an appropriate position and maintained using a suprasternal metal compression bar. The bar was applied in a submuscular plane and anchored to the lateral ribs with sutures. Bars were removed after 6 months. RESULTS Three patients with severe symmetric pectus carinatum underwent the repair. The first patient returned to the operating room after 1 month for repeat fixation of the bar after suture breakage. No other complications occurred. Operative times were comparable to published series. Patient satisfaction after the repair was good. CONCLUSIONS Minimally invasive thoracoscopic repair of symmetric pectus carinatum using chondrotomies and suprasternal bar compression is a feasible alternative to open repair.
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Affiliation(s)
- Robert Bell
- Department of Surgery, University of California San Francisco-East Bay, Oakland, California, USA
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Abstract
BACKGROUND Multiple treatment options currently exist for the correction of pectus carinatum (PC). We performed a survey of Canadian pediatric surgeons to define current practices. METHODS All active members of Canadian Association of Paediatric Surgeons were surveyed online during winter 2011 through the Canadian Association of Paediatric Surgeons Web site. The survey assessed multiple facets of PC evaluation and treatment, with particular emphasis on the practice of bracing. RESULTS Forty-five active members (85%) responded, of whom 32 (71%) currently treat PC. Fifty-three percent of practices are low volume (<5 patients annually). In terms of preferred or most used treatment modality, 69% of surgeons used bracing, 25% performed Ravitch repairs, 3% performed open minimal cartilage resections, and 3% performed reverse Nuss procedures. Of 23 surgeons (72%) who used bracing, 83% used it for most or the patients. Fifty-seven percent judged their bracing results as good or excellent, and 74% felt that most or all patients braced were satisfied; 80% and 88% agreed or strongly agreed that bracing was generally preferable to surgical repair and that bracing should be first line treatment, respectively. CONCLUSIONS Bracing is the preferred treatment for PC by most Canadian pediatric surgeons, despite lack of prospective outcome data. This presents an opportunity for a multicenter prospective study.
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Buchmann J, Arens U, Harke G, Kayser R, Smolenski U. Differenzialdiagnostik manualmedizinischer Syndrome des Thorax und des Abdomens unter Einbeziehung osteopathischer Verfahren. MANUELLE MEDIZIN 2011. [DOI: 10.1007/s00337-011-0843-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Patient satisfaction and clinical results 10 years after modified open thoracoplasty for pectus deformities. Langenbecks Arch Surg 2011; 396:1213-20. [PMID: 21779828 DOI: 10.1007/s00423-011-0827-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Accepted: 07/04/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Indications for surgical treatment for patients with pectus excavatum and carinatum are psychosocial issues, pulmonary or cardiac limitations or pain. When surgery is indicated in our institution, patients are treated with a modified thoracoplasty according to the Ravitch technique. In order to stabilize pectus excavatum, an allogenic bone strut is transplanted which does not require removal. PATIENT AND METHODS Seventy-one patients with a mean age of 17 years who were treated for pectus deformities between 1997 and 2007 were evaluated retrospectively. RESULTS The average period of follow-up was 5.3 years. Sixty-six percent of the patients suffered from pectus excavatum, 34% from pectus carinatum. One osseous revision had to be performed after overcorrection of pectus carinatum into pectus excavatum. Six minor complications occurred. At follow-up, the mean patient satisfaction score was 4.3 (scale 1-5). The Manchester Scar Scale resulted in 96% cosmetically well-healed scars. Clinically, 93% of the surgical results were rated good. CONCLUSIONS This study retrospectively shows that this modification of the Ravitch approach is a safe and effective treatment option for pectus deformities with long-term satisfactory results for the patients without the need for bar removal.
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Pérez D, Cano JR, Quevedo S, López L. New minimally invasive technique for correction of pectus carinatum. Eur J Cardiothorac Surg 2011; 39:271-3. [DOI: 10.1016/j.ejcts.2010.05.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 05/10/2010] [Accepted: 05/18/2010] [Indexed: 10/19/2022] Open
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Abstract
Pectus carinatum or keel chest is a spectrum of progressive inborn anomalies of the anterior chest wall, named after the keel (carina) of ancient Roman ships. It defines a wide spectrum of inborn protrusion anomalies of the sternum and/or the adjacent costal cartilages. Pectus carinatum is often associated with various conditions, notably Marfan disease, homocystinuria, prune belly, Morquio syndrome, osteogenesis imperfecta, Noonan syndrome, and mitral valve prolapse. Treatment of pectus carinatum by nonsurgical methods such as exercise and casting has not been worthwhile, whereas surgical management is simple and successful.
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Affiliation(s)
- Francis Robicsek
- Department of Thoracic and Cardiovascular Surgery, Sanger Heart and Vascular Institute, Carolinas Medical Center, 1001 Blythe Boulevard, Suite 300, Charlotte, NC 28203, USA.
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Thoracoscopic cartilage resection with partial perichondrium preservation in unilateral pectus carinatum: preliminary results. J Pediatr Surg 2011; 46:263-6. [PMID: 21238683 DOI: 10.1016/j.jpedsurg.2010.08.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Revised: 06/26/2010] [Accepted: 08/05/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND/PURPOSE Although minimally invasive repair of pectus excavatum has gained worldwide acceptance, treatment of pectus carinatum is mostly performed with open procedures. Different minimally invasive alternatives have been proposed in the last few years, including subpectoral CO(2) dissection and intrathoracic compression (Abramson technique), or conservative procedures, as dynamic compression system. Recently, another surgical technique has been proposed for the treatment of unilateral pectus carinatum, consisting of a thoracoscopic approach and multiple cartilage incisions. The aim of this work is to present our modification to this approach. METHODS We have modified this technique by introducing complete cartilage resection of all anomalous costal cartilages, performed thoracoscopically. Three thoracoscopic ports were used. Cartilage is removed progressively using a rongeur and preserving the anterior perichondrium. RESULTS We have performed this technique in 4 patients during the last year. Follow-up ranged from 6 to 14 months. No intraoperative or postoperative complications were observed. The results, assessed by the patients themselves, were good in 2 cases, quite good in one, and fair in the first patient of our series, who was reoperated using a classical open approach. Pain was well controlled without the need of an epidural catheter. CONCLUSION Thoracoscopic cartilage resection with perichondrium preservation can be considered as feasible alternative for the treatment of unilateral pectus carinatum.
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Haje SA, Haje DDP, Martins GEV, Ferrer MG. The spine lateral bending and the dynamic chest compression principles for concomitant orthotic treatment of scoliosis and pectus deformities. COLUNA/COLUMNA 2011. [DOI: 10.1590/s1808-18512011000400009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE:To investigate a concomitant orthotic treatment for coexisting scoliosis and pectus deformities. No detailed study on such concomitancy was found in literature. METHODS: A spine bending brace for use day and night, and dynamic chest compressor orthoses for use four hours a day, along with one hour of exercises, were prescribed. From 638 adolescents, 25 met the inclusion criteria for a retrospective study. Two groups of patients were identified: A (15 compliant patients) and B (10 non-compliant patients). The mean follow-up was 27 months for group A and 21 months for group B. Pre and post- treatment clinical signs of scoliosis and pectus were photographically compared. The scoliosis had radiologic evaluation by Cobb angle and Nash-Moe classification for vertebral rotation. RESULTS: For both conditions, scoliosis and pectus deformities, the outcome was significantly better in the compliant group (p<0.001 for both). One highly compliant adolescent with a 52º scoliosis and pectus carinatum, showed a surprising improvement to 27º after 40 months of treatment, when chest braces were interrupted and the weaning from the spine brace has started. A 34º scoliosis was maintained after 60 months of follow-up, with vertebral rotation improvement. CONCLUSION: The concomitant orthotic treatment yielded preliminary positive results for compliant patients, warranting investigation continuity.
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Kálmán A. Initial results with minimally invasive repair of pectus carinatum. J Thorac Cardiovasc Surg 2009; 138:434-8. [DOI: 10.1016/j.jtcvs.2008.12.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2008] [Revised: 10/26/2008] [Accepted: 12/25/2008] [Indexed: 10/21/2022]
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Abstract
BACKGROUND Unlike the minimal access repair of pectus excavatum (PE), a minimal access repair of pectus carinatum (PC) has not been established. This initial experience reports the correction of PC using a minimal access technique in five patients. METHODS The procedure was performed by insertion of a pectus bar through either bilateral or only left midaxillary incision. The pectus bar was placed so that the elevated sternum could be depressed. Thoracoscopy was not employed during the procedures and no stabiliser plates were used. On completion of the procedure, a chest tube was inserted into the thoracic cavity to evacuate the air from the thoracic cavity followed by wound closure. RESULTS The operation time ranged from 75 to 110 min. The chest tube was removed on the second postoperative day and the patients were discharged between the fifth and seventh postoperative day. There was one dislocation in which the bar was finally removed, and in three patients a prolapse of the end of the strut through intercostal space necessitated refixation using wires. CONCLUSION Despite a small series, this method offers a minimal access repair of PC, which is comparable to the technique used for PE. The invasiveness of our method is obviously far less, than of those different open surgical techniques performed worldwide presently. Our postoperative results warrant the application of this technique in patients with PC.
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Kim S, Idowu O. Minimally invasive thoracoscopic repair of unilateral pectus carinatum. J Pediatr Surg 2009; 44:471-4. [PMID: 19231561 DOI: 10.1016/j.jpedsurg.2008.09.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 09/18/2008] [Accepted: 09/21/2008] [Indexed: 11/28/2022]
Abstract
Thoracoscopic repair of pectus excavatum as described by Nuss has become a well established method of repair. However, minimally invasive intrathoracic repair of pectus carinatum has not been reported in literature. We report a case of successful thoracoscopic repair of unilateral pectus carinatum.
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Affiliation(s)
- Sunghoon Kim
- Department of Pediatric Surgery, Children's Hospital and Research Center Oakland, Oakland, CA 94609, USA
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