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Chu CC, Chang JW, Yang HH, Kuo FC, Tsai HL. Outcomes of the Nuss procedure in children with pectus excavatum: 14 years of experience. J Chin Med Assoc 2024; 87:314-319. [PMID: 38224231 DOI: 10.1097/jcma.0000000000001054] [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] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND We aimed to assess the effectiveness of the Nuss procedure for pectus excavatum (PE) and explore the impacts of sex and age on outcomes. METHODS We retrospectively reviewed 594 consecutive children ≤18 years of age who underwent the thoracoscopy-assisted Nuss technique between January 2006 and July 2019. The severity of pectus deformity was calculated according to the Haller index (HI). The classification of PE and clinical data including complications was analyzed. RESULTS Of the 594 patients, 456 (76.8%) were boys and 138 (23.2%) were girls. The mean age at surgery was 10.0 ± 5.0 years. The most common types of PE were 1A and 2A2 according to Park classification. Intraoperative and postoperative complication rates were 2/594 (0.3%) and 74/594 (12.5%), respectively. The most common complication was bar displacement. The bar was removed in 414 patients 3.5 ± 0.8 years later. The mean preoperative HI, postoperative HI with bar, and HI after bar removal were 4.2 ± 1.7, 2.4 ± 0.3, and 2.7 ± 0.5, respectively. Compared to the preoperative HI, both the postoperative HI with bar and HI after bar removal were significantly lower ( p < 0.001). For preschool-age children, the preoperative HI was significantly higher ( p = 0.027) and the change in HI significantly improved compared to school-age children ( p = 0.004). Boys and adolescents needed significantly more bars and stabilizers. CONCLUSION Surgical correction of PE using the Nuss procedure is a safe procedure and improves the HI in children of different ages, even in those younger than 6 years of age.
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Affiliation(s)
- Chih-Chun Chu
- Department of Surgery, Country Hospital, Taipei, Taiwan, ROC
- Division of Pediatric Surgery, Department of Surgery, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Jei-Wen Chang
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hui-Hsin Yang
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Fang-Cheng Kuo
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hsin-Lin Tsai
- Department of Surgery, Country Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Tekinbaş C, Bayraklı ZO. Overview of chest wall deformities. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:S78-S88. [PMID: 38584783 PMCID: PMC10995686 DOI: 10.5606/tgkdc.dergisi.2024.25899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/18/2023] [Indexed: 04/09/2024]
Abstract
Chest wall deformities are congenital disorders characterized by abnormal development and appearance of the thoracic wall. The most common form is the pectus excavatum deformity, known as shoemaker's chest. Pectus carinatum, known as pigeon chest, is the second most common deformity. In general, most patients are asymptomatic, but cardiopulmonary problems may accompany the disease. The indication for treatment is mostly cosmetic. Treating patients before they reach adulthood increases the chance of success. Surgical treatment can be open or minimally invasive.
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Affiliation(s)
- Celal Tekinbaş
- Department of Thoracic Surgery, Karadeniz Technical University Faculty of Medicine, Trabzon, Türkiye
| | - Zeki Oğuzhan Bayraklı
- Department of Thoracic Surgery, Karadeniz Technical University Faculty of Medicine, Trabzon, Türkiye
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Carter M, Inge M, Zeineddin S, Linton SC, Pitt JB, Robson P, Abdullah F, Goldstein SD. Measurement and Thermodynamic Modeling of Energy Flux During Intercostal Nerve Cryoablation. J Surg Res 2024; 293:231-238. [PMID: 37797391 DOI: 10.1016/j.jss.2023.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/27/2023] [Accepted: 08/27/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Intercostal nerve cryoablation is an increasingly adopted technique to decrease postoperative pain in patients undergoing surgical correction of pectus excavatum (SCOPE). Concerns regarding cryo-induced systemic hypothermia have been raised in pediatric patients; however, assessment of a cooled cryoprobe on body temperature has not been performed. We aimed to determine the energy flux from a maximally cooled cryoprobe and model the possible effects on a whole-body system. METHODS To directly measure energy flux, a maximally cooled cryoSPHERE probe (AtriCure, Inc, Mason, OH) was isolated in a well-mixed water bath at 37°C. Real-time temperatures were recorded. Three models were created to estimate intraoperative flux. Perioperative temperatures of 50 patients who received cryoablation during SCOPE were compared to 50 patients who did not receive cryoablation. RESULTS Direct calorimetry measured average energy flux of the maximally cooled cryoprobe to be 28 J/s. Thermodynamic modeling demonstrated the following: 1) The highest possible cryoprobe flux is less than estimated basal metabolic rate (BMR) of the average teenager undergoing SCOPE and 2) Flux in a best model of human tissue energy transfer using available literature is far less than the effects of BMR and insensible losses. Clinically, there were no significant differences in the minimum intraoperative, end procedure or first postoperative body temperatures for patients who received cryoablation and those who did not. CONCLUSIONS Cryoprobe flux is significantly fewer joules per second than BMR. Furthermore, in a clinical series there were no empiric differences in body temperature due to cryoablation employment, contradicting concerns regarding hypothermia secondary to cryoablation.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Madeline Inge
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samuel C Linton
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Philip Robson
- Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Ermerak NO, Yuksel M. Modification of the Nuss procedure: the crossed bar technique for new subtypes of pectus excavatum. Gen Thorac Cardiovasc Surg 2023; 71:577-583. [PMID: 37179507 DOI: 10.1007/s11748-023-01940-9] [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] [Received: 03/09/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND We aim to describe four new subtypes of PE in detail and represent modification of the Nuss procedure called crossed bar technique for their optimum correction with good results. METHODS 101 patients who underwent crossed bar technique between August 2005 and February 2022 were included into the study. RESULTS The mean age of the patient series was 21.1 (range 15-38 years) years. Mean Haller index was 3.87. Mean operation duration was 86.84 min. 2 bars were used in 74 (73.3%) of the patients whereas 3 bars were preferred in 27 (26.7%) of them. Mean hospital stay was 4.1 (2-8) days, and all the patients were seen routinely on postoperative follow-up at 1st, 6th, and 18th months. Quality of life questionnaires revealed satisfaction. CONCLUSIONS Cross bar technique yields satisfactory results for these new subtypes and can be performed safely with good results in these selected group of patients.
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Affiliation(s)
- Nezih Onur Ermerak
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey.
| | - Mustafa Yuksel
- Department of Thoracic Surgery, Demiroglu Bilim University School of Medicine, Istanbul, Turkey
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Bellía-Munzón G, Sanjurjo D, Toselli L, Vallee M, Elmo G, Martínez-Ferro M. Novel index to estimate the cephalocaudal extent of the excavation in pectus excavatum: The Titanic index. J Pediatr Surg 2023; 58:605-607. [PMID: 36681535 DOI: 10.1016/j.jpedsurg.2022.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND/PURPOSE Quantification of the severity of pectus excavatum deformities is currently performed using the Haller index (HI) and the Correction index (CI), amongst others. However, most indexes characterize the severity at the point of maximum excavation. We present a new index, the Titanic index (TI), aimed at the appraisal of the cephalocaudal extent of the excavation and its potential clinical use. MATERIALS AND METHODS Retrospective analysis of a cohort of patients who underwent a minimally invasive repair of pectus excavatum (MIRPE) between July 2020 and April 2022 at a single center. We defined TI as the percentage of the sternum that lied behind the anterior costal line observed in the CT. Demographics, HI, CI, and TI calculated based on computed tomography images (CT) were analyzed. Also, we compared the severity indexes of two groups of patients divided by the number of implants introduced per patient (group A: two implants, and group B: more than two). RESULTS Seventy-eight patients (92% male) were included, with a mean age of 17.2 ± 4.8 years. The mean TI was 37%. Albeit weak, we identified significant correlations between the TI and the HI and, more closely, to the CI. Two implants were introduced in 37 (47%) patients, and more than two in 41 (53%) patients. Compared to patients with two implants, the group of patients who received more than two implants were older and showed worse thoracic indexes. Using receiver operating characteristic curve analysis, we identified the TI as a better predictor of the need for more than two implants than HI and CI. In this regard, a TI larger than 66.5% had a sensitivity of 93% and a specificity of 92%. CONCLUSION We propose a novel index for the categorization of the severity of pectus excavatum. This index might be useful in planning the number of implants required for complete thoracic remodeling during MIRPE. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective Comparative Study.
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Affiliation(s)
- Gastón Bellía-Munzón
- Fundación Hospitalaria Mother and Child Medical Center. Av. Crámer 4602. Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Daniela Sanjurjo
- Fundación Hospitalaria Mother and Child Medical Center. Av. Crámer 4602. Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Luzía Toselli
- Fundación Hospitalaria Mother and Child Medical Center. Av. Crámer 4602. Capital Federal, Buenos Aires, Argentina, C1429AKL.
| | - Maxroxia Vallee
- Fundación Hospitalaria Mother and Child Medical Center. Av. Crámer 4602. Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Gastón Elmo
- Fundación Hospitalaria Mother and Child Medical Center. Av. Crámer 4602. Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Marcelo Martínez-Ferro
- Fundación Hospitalaria Mother and Child Medical Center. Av. Crámer 4602. Capital Federal, Buenos Aires, Argentina, C1429AKL
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Stephens EH, Dearani JA, Jaroszewski DE. Pectus Excavatum in Cardiac Surgery Patients. Ann Thorac Surg 2023; 115:1312-1321. [PMID: 36781097 DOI: 10.1016/j.athoracsur.2023.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Pectus excavatum frequently accompanies congenital heart disease and connective tissue diseases requiring cardiac surgery. Sometimes the indication is cardiac repair, with the pectus being incidentally noticed; other times, the pectus subsequently develops or becomes more significant after cardiac surgery. This review arms cardiac and congenital surgeons with background about the physiologic impact of pectus, indications for repair and repair strategies, and outcomes for cardiac surgery patients requiring pectus repair. METHODS A comprehensive literature review was performed using keywords related to pectus excavatum, pectus repair, and cardiac/congenital heart surgery within the PubMed database. RESULTS The risks of complications related to pectus repair, including in the setting of cardiac surgery or after cardiac surgery, are low in experienced hands, and patients demonstrate cardiopulmonary benefits and symptom relief. Concomitant pectus and cardiac surgery should be considered if it is performed in conjunction with those experienced in pectus repair, particularly given the increased cardiopulmonary impact of pectus after bypass. In the setting of potential bleeding or hemodynamic instability, delayed sternal closure is recommended. For those with anticipated pectus repair after cardiac surgery, the pericardium should be reconstructed for cardiac protection. For those undergoing pectus repair after cardiac surgery without a membrane placed, a "hybrid" approach is safe and effective. CONCLUSIONS Patients undergoing cardiac surgery noted to have pectus should be considered for possible concomitant or staged pectus repair. For those who will undergo a staged procedure, a barrier membrane should be placed before chest closure.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dawn E Jaroszewski
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona.
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Gräfe D, Lacher M, Martynov I, Hirsch FW, Voit D, Frahm J, Busse H, Sesia SB, Krämer S, Zimmermann P. Pectus excavatum in motion: dynamic evaluation using real-time MRI. Eur Radiol 2023; 33:2128-2135. [PMID: 36307555 PMCID: PMC9935721 DOI: 10.1007/s00330-022-09197-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/12/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The breathing phase for the determination of thoracic indices in patients with pectus excavatum is not standardized. The aim of this study was to identify the best period for reliable assessments of morphologic indices by dynamic observations of the chest wall using real-time MRI. METHODS In this prospective study, patients with pectus excavatum underwent morphologic evaluation by real-time MRI at 3 T between January 2020 and June 2021. The Haller index (HI), correction index (CI), modified asymmetry index (AI), and modified eccentricity index (EI) were determined during free, quiet, and forced breathing respectively. Breathing-related differences in the thoracic indices were analyzed with the Wilcoxon signed-rank test. Motion of the anterior chest wall was analyzed as well. RESULTS A total of 56 patients (11 females and 45 males, median age 15.4 years, interquartile range 14.3-16.9) were included. In quiet expiration, the median HI in the cohort equaled 5.7 (4.5-7.2). The median absolute differences (Δ) in the thoracic indices between peak inspiration and peak expiration were ΔHI = 1.1 (0.7-1.6, p < .001), ΔCI = 4.8% (1.3-7.5%, p < .001), ΔAI = 3.0% (1.0-5.0%, p < .001), and ΔEI = 8.0% (3.0-14.0%, p < .05). The indices varied significantly during different inspiratory phases, but not during expiration (p > .05 each). Furthermore, the dynamic evaluation revealed three distinctive movement patterns of the funnel chest. CONCLUSIONS Real-time MRI reveals patterns of chest wall motion and indicate that thoracic indices of pectus excavatum should be assessed in the end-expiratory phase of quiet expiration. KEY POINTS • The thoracic indices in patients with pectus excavatum depend on the breathing phase. • Quiet expiration represents the best breathing phase for determining thoracic indices. • Real-time MRI can identify different chest wall motion patterns in pectus excavatum.
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Affiliation(s)
- Daniel Gräfe
- Department of Pediatric Radiology, University Hospital, Leipzig, Germany.
| | - Martin Lacher
- Department of Pediatric Surgery, University Hospital, Leipzig, Germany
| | - Illya Martynov
- Department of Pediatric Surgery, University Hospital, Leipzig, Germany
| | | | - Dirk Voit
- Biomedizinische NMR, Max-Planck-Institut für Biophysikalische Chemie, Göttingen, Germany
| | - Jens Frahm
- Biomedizinische NMR, Max-Planck-Institut für Biophysikalische Chemie, Göttingen, Germany
| | - Harald Busse
- Department of Diagnostic and Interventional Radiology, University Hospital, Leipzig, Germany
| | - Sergio Bruno Sesia
- Division of General Thoracic Surgery, Bern University Hospital, Bern, Switzerland
| | - Sebastian Krämer
- Division of General Thoracic Surgery, Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital, Leipzig, Germany
| | - Peter Zimmermann
- Department of Pediatric Surgery, University Hospital, Leipzig, Germany
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Daemen JHT, Heuts S, Rezazadah Ardabili A, Maessen JG, Hulsewé KWE, Vissers YLJ, de Loos ER. Development of Prediction Models for Cardiac Compression in Pectus Excavatum Based on Three-Dimensional Surface Images. Semin Thorac Cardiovasc Surg 2023; 35:202-212. [PMID: 34785353 DOI: 10.1053/j.semtcvs.2021.11.006] [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] [Received: 10/30/2021] [Accepted: 11/08/2021] [Indexed: 11/11/2022]
Abstract
In pectus excavatum, three-dimensional (3D) surface imaging provides an accurate and radiation-free alternative to computed tomography (CT) to determine severity. Yet, it does not allow for cardiac evaluation since 3D imaging solely captures the chest wall surface. The objective was to develop a 3D image-based prediction model for cardiac compression in patients evaluated for pectus excavatum. A prospective cohort study was conducted including consecutive patients referred for pectus excavatum who received a thoracic CT. Additionally, 3D images were acquired. The external pectus depth, its length, craniocaudal position, cranial slope, asymmetry, anteroposterior distance and chest width were calculated from 3D images. Together with baseline patient characteristics they were submitted to forward multivariable logistic regression to identify predictors for cardiac compression. Cardiac compression on CT was used as reference. The model's performance was depicted by the area under the receiver operating characteristic (AUROC) curve. Internal validation was performed using bootstrapping. Sixty-one patients were included of whom 41 had cardiac compression on CT. A combination of the 3D image derived external pectus depth and external anteroposterior distance was identified as predictive for cardiac compression, yielding an AUROC of 0.935 (95% confidence interval [CI]: 0.878-0.992) with an optimism of 0.006. In a second model for males alone, solely the external pectus depth was identified as predictor, yielding an AUROC of 0.947 (95% CI: 0.892-1.000) with an optimism of 0.0002. We have developed two 3D image-based prediction models for cardiac compression in patients evaluated for pectus excavatum which provide an outstanding discriminatory performance between the presence and absence of cardiac compression with negligible optimism.
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Affiliation(s)
- 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
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ashkan Rezazadah Ardabili
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands; Faculty of Health, Medicine and Life Sciences (FHML), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Erik R de Loos
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.
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Daemen JHT, de Loos ER, Geraedts TCM, Van Veer H, Van Huijstee PJ, Elenbaas TWO, Hulsewé KWE, Vissers YLJ. Visual diagnosis of pectus excavatum: An inter-observer and intra-observer agreement analysis. J Pediatr Surg 2022; 57:526-531. [PMID: 34183157 DOI: 10.1016/j.jpedsurg.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/28/2021] [Accepted: 06/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND/PURPOSE Among patients suspected of pectus excavatum, visual examination is a key aspect of diagnosis and, moreover, guides work-up and treatment strategy. This study evaluated the inter-observer and intra-observer agreement of visual examination and diagnosis of pectus excavatum among experts. METHODS Three-dimensional surface images of consecutive patients suspected of pectus excavatum were reviewed in a multi-center setting. Interactive three-dimensional images were evaluated for the presence of pectus excavatum, asymmetry, flaring, depth of deformity, cranial onset, overall severity and morphological subtype through a questionnaire. Observers were blinded to all clinical patient information, completing the questionnaire twice per subject. Agreement was analyzed by kappa statistics. RESULTS Fifty-eight subjects with a median age of 15.5 years (interquartile range: 14.1-18.2) were evaluated by 5 (cardio)thoracic surgeons. Pectus excavatum was visually diagnosed in 55% to 95% of cases by different surgeons, revealing considerable inter-observer differences (kappa: 0.50; 95%-confidence interval [CI]: 0.41-0.58). All other items demonstrated inter-observer kappa's of 0.25-0.37. Intra-observer analyses evaluating the presence of pectus excavatum demonstrated a kappa of 0.81 (95%-CI: 0.72-0.91), while all other items showed intra-observer kappa's of 0.36-0.68. CONCLUSIONS Visual examination and diagnosis of pectus excavatum yields considerable inter-observer and intra-observer disagreements. As this variation in judgement could impact work-up and treatment strategy, objective standardization is urged. LEVELS OF EVIDENCE III.
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Affiliation(s)
- 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
| | - Erik R de Loos
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands.
| | - Tessa C M Geraedts
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium; BREATHE Laboratory, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | | | - Ted W O Elenbaas
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
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10
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Computed tomographic evaluation of pectus excavatum in 14 cats. PLoS One 2022; 17:e0262866. [PMID: 35061860 PMCID: PMC8782389 DOI: 10.1371/journal.pone.0262866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 01/06/2022] [Indexed: 11/19/2022] Open
Abstract
Pectus excavatum (PE) is one of the most frequently reported chest deformities. However, limited studies are available with regard to its CT scan findings in cats. In the present research computed tomographic images of the thoraxes of 14 cats diagnosed with PE has been reviewed. This is one of the first studies exploring the use of CT to characterise PE in animals. The aim of this study was to present characteristic CT features of PE in cats. The introduction of new criteria for better assessing thoracic wall deformity–a correction index (CI) and an asymmetry index (AI)–was also proposed. The study revealed a high variety of morphological features of PE in cats. It was demonstrated that among the 14 cats: cranial PE (an atypical location) occurred in seven cats while seven cats had typical (caudal) PE, long PE occurred in five cats, while short PE had nine cats. Of the 14 cats included in the study eight showed symmetric PE, and asymmetric PE was found insix. Thoracic asymmetry was found in six cats. Six cats had sternal torsion. Based on the Vertebral Index moderate or severe PE was revealed in 11 animals. In the group of cats studied the CI ranged from 12.20 to 32.11. The magnitude of AI did not exceed 10% in any of the cats studied. The study confirmed statistically significant differences in the CI values between groups of cats with different degrees of PE severity (p = 0.02). CT examination showed many PE features that have not been discussed so far. The main benefit of CT examination is its ability to reveal asymmetric PE, thoracic asymmetry and sternal torsion. CI and AI provided a clinically useful tool to quantify thoracic wall deformity in order to obtain comparable results between cats with PE.
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11
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Coorens NA, Daemen JHT, Slump CH, Loonen TGJ, Vissers YLJ, Hulsewé KWE, de Loos ER. The Automatic Quantification of Morphological Features of Pectus Excavatum Based on Three-Dimensional Images. Semin Thorac Cardiovasc Surg 2021; 34:772-781. [PMID: 34102293 DOI: 10.1053/j.semtcvs.2021.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 12/16/2022]
Abstract
Visual examination and quantification of severity are essential for clinical decision making in patients with pectus excavatum. Yet, visual assessment is prone to inter- and intra-observer variability and current quantitative methods are inadequate. This study aims to develop and evaluate a novel, automatic and non-invasive method to objectively quantify pectus excavatum morphology based on three-dimensional images. Key steps of the automatic analysis are normalization of image orientation, slicing, and computation of the morphological features encompassing pectus depth, width, length, volume, position, steepness, flaring, asymmetry and mean cross-sectional area. A digital phantom mimicking a patient with pectus excavatum was used to verify the analysis method. Prospective three-dimensional imaging and subsequent surface analysis in patients with pectus excavatum was performed to assess clinical feasibility. Verification of the developed analysis tool demonstrated 100% reproducibility of all morphological feature values. Calculated parameters compared to the predetermined phantom dimensions were accurate for all but four features. The pectus width, length, volume and steepness showed an error of 4 mm (4%), 2 mm (2%), 12 mL (5%) and 1 degree (3%), respectively. Prospective imaging of 52 patients (88% males) demonstrated the feasibility of the developed tool to quantify morphological features of pectus excavatum in the clinical setting. Mean duration to calculate all features in one patient was 7.6 seconds. We have developed and presented a non-invasive pectus excavatum surface analysis tool, that is feasible to automatically quantify morphological features based on three-dimensional images with promising accuracy and reproducibility.
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Affiliation(s)
- Nadine A Coorens
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands; Faculty of Science and Technology (S&T), University of Twente, Enschede, The Netherlands; Faculty of Health, Medicine and Life Sciences (FHML), School for Oncology and Developmental Biology (GROW), Maastricht, 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
| | - Cornelis H Slump
- Faculty of Science and Technology (S&T), University of Twente, Enschede, The Netherlands
| | - Tom G J Loonen
- 3D Lab Radboudumc, Radboud University Medical Center, Nijmegen, 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
| | - Erik R de Loos
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.
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Uemura S, Yoshida A, Kuyama H. Analysis of chest wall elevation after the Nuss procedure using 3D body scanning technique in patients with pectus excavatum. Pediatr Surg Int 2021; 37:777-782. [PMID: 33742267 DOI: 10.1007/s00383-021-04885-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE For the evaluation of the chest wall deformity, we adopted a non-invasive 3D body scanning system. The objective of this study is to evaluate surgical effect on the whole thorax using 3D scanning technique before and after Nuss procedure. METHODS We performed 3D body scanning using Structure Sensor (Occipital Inc, USA) in 11 symmetric patients (average age 13 ± 3.2) under general anesthesia before and after Nuss procedure. Using the scanned data, the improved chest wall was analyzed using 3D-Rugle (Medic Engineering, Japan) imaging software. Preoperative and postoperative 3D data were super-imposed and a thoracic elevating distance in the line of the axial and sagittal section through the deepest point was calculated. Pre- and postoperative external sternal angle (ESA) were calculated from the scanned data. RESULTS Mean thoracic elevation distance at the deepest point was 38.6 ± 6.1 mm and it was 28.4 ± 5.1 mm and 19.4 ± 4.9 mm at 4 cm and 8 cm cranial side, respectively. Average ESA improved from 3.9 ± 1.6 degrees to 15.0 ± 1.1 degrees after the operation. CONCLUSION Chest depression was effectively elevated 39 mm at the deepest point after Nuss procedure. An indirect elevation effect by pectus bars was found on the wide area of the anterior chest.
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Affiliation(s)
- Sadashige Uemura
- Division of Chest Wall Surgery, Nishinomiya Watanabe Cardiovascular Center, 3-25, Ikeda-cho, Nishinomiya, 662-0911, Japan.
| | - Atsushi Yoshida
- Department of Pediatric Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Hisako Kuyama
- Department of Pediatric Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
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Gritsiuta AI, Bracken A, Beebe K, Pechetov AA. Currarino-Silverman syndrome: diagnosis and treatment of rare chest wall deformity, a case series. J Thorac Dis 2021; 13:2968-2978. [PMID: 34164188 PMCID: PMC8182498 DOI: 10.21037/jtd-20-3472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Currarino-Silverman (CS) syndrome is an extremely rare congenital deformity of the anterior chest wall. The syndrome is often combined with congenital heart defects and spinal abnormalities. As of currently, there is a lack of definite description in the literature about this type of pectus deformity. Typically, patients do not require surgical intervention for medical reasons, and the correction is usually only for cosmetic purposes. The purpose of this study was to demonstrate surgical intervention for CS syndrome at a tertiary care facility, and to summarize the available literature. Methods Patients with CS syndrome were retrospectively reviewed from a period of June 2012 to August 2019. An extensive literature search for "Currarino-Silverman syndrome," "pouter pigeon chest," "chondromanubrial deformity," "type 2 pectus carinatum" and "pectus arcuatum" was performed. Results Four clinical cases of CS syndrome are presented, two of which were symptomatic and corrected. The procedure of choice was the modified Ravitch-type thoracoplasty with double osteotomy and implantation of support plates. Conclusions There is no clear definition of CS syndrome in the literature. Correct and uniform classification plays a crucial role in the surgical treatment of this pathology. Due to the extreme rarity of the disease, challenging deformity, and variable anatomy of the fused sternum, there are no clear guidelines in treatment approaches. The correction is mostly pursued only for cosmetic results, and the best surgical option for CS syndrome remains the relatively aggressive Ravitch-type procedure with multi-level wedge osteotomy.
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Affiliation(s)
- Andrei I Gritsiuta
- Department of Surgical Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Thoracic Surgery, Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - Alexander Bracken
- Department of Surgical Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Karisa Beebe
- Department of Surgical Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alexei A Pechetov
- Department of Thoracic Surgery, Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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Biavati M, Kozlitina J, Alder AC, Foglia R, McColl RW, Peshock RM, Kelly RE, Kim Garcia C. Prevalence of pectus excavatum in an adult population-based cohort estimated from radiographic indices of chest wall shape. PLoS One 2020; 15:e0232575. [PMID: 32379835 PMCID: PMC7205298 DOI: 10.1371/journal.pone.0232575] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 04/17/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pectus excavatum is the most common chest wall skeletal deformity. Although commonly evaluated in adolescence, its prevalence in adults is unknown. METHODS AND FINDINGS Radiographic indices of chest wall shape were analyzed for participants of the first (n = 2687) and second (n = 1780) phases of the population-based Dallas Heart Study and compared to clinical cases of pectus (n = 297). Thoracic computed tomography imaging studies were examined to calculate the Haller index, a measure of thoracic axial shape, and the Correction index, which quantitates the posterior displacement of the sternum relative to the ribs. At the level of the superior xiphoid, 0.5%, 5% and 0.4% of adult Dallas Heart Study subjects have evidence of pectus excavatum using thresholds of Haller index >3.25, Correction index >10%, or both, respectively. Radiographic measures of pectus are more common in females than males and there is a greater prevalence of pectus in women than men. In the general population, the Haller and Correction indices are associated with height and weight, independent of age, gender, and ethnicity. Repeat imaging of a subset of subjects (n = 992) demonstrated decreases in the mean Haller and Correction indices over seven years, suggesting change to a more circular axial thorax, with less sternal depression, over time. CONCLUSIONS To our knowledge, this is the first study estimating the prevalence of pectus in an unselected adult population. Despite the higher reported prevalence of pectus cases in adolescent boys, this study demonstrates a higher prevalence of radiographic indices of pectus in adult females.
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Affiliation(s)
- Mikaela Biavati
- Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Julia Kozlitina
- Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Adam C. Alder
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Robert Foglia
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Roderick W. McColl
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Ronald M. Peshock
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Robert E. Kelly
- Department of Surgery and Pediatrics, Eastern Virginia Medical Center and Children’s Hospital of the King’s Daughters, Norfolk, VA, United States of America
| | - Christine Kim Garcia
- Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
- * E-mail:
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Aesthetic outcomes after surgical repair of pectus excavatum in females: Differences between patients and professional evaluators. Arch Plast Surg 2020; 47:126-134. [PMID: 32203989 PMCID: PMC7093272 DOI: 10.5999/aps.2019.00318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 11/28/2019] [Indexed: 12/02/2022] Open
Abstract
Background Pectus excavatum is less common in females than in males, and it often aggravates a coexistent breast asymmetry. We conducted a study comparing female patients’ versus medical professionals’ evaluation of pectus excavatum repair to assess differences in aesthetic outcome ratings. Moreover, we evaluated the influence of surgical correction on patients’ self-perception. Methods Of 30 female patients who were initially screened, 18 patients (mean age, 20 years) who underwent bar removal after surgical correction of pectus excavatum deformity participated in the survey (60%). They completed a questionnaire rating their appearance before and after surgery and responded to a psychological questionnaire about the changes that they had experienced. The mean interval between pectus bar removal and evaluation was 28 months. Standardized preoperative and postoperative patient photographs were evaluated using the same questionnaire by a panel of medical professionals and students (n=24) and the results were compared. Results Patients rated their preoperative deformity as more severe than the other evaluators, revealing the significant impact of the deformity on patients’ self-perception. Postoperatively, patient and professional evaluations were much better than before and were very similar. The psychological evaluation showed a clear improvement in well-being. The ratings of the medical professionals were not influenced by their degree of medical education. Conclusions Surgical correction of pectus excavatum in female patients positively influences body perception and psychological well-being. It should therefore not be considered as a merely aesthetic correction, but as an important procedure to restore a patient’s self-perception.
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Eisinger RS, Islam S. Caring for People With Untreated Pectus Excavatum. Chest 2020; 157:590-594. [DOI: 10.1016/j.chest.2019.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/20/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022] Open
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Measuring the impact of surgical intervention on pediatric pectus excavatum using white light scanning. J Pediatr Surg 2019; 54:2261-2267. [PMID: 30732932 DOI: 10.1016/j.jpedsurg.2019.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/27/2018] [Accepted: 01/10/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Objective preoperative assessment of pectus excavatum (PE) deformity in patients is limited to preoperative measurement of severity using computed tomography (CT) or magnetic resonance imaging (MRI). Postoperative assessment is currently subjective as postoperative CT scans are not recommended in light of radiation exposure and high cost to families. White Light Scanning (WLS) is a novel 3D imaging modality that offers an alternative that is a quick, nonionizing, inexpensive, and safe strategy for measurement both pre- and postsurgery. Our prior investigation demonstrated the feasibility of using WLS to measure PE deformity and showed very strong correlation of a new WLS-derived PE severity index, the Hebal-Malas Index (HMI), with CT-derived HI. The purpose of this study was to demonstrate use of WLS to assess extent of correction of PE deformities after the Nuss procedure. METHODS WLS scan data were gathered prospectively in pediatric patients with PE from 2015 to 2018. HMI was obtained from the preoperative and postoperative WLS scans. Analysis assessed the differences of preoperative and postoperative HMI. Preoperative CT-derived HI was collected from the medical record and estimated postoperative Haller Index was calculated from HMI and correlation of HMI and HI using historical data. RESULTS A total of 71 patients received a preoperative CT scan and underwent surgery for PE. Of those, 63 (89%) received WLS preoperatively and 51 (72%) had complete preoperative and postoperative WLS data. The average postoperative decrease in the WLS-derived HMI was 0.35 (SD: 0.15) and 1.73 (SD: 1.03) in WLS-estimated HI. CONCLUSIONS WLS is highly effective in objectively quantifying the extent of surgical correction in PE patients. LEVEL OF EVIDENCE IV TYPE OF STUDY: Diagnostic Study.
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Glithero KJ, Tackett JJ, DeMason K, Burnweit CA. Successful cardiopulmonary resuscitation following minimally invasive pectus excavatum repair: A case report. Int J Surg Case Rep 2019; 65:255-258. [PMID: 31734479 PMCID: PMC6864329 DOI: 10.1016/j.ijscr.2019.10.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Pectus excavatum is the most common congenital chest wall deformity. The minimally invasive repair of pectus excavatum (MIRPE) is the most commonly practiced method of surgical treatment and there is concern that the pectus bar will prevent effective CPR. There are no recorded cases of successful cardiopulmonary resuscitation with pectus bars in place. PRESENTATION OF CASE A 17-year-old male with pectus excavatum underwent MIRPE. Two years later, he experienced out-of-hospital cardiac arrest and underwent successful cardiopulmonary resuscitation (CPR) in the field with a pectus bar in place. DISCUSSION Successful CPR is possible after MIRPE. Clear identification of patients who have undergone MIRPE and education of CPR providers in providing effective chest compressions and defibrillation for this patient population is necessary. CONCLUSION This is the first documented case of successful CPR in a patient with a pectus bar in place who experienced out-of-hospital cardiac arrest.
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Affiliation(s)
- Kyle J Glithero
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Medical Arts Building, 3200 SW 60th Court, Suite 201, Miami, FL 33155, USA.
| | - John J Tackett
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Medical Arts Building, 3200 SW 60th Court, Suite 201, Miami, FL 33155, USA.
| | | | - Cathy A Burnweit
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Medical Arts Building, 3200 SW 60th Court, Suite 201, Miami, FL 33155, USA.
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Tedde ML, Togoro SY, Eisinger RS, Okumura EM, Fernandes A, Pêgo-Fernandes PM, Campos JRMD. Back to the future: a case series of minimally invasive repair of pectus excavatum with regular instruments. ACTA ACUST UNITED AC 2019; 45:e20170373. [PMID: 30758428 PMCID: PMC6534412 DOI: 10.1590/1806-3713/e20170373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 04/10/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Minimally invasive repair of pectus excavatum (MIRPE) is a surgical treatment for PE. During the procedure, a specialized introducer is used to tunnel across the mediastinum for thoracoscopic insertion of a metal bar. There have been reported cases of cardiac perforation during this risky step. The large introducer can be a dangerous lever in unskilled hands. We set out to determine the safety and feasibility of using regular instruments (i.e., not relying on special devices or tools) to create the retrosternal tunnel during MIRPE. METHODS This was a preliminary study of MIRPE with regular instruments (MIRPERI), involving 28 patients with PE. We recorded basic patient demographics, chest measurements, and surgical details, as well as intraoperative and postoperative complications. RESULTS Patients undergoing MIRPERI had Haller index values ranging from 2.58 to 5.56. No intraoperative complications occurred. Postoperative complications included nausea/vomiting in 8 patients, pruritus in 2, and dizziness in 2, as well as atelectasis, pneumothorax with thoracic drainage, pleural effusion, and dyspnea in 1 patient each. CONCLUSIONS In this preliminary study, the rate of complications associated with MIRPERI was comparable to that reported in the literature for MIRPE. The MIRPERI approach has the potential to improve the safety of PE repair, particularly for surgeons that do not have access to certain special instruments or have not been trained in their use.
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Affiliation(s)
- Miguel Lia Tedde
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
| | - Silvia Yukari Togoro
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
| | | | - Erica Mie Okumura
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
| | - Angelo Fernandes
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
| | - Paulo Manuel Pêgo-Fernandes
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
| | - Jose Ribas Milanez de Campos
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
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Eisinger RS, Harris T, Rajderkar DA, Islam S. Against the Overgrowth Hypothesis: Shorter Costal Cartilage Lengths in Pectus Excavatum. J Surg Res 2019; 235:93-97. [PMID: 30691856 DOI: 10.1016/j.jss.2018.09.080] [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] [Received: 05/12/2018] [Revised: 07/28/2018] [Accepted: 09/25/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pectus excavatum is a common chest wall deformity with no known cause. A common hypothesis is that in patients with pectus excavatum, there is an overgrowth of costal cartilage relative to healthy individuals. MATERIALS AND METHODS We obtained radiological curvilinear three-dimensional measurements of the fourth to eighth costal cartilage and associated ribs in 16 patients with pectus excavatum and 16 age- and gender-matched controls between the ages of 6 and 32 y. An analysis of variance was used to compare bone length, cartilage length, and their ratios between patients and controls. RESULTS Relative to bone length, patients with pectus excavatum overall had shorter costal cartilage lengths (P < 0.001), especially on the left side (P < 0.05). We were unable to localize this observation to specific ribs during post hoc analysis. CONCLUSIONS This is the first study to empirically test the overgrowth hypothesis of pectus excavatum for ribs 4 through 8. Although we and others have found no evidence to support this hypothesis, we surprisingly found the alternate hypothesis to be true: patients with pectus excavatum tend to have shorter costal cartilages. Future studies should expand on these results with larger sample sizes and consider volumetric measurements longitudinally during thoracic development.
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Affiliation(s)
- Robert S Eisinger
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Travis Harris
- Department of Radiology, University of Florida College of Medicine, Gainesville, Florida
| | - Dhanashree A Rajderkar
- Department of Radiology, University of Florida College of Medicine, Gainesville, Florida
| | - Saleem Islam
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida.
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Deviggiano A, Carrascosa P, Vallejos J, Bellia-Munzon G, Vina N, Rodríguez-Granillo GA, Martinez-Ferro M. Relationship between cardiac MR compression classification and CT chest wall indexes in patients with pectus excavatum. J Pediatr Surg 2018; 53:2294-2298. [PMID: 29907314 DOI: 10.1016/j.jpedsurg.2018.05.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 04/30/2018] [Accepted: 05/21/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND/PURPOSE In pectus excavatum (PE) patients owing to the location of the heart in the chest cavity, the most affected site of compression by the depressed chest wall is the right heart, and surgical repair has shown to provide a significant relief in the RH cavities compression. Our aim was to explore the relationship between the site of right cardiac compression, chest wall indexes (CT-CWI) and the sternal torsion angle (STA) based on cardiac magnetic resonance (CMR) and computed tomography (CT) among PE patients. METHODS We included PE patients with no previous surgical correction referred to CMR and chest CT imaging as presurgical evaluations. The following CT-CWI were calculated: Haller Index (HI), correction index (CI) and STA. A CMR compression classification (CMR-CC) was implemented based on the analysis (in the horizontal long axis plane at end of diastole) of the right cardiac compression site, caused by the thoracic cage (sternum/ribs): Type 0 (T0): absence of cardiac compression; Type 1 (T1): compression of the lateral wall of the right ventricle (RV) without involvement of the atrioventricular (AV) groove; Type 2 (T2): compression of the RV involving the AV groove. RESULTS Sixty PE patients underwent CMR and chest CT. Fifty (81%) patients were male, and the median age was 17.5 (14.0; 23.0) years. T0, T1 and T2 were found in 14 (23%), 27 (45%) and 19 (32%) patients. There were significant differences between types with regard to the HI (T0 3.9 ± 1.1, T1 4.8 ± 2.0, T2 6.4 ± 3.1, p < 0.009) and to the CI (T0 22.1 ± 10.4%, T1 31.6 ± 16.1%, T2 46.9 ± 16.3% p < 0.0001) and STA (T0 9.1 ± 7.9°, T1 12.7 ± 10.3°, class T2 23.0 ± 13.6°p = 0.001) respectively. CONCLUSION In this study, we established a cardiac magnetic resonance compression classification of patients with pectus excavatum comprising a simple discrimination of cardiac compression sites, which were related to chest wall indexes. TYPE OF STUDY Study of Diagnostic Test. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Alejandro Deviggiano
- Department of Computed Tomography and Magnetic Resonance Imaging, Diagnóstico Maipu, Buenos Aires, Argentina.
| | - Patricia Carrascosa
- Department of Computed Tomography and Magnetic Resonance Imaging, Diagnóstico Maipu, Buenos Aires, Argentina
| | - Javier Vallejos
- Department of Computed Tomography and Magnetic Resonance Imaging, Diagnóstico Maipu, Buenos Aires, Argentina
| | - Gaston Bellia-Munzon
- Department of Pediatric Surgery, Fundacion Hospitalaria, Children's Hospital, Buenos Aires, Argentina
| | - Natalia Vina
- Department of Computed Tomography and Magnetic Resonance Imaging, Diagnóstico Maipu, Buenos Aires, Argentina
| | - Gaston A Rodríguez-Granillo
- Department of Computed Tomography and Magnetic Resonance Imaging, Diagnóstico Maipu, Buenos Aires, Argentina
| | - Marcelo Martinez-Ferro
- Department of Pediatric Surgery, Fundacion Hospitalaria, Children's Hospital, Buenos Aires, Argentina
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Rha EY, Kim JH, Yoo G, Ahn S, Lee J, Jeong JY. Changes in thoracic cavity dimensions of pectus excavatum patients following Nuss procedure. J Thorac Dis 2018; 10:4255-4261. [PMID: 30174871 DOI: 10.21037/jtd.2018.06.159] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Using a simple and intuitive method, we evaluated changes in the dimensions of the thoracic cavity of pectus excavatum (PE) patients following the Nuss procedure. Methods We performed a retrospective review of 141 patients who had undergone the Nuss procedure. The thoracic cavity was visualized using computed tomography (CT) scans and its dimensions determined by measuring the anteroposterior (AP) and transverse (T) diameters at three anatomical landmarks (the jugular notch, and manubriosternal and xiphisternal joints). The Wilcoxon signed-rank test was used to compare differences between preoperative and postoperative parameters. Kruskal-Wallis tests were performed to compare differences among groups in patient age, type of PE, and number of inserted bars. Results Of the 141 patients (115 men, 26 women), 87 had symmetric and 54 had asymmetric defects. The postoperative AP diameters at the manubriosternal and xiphisternal joints were significantly higher than their preoperative values, whereas the Haller indices and T diameters at the three anatomical landmarks were significantly lower than their preoperative values. In the multiple bars group, the postoperative AP diameters increased significantly compared with their preoperative values. In the multiple bars group, and in patients aged above 13 years, the postoperative T diameters at all three anatomical landmarks decreased significantly compared with their preoperative values. Conclusions Correction of anterior depression of the sternum and compensatory narrowing of the chest width were observed in PE patients following the Nuss procedure. Further research will be necessary to determine the relationship between these observations and postoperative changes in chest volume.
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Affiliation(s)
- Eun Young Rha
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Hyeok Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gyeol Yoo
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seha Ahn
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Yong Jeong
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Abstract
Pectus excavatum is the most common chest wall deformity in children. The central portion of the chest is displaced posteriorly relative to the remainder of the anterior chest wall. Quantification of defect severity can be performed with multiple imaging modalities or external thoracic measures, but is most commonly quantified by the Haller Index (HI) or Pectus Correction Index (PCI). These two measures provide a measure of the chest based on cross sectional imaging, most commonly CT scans, allowing for standard comparison and definitions of pectus defects. The purpose of this article is to describe the creation, calculation, and limitations of the methods quantifying pectus defects.
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Affiliation(s)
- Joseph A Sujka
- Thomas Holder and Keith Aschraft Endowed Chair, The Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108, United States
| | - Shawn D St Peter
- Thomas Holder and Keith Aschraft Endowed Chair, The Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108, United States.
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Surgical Correction of Pectus Excavatum by the Nuss Procedure: A 15-Year Experience Study. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018. [PMID: 29525894 DOI: 10.1007/5584_2017_121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Pectus excavatum is the most common congenital deformity of the chest. The Nuss procedure is minimally invasive surgical correction of this defect, using retrosternal metal bars. The purpose of the present study was to describe a 15-year experience with the Nuss surgery, and to evaluate the long-term clinical results of the procedure. We retrospectively evaluated 239 patients, aged 14-34, who underwent the Nuss surgery in the years 2002-2016. Postoperative complications were observed in 40/236 (16.9%) patients. The most common complication was pneumothorax in 14/239 patients. Less common were the following: wound infection in 4, pleural effusion in 3, allergy to nickel in 1, lung atelectasis in 1, and ventricular failure in 1 patient. Three patients were treated because of severe postoperative pain, and in one case the implant had to be removed. Postoperative complications associated with the number of bars inserted, but not with the patient age or gender. A satisfactory and long lasting corrective effect of surgery was observed in 231/239 (96.7%) of patients. There was no perioperative mortality. We conclude that the Nuss surgery is a safe surgery that demonstrates excellent and long-lasting esthetic results, with a low risk of severe complications.
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The Vacuum Bell device as a sternal lifter: An immediate effect even with a short time use. J Pediatr Surg 2018; 53:406-410. [PMID: 28495420 DOI: 10.1016/j.jpedsurg.2017.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/23/2017] [Accepted: 04/26/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND To minimize cardiac perforation during the minimally invasive repair of pectus excavatum (MIRPE), several surgeons have suggested using a suction device to intraoperatively lift the sternum. Whether or not this technique is effective for all PE patients is not yet known. As such, our aim was to quantify the extent to which a suction device is capable of lifting the sternum with a short duration of use. METHODS 30 PE patients received a low-dose CT scan as part of standard PE evaluation. A Vacuum Bell suction was then applied for only two minutes, and a repeat CT scan was obtained only at the deepest point of the chest wall deformity. We compared chest dimensions before and after Vacuum Bell suction. RESULTS The Vacuum Bell lifted the sternum in all 29 patients included in the analysis. The absolute change in depth ranged from 0.29 to 23.67mm (M=11.02, SD=6.05). The average improvement in Haller index was 0.76. The suction was most effective for individuals with low BMI and smaller chest depths. Efficacy was not associated with gender, age, or chest morphology. CONCLUSIONS The Vacuum Bell device effectively lifted the sternum in PE patients with different demographics and chest morphologies. Future research is needed to address whether or not the device reduces risk of cardiac perforation during MIRPE. LEVELS OF EVIDENCE Prognosis Study Level IV.
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Dore M, Triana Junco P, De La Torre C, Vilanova-Sánchez A, Bret M, Gonzalez G, Nuñez Cerezo V, Jimenez Gomez J, Luis Encinas J, Hernandez F, Martínez Martínez L, Lopez Santamaria M. Nuss Procedure for a Patient with Negative Haller Index. European J Pediatr Surg Rep 2018; 6:e18-e22. [PMID: 29473012 PMCID: PMC5820059 DOI: 10.1055/s-0038-1623537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 12/14/2017] [Indexed: 10/29/2022] Open
Abstract
Introduction Minimally invasive repair for pectus excavatum (MIRPE) is controversial in extremely severe cases of pectus excavatum (PE) and an open repair is usually favored. Our aim is to describe a case of a patient with an extremely severe PE that underwent a minimally invasive approach. Case report An 8-year-old girl with severe sternum depression was assessed. She had a history of exercise intolerance, nocturnal dyspnea, fatigue, and shortness of breath. Chest computed tomography showed that sternum depression was posterior to the anterior vertebral column; therefore, Haller and correction index could not be measured. Spirometry indicated an obstructive ventilation pattern (forced expiratory volume in 1 second = 74.4%), and echocardiogram revealed a dilated inferior vena cava, mitral valve prolapse with normal ventricular function. After multidisciplinary committee evaluation, a MIRPE approach was performed. All symptoms had disappeared at the 3-month postoperative follow-up; the desired sternum shape was achieved and normalization of cardiopulmonary function was observed. The Nuss bars were removed after a 2-year period. After 18-month follow-up, the patient can carry out normal exercise and is content with the cosmetic result. Conclusion Nuss procedure is feasible in our 8-year-old patient. In this case, both the Haller and correction index were not useful to assess the severity of PE. Therefore, under these circumstances, other radiologic parameters have to be taken into consideration for patient evaluation.
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Affiliation(s)
- Mariela Dore
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Madrid, Spain
| | - Paloma Triana Junco
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Madrid, Spain
| | - Carlos De La Torre
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Madrid, Spain
| | | | - Monserrat Bret
- Department of Pediatric Radiology, Hospital Universitario La Paz, Madrid, Madrid, Spain
| | - Gaspar Gonzalez
- Department of Pediatric Traumatology, Hospital Universitario La Paz, Madrid, Madrid, Spain
| | - Vanesa Nuñez Cerezo
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Madrid, Spain
| | - Javier Jimenez Gomez
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Madrid, Spain
| | - Jose Luis Encinas
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Madrid, Spain
| | - Francisco Hernandez
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Madrid, Spain
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Results of pectus excavatum correction using a minimally invasive approach with subxyphoid incision and three-point fixation. Pediatr Surg Int 2018; 34:75-78. [PMID: 29052000 DOI: 10.1007/s00383-017-4195-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study reviews the results of our previously described modification of the minimally invasive (Nuss) procedure for correction of pectus excavatum. It utilizes a subxyphoid incision with central fixation to maximize safe bar passage and minimize bar displacement. METHODS Consecutive patients corrected with the modified Nuss procedure between 2010 and 2015 form the basis of this study. RESULTS During the study period, 73 patients had correction of their pectus excavatum by the modified Nuss procedure, utilizing subxyphoid incision and central fixation. Average age was 14.3 (range 8-19). 54 patients were male, 19 female. The average Haller index was 4.3 (range 3.2-7.2). No episodes of cardiac perforation, hemothorax or significant pneumothorax were recorded. Bar displacement occurred in two patients (2.7%) with one late recurrence after bar removal. CONCLUSIONS Our modification of the Nuss procedure is effective at preventing intrathoracic complications and cardiac perforation. Central fixation had a lower rate of bar displacement compared to published reports. Additional efforts are needed to further reduce bar displacement.
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Effect on Chest Deformation of Simultaneous Correction of Pectus Excavatum with Scoliosis. JOURNAL OF HEALTHCARE ENGINEERING 2017; 2017:8318694. [PMID: 29138688 PMCID: PMC5613367 DOI: 10.1155/2017/8318694] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/20/2017] [Accepted: 08/06/2017] [Indexed: 01/08/2023]
Abstract
Objective This paper is to understand the effect of simultaneous correction of pectus excavatum with scoliosis and to provide some useful information for clinical orthopedic surgery design. Methods The method of a three-dimensional reconstruction has been used to the reconstruction of the chest model of pectus excavatum with scoliosis, and the numerical stimulation has been conducted to the process of minimally invasive correction. Three kinds of correction methods have been considered in the numerical simulation, stretch spine, stretch spine and minimally invasive correction at the same time, and release stretch spine after stretch spine and minimally invasive correction of pectus excavatum at the same time. Results It is found that stretch spine may help to correction of scoliosis but aggravate the sternum collapse, and release stretch spine after stretch spine and minimally invasive correction at the same time could not only be good at scoliosis but also improve the collapse of the sternum, which could help to improve the heartbeat and breath of the patients. Conclusion Among the three kinds of correction methods, release stretch spine after stretch spine and minimally invasive correction at the same time could help to improve both the scoliosis and the collapse of the sternum.
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Differences in myocardial strain between pectus excavatum patients and healthy subjects assessed by cardiac MRI: a pilot study. Eur Radiol 2017; 28:1276-1284. [DOI: 10.1007/s00330-017-5042-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/14/2017] [Accepted: 08/18/2017] [Indexed: 12/12/2022]
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Effects of Pectus Excavatum on the Spine of Pectus Excavatum Patients with Scoliosis. JOURNAL OF HEALTHCARE ENGINEERING 2017; 2017:5048625. [PMID: 29065615 PMCID: PMC5512045 DOI: 10.1155/2017/5048625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/13/2017] [Accepted: 04/30/2017] [Indexed: 11/17/2022]
Abstract
Background There is high risk in the correction surgery of pectus excavatum with scoliosis because of the lack of the correction mechanism of pectus excavatum with scoliosis. This study performed a comprehensive analysis about the impact that pectus excavatum had on scoliosis and elaborated its biomechanical mechanism in pectus excavatum patients with scoliosis. Methods 37 pectus excavatum patients were selected. According to age, Haller index of pectus excavatum, offset coefficient, vertical position, sternal torsion angle, and asymmetric index, 37 patients were, respectively, divided into 2 compared groups. The result was statistically calculated. Results The scoliosis incidence and severity did not correlate with Haller index, offset coefficient, vertical position, sternal torsion angle, and asymmetric index of pectus excavatum, and there was no statistical significance between the two compared groups. Conclusions The incidence and severity of scoliosis in PE patients with scoliosis have nothing to do with the geometric parameters of pectus excavatum but correlate with age. The scoliosis will aggravate with the increase of age. The heart may provide an asymmetric horizontal force to push the spines to the right. The mechanism of how the biomechanical factors exert influences on spines needs to be further investigated to keep the spine stable.
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YE JINDUO, LIU BOLUN, LIU JIFU, ZHANG CHUNYUE, ZHONG WEIHONG, ZHANG CHUNQIU. RESEARCH ON ELECTRICAL MEASUREMENT EXPERIMENT OF DEFORMATION OF ARTIFICIAL THORAX MODEL. J MECH MED BIOL 2016. [DOI: 10.1142/s0219519417500579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The method of numerical simulation has been used in the research setting for purposes related to the correction process of the pectus excavatum with scoliosis. Although a convenient method, the validity and accuracy of this technique need to be tested. Further complicating the validity of this technique is that we are unable to confirm results of numerical simulation via electrical measurement experiments in humans because of ethical considerations, nor are we able to attain cadavers of pectus excavatum with scoliosis to perform electrical measurement experiments on. Both animal thorax and artificial thorax models can be used for thoracic deformation experiments, but the translation of these models to humans is unclear due to contrasting anatomical arrangements of chest cavities. This paper attempts to solve this problem by making a PVC thorax model and carrying out electrical measurement experiments to assess strain–displacement under physiological loading conditions. We present data showing biomechanical responses of the thoracic skeleton to compressive loading, which may be used to guide the development of computational models of the thoracic skeleton and ultimately improve the treatment strategy of pectus excavatum.
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Affiliation(s)
- JINDUO YE
- School of Mechanical Engineering, Tianjin University of Technology, Tianjin 300384, China
- Tianjin Key Laboratory of the Design and Intelligent, Control of the Advanced Mechatronical System, Tianjin University of Technology, Tianjin 300384, China
| | - BOLUN LIU
- School of Mechanical Engineering, Tianjin University of Technology, Tianjin 300384, China
- Tianjin Key Laboratory of the Design and Intelligent, Control of the Advanced Mechatronical System, Tianjin University of Technology, Tianjin 300384, China
| | - JIFU LIU
- Department of Thoracic Surgery, General Hospital of Beijing, Command, Beijing 100700, China
| | - CHUNYUE ZHANG
- School of Mechanical Engineering, Tianjin University of Technology, Tianjin 300384, China
- Tianjin Key Laboratory of the Design and Intelligent, Control of the Advanced Mechatronical System, Tianjin University of Technology, Tianjin 300384, China
| | - WEIHONG ZHONG
- School of Mechanical Engineering, Tianjin University of Technology, Tianjin 300384, China
- Tianjin Key Laboratory of the Design and Intelligent, Control of the Advanced Mechatronical System, Tianjin University of Technology, Tianjin 300384, China
| | - CHUNQIU ZHANG
- School of Mechanical Engineering, Tianjin University of Technology, Tianjin 300384, China
- Tianjin Key Laboratory of the Design and Intelligent, Control of the Advanced Mechatronical System, Tianjin University of Technology, Tianjin 300384, China
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Frawley G, Frawley J, Crameri J. A review of anesthetic techniques and outcomes following minimally invasive repair of pectus excavatum (Nuss procedure). Paediatr Anaesth 2016; 26:1082-1090. [PMID: 27510834 DOI: 10.1111/pan.12988] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pectus excavatum (PE) is the most common congenital chest wall deformity, occurring in 1 : 1000 children with a male to female ratio of 4 : 1. Several procedures have been described to manage this deformity, including cartilage resection with sternal osteotomy (the Ravitch procedure) and a minimally invasive repair technique (the Nuss procedure). While initially described as a nonthoracoscopic technique, the current surgical approach of the Royal Childrens Hospital involves thoracoscopic assistance. Postoperative pain is significant in patients undergoing the pectus repair and multiple analgesic regimens have been advocated with continuous thoracic epidural infusions and opioid infusions the most common. Some authors have advocated patient-controlled analgesia (PCA), paravertebral nerve blocks (PVNB), and wound infusion catheters as alternatives. AIMS The primary aim of this study was to assess our experience with postoperative pain and analgesia requirements associated with the minimally invasive repair of pectus excavatum in children. METHODS This is a retrospective cohort study with a contemporaneous comparison group examining patients treated between January 2005 and December 2015 for minimally invasive repair of pectus excavatum by the Nuss procedure. RESULTS Two hundred and seventeen patients [mean age 14.9 (sd 1.9) years] with pectus excavatum treated at the Royal Childrens Hospital between 2005 and 2015 were identified. All patients were managed with thoracic epidural analgesia and intravenous morphine infusions. The epidural was effective in the postanesthesia care unit in 97.3% (failure to place an epidural rate was 4 (1.9%); no block on awakening 0.9%). A further 4 (1.8%) were removed within 24 h. The mean morphine equivalent dose in the first 24 h was 0.8 mg·kg-1 ·day-1 . PCA was continued for a mean of 3.8 days and the total mean morphine equivalent dose was 2.2 mg·kg-1 ·day-1 . Minor complications occurred in 67 (30.9%) with postoperative nausea and vomiting in 36 patients (16.6%) and urinary retention requiring an indwelling catheter in 40 patients (18.4%). CONCLUSION An epidural-based analgesic regime is associated with low pain scores and few acute complications. The continuation of morphine analgesia after the first postoperative day is common but associated with an increased incidence of urinary retention and nausea and vomiting.
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Affiliation(s)
- Geoff Frawley
- Department of Paediatric Anaesthesia and Pain Management, Royal Childrens Hospital, Melbourne, Vic., Australia. .,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia. .,Murdoch Childrens Research Institute, Critical Care and Neurosciences Theme, Parkville, Vic., Australia.
| | - Jacinta Frawley
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia
| | - Joe Crameri
- Department of Paediatric and Neonatal Surgery, Royal Childrens Hospital, Melbourne, Vic., Australia
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Choi JH, Park IK, Kim YT, Kim WS, Kang CH. Classification of Pectus Excavatum According to Objective Parameters From Chest Computed Tomography. Ann Thorac Surg 2016; 102:1886-1891. [PMID: 27526652 DOI: 10.1016/j.athoracsur.2016.05.079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/12/2016] [Accepted: 05/17/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Previous classification systems of pectus excavatum have been based on subjective morphologic characteristics. We sought to suggest a new classification system derived from objective variables. METHODS Patients who underwent surgical repair of pectus excavatum without a history of previous chest operations were included. Objective morphologic variables were measured from chest computed tomography scan images, and classification was performed by hierarchical clustering of measured indexes. Clinical relevance of the suggested classification was also verified. RESULTS Included were 230 patients who underwent operation for pectus excavatum from January 2001 to August 2013. These patients were classified into two major groups: typical (group I; 197 [85.7%]) and atypical (group II; 33 [14.3%]). Group I was further classified into three subgroups according to flatness and symmetry of the chest wall. Group II was further classified into four subgroups according to the severity of sternal torsion and sternal angulation. Two unique types of deformity were identified in group II: the double distortion subgroup (group IIa; 8 [3.5%]) and the reverse torsion subgroup (group IIc; 16 [7.0%]). Scoliosis was more frequently associated with group IIa (p = 0.008). CONCLUSIONS Morphologic classification obtained from computed tomography indexes hierarchical clustering identified seven distinct subtypes of pectus excavatum.
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Affiliation(s)
- Jin-Ho Choi
- Department of Thoracic and Cardiovascular Surgery, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - In Kyu Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Woo Sun Kim
- Department of Radiology and Institute of Radiation Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea.
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Karakuş OZ, Ulusoy O, Hakgüder G, Ateş O, Olguner Ç, Olguner M, Akgür FM. Nuss procedure: Technical modifications to ease bending of the support bar and lateral stabilizer placement. Ann Thorac Med 2016; 11:214-8. [PMID: 27512512 PMCID: PMC4966225 DOI: 10.4103/1817-1737.185758] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Modifications defined to ease bending of the support bar and lateral stabilizer placement during minimal invasive repair of pectus excavatum (MIRPE) have not been reported. We herein report our experience with MIRPE including several technical modifications. METHODS A total of 87 patients who underwent MIRPE were evaluated retrospectively. Technical modifications are (1) a template drawn preoperatively according to the anthropometric measurements, (2) more laterally placed thoracal incisions, (3) single existing incision for multiple support bars, (4) to secure lateral stabilizers to support bar in inverted position. RESULTS The mean patient age was 11.2 ± 3.8 years. The mean operating time was 63.7 ± 18.7 min. The mean Haller index was 5.4 ± 2.1. Eight patients necessitated two support bars. The support bars were removed in 69 patients after the completion of treatment. Support bars were left in place 26.8 ± 4.3 months. Final chest contours of the 56 patients were evaluated as 12 months passed after support bar removal and excellent repair results were determined in 84.2%. CONCLUSION Preoperative bending of the support bar according to anthropometric measurements and fixation of the lateral stabilizers to the support bar in inverted position facilitates bar shaping and lateral stabilizer placement.
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Affiliation(s)
- Osman Zeki Karakuş
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
| | - Oktay Ulusoy
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
| | - Gülce Hakgüder
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
| | - Oğuz Ateş
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
| | - Çimen Olguner
- Department of Anesthesiology, Dokuz Eylül University, Medical School, Izmir, Turkey
| | - Mustafa Olguner
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
| | - Feza Mirac Akgür
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
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Štefánková E, Omaník P, Neščáková E, Stanová B, Cingel V. Metrical evaluation of Slovak patients with pectus excavatum. Surg Radiol Anat 2015; 38:663-74. [PMID: 26645297 DOI: 10.1007/s00276-015-1594-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 11/23/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE We have started to assess the severity of pectus excavatum by means of anthropometric methods prior to CT examination since 2012. The aim of the study was to establish a significance of anthropometry as first-line diagnostic method. Afterwards, we analyzed statistical significance of differences in selected anthropometric indicators before and after surgical intervention. The analysis was also focused on the data from CT scans. METHODS The followed group represented 27 patients, including 6 girls and 21 boys aged 7-18 years (mean age 15.59 years). Evaluation of anthropometric measurements was realized by somatometry, and other metrical measurements were calculated from thoracic CT scans of patients. All measurements were managed with the approval of the Ethics Committee. RESULTS The significant differences were found in sagittal diameter and thoracic index in 64.0 % of the patients. Data analyzed from CT showed that flat chest prevailed in both gender (100 %). The largest group represented asymmetric type of pectus excavatum (40.74 %). The superiority of the asymmetric type to the right was confirmed. The values of the Haller index were in range 2.00-5.17 (mean value 3.64). 81.5 % of patients met criterion for surgical correction. Most patients with pectus excavatum had a milder form of deformation. CONCLUSIONS Anthropometry provides feasible and non-invasive method of pectus deformities evaluation. Based on the study results, anthropometry should be performed prior to CT examination in order to select patients for surgical treatment. Anthropometric measurements are helpful in accurate documentation of growth, longitudinal observation of the patient, and can support decision concerning the type of surgery.
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Affiliation(s)
- Eva Štefánková
- Department of Paediatric Surgery, Faculty of Medicine, Children's University Hospital, Comenius University, Limbova 1, 833 40, Bratislava, Slovakia.
| | - Pavol Omaník
- Department of Paediatric Surgery, Faculty of Medicine, Children's University Hospital, Comenius University, Limbova 1, 833 40, Bratislava, Slovakia
| | - Eva Neščáková
- Department of Anthropology, Faculty of Natural Sciences, Comenius University, Mlynská dolina, 842 15, Bratislava, Slovakia
| | - Barbara Stanová
- Department of Anthropology, Faculty of Natural Sciences, Comenius University, Mlynská dolina, 842 15, Bratislava, Slovakia
| | - Vladimír Cingel
- 1st Department of Surgery, Faculty of Medicine, Comenius University, Mickiewiczova 13, 813 69, Bratislava, Slovakia
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Z-Type Pattern Pectus Excavatum/Carinatum in A Case of Noonan Syndrome. Ann Thorac Surg 2015; 99:1835-7. [DOI: 10.1016/j.athoracsur.2015.01.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 11/28/2014] [Accepted: 01/16/2015] [Indexed: 11/20/2022]
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Radiologic factors related to double-bar insertion in minimal invasive repair of pectus excavatum. World J Pediatr 2015; 11:148-53. [PMID: 25416004 DOI: 10.1007/s12519-014-0522-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 01/20/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pectus excavatum is the most common congenital chest wall deformity, with a high incidence in live births. This study aimed to evaluate the measured factors on CT images related to the number of pectus bars for surgical correction. METHODS A total of 497 patients who had undergone minimally invasive repair between April 2007 and July 2011 were classified into single-bar (n=358) and double-bar (n=139) insertion groups. We measured eight distinct distances and one angle on CT scans to reflect quantitative assessment. Univariate analysis and multivariate logistic regression analysis were performed to detect statistically significant association between radiologic measurements and the pectus bars required. RESULTS After adjusting for age and gender, the transverse distance (T), the transverse distance of the depression area (A), the inclined distance of the depression area (B), the AP distance of the depression area (C), the depression angle (G), and the eccentric distance of deformity (E) were significantly correlated with double-bar insertion. The regression model showed that age (P<0.0001), gender (P<0.0001), depression angle (G) (P<0.0001), direction of the depression (DD) (P<0.0001) and depression depth (D) (P<0.0001) were significantly associated with double-bar insertion. CONCLUSION CT scan provides useful factors which can be of assistance in predicting the number of pectus bars for the surgical correction of pectus excavatum.
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Koumbourlis AC. Pectus deformities and their impact on pulmonary physiology. Paediatr Respir Rev 2015; 16:18-24. [PMID: 25464892 DOI: 10.1016/j.prrv.2014.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 10/29/2014] [Indexed: 11/24/2022]
Abstract
Pectus excavatum (PE) and pectus carinatum (PC) are the most common anomalies of the thoracic cage and they have been recognized since ancient times [1-3]. The two conditions differ in their appearance, and their effect on lung function. There is no direct correlation between the appearance of the deformities and the clinical symptoms. Whether, and when these deformities should be corrected as well as with which method (surgical or conservative) remain controversial. The following article reviews the current concepts regarding the pathophysiology of both conditions as well as the advances in their evaluation and management.
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Affiliation(s)
- Anastassios C Koumbourlis
- Professor of Pediatrics, George Washington University, Chief, Pulmonary & Sleep Medicine, Children's National Medical Center.
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Morphologic assessment of thoracic deformities for the preoperative evaluation of pectus excavatum by magnetic resonance imaging. Eur Radiol 2014; 25:785-91. [DOI: 10.1007/s00330-014-3450-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 07/25/2014] [Accepted: 09/22/2014] [Indexed: 11/29/2022]
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Sarwar ZU, DeFlorio R, O׳Connor SC. Pectus Excavatum: Current Imaging Techniques and Opportunities for Dose Reduction. Semin Ultrasound CT MR 2014; 35:374-81. [DOI: 10.1053/j.sult.2014.05.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tocchioni F, Ghionzoli M, Calosi L, Guasti D, Romagnoli P, Messineo A. Rib cartilage characterization in patients affected by pectus excavatum. Anat Rec (Hoboken) 2013; 296:1813-20. [PMID: 24170345 DOI: 10.1002/ar.22824] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 09/25/2013] [Indexed: 11/07/2022]
Abstract
Pectus excavatum (PE) is the most frequent anterior chest deformity which may be frequently associated with connective tissue disorders. We performed microscopic analyses to better understand cartilage behavior and obtain clues on its pathogenesis. In 37 PE patients, none with Marfan syndrome, we analyzed costal cartilage by light microscopy, immunohistochemistry and transmission electron microscopy. Control tissue specimens were harvested from four patients without any connective tissue disease. In both control and PE patients, chondrocytes were on the average <15 µm in diameter and occupied <10% of tissue volume; in most cases the extracellular matrix was stained by alcian blue, instead of safranin; no difference between PE and control samples was significant. All samples showed an uneven collagen type II immunolabeling both within the cells and pericellular matrix, and occasionally of the territorial matrix. In all cases numerous cells underwent apoptosis accompanied by matrix condensation as shown by electron microscopy. Our results suggest that matrix composition and the cell number and size of costal cartilage are dependent on the subject and not on the disease; the microscopic organization of cartilage is correlated with the stabilization of the defective shape rather than with the onset of the deformity.
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Affiliation(s)
- Francesca Tocchioni
- Department of Pediatric Surgery, University of Florence and Children's University Hospital A. Meyer, Florence, Italy
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Albertal M, Vallejos J, Bellia G, Millan C, Rabinovich F, Buela E, Bignon H, Martinez-Ferro M. Changes in chest compression indexes with breathing underestimate surgical candidacy in patients with pectus excavatum: a computed tomography pilot study. J Pediatr Surg 2013; 48:2011-6. [PMID: 24094949 DOI: 10.1016/j.jpedsurg.2013.01.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/18/2013] [Accepted: 01/29/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Haller Index (HI) ≥3.25 by computed tomography (CT) at end-inspiration has been used to indicate surgical correction in patients with pectus excavatum. However, chest wall diameters vary with breathing and may modify HI values and surgical indications. The aim of our study was to report the changes in HI with breathing and their impact in the surgical indication rates. METHODS Thirty six patients with pectus excavatum underwent chest CT evaluation at both end-inspiration and end-expiration. HI was derived by dividing the transverse diameter (TD) of the chest by the anteroposterior diameter (APD). Cardiac compression index (CCI) was then calculated by dividing the cardiac TD by the APD. RESULTS Mean patient age was 19 ± 7 years old and 86.8% were males. From end-inspiration to end-expiration, large changes in APD values corresponded to large changes (29.6%) in HI values. CCI increased significantly during end-expiration, primarily driven by an increase on the cardiac TD. Surgical indication was found in 71% and 91% of patients during end-inspiration and end-expiration, respectively (p<0.05). CONCLUSIONS This study showed that the severity indexes of the pectus excavatum were all significantly more severe at end-expiration than at end-inspiration, leading to an increase in surgical candidacy. We therefore recommend performing the CT at end-expiration.
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Affiliation(s)
- Mariano Albertal
- Department of Pediatric Surgery, Fundacion Hospitalaria, Private Children's Hospital, Buenos Aires, Argentina
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Tocchioni F, Ghionzoli M, Messineo A, Romagnoli P. Pectus excavatum and heritable disorders of the connective tissue. Pediatr Rep 2013; 5:e15. [PMID: 24198927 PMCID: PMC3812532 DOI: 10.4081/pr.2013.e15] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 06/20/2013] [Accepted: 08/13/2013] [Indexed: 12/03/2022] Open
Abstract
Pectus excavatum, the most frequent congenital chest wall deformity, may be rarely observed as a sole deformity or as a sign of an underlying connective tissue disorder. To date, only few studies have described correlations between this deformity and heritable connective tissue disorders such as Marfan, Ehlers-Danlos, Poland, MASS (Mitral valve prolapse, not progressive Aortic enlargement, Skeletal and Skin alterations) phenotype among others. When concurring with connective tissue disorder, cardiopulmonary and vascular involvement may be associated to the thoracic defect. Ruling out the concomitance of pectus excavatum and connective tissue disorders, therefore, may have a direct implication both on surgical outcome and long term prognosis. In this review we focused on biological bases of connective tissue disorders which may be relevant to the pathogenesis of pectus excavatum, portraying surgical and clinical implication of their concurrence.
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Kelly RE, Quinn A, Varela P, Redlinger RE, Nuss D. Dismorfología de las deformidades de la pared torácica: distribución de frecuencias de los subtipos de pectus excavatum típico y subtipos poco comunes. Arch Bronconeumol 2013; 49:196-200. [DOI: 10.1016/j.arbres.2012.09.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 08/10/2012] [Accepted: 09/10/2012] [Indexed: 11/29/2022]
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Yoshida A, Uemura S, Yamamoto M, Nouso H, Kuyama H, Muta Y. Correlation of asymmetric chest wall deformity and growth in patients with pectus excavatum. J Pediatr Surg 2013; 48:771-5. [PMID: 23583132 DOI: 10.1016/j.jpedsurg.2012.11.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 11/05/2012] [Accepted: 11/09/2012] [Indexed: 11/18/2022]
Abstract
PURPOSE Pectus excavatum involves wide range of chest wall depression. The degree of depression or asymmetry varies between young and adolescent patients. It has not been clear how the deformity progresses as patients grow. To elucidate the change of asymmetric deformity, preoperative computed tomography (CT) scan was evaluated according to different age groups. METHODS Preoperative CT scans of 154 patients with pectus excavatum were collected and analyzed using Haller's CT index, asymmetric index and sternal rotation angle. Patients were divided into 5 age groups as follows; group 1: 4-6 y (n=53), group 2: 7-9 y (n=25), group 3: 10-12 y (n=25), group 4: 13-15 y (n=23), group 5: 16-23 y (n=28). The degree of asymmetric chest wall deformity was expressed using sternal rotation angle as follows; symmetrical (-5º to +5º), left-mild (-5º to -15º), right-mild (+5º to +15º), right-moderate (+15º to +25º) and right-severe (over +25º). RESULTS As the age of patients increased, asymmetric index increased from 1.025±0.065 in group 1 to 1.124±0.111 in group 5 and sternal rotation angle also increased from 6.11±8.61 in group 1 to 15.41±11.98 in group 5. In these two parameters, significant difference was seen between group 1 and 4, group 2 and 4, group 1 and 5 and group 2 and 5. However, average CT index revealed no significant difference in any age groups. In group 1, 83% of patients were classified in symmetrical or left- and right-mild. The incidence of right-moderate plus right-severe was 17% in group 1, 20% in group 2, 40% in group 3, 52.1% in group 4 and 50% in group 5. CONCLUSIONS The degree of chest depression did not show any change in all age groups. Asymmetric deformity on the right side progressed around the age of 10 to 12. Half of patients over the age of 13 showed moderate or severe asymmetry. These results were suggestive to consider the optimum age for the correction of pectus excavatum.
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Affiliation(s)
- Atsushi Yoshida
- Department of Pediatric Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan.
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Kang CH, Park S, Park IK, Kim YT, Kim JH. Long-term Surveillance Comparing Satisfaction between the Early Experience of Nuss Procedure vs. Ravitch Procedure. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:308-15. [PMID: 23130304 PMCID: PMC3487014 DOI: 10.5090/kjtcs.2012.45.5.308] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 04/12/2012] [Accepted: 04/28/2012] [Indexed: 11/16/2022]
Abstract
Background Long-term surveillance comparing satisfaction between the early experience of Nuss procedure vs. Ravitch procedure. Materials and Methods A total of 100 patients that underwent surgical correction of a pectus excavatum between 2001 and 2004 and were followed for ≥2 years were included. Surveillance on the degree of satisfaction was performed using five-levels of the Likert scale and self-assessment scoring. Results Nuss or Ravitch surgery was performed in 63 and 37 patients, respectively. The Nuss procedure required a shorter operation time and shorter hospital stay than the Ravitch procedure (p<0.001). The surveillance demonstrated that 17.6% of the Nuss group and 35.7% of the Ravitch group were not satisfied with the outcome of the surgery (p=0.072). The most common causes of dissatisfaction were redepression in the Nuss group (n=5) and incomplete correction in the Ravitch group (n=7). The multivariate analysis showed that reoperation and a high postoperative pectus index were significant risk factors for a low satisfaction score. Conclusion The Nuss procedure had several advantages over the Ravitch procedure in the immediate postoperative period. However, the long-term satisfaction was determined by a complete correction without recurrence or need for re-intervention rather than by the operation type.
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Affiliation(s)
- Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Korea
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Ghionzoli M, Brandigi E, Messineo A, Messeri A. Pain and anxiety management in minimally invasive repair of pectus excavatum. Korean J Pain 2012; 25:267-71. [PMID: 23091689 PMCID: PMC3468805 DOI: 10.3344/kjp.2012.25.4.267] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 06/29/2012] [Accepted: 06/29/2012] [Indexed: 11/25/2022] Open
Abstract
The Nuss procedure for the correction of Pectus Excavatum (PE) is associated with intense postoperative pain. Our strategy to control early postoperative pain is to combine epidural with intravenous analgesia. Our aim was to analyse our pain control strategy by reviewing all the PE cases treated at our institution. Sixty consecutive patients, aged between 12 and 26 years old, received the PE operation at our institution from January, 2007 to September, 2010. The median age was 16 (12-27) with a male/female ratio of about 7/1. An epidural catheter was employed in all the cases, with 38 patients (63%) requiring additional drugs to control pain, which remained in place for 74 hours (72-96). The pain score was higher in male patients, but lower in those younger than 16 years old. Moreover, patients that consumed benzodiazepines had a significant decrease in cumulative opioid intake (P = 0.0408). Both gender and age had an impact on pain control, while we noticed a synergistic effect between opiates and tranquillizers.
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Affiliation(s)
- Marco Ghionzoli
- Department of Pediatric Surgery, Children's Hospital A. Meyer, Florence, Italy
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Tocchioni F, Ghionzoli M, Pepe G, Messineo A. Pectus excavatum and MASS phenotype: an unknown association. J Laparoendosc Adv Surg Tech A 2012; 22:508-13. [PMID: 22568544 DOI: 10.1089/lap.2012.0009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Severe pectus excavatum (PE) is a deep chest wall deformity that generates both a cosmetic damage and a cardiac/respiratory function impairment. Excluding the scarce reports on Marfan's syndrome (MFS) and Ehlers-Danlos's syndrome (EDS), few studies have examined the relation between severe PE and connective tissue disorders. The aim of this study is to verify the clinical significance of such correlation. SUBJECTS AND METHODS Ninety-two consecutive patients, of whom 79 were males, between 6 and 34 years old, classified as having severe PE, were seen at our institution from June 2005 to September 2010. All patients underwent clinical, ophthalmological, cardiac, and radiological (chest and spine magnetic resonance imaging) screening. The following features were observed: skin stretch marks, scoliosis, joint hypermobility, echocardiographic signs, spinal defects, and myopia. RESULTS Classical connectivopathies such as MFS or EDS were present in only 5 patients (approximately 5%), whereas a single deformity was present in 4. The largest group (approximately 71%) was represented by phenotypical alterations such as mitral valve prolapse, aortic root enlargement, and skeletal and skin alterations (MASS). Among those patients, the most frequent clinical manifestations were the skeletal ones, followed by skin marks and mitral valve prolapse. CONCLUSIONS PE showed an evident association with an array of features that we describe as MASS. Although not one of this subgroup of patients has been described with increased aortic root diameter when screened (a feature widely present in MFS patients), they probably would require a thorough and longer follow-up than those affected by isolated PE because of the potential occurrence of severe cardiovascular complications such as aneurysms and dissection, which are major causes of morbidity and mortality in MFS.
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Affiliation(s)
- Francesca Tocchioni
- Department of Pediatric Surgery, Children's Hospital A Meyer, Florence, Italy
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