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Notrica DM, McMahon LE, Jaroszewski DE. Pectus Disorders: Excavatum, Carinatum and Arcuatum. Adv Pediatr 2024; 71:181-194. [PMID: 38944483 DOI: 10.1016/j.yapd.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
This article reviews pectus excavatum, carinatum, and arcuatum. Topics covered include etiology, epidemiology, associated syndromes, physiologic impact, workup, indications for treatment, surgical and nonsurgical therapy, results, complications, and emerging therapies. Pectus excavatum is an inward deformation of the sternum and/or anterior chest wall. Pectus carinatum is ether an outward protrusion or tilt of the sternum with potential psychological impact, but no demonstrated physiologic impact. Nonoperative compression bracing is successful in carinatum patients with chest wall flexibility who are compliant with a bracing program. Pectus arcuatum is an abnormally short, fully fused sternum with a high anterior protrusion.
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Affiliation(s)
- David M Notrica
- Phoenix Children's Division of Pediatric Surgery, 1919 East Thomas Road, Phoenix, AZ 85016, USA; University of Arizona College of Medicine Phoenix, Department of Child Health and Surgery, 475 N. 5th Street Phoenix, AZ 85004, USA; Mayo Clinic School of Medicine and Science, 5757 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| | - Lisa E McMahon
- Phoenix Children's Division of Pediatric Surgery, 1919 East Thomas Road, Phoenix, AZ 85016, USA; University of Arizona College of Medicine Phoenix, Department of Child Health and Surgery, 475 N. 5th Street Phoenix, AZ 85004, USA; Mayo Clinic School of Medicine and Science, 5757 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Dawn E Jaroszewski
- Mayo Clinic School of Medicine and Science, 5757 East Mayo Boulevard, Phoenix, AZ 85054, USA; Mayo Clinic Arizona, Division of Thoracic Surgery, 5757 East Mayo Boulevard, Phoenix, AZ 85054, USA
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Weinhandl AC, Ermerak NO, Yüksel M, Rebhandl W. 'Short Bars Crossed' to Remodel the Entire Chest Wall in Children and Adolescents with Pectus Excavatum. J Pediatr Surg 2024:S0022-3468(24)00350-6. [PMID: 38914508 DOI: 10.1016/j.jpedsurg.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/26/2024] [Accepted: 05/30/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND The cross-bar technique of minimally invasive pectus excavatum (PE) correction remains underreported, which is especially true of pediatric patients. We therefore reviewed the experience of a Turkish and an Austrian center. An additional novelty characterizing both pediatric cohorts was the use of short bars. METHODS In a retrospective study, pediatric PE corrections involving 'short bars crossed' were analyzed for complications and intra-/postoperative outcomes. Cases with two or three bars were included, given that a horizontal third bar was placed whenever considered useful for upper-chest elevation. All bars were fitted with a single stabilizer near the surgical entry point. In the Austrian center, intercostal nerve cryoablation was used for pain management. Descriptive statistics are presented. RESULTS Seventy-eight patients ≤18 years old were evaluable at the Turkish (n = 56) and Austrian (n = 22) centers. Total median values were 16.2 (IQR: 15.1-17.4) years for age and 4.60 (IQR: 3.50-6.11) for Haller index. Ten mild or moderate complications (12.8%) were observed, including just one revision requirement due to bar migration (1.28%). Intercostal nerve cryoablation (n = 13) was associated with longer surgical procedures at 150 (IQR: 137-171) versus 80 (IQR: 60-100) minutes but with shorter hospital stays, given an IQR of 3-4 days versus 4-5 days. CONCLUSION 'Short bars crossed'-with a single stabilizer in a ventral position close to the surgical entry point-ensure a wide distribution of forces, protect against bar migration, are safe and effective, and offer stability at an age characterized by growth and physical activity. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anja C Weinhandl
- University Clinic of Pediatric and Adolescent Surgery, Comprehensive Center for Pediatrics, Medical University of Vienna, Austria
| | - Nezih O Ermerak
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Mustafa Yüksel
- Department of Thoracic Surgery, Emeritus Prof of Marmara University Lecturer of TC, Demiroglu Bilim University Medical School, Istanbul, Turkey
| | - Winfried Rebhandl
- University Clinic of Pediatric and Adolescent Surgery, Comprehensive Center for Pediatrics, Medical University of Vienna, Austria.
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Karamitros G, Kakogeorgou V, Chandler NM, Goulas S. Evaluating the web as a source of information for patients with chest wall deformities: insights into engagement and disparities. Pediatr Surg Int 2024; 40:150. [PMID: 38833023 DOI: 10.1007/s00383-024-05732-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Recent data highlight the internet's pivotal role as the primary information source for patients. In this study, we emulate a patient's/caregiver's quest for online information concerning chest deformities and assess the quality of available information. METHODS We conducted an internet search using combination of the terms "pectus excavatum," "pectus excavatum surgery," "funnel chest," "pectus excavatum repair" and identified the first 100 relevant websites from the three most popular search engines: Google, Yahoo, and Bing. These websites were evaluated using the modified Ensuring Quality Information for Patients (EQIP) instrument. RESULTS Of the 300 websites generated, 140 (46.7%) were included in our evaluation after elimination of duplicates, non-English websites, and those targeting medical professionals. The EQIP scores in the final sample ranged from 8 to 32/36, with a median score of 22. Most of the evaluated websites (32.8%) originated from hospitals, yet none met all 36 EQIP criteria. DISCUSSION None of the evaluated websites pertaining to pectus excavatum achieved a flawless "content quality" score. The diverse array of websites potentially complicates patients' efforts to navigate toward high-quality resources. Barriers in accessing high-quality online patient information may contribute to disparities in referral, patient engagement, treatment satisfaction, and overall quality of life. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Georgios Karamitros
- Division of Plastic Surgery, Department of Surgery, University Hospital of Ioannina, Ioannina, Greece.
- Medical School, Department of Plastic Surgery, University of Ioannina, Stavrou Niarchou Avenue, 45500, Ioannina, Greece.
| | - Vasiliki Kakogeorgou
- Department of Orthopaedics, General Hospital of Nea Ionia "Konstantopouleio", Nea Ionia, Greece
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Sofoklis Goulas
- Brookings Institution, Washington, DC, USA
- Hoover Institution, Stanford University, Stanford, CA, USA
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Donati F, Cipriani MS, Pistorio A, Guerriero V, Mattioli G, Torre M. Pectus Bar Dislocation: Comparison Between Three Different Stabilization Techniques Adopted in a Single Centre. J Pediatr Surg 2024:S0022-3468(24)00351-8. [PMID: 38914509 DOI: 10.1016/j.jpedsurg.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 05/16/2024] [Accepted: 05/26/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Bar dislocation has always been considered a fearsome complication of Minimally Invasive Repair of Pectus Excavatum (MIRPE), therefore multiple techniques and types of stabilization have been introduced. The aim of the study is to compare different stabilization techniques in a cohort of patients operated by the same first operator. METHODS MIRPE was adopted at our institution in 2005. Data on MIRPE patients from January 2013 to December 2022 were collected prospectively and reviewed. Patients with a follow-up of at least 12 months were included. Throughout the years different ways of stabilization were used. Patients were divided in 3 groups according to the stabilization strategy adopted- Group A: no stabilizer; Group B: single bar fixation; Group C: bridge fixation. Dislocation was diagnosed if a bar rotated more than 30° or displaced laterally for more than 1.5 cm. We compared bar dislocation percentage of each group. RESULTS We positioned 733 bars in 468 patients. Group A included 113 bars (15.4%), Group B 415 bars (56.6%), Group C 205 bars (28%). No patients were lost at follow-up. Total dislocation rate was 4.1% (30 bars). Dislocation was observed in 10 bars of group A (8.8%), 20 bars of group B (4.8 %), 0 bars of group C (0%). Differences between groups were statistically significant. CONCLUSIONS The use of stabilizers reduced dislocation percentage. In particular, bridge fixation technique reduced to zero bar dislocation and is now our preferred technique of stabilization. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Francesco Donati
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Largo Gaslini 5, 16147 Genoa, Italy.
| | - Maria Stella Cipriani
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Largo Gaslini 5, 16147 Genoa, Italy
| | - Angela Pistorio
- Scientific Directorate - Biostatistics Unit, IRCCS Istituto Giannina Gaslini, Largo Gaslini 5, 16147 Genoa, Italy
| | - Vittorio Guerriero
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Largo Gaslini 5, 16147 Genoa, Italy
| | - Girolamo Mattioli
- Pediatric Thoracic and Airway Surgery Unit, IRCCS Istituto Giannina Gaslini, Largo Gaslini 5, 16147 Genoa, Italy; Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Michele Torre
- Pediatric Thoracic and Airway Surgery Unit, IRCCS Istituto Giannina Gaslini, Largo Gaslini 5, 16147 Genoa, Italy; Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
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Huerta CT, Cobler-Lichter MD, Lynn R, Ramsey WA, Delamater JM, Alligood DM, Parreco JP, Sola JE, Perez EA, Thorson CM. Outcomes After Pectus Excavatum Repair: Center Volume Matters. J Pediatr Surg 2024; 59:935-940. [PMID: 38360451 DOI: 10.1016/j.jpedsurg.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE Pectus excavatum (Pectus) repair may be offered for those with significant cardiopulmonary compromise or severe cosmetic defects. The influence of hospital center volume on postoperative outcomes in children is unknown. This study aimed to investigate the outcomes of children undergoing Pectus repair, stratified by hospital surgical volume. METHODS The Nationwide Readmission Database was queried (2016-2020) for patients with Pectus (Q67.6). Patients were stratified into those who received repair at high-volume centers (HVCs; ≥20 repairs annually) versus low-volume centers (LVCs; <20 repairs annually). Demographics and outcomes were analyzed using standard statistical tests. RESULTS A total of 9414 patients with Pectus underwent repair during the study period, with 69% treated at HVCs and 31% at LVCs. Patients at LVCs experienced higher rates of complications during index admission, including pneumothorax (23% vs. 15%), chest tube placement (5% vs. 2%), and overall perioperative complications (28% vs. 24%) compared to those treated at HVCs, all p < 0.001. Patients treated at LVCs had higher readmission rates within 30 days (3.8% vs. 2.8% HVCs) and overall readmission (6.8% vs. 4.7% HVCs), both p < 0.010. Among readmitted patients (n = 547), the most frequent complications during readmission for those initially treated at LVCs included pneumothorax/hemothorax (21% vs. 8%), bar dislodgment (21% vs. 12%), and electrolyte disorders (15% vs. 9%) compared to those treated at HVCs. CONCLUSION Pediatric Pectus repair performed at high-volume centers was associated with fewer index complications and readmissions compared to lower-volume centers. Patients and surgeons should consider this hospital volume-outcome relationship. TYPE OF STUDY Retrospective Comparative. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Royi Lynn
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | - Jessica M Delamater
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | - Daniel M Alligood
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | | | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA; Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA; Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA; Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Zeineddine RM, Botros M, Shawwaf KA, Moosavi R, Aly MR, Farina JM, Lackey JJ, Sandstrom BA, Jaroszewski DE. Does a high Haller index influence outcomes in pectus excavatum repair? J Thorac Cardiovasc Surg 2024:S0022-5223(24)00292-7. [PMID: 38608864 DOI: 10.1016/j.jtcvs.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/21/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Severity for pectus excavatum includes Haller index (HI) > 3.25. An extremely high HI (≥8) may influence surgical approach and complications. This study reviews outcomes of patients with high HI after repair. METHODS A single institution retrospective analysis was performed on adult patients with HI ≥ 8 undergoing pectus excavatum repairs. For outcomes, a propensity score-matched control group with a HI ≤ 4 was utilized. RESULTS In total, 64 cases (mean age, 33.5 ± 10.9 years; HI, 13.1 ± 5.0; 56% women) were included. A minimally invasive repair was successful in 84%. A hybrid procedure was performed in the remaining either to repair fractures of the ribs (8 patients) and sternum (5 patients) or when osteotomy and/or cartilage resection was required (10 patients). In comparison with the matched cohort (HI ≤ 4), patients with high HI had longer operative times (171 vs 133 minutes; P < .001), more frequently required hybrid procedures (16% vs 2%; P = .005), experienced higher incidences of rib (22% vs 3%; P = .001) and sternal fractures (12% vs 0%; P = .003), and had increased repair with 3 bars (50% vs 19%; P < .001). There were no significant differences between the groups for length of hospital stay or postoperative 30-day complications. CONCLUSIONS Patients with an extremely high HI can be challenging cases with greater risks of fracture and need for osteotomy/cartilage resection. Despite this, minimally invasive repair techniques can be utilized in most cases without increased complications when performed by an experienced surgeon.
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Affiliation(s)
- Rawan M Zeineddine
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Michael Botros
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Kenan A Shawwaf
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Ryan Moosavi
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Jesse J Lackey
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Beth A Sandstrom
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz.
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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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Roostaei G, Amini H, Abtahi H, Kazemizadeh H, Edalatifard M, Rahimi B, Asadi S, Khoshnam‐Rad N. Post-operative arrest following pectus excavatum repair: A case report with a systematic review of the published case reports. Clin Case Rep 2024; 12:e8650. [PMID: 38464576 PMCID: PMC10920322 DOI: 10.1002/ccr3.8650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024] Open
Abstract
Key Clinical Message Common complications after PE surgery include ventricular tachycardia, cardiac arrest, pneumothorax, and bar displacement. These can lead to severe outcomes, emphasizing the need for caution and meticulous post-operative monitoring. Patients and their families should be well-informed about potential risks during the consent process. Abstract The objective of this study was to raise awareness among medical staff and surgeons about potential complications, particularly rare and life-threatening ones, associated with pectus excavatum (PE) surgery. PE is the most common chest wall deformity, characterized by sternal depression. Patients primarily seek treatment for cosmetic concerns, but some also report exercise intolerance and shortness of breath. Although surgical repair is the standard treatment, the incidence and nature of severe complications remain unclear and underreported. This study presents a case of a lethal cardiac event following PE surgery and conducts a systematic review of published case reports. This study describes a case of a lethal complication of ventricular fibrillation and cardiac arrest following the Ravitch procedure for correction of PE in a 10-year-old boy. A systematic review of relevant cases of PE surgery complications was conducted. Of the 506 initial records retrieved, 93 case reports from 83 articles were identified over the 23 years. Among them, 72 patients were male, and 20 cases were female. The average age of patients was 19.2 ± 7.7 years (range: 5-53). Complications had occurred up to 37 years from the time of surgery, with most of the cases (22.5%) occurring during the operation. The most frequent complications included cardiothoracic issues and displacement of the implanted steel bar. In nine patients, complications led to fatal outcomes. Due to the possible risks of PE surgery, particularly in cosmetically motivated cases, surgeons must exercise extreme caution and remain vigilant for rare and potentially life-threatening complications.
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Affiliation(s)
- Ghazal Roostaei
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hesam Amini
- Department of Thoracic Surgery, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hamidreza Abtahi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hossein Kazemizadeh
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Maryam Edalatifard
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Besharat Rahimi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Sanaz Asadi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Niloofar Khoshnam‐Rad
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
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Aly MR, Farina JM, Bostoros PM, Botros MM, Pulivarthi VS, Peterson MA, Lackey JJ, Jaroszewski DE. Risk Factors and Techniques for Safe Pectus Bar Removal in Adults After Modified Nuss Repair. Ann Thorac Surg 2023; 116:787-794. [PMID: 36549569 DOI: 10.1016/j.athoracsur.2022.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/26/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Nuss repair involves implants designed for removal after 2 to 3 years. Although rare, significant complications can occur with bar removal, and the incidence of these complications may be higher in adults. This study was performed to review complications and risk factors associated with bar removal and discuss strategies to improve operative safety. METHODS A retrospective study was performed including all patients after pectus excavatum repair who underwent Nuss implant removal at Mayo Clinic Arizona (Phoenix, AZ) from 2013 to 2022. RESULTS In total, 1555 bars were removed (683 patients; 71% men; median age, 34 years[(range, 15-71 years]). Of the removals, 12.45% of patients had bars placed at outside institutions. Major complications were rare, with bleeding most common (2.05%), followed by pneumothorax (0.88%), infection (0.59%), and effusions (0.44%). Most major bleeding (85.71%) occurred from the bar track during removal and was controlled by packing the track. One patient required subsequent hematoma evacuation and transfusion. Bleeding secondary to lung injury was also successfully controlled with packing. Bar removal in 1 patient with significantly displaced bars required sternotomy and cardiopulmonary bypass as a result of aortic injury. Risk factors identified for bleeding included sternal erosion (P < .001), bar migration (P < .001), higher number of bars (P = .037), and revision of a previous pectus repair (P = 0.001). Bar migration was additionally associated with major complications (P < .001). Older age, although a risk factor for overall complications (P = 0.001), was not a risk factor for bleeding. CONCLUSIONS Bar removal can be safely performed in most patients; however, significant complications, including bleeding, may occur. Identifying potential risk factors and being prepared for rescue maneuvers are critical to prevent catastrophic outcomes.
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Affiliation(s)
- Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Peter M Bostoros
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michael M Botros
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Venkata S Pulivarthi
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michelle A Peterson
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jesse J Lackey
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona.
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10
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Beati F, Frediani S, Pardi V, Aloi I, Bertocchini A, Accinni A, Inserra A. Case report-Every thoracic surgeon's nightmare: cardiac and lung perforation during placement of Nuss bar for pectus excavatum. Front Pediatr 2023; 11:1241273. [PMID: 37744443 PMCID: PMC10513049 DOI: 10.3389/fped.2023.1241273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/14/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction The prevalence of life-threatening complications (LTCs) related to the minimally invasive repair of pectus excavatum (MIRPE) is unknown and underreported. The aim of this study is to contribute to the real prevalence of these rare but dramatic complications and show what went wrong in order to prevent it in the future. Case presentation A 15-year-old boy affected by pectus excavatum with severe asymmetric deformity of the chest wall was evaluated for elective corrective surgery. Preoperative computed tomography showed a Haller index of 5.7 and a correction index of 0.40. MIRPE was performed under right video-assisted thoracoscopy. Cardiac arrhythmias occurred after placement of the bar introducer. The introducer was removed, and massive bleeding was noted. Emergency Clamshell thoracotomy was performed, and cardiac surgeon was alerted immediately. A first pulmonary wound was found and controlled. Two cardiac lacerations were found: on the interventricular wall and on the right atrium. Under cardiopulmonary bypass, cardiac lacerations were sutured and other three pulmonary wounds were repaired. An urgent fasciotomy was performed for compartmental syndrome of the right lower art after femoral cannulation. Pulmonary distress occurred; the patient was admitted on ECMO (ExtraCorporeal Membrane Oxygenation) in intensive care unit. Right lower lobectomy was carried out on the fifth postoperative day due to massive pulmonary bleeding requiring temporary tracheostomy. The patient was discharged to rehabilitation after 3 months with no brain injuries, minor hearing loss, and tracheostomy. Conclusion We want to maintain the high alertness required for this procedure. Reporting these scaring complications contributes to the real prevalence of LTCs. We suggest the use of bilateral thoracoscopy and crane elevator in severe sternal defects. We also suggest to have a cardiac surgeon available in the hospital owing to cardiac perforation.
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Affiliation(s)
| | - Simone Frediani
- General and Thoracic Pediatric Surgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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Heydweiller AC, König TT, Yavuz ST, Schwind M, Oetzmann von Sochaczewski C, Rohleder S. [Influencing factors on operating times for metal bar removal after Nuss repair]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:796-803. [PMID: 37353682 PMCID: PMC10447265 DOI: 10.1007/s00104-023-01914-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Metal bar removal after the Nuss repair procedure is prone to be cancelled in cases of operating time shortages due it being suitable to be postponed without harming patients. Consequently, planning operation times as exactly as possible could be one solution. OBJECTIVE Statistical modelling of operation times of metal bar removal after Nuss repair using the prespecified independent predictors of age, sex, intraoperative complications, and number of implanted metal bars. MATERIAL AND METHODS We included all patients whose operation notes included an operation time, which was modelled via linear regression and subject to internal validation via bootstrap. Exploratory analyses also consisted of the surgeon's experience, the number of stabilizers, the body mass index, and preceding re-do surgery for bar dislocation. RESULTS We included 265 patients (14% ♀) with a median age of 19 years (interquartile range 17-20 years), of whom 81% had 1 and 17% had 2 metal bars removed. The prespecified regression model was statistically significant (likelihood ratio 56; df = 5; P < 0.001) and had a bias corrected R2 of 0.148. Patient age influenced operation times by 2.1min per year of life (95% confidence interval 1.3-2.9min; P < 0.001) and 16min per explanted metal bar (95% confidence interval: 10-22min; P < 0.001). CONCLUSION The patient-specific factors of age and the number of explanted metal bars influenced the operation times and can be included into scheduling operation times.
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Affiliation(s)
- Andreas C Heydweiller
- Sektion Kinderchirurgie der Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Tatjana T König
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Mainz, Deutschland
| | - S Tolga Yavuz
- Klinik für Allgemeine Pädiatrie, Universitätsklinik Bonn, Bonn, Deutschland
| | - Martin Schwind
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Mainz, Deutschland
| | - Christina Oetzmann von Sochaczewski
- Sektion Kinderchirurgie der Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland.
- Sektion Kinderchirurgie, Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - Stephan Rohleder
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Mainz, Deutschland
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Cujiño-Álvarez IF, Torres-Salazar D, Velásquez-Galvis M. Cardiorespiratory arrest during and after nuss procedure: case report. J Cardiothorac Surg 2023; 18:166. [PMID: 37118746 PMCID: PMC10148508 DOI: 10.1186/s13019-023-02262-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 04/03/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Pectum excavatum is a congenital thoracic alteration that can present important physiological alterations depending on the severity of the case. The Nuss procedure is a minimally invasive technique for managing chest wall deformity, in which there is a risk of perioperative complications. CASE PRESENTATION This article presents the case of a 16-year-old patient who underwent placement of a Nuss bar and suffered intraoperative and postoperative cardiorespiratory arrest. CONCLUSIONS it is important to consider the possible early and late complications scenarios as well as their treatment in patients with pectum excavatum scheduled for a Nuss procedure.
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Affiliation(s)
- Indira F Cujiño-Álvarez
- Anesthesiology Department, Anesthestiologist. Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia.
| | - Daniela Torres-Salazar
- Anesthesiology Resident. Universidad Icesi, Facultad de Ciencias de la Salud, Calle 18 No. 122- 135, Cali, Colombia
| | - Mauricio Velásquez-Galvis
- Thoracic Surgery Department, Thoracic Surgeon. Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
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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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Parrado RH, Notrica DM, Jaroszewski DE, McMahon LE. Surgical technique for Nuss bar exchange due to metal allergy. J Pediatr Surg 2023; 58:179-180. [PMID: 35973861 DOI: 10.1016/j.jpedsurg.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Raphael H Parrado
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016, USA; Division of Pediatric Surgery, Department of Surgery, Shawn Jenkin's Children's Hospital, Charleston, SC, USA.
| | - David M Notrica
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Division of Pediatric Surgery, Department of Surgery, Shawn Jenkin's Children's Hospital, Charleston, SC, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA
| | - Lisa E McMahon
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
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Nagasao T, Aizezi N, Tamai M, Kogure T, Morotomi T. Separation of the seventh costal-sternal junction-A new technique to improve outcomes for the Nuss procedure for pectus excavatum. J Plast Reconstr Aesthet Surg 2023; 76:4-9. [PMID: 36513003 DOI: 10.1016/j.bjps.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/31/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In the standard Nuss procedure for pectus excavatum, the costal arch is often elevated together with the sternum, resulting in unevenness of the lower part of the thorax. This complication is commonly called rib flaring. This paper presents a technique to avoid rib flaring and evaluates its effectiveness. MATERIALS AND METHODS In our technique, a part of the seventh costal cartilage is removed, disconnecting the costal arch from the sternum. The effectiveness of this technique was evaluated in a retrospective clinical study of 63 pectus excavatum patients who were randomly collected and were divided into two groups. One group-defined as the Standard Group-includes 27 patients (29.8 ± 6.5SD y/o) on whom standard Nuss procedure was conducted; the other group-defined as the Separation Group-includes 36 patients (31.8 ± 6.1SD y/o) on whom the cartilage removal was conducted in addition to the standard Nuss procedure. The degree of postoperative costal-arch elevation was defined as ECA (Elevation of Costal Arch) and was compared between the two groups. RESULTS ECA was significantly greater for the Standard Group (10.2 ± 3.3SD mm) than for the Separation Group (-1.1 ± 3.42SDmm). CONCLUSION Postoperative protrusion of the costal arch is prevented by the separation of the seventh costal cartilage from the sternum. Our original technique is a useful option for the treatment of pectus excavatum.
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Affiliation(s)
- Tomohisa Nagasao
- Department of Plastic and Reconstructive Surgery, Medical/Graduate School of KAGAWA University, Kagawa, Japan.
| | - Niyazi Aizezi
- Department of Plastic and Reconstructive Surgery, Medical/Graduate School of KAGAWA University, Kagawa, Japan
| | - Motoki Tamai
- Department of Plastic and Reconstructive Surgery, Medical/Graduate School of KAGAWA University, Kagawa, Japan
| | - Tetsukuni Kogure
- Department of Plastic and Reconstructive Surgery, Medical/Graduate School of KAGAWA University, Kagawa, Japan
| | - Tadaaki Morotomi
- Department of Plastic and Reconstructive Surgery, Medical/Graduate School of KINDAI University, Osaka, Japan
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Complications following metal bar removal after Nuss repair are rare in a duocentric retrospective evaluation. Pediatr Surg Int 2022; 38:1919-1924. [PMID: 36138322 PMCID: PMC9653328 DOI: 10.1007/s00383-022-05250-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Minimally invasive pectus excavatum repair has gained widespread acceptance and its results and complications are well-described. However, there is a substantial debate on the risks and frequencies of complications following metal bar removal. We, therefore, aimed to analyse all complications that occurred during and after metal bar removal at our two paediatric surgical centres. METHODS Bar removal surgeries were identified via procedural codes and electronic records were reviewed using a pre-specified data extraction chart. Both intra- and postoperative complications were included and the latter scored according to Clavien-Dindo. We analysed the influence of the pre-specified potential predictors age, sex, and the number of implanted metal bars on the occurrence of complications using logistic regression. RESULTS We included 279 patients with a median age of 19 years (interquartile range 17-20 years). 15 patients experienced 17 complications. Of 11 postoperative complications, only an enlarging pleural effusion required a chest drain in local anaesthesia, resulting in a Claven-Dindo grade IIIa, whereas the remainder were classified as grade I. Neither age (adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.84-1.13, P = 0.73), nor sex (aOR 0.88, 95% CI 0.19-4.07, P = 0.87) or the number of bars (aOR 0.64, 95% CI 0.15-2.71, P = 0.547) did influence the occurrence of complications. CONCLUSION Complications following metal bar removal were scarce in our duocentric retrospective series and usually of minor relevance. However, to address the perceived paucity of data on the frequency and severity of complications following metal bar removal, further studies, including large database research is necessary.
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Senica SO, Gasparella P, Soldatenkova K, Smits L, Ābola Z. Cardiac perforation during minimally invasive repair of pectus excavatum: a rare complication. J Surg Case Rep 2022; 2022:rjac538. [PMID: 36452283 PMCID: PMC9701555 DOI: 10.1093/jscr/rjac538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/03/2022] [Indexed: 09/26/2023] Open
Abstract
Life-threatening complications (LTCs) and negative results of surgical treatments often go unreported. Minimally invasive repair of pectus excavatum (MIRPE) represents a procedure with a low incidence of adverse outcomes. However, 15 potentially fatal cases of MIRPE-related heart injury have been published. We report a case of cardiac perforation (CP) during MIRPE. A 12-year-old female was admitted for elective repair of a severe asymmetric pectus excavatum. Preoperative computed tomography showed a Haller index of 4.9. MIRPE was performed under bilateral video-assisted thoracoscopy. After the placement of the pectus bar, cardiac arrhythmias, hypotension and bilateral hemothorax occurred. Emergency thoracotomy without pectus bar removal showed CP. The wound sites were repaired and the pectus bar was eventually successfully implanted. The patient was discharged on postoperative day 11. After 10 months, she remains asymptomatic. Reporting rare complications is essential for accurate calculations of the true prevalence of LTCs, maintaining high alertness in pediatric surgeons.
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Affiliation(s)
| | - Paolo Gasparella
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Graz 8036, Austria
| | - Ksenija Soldatenkova
- Department of Pediatric Surgery, Children's Clinical University Hospital, Riga 1004, Latvia
| | - Lauris Smits
- Department of Heart Surgery, Children's Clinical University Hospital, Riga 1004, Latvia
| | - Zane Ābola
- Department of Pediatric Surgery, Children's Clinical University Hospital, Riga 1004, Latvia
- Department of Pediatric Surgery, Riga Stradins University, Riga 1007, Latvia
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Wang W, Wang W, Long W, Chen C, Liu Y, Cai B, Luo J, Chen K. Experience of the Wang procedure in treating pectus excavatum in two hundred fifty-six paediatric patients. INTERNATIONAL ORTHOPAEDICS 2022; 46:2307-2313. [PMID: 35781529 DOI: 10.1007/s00264-022-05483-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION To analyze and summarize the orthopaedic effect and application experience of the Wang procedure in the treatment of pectus excavatum in paediatric patients. METHODS The clinical data of 256 children ranging from 0.83~14 years (4.89±2.83 years) who underwent the Wang procedure for pectus excavatum from January 2017 to September 2020 in our hospital were analyzed retrospectively. A 1~2-cm incision was made in front of the xiphoid, and a tunnel was constructed on the deep surface of the thoracic cage. Steel wires were inserted through the bilateral costal arch and the lower sternum, and a steel bar was placed in the tunnel. The wires were pulled taut and fixed to the bar, and the incision was sutured. RESULTS All the procedures were performed using one steel bar. The range of the procedure duration, the intra-operative bleeding volume, and the hospitalization stays of the patients were 18 to 45 (24.02±4.89) minutes, one to ten (2.16±1.68) mL, and three to nine days (5.71±1.35 days) respectively. Post-operative pneumothorax occurred in three cases without other complications. All the cases received follow-up for one to 45 months after discharge, during which six cases experienced poor wound healing, removed steel plate in 82 cases, and three cases of pectus excavatum recurrence. CONCLUSIONS The Wang procedure is a good option for treating pectus excavatum, secondary pectus excavatum, or recurrent pectus excavatum in paediatric patients.
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Affiliation(s)
- Wenjie Wang
- Institute of Chest Wall Surgery, Guangdong Second People's Hospital, Guangzhou, 510317, China
| | - Wenlin Wang
- Institute of Chest Wall Surgery, Guangdong Second People's Hospital, Guangzhou, 510317, China.
| | - Weiguang Long
- Institute of Chest Wall Surgery, Guangdong Second People's Hospital, Guangzhou, 510317, China
| | - Chunmei Chen
- Institute of Chest Wall Surgery, Guangdong Second People's Hospital, Guangzhou, 510317, China
| | - Yang Liu
- Institute of Chest Wall Surgery, Guangdong Second People's Hospital, Guangzhou, 510317, China
| | - Bin Cai
- Institute of Chest Wall Surgery, Guangdong Second People's Hospital, Guangzhou, 510317, China
| | - Juan Luo
- Institute of Chest Wall Surgery, Guangdong Second People's Hospital, Guangzhou, 510317, China
| | - Kai Chen
- Institute of Chest Wall Surgery, Guangdong Second People's Hospital, Guangzhou, 510317, China
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Neurolysis for analgesia following pectus repair in a national cohort. J Pediatr Surg 2022; 57:315-318. [PMID: 35339278 DOI: 10.1016/j.jpedsurg.2022.02.008] [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: 09/04/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Pectus excavatum and pectus carinatum are the most common chest wall deformities of childhood. Surgical repair can be complicated by post-operative analgesic challenges. Thoracic epidural analgesia, patient-controlled analgesia, and multimodal pain control are among the most common strategies. We sought to define the current utilization of intraoperative thoracic neurolysis, hypothesizing that this would minimize length of stay (LOS) and post-operative narcotic use with relatively higher proportion of non-narcotic post-operative analgesia. METHODS We performed a retrospective review of the Pediatric Health Information System (PHIS) database between 2017 and 2020. We first identified patients who underwent a pectus repair via ICD-10-PCS codes. We used ICD-10-PCS codes 01580ZZ and 01584ZZ to identify those patients who underwent concomitant thoracic neurolysis. Statistical analyses were performed using R; p value less than 0.05 was considered significant. RESULTS We identified 2979 patients who underwent a pectus repair. 184 underwent a concomitant thoracic nerve destruction procedure (6.7%); 13 were performed in 2017 (2.01%), 76 in 2018 (10.7%), and 84 in 2019 (9.6%). LOS was shorter in those patients who underwent neurolysis (mean=2.55 vs 3.73 days, SD=1.33 vs 1.78 days, p<0.001). There were fewer post-operative ICU admissions in neurolysis patients (3/184 vs. 193/2795, p = 0.003). The cost of procedures that included a neurolysis were higher, though not significantly so (mean=$24,885.64 vs $22,200.59). CONCLUSION Thoracic neurolysis may be a useful analgesic strategy, expediating post-operative discharge and potentially obviating the need for intensive care. Further larger-scale prospective trials should be considered to further elucidate the role of this analgesia method. LEVEL OF EVIDENCE Level III.
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20
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Chavoin JP, Facchini F, Leyx P, Hunt I, Benjoar MD, Molins L, Tiffet O, Ratdke C, Dornseifer U, Giovannini M, Chaput B, Redmond K. [Place of 3D custom-made implants after failure of modeling steno-chondro-plasties]. ANN CHIR PLAST ESTH 2022; 67:414-424. [PMID: 35933312 DOI: 10.1016/j.anplas.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Most common congenital malformation of the thorax, Pectus Excavatum affects about one in 500 people. Several surgical or medical techniques have been proposed. Some are followed by complications or insufficient results even though their constant functional value is highly controversial. Secondary surgery with a deep customized 3D elastomer implant, may be an elegant effective and safe solution compared to others; it allows a good aesthetic result expected by patients in the absence of any respiratory or cardio-vascular functional context.
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Affiliation(s)
- J-P Chavoin
- Service de chirurgie plastique reconstructrice et esthétique, CHU Toulouse Rangueil, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France.
| | - F Facchini
- Service de chirurgie infantile, Hopital pédiatrique Meyer, Viale Gaetano Pieraccini 24, 50139 Florence, Italie
| | - P Leyx
- Recherche et développement, Anatomik Modeling SAS, 19, rue Jean Mermoz, 31100 Toulouse, France
| | - I Hunt
- Pectus Clinic, service de chirurgie thoraciqueSpire St. Anthony's Hospital Worcester Park, Sutton SM3, 9DW Londres, Royaume Uni
| | | | - L Molins
- Hôpital Clinique universitaire du Sacré-cœur, C. de Viladomat 288, 08029 Barcelone, Espagne
| | - O Tiffet
- Service de chirurgie Thoracique, CHU de St.Etienne, hôpital Nord, avenue Albert Raimond, 42270 Saint-Etienne, France
| | - C Ratdke
- Service de chirurgie plastique reconstructrice et esthétique, clinique universitaire de Vienne, 18-20 Waringer Gurtel, 1090 Vienne, Autriche
| | - U Dornseifer
- Service de chirurgie plastique reconstructrice et esthétique, Isar Klinikum, Sonnenstrasse 24-26, 80331 Munich, Allemagne
| | - M Giovannini
- Chirurgie Générale et thoracique, via di Roncrio 25, 40100 Bologne, Italie
| | - B Chaput
- Service de chirurgie plastique reconstructrice et esthétique, CHU Toulouse Rangueil, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France
| | - K Redmond
- Service de Chirurgie cardio-thoracique Hôpital Universitaire Mater Misericordia, Ecole street, Dublin 7, Irlande
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Current Development of Minimally Invasive Repair of Pectus Excavatum (MIRPE). CHILDREN 2022; 9:children9040478. [PMID: 35455522 PMCID: PMC9024707 DOI: 10.3390/children9040478] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022]
Abstract
For decades, open surgical repair was the only available method to treat congenital and acquired chest wall deformities (CWDs). In 1998, D. Nuss described a minimally invasive procedure for surgical repair of Pectus excavatum (PE). Today, the Nuss procedure is performed with increasing frequency worldwide and considered as the “gold standard”. After its introduction, the method experienced numerous modifications such as routine thoracoscopy and/or sternal elevation, increasing safety of the procedure. Placement of multiple bars and/or the so called cross-bar technique were introduced to correct complex CWDs. Standardized pain management, the introduction of cryo-analgesia and a standardized postoperative physiotherapy program including deep breathing exercises facilitate the establishment of an enhanced recovery after surgery (ERAS) process. However, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. Furthermore, several studies report near-fatal complications, not only during bar placement, but also during bar removal. This review focuses upon the most relevant modifications, including recent published surgical techniques of MIRPE, in order to describe current developments in the field.
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22
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Abbas AE. Commentary: Funneling the funnel chest surgery debate into a reasonable approach to management of adult pectus excavatum. JTCVS Tech 2022; 12:220-221. [PMID: 35403024 PMCID: PMC8987600 DOI: 10.1016/j.xjtc.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/06/2022] [Accepted: 02/15/2022] [Indexed: 11/02/2022] Open
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Jung Y, Yi E, Lee K, Chung JH, Cho S, Lee S. Surgical versus Vacuum Bell Therapy for the Correction of Pectus Excavatum: A Comparison of 1-Year Treatment Outcomes. J Chest Surg 2021; 54:473-479. [PMID: 34815370 PMCID: PMC8646059 DOI: 10.5090/jcs.21.073] [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] [Received: 07/02/2021] [Revised: 08/22/2021] [Accepted: 09/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background The purpose of this study was to compare 1-year clinical outcomes between patients who underwent a Nuss operation or vacuum bell therapy and to present vacuum bell therapy as a possible alternative treatment modality for patients who prefer non-surgical correction of pectus excavatum. Methods We conducted a retrospective review of pectus excavatum patients who had undergone vacuum bell therapy for more than 1 year and examined patients who had undergone Nuss bar removal more than 1 year previously. The treatment outcomes were evaluated by comparing changes in the Haller index before and after treatment in both patient groups. Results We included 57 patients in this study and divided them into 2 groups according to the type of treatment received. Both groups showed no significant difference in the post-treatment Haller index after 1 year of follow-up, although the Nuss operation group showed a greater change in the Haller index than the vacuum bell group. Conclusion Although the Nuss operation is a well-established and effective treatment of choice to correct pectus excavatum, vacuum bell therapy showed comparable outcomes and could become an alternative treatment modality for select patients who prefer non-invasive treatment.
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Affiliation(s)
- Younggi Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Eunjue Yi
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Kwanghyoung Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Jae Ho Chung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
| | | | - Sungho Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Korea
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Núñez García B, Álvarez García N, Aquino-Esperanza J, Esteva Miró C, Pérez-Gaspar M, Jiménez Gómez J, Betancourth Alvarenga JE, Santiago Martínez S, Jiménez-Arribas P, Güizzo JR. Efficacy and Safety of Taulinoplasty Compared with the Minimally Invasive Repair of Pectus Excavatum Approach to Correct Pectus Excavatum. J Laparoendosc Adv Surg Tech A 2021; 31:1402-1407. [PMID: 34847730 DOI: 10.1089/lap.2021.0216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Background: Minimally invasive repair of pectus excavatum (MIRPE) technique is the current most used surgical method for pectus excavatum (PE) correction. To avoid MIRPE-required invasion of the mediastinum or pleural cavity, we developed taulinoplasty approach as an alternative option for the reduction of the sunken chest. Materials and Methods: This is a single-center unblind nonrandomized prospective pilot study, involving 26 MIRPE and 23 taulinoplasty patients. The primary safety endpoint was the presence of surgical complications, and the primary efficacy endpoint was Haller index measured postoperatively in taulinoplasty patients. Secondary endpoints were intensive care unit (ICU) and hospital length of stay (LOS), duration of surgical procedure, and postoperative pain management. Chi-square, Mann-Whitney, or Student "t" tests were used for comparison as appropriate. Results: There were no difference in median age (14.5 and 14 years), Haller index (4.63 and 4.17), or comorbidities. MIRPE and taulinoplasty procedures showed no difference regarding major or minor surgical complications. The efficacy endpoint of taulinoplasty was measured 5.5 (1.5-12) months after the procedure, exhibiting a significant reduction in the Haller index [4.17 (3.7-4.7) at baseline and 3.7 (2.9-4.1) postoperatively, P = .03]. Taulinoplasty required less surgical time (60.4 ± 15.5 versus 70.7 ± 15.9 minutes, P < .01); shorter ICU and hospital LOS (P < .01, respectively); and required fewer days of peridural, intravenous, and oral analgesia (P < .01, respectively). Conclusions: In this pilot study, taulinoplasty technique was as safe as the MIRPE approach and effective for the correction of PE, reducing surgical time, ICU and hospital LOS, and achieving better postoperative pain control.
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Affiliation(s)
| | | | - José Aquino-Esperanza
- Institut d'Investigació i Innovació Parc Taulí I3PT, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Clara Esteva Miró
- Department of Pediatric Surgery, Parc Taulí University Hospital, Sabadell, Spain
| | - Mireia Pérez-Gaspar
- Department of Pediatric Surgery, Parc Taulí University Hospital, Sabadell, Spain
| | - Javier Jiménez Gómez
- Department of Pediatric Surgery, Parc Taulí University Hospital, Sabadell, Spain
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Sayan B, Bekiroglu N, Yuksel M. Pectus cross bars increase hospital readmission rates due to serous pleural effusion. Gen Thorac Cardiovasc Surg 2021; 70:352-358. [PMID: 34784003 DOI: 10.1007/s11748-021-01732-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/02/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Pectus Excavatum's (PE) surgical treatment should be patient specific. In this article, we aimed to compare parallel and cross bar variations of the Nuss method and analyze if there is any difference in results. METHODS In this study, a total of 891 patients treated with the Nuss method between August 2005 and February 2018 were considered. These were retrieved from a prospectively recorded PE database. Of these, 276 double-bar patients were included in the study. Patients with parallel bars (225 cases) and patients with crossed bars (51 cases) were compared in terms of age, gender, symmetry, family history, additional anomalies, mean operation time, postoperative hospital stay (days) and hospital readmission rate. RESULTS The mean age was measured at 20.7 for parallel bar patients and 20.1 for crossed bars patients. There was no statistically significant difference in terms of age, gender, and mean operation time between two groups. On the other hand, statistical significance was found between two groups when analyzing the deformities' symmetry, patients' family history and additional anomalies. The statistically significant difference of postoperative hospital stay between two groups is clinically negligible. Postoperative hospital readmission rates due to serous pleural effusion were found to be significantly increased in patients with crossed bars (p < 0.001). CONCLUSION While pleural effusion requiring readmission was statistically more frequent in cross bars, in centers where thoracentesis can be managed, Nuss method can still be applied safely, even in cases with difficult, complex deformities. LEVEL OF EVIDENCE III. Treatment study.
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Affiliation(s)
- Bihter Sayan
- Department of Thoracic Surgery, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey.
| | - Nural Bekiroglu
- Department of Biostatistics, School of Medicine, Marmara University, Istanbul, Turkey
| | - Mustafa Yuksel
- Department of Thoracic Surgery, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
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Liu S, Wang L, Zhang H, Zeng W, Hu F, Xiao H, Li G, Mei J, Zhu J. Modified Nuss procedure with a novel steel bar in patients with pectus excavatum post-congenital heart surgery. Interact Cardiovasc Thorac Surg 2021; 34:424-430. [PMID: 34661678 PMCID: PMC8860435 DOI: 10.1093/icvts/ivab284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/29/2021] [Accepted: 09/20/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Pectus excavatum (PE) can be secondary in patients who underwent sternotomy for cardiac surgery. Retrosternal adhesions increase the complexity and risk of traditional Nuss repair. Thus, we summarized the outcomes of our modified Nuss procedure using a newly designed bar. METHODS A retrospective analysis was performed on 35 patients who underwent modified PE repair after open heart surgery from January 2011 to July 2019. The surgery was performed using a novel bar with no need for intraoperative reshaping and rotation, assisted by thoracoscopy and subxiphoid incision when necessary. RESULTS There were 19 males and 16 females with a median age of 5.3 years (interquartile range, 4.1–10.9) at PE repair. All patients underwent the modified procedure uneventfully with no death. The median operating time was 70 min. Twenty-nine (82.9%) patients required subxiphoid incision assistance. There was 1 case (2.8%) with unexpected sternotomy due to intraoperative bleeding. The median length of postoperative hospital stay was 4 days. During the median 3.5 years of follow-up, no bar dislocation was found and 30 (85.7%) patients had their bars removed with no recurrence recorded. After PE repair, the Haller index improved significantly (2.6 ± 0.4 vs 4.9 ± 1.3, P < 0.05) and further decreased till the time of bar removal (2.5 ± 0.4 vs 2.6 ± 0.4, P < 0.05). All patients were satisfied with the cosmetic outcome. CONCLUSIONS The novel bar can be placed and removed easily with a low rate of adverse events. This modified Nuss procedure seems to be a safe, effective and convenient approach for the management of PE after cardiac surgery.
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Affiliation(s)
- Siming Liu
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Wang
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hongkun Zhang
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wenhui Zeng
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fengqing Hu
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haibo Xiao
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Guoqing Li
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ju Mei
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiaquan Zhu
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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de Loos ER, Daemen JHT, Coorens NA, Maessen JG, Vissers YLJ, Hulsewé KWE. Sternal elevation by the crane technique during pectus excavatum repair: A quantitative analysis. JTCVS Tech 2021; 9:167-175. [PMID: 34647091 PMCID: PMC8501226 DOI: 10.1016/j.xjtc.2021.05.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/25/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction The crane technique is used to facilitate sternal elevation to provide safe mediastinal passage during the Nuss procedure. The aim was to objectively quantitate the elevation of the crane by 3-dimensional chest images acquired during the Nuss procedure. Methods A prospective cohort study was conducted. Patients undergoing the Nuss procedure were eligible. Sternal elevation was achieved by the crane technique providing a simultaneous lift of the anterior chest wall and reduction of the pectus excavatum depth. Both effects were evaluated. Three-dimensional surface images were acquired before incision, following sternal lift, and after bar implantation and quantitatively compared. Reduction of the external pectus excavatum depth was expressed as a percentage. Results Thirty patients were included. Ninety percent were male, with a median age of 15.5 years (interquartile range [IQR], 14.5-17.4), Haller index of 3.56 (IQR, 3.09-4.65), and external pectus depth of 18 mm (IQR, 11-23). Sternal elevation by the crane provided a median 78% (IQR, 63-100) reduction of the deformity, corresponding with a residual depth of 3 mm (IQR, 0-7). The percentual reduction diminished with increasing depth of the sternal depression (correlation, –0.86). Besides reducing the deformity, the crane caused an elevation of the anterior chest over a large surface area with a maximum lift of 26 mm (IQR, 19-32). Conclusions The crane is an effective sternal elevation technique, providing 78% reduction of the sternal depression, although its effect lessens with increasing depth. In addition, it produces an elevation of the anterior chest over a large surface area.
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Affiliation(s)
- Erik R de Loos
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jean H T Daemen
- Division of General Thoracic Surgery, Department of 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
| | - Nadine A Coorens
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, 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
| | - Yvonne L J Vissers
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Karel W E Hulsewé
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
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28
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Muff JL, Guglielmetti LC, Gros SJ, Buchmüller L, Frongia G, Haecker FM, Holland-Cunz SG, de Trey T, Vuille-Dit-Bille RN. Failed preoperative vacuum bell therapy does not affect outcomes following minimally invasive repair of pectus excavatum. Pediatr Surg Int 2021; 37:1429-1435. [PMID: 34272597 PMCID: PMC8408062 DOI: 10.1007/s00383-021-04963-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/02/2021] [Indexed: 11/06/2022]
Abstract
PURPOSE It is unknown if failed preoperative vacuum bell (VB) treatment in patients undergoing minimally invasive repair of pectus excavatum (MIRPE), delays repair and/or affects postoperative outcomes. METHODS A retrospective data analysis including all consecutive patients treated at one single institution undergoing MIRPE was performed between 2000 and 2016. Patients were stratified into preoperative VB therapy versus no previous VB therapy. RESULTS In total, 127 patients were included. Twenty-seven (21.3%) patients had preoperative VB treatment for 17 months (median, IQR 8-34). All 27 patients stopped VB treatment due to the lack of treatment effect. Eight (47.1%) of 17 assessed VB patients showed signs of skin irritation or hematoma. VB treatment had no effect on length of hospital stay (p = 0.385), postoperative complications (p = 1.0), bar dislocations (p = 1.0), and duration of bar treatment (p = 0.174). Time spent in intensive care unit was shorter in patients with VB therapy (p = 0.007). Long-term perception of treatment including rating of primary operation (p = 0.113), pain during primary operation (p = 0.838), own perspective of look of chest (p = 0.545), satisfaction with the procedure (p = 0.409), and intention of doing surgery again (p = 1.0) were not different between groups. CONCLUSIONS Failed preoperative VB therapy had no or minimal effect on short-term outcomes and long-term perceptions following MIRPE.
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Affiliation(s)
- J L Muff
- Department of Pediatric Surgery, University Children's Hospital of Basel, Spitalstrasse 33, 4056, Basel, Switzerland
| | - L C Guglielmetti
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - S J Gros
- Department of Pediatric Surgery, University Children's Hospital of Basel, Spitalstrasse 33, 4056, Basel, Switzerland
| | - L Buchmüller
- Department of Pediatric Surgery, University Children's Hospital of Basel, Spitalstrasse 33, 4056, Basel, Switzerland
| | - G Frongia
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - F -M Haecker
- Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St.Gallen, Claudiusstrasse 6, CH-9006, St.Gallen, Switzerland.,Faculty of Medicine, University of Basel, 4056, Basel, Switzerland
| | - S G Holland-Cunz
- Department of Pediatric Surgery, University Children's Hospital of Basel, Spitalstrasse 33, 4056, Basel, Switzerland
| | - T de Trey
- Department of Pediatric Surgery, University Children's Hospital of Basel, Spitalstrasse 33, 4056, Basel, Switzerland
| | - Raphael N Vuille-Dit-Bille
- Department of Pediatric Surgery, University Children's Hospital of Basel, Spitalstrasse 33, 4056, Basel, Switzerland.
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Complications and trends in minimally invasive repair of pectus excavatum: A large volume, single institution experience. J Pediatr Surg 2021; 56:1846-1851. [PMID: 33279219 DOI: 10.1016/j.jpedsurg.2020.11.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND/PURPOSE Complication risk in minimally invasive repair of pectus excavatum (MIRPE) is not negligible, particularly during learning curve. We reviewed the complications of a large series, evaluated the correlation with technical details and learning curve, and presented the strategies implemented to reduce them. METHODS Data on MIRPE patients from 2005 to 2020 (divided in two groups: before and after 2013) were collected prospectively and reviewed. Complications were correlated to the number and type of bar/stabilizers, and to the surgeon learning curve. RESULTS We placed 783 bars (484 Biomet, 273 Intrauma and 26 others) in 600 patients and removed 524 bars in 436 patients. Complications occurred in 108 MIRPE (18%): 3.7% intraoperative, 14.3% postoperative. No cardiac perforations were reported; in the second period we had fewer complications (15.3% versus 28.2%) particularly in intraoperative ones (0.3% versus 9%), the intervention was faster (64 versus 83 min and 92 versus 127 for 1 and 2 bars) and hospitalization shorter (5 versus 7.5 days). Complication rate of bar removal was 2.7% (all Biomet bars): one intra-thoracic bleeding and 2 lung injuries. CONCLUSIONS MIRPE has a significant rate of complication, especially during learning curve. Postoperative complications are more frequent and less dependent on learning curve. Severe complications can be observed during bar removal. We have adopted new bars to reduce complications, but dislocation remains an unresolved problem.
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30
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Obeid MF, Kelly R, McKenzie FD. Development and Validation of a Hybrid Nuss Procedure Surgical Simulator and Trainer. IEEE Trans Biomed Eng 2021; 68:2520-2528. [PMID: 33382643 DOI: 10.1109/tbme.2020.3048516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This work presents the development and validation of an interactive simulation training platform for the minimally invasive repair of pectus excavatum, otherwise known as the Nuss procedure. METHODS The challenges and implications of developing both an all-virtual and an all-physical version of the simulator are investigated in a training context. A hybrid system is then developed that integrates virtual and physical constituents and a haptic interface to reproduce the primary steps of the procedure and to satisfy clinically relevant prerequisites for its training system. Furthermore, this work carries out a study to investigate the system's face, content, and construct validity. RESULTS Objective and subjective evaluations of the system demonstrate its utility for surgical training and establish various levels of its validity. CONCLUSION A hybrid virtual/physical configuration of the trainer can efficiently and realistically reproduce the primary steps of the procedure. SIGNIFICANCE Outside of this work, a simulation and training platform for the Nuss procedure is not available. This system was developed in close collaboration with the pioneers of this surgical technique.
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Zuidema WP, van der Steeg AFW, Oosterhuis JWA, van Heurn E. Trends in the Treatment of Pectus Excavatum in the Netherlands. Eur J Pediatr Surg 2021; 31:261-265. [PMID: 32455445 DOI: 10.1055/s-0040-1712182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Pectus excavatum (PE) is the most common deformity of the anterior chest wall and can be corrected surgically with different techniques. In the past years, medical literature suggests that the minimal invasive surgical correction of PE (MIRPE) has currently become the operation technique of choice in Europe, and the number of PE patients undergoing surgery has increased. The aim of this study was to evaluate trends in the number of patients operated on and the surgical techniques generally used in patients with PE in the Netherlands. MATERIALS AND METHODS From the registration by Statistics Netherlands, the numbers of live births and gender were obtained for the period 1980 to 2017. Furthermore, from the Dutch hospital registration performed by Kiwa Prismant systems, the number of total surgical procedures of PE patients from the period 1998 to 2017, and the numbers of open and MIRPE surgery were obtained over the period 2005 to 2013. RESULTS The birth rate in Netherlands has stayed more or less stable in the last two decades. The number of PE patients asking for correction, however, has increased. In addition, the percentage of thoracoscopic assisted correction has increased. CONCLUSION The increase in correction of PE is not due to an increased incidence but to an increase of patient wishes. The use of MIRPE is gaining popularity over time.
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Affiliation(s)
- Wietse P Zuidema
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Jan W A Oosterhuis
- Department of Thoracic Surgery, Medical Centre Haaglanden, Den Haag, The Netherlands
| | - Ernest van Heurn
- Department of Pediatric Surgery, AMC/VUMC, Amsterdam, The Netherlands
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32
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Preventing bar-related complications for chest wall deformities. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.904117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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33
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HAJE DAVIDEPODESTÁ, HAJE SYDNEYABRÃO, VOLPON JOSÉBATISTA, SILVA ANACAROLINAOLIVEIRADA, LIMA LEONARDOFERREIRABRAZ, HUANG WILSON. LOCALIZED PECTUS EXCAVATUM TREATED WITH BRACE AND EXERCISE: LONG TERM RESULTS OF A BRAZILIAN TECHNIQUE. ACTA ORTOPEDICA BRASILEIRA 2021; 29:143-148. [PMID: 34290561 PMCID: PMC8266278 DOI: 10.1590/1413-785220212903241550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/24/2020] [Indexed: 12/02/2022]
Abstract
Objective: Pectus excavatum is a deformity that affects aesthetics and causes emotional disorders. Surgical correction is well established, but conservative treatment is less common. We investigated the long-term results of using a brace and performing specific physical exercises to treat localized pectus excavatum, a type of deformity in which the depressed area is restricted to the midline region along the nipple line. Methods: We selected 115 patients (mean age 12.8 years), with a minimum follow-up of 36 months, who were evaluated more than one year after the end of treatment and skeletal maturity. Results were correlated with deformity flexibility, severity, regular use of the device, and performance of specific exercises. The chi-square (χ2) and the Cochran-Mantel-Haenszel tests were used for statistical analysis. Results: Treatment was successful in 58% of patients, however, when exercises were performed and the brace was used regularly by patients with flexible deformities, the rate increased to 83% (p = 0.005). Severity and adherence to treatment greatly impacted successful treatment (p = 0.009 and < 0.001, respectively). Conclusion: The proposed treatment method was effective for correction or partial correction of the deformity in motivated patients followed up until skeletal maturity, especially when started early in milder and more flexible deformities. Level of Evidence V, Expert opinion.
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Affiliation(s)
- DAVI DE PODESTÁ HAJE
- Centro Clínico Orthopectus, Brazil; Hospital de Base do Distrito Federal, Brazil
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Zuidema WP, Graumans MJ, Oosterhuis JWA, van der Steeg AFW, van Heurn E. The Quality of Web Sites' Health Information on Minimal Invasive Repair of Pectus Excavatum Using the DISCERN Instrument. Eur J Pediatr Surg 2021; 31:157-163. [PMID: 32396941 DOI: 10.1055/s-0040-1710026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The Internet is a frequently used tool for patients with pectus excavatum (PE) to get information about symptoms and treatment options. In addition, it is used by both health care providers as a marketing tool and support group systems. The Internet health information varies in precision, quality, and reliability. The study purpose was to determine the quality of information on the PE Web sites using the DISCERN instrument, including information about operation and potential complications after a Nuss bar procedure. MATERIALS AND METHODS Four search engines, Google, Yahoo, Ask, and Bing, were used to explore seven key terms concerning PE. Search language was English. The DISCERN quality instrument was used to evaluate the Web sites. Also, information on possible complications was scored per Web site. RESULTS A total of 560 Web sites were assessed in March 2019. Excluded were 139 Web sites. There were 333 duplicates, leaving 88 unique Web sites. Of these, 58.1% were hospital-related information Web sites, 28.4% medical information Web sites, and 3.4% patient forum sites. Interactive multimedia was used on 21.6% of the sites. Pain postoperatively was mentioned on 64.8% of the sites, while only 9.1% mentioned the mortality risk of the surgical correction of PE for Nuss bar placement. The quality of the unique Web sites showed a mean DISCERN score of 42.5 (standard deviation 12.2). Medical information Web sites, encyclopedia, and government-sponsored sites had higher DISCERN scores. Hospital-related information sites, medical companies, and lay persons' sites, had lower total scores. CONCLUSION The overall quality of PE Web sites is low to moderate, with serious shortcomings.
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Affiliation(s)
- Wietse P Zuidema
- Department of Pediatric Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Maarten J Graumans
- Department of Pediatric Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Jan W A Oosterhuis
- Department of Thoracic Surgery, Medical Centre Haaglanden, Den Haag, The Netherlands
| | | | - Ernest van Heurn
- Department of Pediatric Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
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Obermeyer RJ, Goretsky MJ, Kelly RE, Frantz FW, Kuhn MA, McGuire MM, Duke DS, Paulson JF. Selective use of sternal elevation before substernal dissection in more than 2000 Nuss repairs at a single institution. J Pediatr Surg 2021; 56:649-654. [PMID: 32753276 DOI: 10.1016/j.jpedsurg.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/16/2020] [Accepted: 07/05/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND/PURPOSE Evaluate the safety of sternal elevation (SE) used selectively before creating the substernal tunnel during the Nuss procedure. METHODS An IRB-approved (01-05-EX-0175-HOSP), single institution, retrospective review was performed (1/1/1997-11/20/2017). Primary and secondary Nuss repairs (i.e., previous Nuss, Ravitch, thoracotomy, or sternotomy) are included. SE use, cardiac injuries, and pectus bar infections are reported. Chi square and Fisher's exact test (FE) were used (critical p < .05). RESULTS 2037 patients [(80% male; mean age 15.2 years (SD = 4.4, range 3-46); mean Haller index (HI) 5.3 (SD = 5.7, range 1.73-201)] underwent Nuss repair. SE was used before creating the substernal tunnel in 171 (8.4%): 160 (8.2%) of 1949 primary and 11 (12.5%) of 88 secondary repairs. SE use increased significantly [χ2(2) = 118.93; p < .001] over time and with increasing HI [χ2(3) = 59.9; p < .001]. No cardiac injuries occurred in primary repairs but two occurred in patients with previous sternotomy. Infection rates were not different with (2.9%) or without SE (1.8%) [χ2(1) =1.14; p = .285] and not higher with off-label VB (1.5%) versus other SE techniques (3.8%) [FE, p = .65)]. CONCLUSION Selective use of sternal elevation before substernal dissection during the Nuss procedure is safe but may not prevent cardiac injuries in patients with previous sternotomy. Infection rates were not increased with SE. TYPE OF STUDY Retrospective review. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Robert J Obermeyer
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA.
| | - Michael J Goretsky
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Robert E Kelly
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA; Old Dominion University, Norfolk, VA, USA
| | - Frazier W Frantz
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - M Ann Kuhn
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Margaret M McGuire
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Duane S Duke
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - James F Paulson
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA; Old Dominion University, Norfolk, VA, USA; Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
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Chavoin JP, Facchini F, Patel AJ, Hunt IJ. The Role of Computer-Aided Design Implant Insertion in Revision Pectus Surgery Revision Pectus Surgery with Implants. Ann Thorac Surg 2021; 112:e387-e390. [PMID: 33744219 DOI: 10.1016/j.athoracsur.2020.12.095] [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: 11/22/2020] [Accepted: 12/13/2020] [Indexed: 10/21/2022]
Abstract
Pectus Excavatum affects about 1 in 500 people. Several surgical techniques have been proposed including correction of the chest wall through a Nuss or Modified Ravitch procedure. Further corrective revision surgery remains challenging and certainly potential life-threatening complications are described with less predictable outcomes. Secondary surgery with a deep customized 3D elastomer implant is an elegant effective and safe solution compared to further corrective revision surgery.
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Affiliation(s)
- Jean-Pierre Chavoin
- Department of Plastic and Reconstructive Surgery, University Hospital Rangueil, Toulouse, France
| | - Flavio Facchini
- Department of Paediatric Surgery, Universtiy Ospedale Pediatrico Meyer, Firenze, Italy
| | - Akshay J Patel
- Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Ian J Hunt
- Department of Thoracic Surgery, St. George's Hospital, London, UK.
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Haecker FM, Hebra A, Ferro MM. Pectus bar removal - why, when, where and how. J Pediatr Surg 2021; 56:540-544. [PMID: 33228972 DOI: 10.1016/j.jpedsurg.2020.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Despite its less invasive nature, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. On the other hand, Pectus bar removal (PBR) is often considered a simple procedure and often scheduled in an outpatient setting. However, several studies report near-fatal complications not only during bar placement, but also during bar removal. The aim of our study was to clarify why a pectus bar should be removed, timing for removal, where PBR should be performed, and overall setup for safe removal. METHODS A comprehensive review was performed in accordance with PRISMA guidelines, searching for articles published since 1998 in English. "Pectus bar removal AND (near-fatal) complications" were the applied terms. Inclusion criteria were articles reporting on the focus of PBR after MIRPE. Eligible study designs included (retrospective) case study series, case report and reviews. Full-text articles in which the technique in general was described were omitted. RESULTS Recently published results of an online survey raised awareness about type and number of possible complications during PBR. Furthermore, our comprehensive literature review identified only a few, but serious complications during PBR. CONCLUSIONS PBR has a high safety profile but in rare cases may be associated with major complications such as life-threatening hemorrhage from various thoracic sources. This risk is higher in patients with a history of complex MIPRE. In an effort to decrease these complications we recommend bilateral opening of surgical incisions, unbending the bar and meticulous mobilization of the bar. To manage these complications if they occur, we recommend removal in a hospital setting with adequate resources and personal including cardiac surgeons. If the postoperative course is uneventful discharge on the same day is reasonable.
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Affiliation(s)
- Frank-Martin Haecker
- Department of Pediatric Surgery, American Hospital Dubai, Dubai, U.A.E; Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland.
| | - Andre Hebra
- Nemours Children's Hospital, Orlando, FL, USA
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Challenging beliefs:A review of the paradigm shift in the treatment of pectus excavatum from radical resection to minimally invasive bracing and non-surgical vacuum bell suction. Afr J Thorac Crit Care Med 2020; 26. [PMID: 34240036 PMCID: PMC8203075 DOI: 10.7196/ajtccm.2020.v26i4.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 12/01/2022] Open
Abstract
In 1997, Nuss introduced a minimally invasive non-destructive procedure for pectus excavatum, which revolutionised the treatment of
the condition. This review will give a brief history on the management of this condition, followed by a review of 1 034 cases that have been
repaired from 2008 to 2018.
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Toselli L, Bellía Munzón G, Martinez J, Vallee M, Sanjurjo D, Nazar Peirano M, Martínez-Ferro M. Safety-string: A handy maneuver to control pectus bar removal bleeding complications. J Pediatr Surg 2020; 55:1162-1164. [PMID: 32143902 DOI: 10.1016/j.jpedsurg.2020.01.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/10/2019] [Accepted: 01/29/2020] [Indexed: 11/19/2022]
Abstract
The pectus bar removal procedure is often considered a simple, straightforward surgery with a low incidence of complications. However, life-threatening bleeding complications have been reported requiring major measures for hemostatic control. Our objective is to share a simple maneuver that our group has systematically included in the bar removal procedure to facilitate bleeding control in case hemorrhage occurs.
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Affiliation(s)
- Luzia Toselli
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602, Capital Federal, Buenos Aires, Argentina, C1429AKL.
| | - Gastón Bellía Munzón
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602, Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Jorge Martinez
- 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
| | - Daniela Sanjurjo
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602, Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Maximiliano Nazar Peirano
- 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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Jang YE, Park JB, Kang CH, Park S, Kim EH, Lee JH, Kim HS, Kim JT. Cardiopulmonary resuscitation in pediatric pectus excavatum patients-Where is the heart? Paediatr Anaesth 2020; 30:698-707. [PMID: 32298510 DOI: 10.1111/pan.13878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/27/2020] [Accepted: 04/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND In children with pectus excavatum, the posteriorly depressed sternum compresses and displaces the heart. However, the currently recommended compression site and depth for cardiopulmonary resuscitation have not been studied in this population. AIM This retrospective study investigated the location of the center of ventricles with the largest cross-sectional area to determine the optimal site and depth for chest compressions in pediatric pectus excavatum patients. METHODS Chest computed tomography images of 94 pediatric pectus excavatum patients before and after correction surgery were compared with normal patients. The caudal displacement of the ventricles was calculated by dividing the length of sternum by the length from the suprasternal notch to the transverse level of the largest cross-sectional area of the ventricles. The proportional leftward deviation of the center of the ventricles from the midline versus transverse diameter of the thorax was calculated. The remaining internal thickness was calculated at the midline assuming the recommended compression depth of one-third of the anterior to posterior diameter. RESULTS Compared with the normal population (mean = 81% [SD = 10.3%]), pediatric pectus excavatum patients showed caudal displacement of ventricles before (98.2% [15.1%], 95% CI of mean difference; 13.7%-20.5%, P < .001) and after correction (100.4% [13.5%], 95% CI of mean difference; 16.2%-22.5%, P < .001). Compared with the normal population (6.9% [2.7%]), pediatric pectus excavatum patients showed leftward deviation of ventricles before (16.2% [5.5%], 95% CI of mean difference; 8.2%-10.4%, P < .001) and after correction (13.3% [4.8%], 95% CI of mean difference; 5.3%-7.3%, P < .001). The remaining internal thickness assuming the recommended chest compression was <10 mm in 54/94(57.4%) and 18/94 (19.1%) of pediatric pectus excavatum patients before and after correction, respectively. CONCLUSIONS Pediatric pectus excavatum patients showed significant caudal displacement and leftward deviation of the ventricles compared with the normal population despite correction surgery and the currently recommended compression site and depth might injure intrathoracic structures without effective cardiac compression during cardiopulmonary resuscitation.
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Affiliation(s)
- Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University Hospital, Seoul National University, Seoul, Korea
| | - Jung-Bin Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University Hospital, Seoul National University, Seoul, Korea
| | - Chang-Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Seoul National University Hospital, Seoul National University, Seoul, Korea
| | - Samina Park
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Seoul National University Hospital, Seoul National University, Seoul, Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University Hospital, Seoul National University, Seoul, Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University Hospital, Seoul National University, Seoul, Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University Hospital, Seoul National University, Seoul, Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University Hospital, Seoul National University, Seoul, Korea
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Ben XS, Deng C, Tian D, Tang JM, Xie L, Ye X, Zhou ZH, Zhou HY, Zhang DK, Shi RQ, Qiao GB, Chen G. Multiple-bar Nuss operation: an individualized treatment scheme for patients with significantly asymmetric pectus excavatum. J Thorac Dis 2020; 12:949-955. [PMID: 32274163 PMCID: PMC7139081 DOI: 10.21037/jtd.2019.12.43] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Research into multiple-bar Nuss operations for the treatment of wide-range or significantly asymmetric pectus excavatum is rarely reported. This paper aims to explore the curative effects of multiple-bar Nuss operations on wide-range or significantly asymmetric pectus excavatum. Methods We reviewed the clinical data of 153 patients with pectus excavatum who were treated in our hospital from September 2006 to August 2014. All the patients had wide-range or significantly asymmetric pectus excavatum and underwent multiple-bar Nuss operations performed by the author. Results All 153 patients agreed to undergo the operation. The median age was 17 y (10.2–41 y). The median Haller index was 3.98 (3.2–25). One hundred and fifty-one patients accepted treatment with two bars, and 2 cases accepted treatment with three bars. The median operation time was 123 min (65–500 min), the median blood loss was 20 mL (2–200 mL), and the median postoperative hospital stay was 6 days (3–33 days). The incidence rates of pleural effusion, pneumothorax and hydropneumothorax that required drainage treatment were 0.7% (1/153), 1.3% (2/153) and 3.3% (5/153), respectively. Displacement of a bar occurred in one case, and bar exposure occurred in 7 cases. Therefore, 2 cases had the bars removed early, within 2 years postoperation. One patient with severe depression (Haller index: 8.8) had an unhealed auxiliary incision of the xiphoid process, and although the incision was cured after the early removal of the inferior bar, the deformity recurred. There were no cases of death. Currently, 51.6% (79/153) of the cases have had the bars removed. The most recent follow-up revealed that patients’ median satisfaction score for the surgical correction effect was 9 points (10 points indicated full satisfaction). Conclusions For patients with significantly asymmetric and severely deformed pectus excavatum, the multiple-bar Nuss operation not only is safe and effective but can also achieve a better cosmetic appearance. However, we should continue to explore technical improvements.
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Affiliation(s)
- Xiao Song Ben
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Cheng Deng
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Dan Tian
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Ji Ming Tang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Liang Xie
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiong Ye
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Zi Hao Zhou
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Hai Yu Zhou
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Dong Kun Zhang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Rui Qing Shi
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Gui Bin Qiao
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Gang Chen
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital/Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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Haecker FM, Krebs T, Kocher GJ, Schmid RA, Sesia SB. Sternal elevation techniques during the minimally invasive repair of pectus excavatum. Interact Cardiovasc Thorac Surg 2020; 29:497-502. [PMID: 31199434 DOI: 10.1093/icvts/ivz142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/06/2019] [Accepted: 05/13/2019] [Indexed: 11/13/2022] Open
Abstract
The aim of the review was to evaluate the routine use of sternal elevation techniques (SETs) during minimally invasive repair of pectus excavatum (MIRPE, the Nuss procedure). We performed a review of the literature between January 1998 and September 2018 with focus on different methods of SET during MIRPE. Reported effects and side effects were evaluated and compared with our own experience concerning the routine use of the vacuum bell for sternal elevation during MIRPE during the last 13 years. SET is more often used in adult patients than in adolescents. SET improves visualization and safety of MIRPE. Advancement of the pectus introducer, retrosternal dissection and placement of the pectus bar are easier. The risk of cardial and/or pericardial lesion is reduced significantly. Different types of retractors, a crane combined with a wire and/or customized hooks are reported to be used as SET. Furthermore, routine use of a subxiphoid incision is reported. However, more technical equipment, and in some SETs additional incisions are necessary. In contrast, no additional skin incision is necessary for the vacuum bell. The routine intraoperative use of the vacuum bell was safe and effective in 131 patients. It facilitates the retrosternal dissection and the insertion of the pectus bar like other SETs. Besides a temporary mild hematoma, no relevant side effect was observed. In conclusion, an increasing number of authors report on the routine use of SET during MIRPE to improve safety of the procedure. We recommend the routine intraoperative use of the vacuum bell during MIRPE.
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Affiliation(s)
- Frank-Martin Haecker
- Pediatric Surgery, Surgical Clinic, American Hospital Dubai, Dubai, United Arab Emirates.,Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Thomas Krebs
- Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Gregor J Kocher
- Division of General Thoracic Surgery, Bern University Hospital/Inselspital, Bern, Switzerland
| | - Ralph A Schmid
- Division of General Thoracic Surgery, Bern University Hospital/Inselspital, Bern, Switzerland
| | - Sergio B Sesia
- Division of General Thoracic Surgery, Bern University Hospital/Inselspital, Bern, Switzerland
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Qamar SR, Wu Y, Nicolaou S, Murray N. State of the Art Imaging Review of Blunt and Penetrating Cardiac Trauma. Can Assoc Radiol J 2020; 71:301-312. [PMID: 32066272 DOI: 10.1177/0846537119899200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Traumatic cardiovascular injuries are only second to the central nervous system injuries as a cause of death in young adult population. Multidetector computed tomography is the gold standard diagnostic modality in patients with blunt or penetrating chest trauma and clinical suspicion of cardiac injury. The imaging spectrum of cardiac injuries includes but not limits to pericardial rupture, myocardial contusions, valve rupture, coronary artery injuries, cardiac herniations, and cardiac tamponade. In this review article, we discuss clinical presentation, types, and mechanism of cardiac trauma with emphasis on the imaging findings and illustrations in blunt, penetrating traumatic, and iatrogenic cardiac injuries.
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Affiliation(s)
- Sadia Raheez Qamar
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yuhao Wu
- Department of Medical Imaging, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Savvas Nicolaou
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicolas Murray
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Kovács T, Pásztor G, Rieth A. Internal Mammary Artery Compression After Pectus Excavatum Repair Does Not Increase Risk of Hemorrhagic Complications in Pediatric Patients. Front Pediatr 2020; 8:619065. [PMID: 33469524 PMCID: PMC7813807 DOI: 10.3389/fped.2020.619065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/07/2020] [Indexed: 11/30/2022] Open
Abstract
Objectives: Minimal invasive repair of pectus excavatum (MIRPE) described by Nuss is the most popular correction nowadays of this deformity. During the introduction of the bars, they can hurt or compress the internal mammary arteries (IMA). The aim of this study was to observe the prevalence of IMA compression in children after MIRPE. Also, we examined if IMA obstruction increases the risk of complications at bar removal, and if these vascular changes are reversible. Materials and Methods: All patients operated on pectus excavatum in our tertiary pediatric surgical center between 2013 and 2019 were involved in the study. Data of age, sex, number of bars and characteristics of the deformity were examined. IMA flow was checked by Doppler ultrasound (DUS) after MIRPE and after bar removal, too. Results: Among 41 patients with mean age of 15.2 years there were 18 asymmetrical deformities, 23 sternal rotations. Mean pectus index was 4.01. After the Nuss procedure 7(9%) stenoses and 10(12%) occlusions of IMA were found on DUS. After bar removal 3 of 4 stenoses have resolved, but all examined occlusions (3/3) persisted. There were no complications during bar removals. Conclusion: IMA compression after MIRPE in children is uncommon, and is not influenced by severity of deformity. Obstruction of these vessels does not increase the risk of hemorrhagic complications at bar removal. Data of larger cohort are needed to determine reversibility of these changes.
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Affiliation(s)
- Tamás Kovács
- Unit of Pediatric Surgery, Department of Pediatrics, Albert Szent-Gyorgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Gyula Pásztor
- Department of Radiology, Albert Szent-Gyorgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Anna Rieth
- Unit of Pediatric Surgery, Department of Pediatrics, Albert Szent-Gyorgyi Clinical Center, University of Szeged, Szeged, Hungary
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Floccari LV, Sucato DJ, Ramo BA. Scoliosis Progression After the Nuss Procedure for Pectus Excavatum: A Case Report. Spine Deform 2019; 7:1003-1009. [PMID: 31731992 DOI: 10.1016/j.jspd.2019.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 01/10/2019] [Accepted: 01/12/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Pectus excavatum and scoliosis are associated conditions with a high rate of coincidence. However, there are no reports to guide surgeons on the management of adolescents with moderate scoliosis and pectus excavatum, because there are conflicting conclusions in the literature regarding how the Nuss procedure with substernal bar affects scoliosis. CASES In 2017, we encountered two patients with moderate scoliosis treated with a spinal orthosis. After undergoing the Nuss procedure for pectus excavatum, their scoliosis acutely progressed into surgical magnitude requiring posterior instrumented spinal fusion. The first patient progressed 26° despite the pre-Nuss radiographs showing him to be Risser 4/5, while the second patient also progressed 26° from the Nuss procedure. Both patients acknowledged noncompliance with brace wear because of discomfort after the Nuss procedure. However, their progression rate still doubles the rate of reported rapid accelerators, indicating that a significant component of curve progression is directly attributed to forces on the spine from the corrective maneuver with substernal bar. CONCLUSION The purpose of this case report is to describe the features of these two patients to help with clinical decision-making in patients with moderate scoliosis (curves >25°) who are contemplating the Nuss procedure for correction of pectus excavatum. We caution patients and providers that spinal deformity could worsen with surgical intervention of the pectus excavatum via the Nuss procedure and necessitate scoliosis surgery.
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Affiliation(s)
- Lorena V Floccari
- Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX, 75219, USA.
| | - Daniel J Sucato
- Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX, 75219, USA
| | - Brandon A Ramo
- Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX, 75219, USA
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Chavoin JP, Grolleau JL, Chaput B, Moreno B, Le Pimpec Barthes F, Assouad J, Brouchet L, Dahan M. Le pectus excavatum : chirurgie secondaire par implants. ANN CHIR PLAST ESTH 2019; 64:620-633. [DOI: 10.1016/j.anplas.2019.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
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Kauffman JD, Benzie AL, Snyder CW, Danielson PD, Chandler NM. Short-term Outcomes After Pectus Excavatum Repair in Adults and Children. J Surg Res 2019; 244:231-240. [PMID: 31301479 DOI: 10.1016/j.jss.2019.06.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/30/2019] [Accepted: 06/14/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pectus excavatum is a common congenital chest wall deformity often repaired during adolescence, although a subset of patients undergo repair as adults. The goal of our study was to determine the effects of age at repair and repair technique on short-term surgical outcomes. MATERIALS AND METHODS We performed a cohort study of patients in the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project pediatric (age<18 y) and adult databases who underwent pectus excavatum repair. The primary outcome was the incidence of 30-d complications. Secondary outcomes included length of stay, reoperation, and readmission. Multivariable logistic regression was used to estimate the independent effects of patient age and type of repair on postoperative outcomes. RESULTS Of the 2268 subjects included, 2089 (92.1%) were younger than 18 y. Overall, 3.4% of patients suffered a 30-d complication, and the risk was similar between age groups (risk ratio [RR], 0.69; 95% confidence interval [CI], 0.08-5.03; P = 0.731). Steroid therapy was an independent risk factor for complications (RR, 8.0; 95% CI, 1.9-19.7; P = 0.006). Median length of stay was 4 d (interquartile range, 3-5) and was similar between age groups. Risk for readmission and reoperation were 2.8% and 1.5%, respectively, and were similar for pediatric and adult patients. When comparing minimally invasive repair with and without thoracoscopy, risk for 30-d complications was lower among patients repaired with thoracoscopy (RR, 0.56; CI, 0.32-0.96; P = 0.034). CONCLUSIONS Pediatric and adult patients experience comparable rates of postoperative complications, readmission, and reoperation after pectus excavatum repair. Use of thoracoscopy during minimally invasive repair is associated with lower risk of complications. These findings suggest that thoracoscopy should be used routinely for minimally invasive repair of pectus excavatum.
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Affiliation(s)
- Jeremy D Kauffman
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Annie Laurie Benzie
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Christopher W Snyder
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Paul D Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.
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Nissen AP, Kilbourne MJ, Jeschke R, Lee R, Rice RD. Delayed Presentation of Cardiac Perforation After Modified Ravitch Pectus Excavatum Repair. Ann Thorac Surg 2019; 109:e29-e31. [PMID: 31233721 DOI: 10.1016/j.athoracsur.2019.04.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022]
Abstract
Pectus excavatum repair using a Nuss bar is a widely performed procedure and generally regarded to be quite safe. Rare catastrophic cardiovascular complications have been previously reported, by even the most experienced surgeons. These cases typically present with fulminant cardiogenic shock and have an associated high mortality rate. We present a delayed and atypical presentation for a patient with a cardiac perforation after repair of pectus excavatum who underwent successful repair.
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Affiliation(s)
- Alexander P Nissen
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Michael J Kilbourne
- Department of Cardiothoracic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Robert Jeschke
- Department of Cardiothoracic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Richard Lee
- Division of Cardiothoracic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Robert D Rice
- Department of Cardiothoracic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia.
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Wang W, Long W, Chen C. [Experience with Wang procedure for treatment of pectus excavatum in young children]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:249-252. [PMID: 30890516 DOI: 10.12122/j.issn.1673-4254.2019.02.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review the experience with Wang procedure for treatment of pectus excavatum in young children. METHODS The clinical data of 21 children with a mean age of 3.3 ± 1.1 years (ranging from 1.5-6 years) undergoing Wang procedure for pectus excavatum were analyzed. A longitudinal incision (1 to 2 cm) was made in the front of the xiphoid, and two tunnels were created using steel bars beneath the muscles on two sides of the chest wall. The fibrous tissue between the diaphragm and the sternum was dissociated, and the steel wires were sutured through the deformed chest wall. After the steel bar was placed in the tunnels, the wires were pulled and fixed in the middle of the bar, and the incision was sutured. RESULTS All the operations were performed using 3 wires and 1 steel bar. The operation time was 25 to 51 (38.1 ± 9.6) min with an intraoperative bleeding volume of 5 to 10 (7.1±1.5) mL. The time of hospitalization of the patients ranged from 6 to 10 days (mean 8.1±1.3 days). In all the patients, the incision healed smoothly without serious pain or obvious complications. All the patients were followed up for 1 to 13 months after the operation. During the follow- up, no recess recurred and no such complications as bar displacement or transposition occurred. According to the evaluation criteria after pectus excavatum operation, 13 cases had a total score of 9, and 8 had a total score of 8. The overall effect was satisfactory, and there were no cases rated as basically satisfactory or unsatisfactory. CONCLUSIONS Wang procedure is a good option for treatment of pectus excavatum in young children.
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Affiliation(s)
- Wenlin Wang
- Department of Chest Wall Surgery, Guangdong Second General Provincial Hospital, Guangzhou 510317, China
| | - Weiguang Long
- Department of Chest Wall Surgery, Guangdong Second General Provincial Hospital, Guangzhou 510317, China
| | - Chunmei Chen
- Department of Chest Wall Surgery, Guangdong Second General Provincial Hospital, Guangzhou 510317, China
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