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Wu L, Nagasao T, Hosokawa A, Miyanagai T. Presence of manubrium-sternum joint does not assure sufficient elevation of sternum in Nuss procedure for pectus excavatum patients. Gen Thorac Cardiovasc Surg 2024; 72:480-486. [PMID: 38231367 DOI: 10.1007/s11748-023-02001-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/06/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND The manubrium and body of the sternum are connected by the manubrium-sternum joint (MSJ). In performing the Nuss procedure for pectus excavatum patients, the body of the sternum is elevated as the operator flips correction bars upside down. Theoretically, the presence of the MSJ should allow elevation of the sternum body. However, does the MSJ secure sufficient elevation of the sternum? This study aims to elucidate this clinical question. METHODS Seventy-four adult pectus excavatum patients with moderate to serious deformity (with Haller Index being equal to or greater than 5) were included in the study. The MSJ was open in all patients. For 29 patients, the sternum was elevated by only bar flipping (Non-Separation Group); for 45 patients, the sternum was horizontally separated after bar flipping (Separation Group). Whether or not additional elevation for Separation Group patients results from the division was observed, and the degree of the additional elevation was evaluated. Furthermore, 74 patients subjectively evaluated postoperative pain and gave scores with a Visual Analog Scale ranging from 0 (no pain) to 10 (intolerable pain). The VAS scores were compared between the two groups. RESULTS In the Separation Group, the sternums of all patients achieved additional elevation from sternum separation. The pain scores were lower for the Separation Group than for the Non-Separation Group. CONCLUSION Even when the MSJ is present, horizontal separation enhances the elevation of the sternum. Furthermore, horizontal separation of the sternum reduces postoperative pain.
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Affiliation(s)
- LinXuan Wu
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine/Graduate School of Medicine, Kagawa University, Ikenobe 1750-1, Kida County, Miki-Cho, Kagawa Prefecture, Japan
| | - Tomohisa Nagasao
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine/Graduate School of Medicine, Kagawa University, Ikenobe 1750-1, Kida County, Miki-Cho, Kagawa Prefecture, Japan.
| | - Atsushi Hosokawa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine/Graduate School of Medicine, Kagawa University, Ikenobe 1750-1, Kida County, Miki-Cho, Kagawa Prefecture, Japan
| | - Tomoki Miyanagai
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine/Graduate School of Medicine, Kagawa University, Ikenobe 1750-1, Kida County, Miki-Cho, Kagawa Prefecture, Japan
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Laven IEWG, van Polen EJ, Vissers YLJ, de Loos ER. Scapula alata, a rare complication after minimally invasive repair of pectus excavatum. BMJ Case Rep 2024; 17:e260788. [PMID: 38802259 DOI: 10.1136/bcr-2024-260788] [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: 05/29/2024] Open
Abstract
A male patient in his early 30s underwent minimally invasive repair of pectus excavatum. According to standard Nuss bar procedure, a 30-degree thoracoscope was introduced through a right midaxillary 10 mm trocar in the 4th intercostal space. Two bars and five stabilisers were placed in a retromuscular position. After discharge, the patient experienced right upper back pain requiring prolonged opioid usage for three months and right scapular winging limiting functional activities. After conservative treatment with physiotherapy for 11 months, the patient still suffered from residual scapula alata with pain and muscle weakness. On suspicion of long thoracic nerve neuropraxia related to the thoracoscope placement, an electromyogram was conducted 16 months following surgery, revealing mild polyphasic potentials of the serratus anterior muscle without abnormal muscle unit action potential. After extended conservative therapy for another year, physical examination 28 months after surgery showed almost complete resolution of scapular winging.
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Affiliation(s)
- Iris E W G Laven
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
| | - Elise J van Polen
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
| | - Yvonne L J Vissers
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
| | - Erik R de Loos
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
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Media AS, Christensen TD, Katballe N, Juhl-Olsen P, Vad H, Petersen RH, Højsgaard A, Vincenzo de Paoli F. Complication rates rise with age and Haller index in minimally invasive correction of pectus excavatum: A high-volume, single-center retrospective cohort study. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00107-7. [PMID: 38340954 DOI: 10.1016/j.jtcvs.2024.01.047] [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: 05/05/2023] [Revised: 01/09/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVES The study objectives were to describe the compounded complication rate of minimally invasive repair of pectus excavatum, identify predisposing risk factors, and evaluate the optimal timing of correction. Minimally invasive repair of pectus excavatum is the standard treatment for pectus excavatum and consists of 2 invasive procedures, for example, correction with bar insertion followed by bar removal after 2 to 3 years. METHODS A retrospective cohort study identifying children, adolescents, and adults of both genders corrected for pectus excavatum with minimally invasive repair of pectus excavatum between 2001 and 2022. Information on complications related to bar insertion and removal procedures for each individual patient was compiled into a compounded complication rate. Complication severities were categorized according to the Clavien-Dindo classification. RESULTS A total of 2013 patients were corrected by minimally invasive repair of pectus excavatum with a median age (interquartile range) for correction of 16.6 (5) years. Overall compounded complication rate occurred at a frequency of 16.4%, of which 9.3% required invasive reinterventions (Clavien-Dindo classification ≥IIIa). The complication rate related to bar insertion was 2.6-fold higher compared with bar removal (11.8% vs 4.5%, respectively). Multivariable analysis revealed age (adjusted odds ratio, 1.05; P < .001), precorrection Haller Index (adjusted odds ratio, 1.10; P < .033), and early-phase institutional experience (adjusted odds ratio, 1.59; P < .002) as independent predisposing risk factors. The optimal age of correction was 12 years, and the compounded complication rate correlated exponentially with age with a doubling time of 7.2 years. Complications increased 2.2-fold when the Haller index increased to 5 or more units. CONCLUSIONS Minimally invasive repair of pectus excavatum is associated with a high compounded complication rate that increases exponentially with age and high Haller Index. Consequently, we recommend repair during late childhood and early adolescence, and emphasize the importance of informing patients and relatives about the significant risks of adult correction as well as the need of 2 consecutive procedures taking the complication profile into account before planning surgery.
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Affiliation(s)
- Ara S Media
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Katballe
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Vad
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Anette Højsgaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Frank Vincenzo de Paoli
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark.
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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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Sargent B, Varela K, Eggett D, McKenna E, Bates C, Brown R, Garcia V, Howell L. Modeling of the chest wall response to prolonged bracing in pectus carinatum. PLoS One 2023; 18:e0288941. [PMID: 37578962 PMCID: PMC10424870 DOI: 10.1371/journal.pone.0288941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/06/2023] [Indexed: 08/16/2023] Open
Abstract
Pectus carinatum is a chest wall deformity that is often treated through the wearing of an external brace. The treatment of the deformity could benefit from a greater understanding of chest wall characteristics under prolonged loading. These characteristics are difficult to model directly but empirical studies can be used to create statistical models. 185 patients from 2018-2020 received bracing treatment. Data on the severity of the deformity, treatment pressures, and time of wear were recorded at the first fitting and all subsequent follow-up visits. This data was analyzed using a statistical mixed effects model to identify significant measures and trends in treatment. These models were designed to help quantify changes in chest wall characteristics through prolonged bracing. Two statistical models were created. The first model predicts the change in the amount of pressure to correct the deformity after bracing for a given time and pressure. The second model predicts the change in pressure response by the body on the brace after bracing for a given time and pressure. These models show a high significance in the amount of pressure and time to the changes in the chest wall response. Initial deformity severity is also significant in changes to the deformity. The statistical models predict general trends in pectus carinatum brace treatment and can assist in creating treatment plans, motivating patient compliance, and can inform the design of future treatment systems.
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Affiliation(s)
- Brandon Sargent
- Department of Mechanical Engineering, Gonzaga University, Spokane, Washington, United States of America
| | - Katie Varela
- Department of Mechanical Engineering, Brigham Young University, Provo, Utah, United States of America
| | - Dennis Eggett
- Department of Statistics, Brigham Young University, Provo, Utah, United States of America
| | - Emily McKenna
- Chest Wall Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Christina Bates
- Chest Wall Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Rebeccah Brown
- Chest Wall Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Victor Garcia
- Chest Wall Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Larry Howell
- Department of Mechanical Engineering, Brigham Young University, Provo, Utah, United States of America
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Manworren RCB, Di Franco MV, Mishra T, Kaduwela N. Pain Quality After Pediatric Pectus Excavatum Repair. Pain Manag Nurs 2022; 23:811-818. [PMID: 35927201 DOI: 10.1016/j.pmn.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 06/08/2022] [Accepted: 06/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Neuropathic pain medications are included in multimodal postoperative analgesic strategies, but quality of perioperative pain is rarely assessed. AIMS The purpose of this study was to describe adolescents' pain experiences after thoracoscopic pectus excavatum repair (Nuss procedure) using the Adolescent Pediatric Pain Tool. DESIGN This prospective descriptive longitudinal study was designed to test the hypothesis that pain quality descriptors reported are consistent with neuropathic pain. METHODS A convenience sample of 23 adolescents aged 12 to 17 years from a single urban, university affiliated, nonprofit children's hospital consented to self-report pain using the Adolescent Pediatric Pain Tool before and during hospitalization, and up to 14 months after Nuss procedure. Visual analytic techniques were used to analyze reported pain intensity, location, and affective, evaluative, sensory, and temporal qualities. RESULTS Postoperative pain quality, intensity, number of sites, and surface area decreased over time. Word clouds illustrated that neuropathic sensory and temporal pain quality descriptors increased in frequency 2 to 6 weeks after surgery and were the predominant descriptors 2 to 4 months after surgery. Dot matrix charts illustrated an inconsistent relationship of pain quality and intensity with pain surface area. CONCLUSIONS Pain quality should be assessed with valid, reliable, and developmentally appropriate tools. Visual analytics help illustrate pain quality at single points in time and longitudinally and may be helpful in guiding postoperative pain treatment.
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Affiliation(s)
- Renee C B Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Maria Victoria Di Franco
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; University of Illinois, Champaign-Urbana, Illinois
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Viggiano D, Bongiolatti S, Borgianni S, Lo Piccolo R, Voltolini L, Gonfiotti A. Nuss Technique for Pectus Excavatum in Adult Patients: Cosmetic Satisfaction and Improvement of Quality of Life in a Single-Center Experience. Front Surg 2022; 9:903791. [PMID: 35722532 PMCID: PMC9198457 DOI: 10.3389/fsurg.2022.903791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/27/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives Since its introduction, the Nuss minimally invasive procedure for pectus excavatum (PE) repair (MIRPE) has become the method of choice. The current study describes our experience of PE correction in adults, with particular focus on postoperative outcomes, pain, quality of life, and patients’ satisfaction. Methods We enrolled for this observational study n = 93 adult patients from 2011 to 2018. The Haller index was used to quantify PE severity. Pulmonary function tests and cardiac examinations were performed preoperatively; we developed a standardized surgical technique and postoperative treatment, including follow-up at 3, 12, and 24 months after surgery and 6 months after bar removal. We also evaluated the quality of life and the satisfaction with the cosmetic result after the procedure with standardized questionnaires. Results No operative or perioperative deaths occurred nor life-treating complications. Thirteen complications occurred in 12 patients, with a total complication rate of 14% (n = 13/93). Pain intensity decreased in the follow-up [pain score visual analog scale at 3 months: median 1 (0–8); 12 months: median 1 (0–5); and 24 months: median 1 (0–4)]. Better or much better quality of life after the Nuss procedure was observed: n = 79 (84.1%) at 3 months, n = 80 (86%) at 12 months, and n = 85 (91.4%) at 24 months. After 2 years of observation, more than 90% of patients described improvement in their quality of life and satisfaction with the cosmetic results. Only a very small group of patients suffered from pain in the follow-up. Conclusion Our results demonstrate that the MIRPE procedure is safe and can be performed with excellent results in adults both for improvement of quality of life and for satisfaction with cosmetic results.
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Affiliation(s)
- Domenico Viggiano
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
- Correspondence: Domenico Viggiano
| | | | - Sara Borgianni
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Roberto Lo Piccolo
- Department of Pediatric Surgery, University of Florence and Children’s University Hospital A. Meyer, Florence, Italy
| | - Luca Voltolini
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
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Vega-Artiles ÁG, Pérez D, Martel O, Cuadrado A, Yánez A. Stiffness reduction of the rib cage to perform a minimally invasive pectus excavatum repair: biomechanical evaluation. Interact Cardiovasc Thorac Surg 2022; 34:99-104. [PMID: 34999813 PMCID: PMC8923401 DOI: 10.1093/icvts/ivab210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/19/2021] [Accepted: 07/07/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To study the influence of sternal transection and costal chondrotomies on the stiffness and stresses in the rib cage of adult patients undergoing Nuss pectus excavatum procedure. METHODS Four pectus excavatum models with different Haller indexes were created by parameterizing a 3D model of a rib cage obtained based on a computed tomography scan of a patient with no pectus deformity. Using the finite element method, insertion of intrathoracic bars into all models was simulated in 3 conditions, namely, non-intervened, transverse sternal section and costal chondrotomies. Stiffness, stress distribution and maximum stresses for each case were obtained and compared. RESULTS Transverse sternotomy provided a reduction of 44% to 54% in the stiffness of the rib cage, depending on the Haller index analysed, while chondrotomies promoted a stiffness reduction of 70%. Stress distribution in the rib cage followed similar pattern for all the tested Haller index, but the maximum stress decreased by 36% when performing a transverse sternotomy, whereas when performing costal chondrotomies, it decreased by 47%. CONCLUSIONS Computational results report that transverse sternotomy reduces appreciably the stiffness of the rib cage, while costal chondrotomies promote even a higher stiffness reduction. Thus, these surgical procedures could improve the clinical outcomes of adult patients undergoing a pectus excavatum repair.
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Affiliation(s)
- Ángel Gabriel Vega-Artiles
- Department of Mechanical Engineering, University of Las Palmas de Gran
Canaria, Las Palmas de Gran Canaria, Spain
| | - David Pérez
- Department of Thoracic Surgery, Hospital Universitario Insular de Gran
Canaria, Las Palmas de Gran Canaria, Spain
| | - Oscar Martel
- Department of Mechanical Engineering, University of Las Palmas de Gran
Canaria, Las Palmas de Gran Canaria, Spain
| | - Alberto Cuadrado
- Department of Mechanical Engineering, University of Las Palmas de Gran
Canaria, Las Palmas de Gran Canaria, Spain
| | - Alejandro Yánez
- Department of Mechanical Engineering, University of Las Palmas de Gran
Canaria, Las Palmas de Gran Canaria, Spain
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de Loos ER, Pennings AJ, van Roozendaal LM, Daemen JHT, van Gool MH, Lenderink T, van Horck M, Hulsewé KWE, Vissers YLJ. Nuss Procedure for Pectus Excavatum: A Comparison of Complications Between Young and Adult Patients. Ann Thorac Surg 2020; 112:905-911. [PMID: 33181130 DOI: 10.1016/j.athoracsur.2020.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/24/2020] [Accepted: 10/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Nuss procedure is the gold standard surgical treatment for pectus excavatum in young patients. Its use in adults has also been described, although it may be associated with increased postoperative morbidity resulting from higher chest wall rigidity. This study aimed to examine the risk of complications after the Nuss procedure in adult patients compared with young patients with pectus excavatum. METHODS This single-center retrospective cohort study evaluated all patients who underwent the Nuss procedure between 2006 and 2018. Patients were stratified by age as young (≤24 years old) and adult (>24 years old). The primary end point was the occurrence of perioperative or postoperative complications, subdivided into major (Clavien-Dindo class IIIa or higher) and minor (less severe than Clavien-Dindo class III). Between-group differences were analyzed using the Mann-Whitney U and the χ2 test with post hoc analysis. RESULTS A total of 327 participants were included, 272 in the young group (median age, 16 years; interquartile range [IQR], 15 to 18 years; range, 11 to 24 years) and 55 in the adult group (median age, 32 years; IQR, 27 to 38 years; range, 25 to 47 years). The median Haller index was similar between groups (young, 3.7; IQR, 3.2 to 4.4 vs adult,3.6; IQR, 3.0 to 4.3; P = .44). The median follow-up was 34 and 36 months, respectively. The incidence of major complications was comparable between young and adult participants (P = .43). Minor complications occurred more often among adults (young, 4% vs adult, 11%; P = .002). Chronic postoperative pain was the only minor complication with a significant difference in incidence (young, 1% vs adult, 7%; P = .008). CONCLUSIONS The Nuss procedure is a safe surgical treatment for pectus excavatum in both young and adult patients. The risk of major complications is comparable. However, adults more often have chronic pain.
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Affiliation(s)
- Erik R de Loos
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands.
| | - Alexander J Pennings
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Lori M van Roozendaal
- 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, School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - Matthijs H van Gool
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Timo Lenderink
- Department of Cardiology, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Marieke van Horck
- Department of Pediatrics, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Karel W E Hulsewé
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Yvonne L J Vissers
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
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İşcan M, Kılıç B, Turna A, Kaynak MK. The effect of minimally invasive pectus excavatum repair on thoracic scoliosis. Eur J Cardiothorac Surg 2020; 59:ezaa328. [PMID: 33123728 DOI: 10.1093/ejcts/ezaa328] [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: 03/13/2020] [Revised: 07/17/2020] [Accepted: 07/23/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The Nuss technique comprises the placement of an intrathoracic bar behind the sternum. However, besides improving the body posture through the correction of the pectus excavatum (PE), this procedure may cause or worsen thoracic scoliosis as a result of the considerable stress loaded on the chest wall and the thorax. Our goal was to investigate the impact of the Nuss procedure on the thoracic spinal curvature in patients with PE. METHODS A total of 100 patients with PE who underwent the Nuss procedure were included in the study and evaluated retrospectively. The Haller index (HI), asymmetry index and sternal torsion angle were calculated from thoracic computed tomography images before the operation. To evaluate the scoliosis in the T2-T8 thoracic vertebrae, Cobb angles were calculated on a plain chest X-ray before the Nuss operation and after the removal of the bar. Cobb angles were classified as normal (5°), scoliotic posture (5°-10°) and scoliosis (>10°). All angles before and after the Nuss operation were compared. The patients were followed up for a mean of 41 months. Substernal bars were removed after a mean of 33 months. RESULTS The mean age of the patients was 19.6 ± 6.7 years. The Cobb angle was statistically significantly increased in all patients (P = 0.01), male patients (P = 0.01) and children (P = 0.046) but not in adults (P = 0.11) and female patients (P = 0.54). The Cobb angle was increased in patients with severe (HI ≥ 3.5) but not in patients with moderate (3.2 < HI < 3.5) or mild (2.0 < HI < 3.2) PE deformity. CONCLUSIONS The present study shows that the Cobb angle indicates that the severity of thoracic scoliosis increases following the Nuss procedure, particularly in male patients, in patients with mild and moderate sternal torsion angle and in those with a high preoperative HI. This alteration might be due to correctional forces and torque applied by the bar. Patients undergoing the Nuss procedure for the correction of PE should be followed up strictly for timely diagnosis and management of the scoliosis.
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Affiliation(s)
| | - Burcu Kılıç
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, Istanbul, Turkey
| | - Akif Turna
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, Istanbul, Turkey
| | - Mehmet Kamil Kaynak
- Department of Thoracic Surgery, Istanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, Istanbul, Turkey
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Nagasao T, Aizezi N, Noguchi M, Morotomi T, Kudo H, Kogure T. Bone-cartilage proportion in deformed ribs of male pectus excavatum patients. J Plast Surg Hand Surg 2019; 53:143-148. [PMID: 30889996 DOI: 10.1080/2000656x.2018.1554532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This study verifies the hypothesis that bone/cartilage proportion in deformed ribs of male pectus excavatum patients varies according to their ages. Anatomical evaluation of the thoraces was performed for 79 male pectus excavatum patients, referring to their three-dimensional computer-tomographic images. The patients were divided into Child Group (5-9 years old: n = 35); Adolescent Group (12-15 years old: n = 15) and Adult Group (18+ years old: n = 29). For each patient, the most concave point of the sternum was identified and the pair of ribs closest to the point were defined as Key Ribs. On each Key Rib, the most ventral point was defined as Prominent Point (PP); the junction between the bone and cartilage was defined as Costo-Chondral Junction (CCJ). The distances of these points from the spine were defined as Distance of Prominent Point (DPP) and Distance of Costo-Chondral Junction (DCCJ), respectively. The horizontal length of the Key Rib was defined as Rib Length (RL). Inter- and intra-group comparisons were performed for DPP/RL and DCCJ/RL. Inter-Group Comparison: DCCJ/RL is significantly smaller and DPP/RL is significantly greater in Adult Group than in Child Group, meaning CCJs shift medially and PPs shift laterally as patients get older. Intra-Group Comparison: In Child Group, DCCJ/RL is significantly greater than DPP/RL, meaning CCJs exist lateral to PPs. Contrarily, in Adult Group, DCCJ/RL is significantly smaller than DPP/RL, meaning CCJs exists medial to PPs. Bone/cartilage proportion in the concave part of the chest shifts according to patients' ages. To perform the Nuss procedure effectively, this age-related anatomical change must be taken into consideration.
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Affiliation(s)
- Tomohisa Nagasao
- a Department of Plastic and Reconstructive Surgery , Medical/Graduate School of Kagawa University , Takamatsu , Japan
| | - Niyazi Aizezi
- a Department of Plastic and Reconstructive Surgery , Medical/Graduate School of Kagawa University , Takamatsu , Japan
| | - Masahiko Noguchi
- b Department of Plastic and Reconstructive Surgery , Nagano Children's Hospital , Nagano , Japan
| | - Tadaaki Morotomi
- c Department of Plastic and Reconstructive Surgery , Medical/Graduate School of KINDAI University , Osaka , Japan
| | - Hiroo Kudo
- a Department of Plastic and Reconstructive Surgery , Medical/Graduate School of Kagawa University , Takamatsu , Japan
| | - Tetsukuni Kogure
- a Department of Plastic and Reconstructive Surgery , Medical/Graduate School of Kagawa University , Takamatsu , Japan
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Computer-Aided Design and Manufacturing Technology for Identification of Optimal Nuss Procedure and Fabrication of Patient-Specific Nuss Bar for Minimally Invasive Surgery of Pectus Excavatum. APPLIED SCIENCES-BASEL 2018. [DOI: 10.3390/app9010042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Nuss procedure is one of the most widely used operation techniques for pectus excavatum (PE) patients. It attains the normal shape of the chest wall by lifting the patient’s chest wall with the Nuss bar. However, the Nuss bar is for the most part bent by a hand bender according to the patient’s chest wall, and this procedure causes various problems such as the failure of the operation and a decreased satisfaction of the surgeon and patient about the operation. To solve this problem, we proposed a method for deriving the optimal operation result by designing patient-specific Nuss bars through computer-aided design (CAD) and computer-aided manufacturing (CAM), and by performing auto bending based on the design. In other words, a three-dimensional chest wall model was generated using the computed tomography (CT) image of a pectus excavatum patient, and an operation scenario was selected considering the Nuss bar insertion point and the post-operative chest wall shape. Then, a design drawing of the Nuss bar that could produce the optimal operation result was derived from the operation scenario. Furthermore, after a computerized numerical control (CNC) bending machine for the Nuss bar bending was constructed, the Nuss bar prototype was manufactured based on the derived design drawing of the Nuss bar. The Nuss bar designed and manufactured with the proposed method has been found to improve the Haller index (HI) of the pectus excavatum patient by approximately 37% (3.14 before to 1.98 after operation). Moreover, the machining error in the manufacturing was within ±5% compared to the design drawing. The method proposed and verified in this study is expected to reduce the failure rate of the Nuss procedure and significantly improve the satisfaction of the surgeon and patient about the operation.
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Tse KM, Tan LB, Lee SJ, Rasheed MZ, Tan BK, Lee HP. Feasibility of using computer simulation to predict the postoperative outcome of the minimally invasive Nuss procedure: Simulation prediction vs. postoperative clinical observation. J Plast Reconstr Aesthet Surg 2018; 71:1496-1506. [DOI: 10.1016/j.bjps.2018.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/16/2018] [Accepted: 05/28/2018] [Indexed: 10/14/2022]
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Manworren RC, Anderson MN, Girard ED, Ruscher KA, Verissimo AM, Palac H, Weiss R, Rader C, Hight D. Postoperative Pain Outcomes After Nuss Procedures: Comparison of Epidural Analgesia, Continuous Infusion of Local Anesthetic, and Preoperative Self-Hypnosis Training. J Laparoendosc Adv Surg Tech A 2018; 28:1234-1242. [DOI: 10.1089/lap.2017.0699] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Renee C.B. Manworren
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew N. Anderson
- Department of Neurosurgery, Rhode Island Hospital, Brown University, Providence, Rhode Island
| | - Eric D. Girard
- Department of Surgery, School of Medicine, University of Louisville, Louisville, Kentucky
| | - Kimberly A. Ruscher
- Department of Pediatric Surgery, Sacred Heart at Riverbend, Springfield, Oregon
| | - Ana Maria Verissimo
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Hannah Palac
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Center for Behavorial Intervention Technologies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Weiss
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Christine Rader
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Donald Hight
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
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Aizezi N, Nagasao T, Morotomi T, Tamai M, Imajo K. Separation patterns of orbital wall and risk of optic canal injury in Le Fort 3 osteotomy. J Craniomaxillofac Surg 2018; 46:795-801. [PMID: 29628302 DOI: 10.1016/j.jcms.2018.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 02/20/2018] [Accepted: 03/13/2018] [Indexed: 10/17/2022] Open
Abstract
PURPOSE The authors hypothesized that the risks of optic canal injury in down-fracturing after Le Fort 3 osteotomy vary depending on the separation patterns of the orbital walls. This study verifies this hypothesis using biomechanical simulation. METHODS Ten finite-element skull models were produced using computer tomography data from ten persons. These models were modified to simulate Le Fort 3 osteotomy models by removing junctions between the neurocranium and facial cranium. The separation of the orbital wall was performed in four differing ways. In Type 1, all walls were completely separated. In Type 2, only the lateral wall was separated. In Type 3, the inferior wall was left unseparated. In Type 4, the lateral wall was left unseparated. Biomechanical simulation of down-fracturing was performed on the resulting 40 models. By observing irregular fractures occurring inside the orbit, the rate of optic canal involvement was evaluated for each of the four orbital-wall separation patterns. RESULTS The rates of optic canal involvement were: Type 1 (0/10), Type 2 (0/10), Type 3 (0/10), and Type 4 (4/10). CONCLUSION When the lateral wall is incompletely separated in Le Fort 3 osteotomy, irregular fracture can develop inside the orbit and involve the optic canal during the down-fracturing process. Hence, the lateral orbital wall should be completely separated to avoid potential blindness due to optic canal injury.
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Affiliation(s)
- Niyazi Aizezi
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine/Graduate School of Medicine, Kagawa University. (Head: Tomohisa NAGASAO), Ikenobe, Japan
| | - Tomohisa Nagasao
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine/Graduate School of Medicine, Kagawa University. (Head: Tomohisa NAGASAO), Ikenobe, Japan.
| | - Tadaaki Morotomi
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine/Graduate School of Medicine, Kindai University. (Head: Noritaka ISOGAI), Ikenobe, Japan
| | - Motoki Tamai
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine/Graduate School of Medicine, Kagawa University. (Head: Tomohisa NAGASAO), Ikenobe, Japan
| | - Koji Imajo
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine/Graduate School of Medicine, Kagawa University. (Head: Tomohisa NAGASAO), Ikenobe, Japan
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Comparison of Ultrasonography-guided Bilateral Intercostal Nerve Blocks and Conventional Patient-controlled Intravenous Analgesia for Pain Control After the Nuss Procedure in Children: A Prospective Randomized Study. Clin J Pain 2018; 33:604-610. [PMID: 27841838 PMCID: PMC5462349 DOI: 10.1097/ajp.0000000000000449] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objectives: Patients experience severe pain after pectus excavatum (PE) surgery. The aim of this prospective, randomized study was to compare analgesic effects of ultrasonography-guided bilateral intercostal nerve blocks (UG-ICNBs) with those of conventional patient-controlled intravenous analgesia (PCIA) on acute pain after the Nuss procedure for PE repair in children. Methods: A prospective randomized study was performed in children with PE who were scheduled for the Nuss procedure. Participants were randomly assigned to receive either UG-ICNBs or PCIA for postoperative analgesia. Faces Pain Scale-Revised scores, opioid consumption, analgesia-associated side effects (respiratory depression, pruritus, nausea, vomiting) during the first 24 hours, and lengths of stay in the postanesthesia care unit (PACU) and hospital were recorded after the surgery. Results: Sixty-two children undergoing the Nuss procedure were enrolled in the trial. Faces Pain Scale-Revised scores were significantly decreased in the UG-ICNBs group compared with the PCIA group for up to 6 hours after surgery. The opioid doses required in the PACU and during the first 24 hours after surgery were significantly greater in the PCIA group compared with the UG-ICNBs group. Accordingly, patients in the UG-ICNBs group showed a lower incidence of analgesia-associated side effects and faster PACU discharge compared with the PCIA group. Conclusions: Our study suggests that UG-ICNBs might be more effective than PCIA for postoperative analgesia in children who undergo the Nuss procedure for PE.
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Kabagambe SK, Goodman LF, Chen YJ, Keller BA, Becker JC, Raff GW, Stark RA, Stephenson JT, Rahm A, Farmer DL, Hirose S. Subcutaneous local anesthetic infusion could eliminate use of epidural analgesia after the Nuss procedure. Pain Manag 2017; 8:9-13. [PMID: 29210330 DOI: 10.2217/pmt-2017-0042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To compare outcomes of continuous subcutaneous infusion of local anesthetic and epidural analgesia following the Nuss procedure. PATIENTS & METHODS A retrospective chart review compared patients managed with subcutaneous local anesthetic infusion (n = 12) versus thoracic epidural (n = 19) following the Nuss procedure from March 2013 to June 2015. RESULTS There was no difference in hospital length of stay or days on intravenous narcotics. Epidural catheter placement prolonged operating room time (146.58 ± 28.30 vs 121.42 ± 21.98 min, p = 0.01). Average pain scores were slightly higher in the subcutaneous infusion group (3.72 ± 1.62 vs 2.35 ± 0.95, p = 0.02), but of negligible clinical significance. CONCLUSION Continuous subcutaneous infusion of local anesthetic could eliminate the need for thoracic epidural for pain management after the Nuss procedure.
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Affiliation(s)
- Sandra K Kabagambe
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA
| | - Laura F Goodman
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA
| | - Y Julia Chen
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA
| | - Benjamin A Keller
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA
| | - James C Becker
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA
| | - Gary W Raff
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
| | - Rebecca A Stark
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
| | - Jacob T Stephenson
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
| | - Amy Rahm
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
| | - Diana L Farmer
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
| | - Shinjiro Hirose
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
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Park HJ, Kim JJ, Park JK, Moon SW. Effects of Nuss procedure on thoracic scoliosis in patients with pectus excavatum. J Thorac Dis 2017; 9:3810-3816. [PMID: 29268389 DOI: 10.21037/jtd.2017.08.128] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The objectives of this study are to investigate the association between pectus excavatum (PE) and thoracic scoliosis (TS) and to analyze the effects of the Nuss procedure on the thoracic spinal curvature in patients with PE. Methods A total of 468 patients who underwent the Nuss procedure and pectus bar removal for PE from March 2011 to January 2015 were assessed and included into the present study. Results TS prevalence was 9.4% pre-correctively and 9.8% post-correctively. There was a positive correlation between age and Cobb angle (CA), pre-correctively and post-correctively (both, P<0.001). The late correction group (LG, age ≥10 years) had a higher CA and more frequent TS than the early correction group (EG, age <10 years) (pre-correction: CA 6.3±4.9° vs. 4.5±3.8°, P<0.001, TS P<0.001; post-correction: 7.6±7.2° vs. 4.1±3.3°, P<0.001, TS P<0.001). The post-corrective changes in CA were different according to the time of correction (decreased in EG: 4.5±3.8° vs. 4.1±3.3°, P=0.078; increased in LG: 6.3±4.9° vs. 7.6±7.2°, P=0.002). In patients with pre-corrective TS, CA after correction was decreased (post-correctively 11.9±10.0° vs. pre-correctively 13.9±6.0°, P=0.090). In addition, post-corrective CA was significantly decreased in EG (pre-correction 13.9±7.4° vs. post-correction 6.6±8.1°, P<0.001). However, post-corrective CA was increased in LG (pre-correction 13.8±4.5° vs. post-correction 16.7±9.2°, P=0.053). The number of patients with TS after correction was decreased in EG (P=0.194) and significantly increased in LG (P=0.028). There were both pre-corrective and post-corrective predictive factors for TS (Pre-corrective: age P<0.001, severity P=0.016, and BMI P=0.046; post-corrective: age at the time of correction P<0.001, weight P=0.046, and pre-corrective CA P<0.001). Conclusions The Nuss procedure had some significant effects on the thoracic spinal curvature, with early correction able to reduce TS in patients with PE.
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Affiliation(s)
- Hyung Joo Park
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's University of Korea, Seoul, Republic of Korea
| | - Jae Jun Kim
- Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's College of Medicine, The Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Jae Kil Park
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's University of Korea, Seoul, Republic of Korea
| | - Seok Whan Moon
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's University of Korea, Seoul, Republic of Korea
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Pechetov AA, Esakov YS, Gubaydullina GF, Makov MA, Khlan TN. [Differential approach for chest wall reconstruction for pectus excavatum in adults]. Khirurgiia (Mosk) 2017:24-29. [PMID: 28745702 DOI: 10.17116/hirurgia2017724-29] [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: 06/07/2023]
Abstract
AIM To perform the prospective non-randomized single-center trial of pectus excavatum correction in adults. MATERIAL AND METHODS For the period March 2012 - March 2016 64 patients aged 18-44 years were treated. Median age was 23 years. Male/female ratio was 41/23. All patients were included into standard survey protocol: chest MDCT, MRI of thoracic spine, pulmonary function test, echocardiography. Quality of life and complications rate after the Nuss procedure (n=50, 78.1%, group 1) and radical thoracoplasty using nikelid-titanium bar (n=14, group 2) were evaluated. RESULTS There was earlier recovery in the 1st group: 3 (2; 4) and 6 (5; 7) days after minimally invasive and radical thoracoplasty, respectively. Postoperative Dindo-Clavien I-IIIa complications developed in 46 (71.8%) patients. Most of them did not require additional procedures. CONCLUSION Nuss procedure is safe method and can be performed with good results in adults.
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Affiliation(s)
- A A Pechetov
- Vishnevsky Institute of Surgery, Health Ministry of the Russian Federation, Moscow, Russia
| | - Yu S Esakov
- Vishnevsky Institute of Surgery, Health Ministry of the Russian Federation, Moscow, Russia
| | - G F Gubaydullina
- Faculty of Fundamental Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - M A Makov
- Vishnevsky Institute of Surgery, Health Ministry of the Russian Federation, Moscow, Russia
| | - T N Khlan
- Vishnevsky Institute of Surgery, Health Ministry of the Russian Federation, Moscow, Russia
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YE JINDUO, LIU BOLUN, LIU JIFU, ZHANG CHUNYUE, ZHONG WEIHONG, ZHANG CHUNQIU. RESEARCH ON ELECTRICAL MEASUREMENT EXPERIMENT OF DEFORMATION OF ARTIFICIAL THORAX MODEL. J MECH MED BIOL 2016. [DOI: 10.1142/s0219519417500579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The method of numerical simulation has been used in the research setting for purposes related to the correction process of the pectus excavatum with scoliosis. Although a convenient method, the validity and accuracy of this technique need to be tested. Further complicating the validity of this technique is that we are unable to confirm results of numerical simulation via electrical measurement experiments in humans because of ethical considerations, nor are we able to attain cadavers of pectus excavatum with scoliosis to perform electrical measurement experiments on. Both animal thorax and artificial thorax models can be used for thoracic deformation experiments, but the translation of these models to humans is unclear due to contrasting anatomical arrangements of chest cavities. This paper attempts to solve this problem by making a PVC thorax model and carrying out electrical measurement experiments to assess strain–displacement under physiological loading conditions. We present data showing biomechanical responses of the thoracic skeleton to compressive loading, which may be used to guide the development of computational models of the thoracic skeleton and ultimately improve the treatment strategy of pectus excavatum.
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Affiliation(s)
- JINDUO YE
- School of Mechanical Engineering, Tianjin University of Technology, Tianjin 300384, China
- Tianjin Key Laboratory of the Design and Intelligent, Control of the Advanced Mechatronical System, Tianjin University of Technology, Tianjin 300384, China
| | - BOLUN LIU
- School of Mechanical Engineering, Tianjin University of Technology, Tianjin 300384, China
- Tianjin Key Laboratory of the Design and Intelligent, Control of the Advanced Mechatronical System, Tianjin University of Technology, Tianjin 300384, China
| | - JIFU LIU
- Department of Thoracic Surgery, General Hospital of Beijing, Command, Beijing 100700, China
| | - CHUNYUE ZHANG
- School of Mechanical Engineering, Tianjin University of Technology, Tianjin 300384, China
- Tianjin Key Laboratory of the Design and Intelligent, Control of the Advanced Mechatronical System, Tianjin University of Technology, Tianjin 300384, China
| | - WEIHONG ZHONG
- School of Mechanical Engineering, Tianjin University of Technology, Tianjin 300384, China
- Tianjin Key Laboratory of the Design and Intelligent, Control of the Advanced Mechatronical System, Tianjin University of Technology, Tianjin 300384, China
| | - CHUNQIU ZHANG
- School of Mechanical Engineering, Tianjin University of Technology, Tianjin 300384, China
- Tianjin Key Laboratory of the Design and Intelligent, Control of the Advanced Mechatronical System, Tianjin University of Technology, Tianjin 300384, China
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Minimally invasive repair of pectus excavatum (MIRPE) in adults: is it a proper choice? Wideochir Inne Tech Maloinwazyjne 2016; 11:98-104. [PMID: 27458490 PMCID: PMC4945611 DOI: 10.5114/wiitm.2016.60456] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/15/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The Nuss procedure is suitable for prepubertal and early pubertal patients but can also be used in adult patients. AIM To determine whether the minimally invasive technique (MIRPE) can also be performed successfully in adults. MATERIAL AND METHODS Between July 2006 and January 2016, 836 patients (744 male, 92 female) underwent correction of pectus excavatum with the MIRPE technique at our institution. The mean age was 16.8 years (2-45 years). There were 236 adult patients (28.2%) (> 18 years) - 20 female, 216 male. The mean age among the adult patients was 23.2 years (18-45 years). The recorded data included length of hospital stay, postoperative complications, number of bars used, duration of the surgical procedure and signs of pneumothorax on the postoperative chest X-ray. RESULTS The MIRPE was performed in 236 adult patients. The average operative time was 44.4 min (25-90 min). The median postoperative stay was 4.92 ±2.81 days (3-21 days) in adults and 4.64 ±1.58 (2-13) in younger patients. The difference was not statistically significant (p = 0.637). Two or more bars were used in 36 (15.8%) adult patients and in 44 (7.5%) younger patients. The difference was not statistically significant either (p = 0.068). Regarding the overall complications, complication rates among the adult patients and younger patients were 26.2% and 11.8% respectively. The difference was statistically significant (p = 0.007). CONCLUSIONS MIRPE is a feasible procedure that produces good long-term results in the treatment of pectus excavatum in adults.
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Sacco Casamassima MG, Gause C, Goldstein SD, Karim O, Swarup A, McIltrot K, Yang J, Abdullah F, Colombani PM. Patient Satisfaction After Minimally Invasive Repair of Pectus Excavatum in Adults: Long-Term Results of Nuss Procedure in Adults. Ann Thorac Surg 2016; 101:1338-45. [DOI: 10.1016/j.athoracsur.2015.09.102] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/18/2015] [Accepted: 09/24/2015] [Indexed: 11/25/2022]
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Sacco Casamassima MG, Papandria D, Goldstein SD, Yang J, McIltrot KH, Abdullah F, Colombani PM. Contemporary management of recurrent pectus excavatum. J Pediatr Surg 2015; 50:1726-33. [PMID: 25962841 DOI: 10.1016/j.jpedsurg.2015.04.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 04/09/2015] [Accepted: 04/18/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Optimal management of recurrent pectus excavatum (PE) has not been established. Here, we review our institutional experience in managing recurrent PE to evaluate long-term outcomes and propose an anatomic classification of recurrences, and a decision-making algorithm. METHODS Clinical records of patients undergoing repair of recurrent PE (1996-2011) were reviewed. Univariate and multivariate logistic regression analyses were employed to examine patient characteristics as potential predictors for re-recurrence. RESULTS Eighty-five patients with recurrent PE were identified during the study period. The initial operation was a Ravitch procedure in 85% of cases. Revision procedures were most frequently Nuss repairs (N=73, 86%), with remaining cases managed via open approach. Overall cosmetic and functional results were satisfactory in 67 patients (91.8%) managed with Nuss and in 7 (58%) patients managed with other techniques. Seven (8%) patients required additional surgical revision. Multivariate analysis identified no statistically significant patient or procedural factors predictive of re-recurrence. CONCLUSION This study demonstrates that the Nuss procedure can be an effective intervention for recurrent pectus excavatum, regardless of the initial repair technique. However, open repair remains valuable when managing severe cases with abnormalities of the sternocostal junction and cartilage regrowth under the sternum.
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Affiliation(s)
| | - Dominic Papandria
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Seth D Goldstein
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jingyan Yang
- Department of Health, Behavior &Society, Johns Hopkins Bloomberg School of Public Health, MD, USA
| | - Kimberly H McIltrot
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fizan Abdullah
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul M Colombani
- Department of Pediatric Surgery, All Children's Hospital Johns Hopkins, St Petersburg, FL, MD, USA.
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Nagasao T, Miyamoto J, Shimizu Y, Kasai S, Kishi K, Kaneko T. Effective scoring of scapha prevents helix irregularity in prominent ear correction — A biomechanical study. J Craniomaxillofac Surg 2014; 42:711-7. [DOI: 10.1016/j.jcms.2011.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 06/12/2011] [Accepted: 06/26/2011] [Indexed: 10/17/2022] Open
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Li S, Tang ST, Tong Q, Yang Y, Yang L, Li S, Pu J. Nuss repair of pectus excavatum after surgery for congenital heart disease: Experience from a single institution. J Thorac Cardiovasc Surg 2014; 148:657-61. [DOI: 10.1016/j.jtcvs.2014.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/16/2013] [Accepted: 01/10/2014] [Indexed: 10/25/2022]
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Nagasao T, Shimizu Y, Morotomi T, Takano N, Jiang H, Kishi K. Irregular location of major pectoral muscle can be a causative factor of pectus excavatum. Med Hypotheses 2014; 82:512-7. [DOI: 10.1016/j.mehy.2014.01.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Tomohisa Nagasao
- Department of Plastic and Reconstructive Surgery, Keio University, Japan.
| | - Yusuke Shimizu
- Department of Plastic and Reconstructive Surgery, Keio University, Japan
| | - Tadaaki Morotomi
- Department of Plastic and Reconstructive Surgery, Kinki University, Japan
| | - Naoki Takano
- Department of Mechanical Engineering, Keio University, Japan
| | - Hua Jiang
- Department of Plastic and Reconstructive Surgery, Shanghai Second Military Medical School, China
| | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University, Japan
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Clinical Results and Patient Satisfaction after Pectus Excavatum Repair Using the MIRPE and MOVARPE Technique in Adults. Plast Reconstr Surg 2013; 132:1591-1602. [DOI: 10.1097/prs.0b013e3182a97dc1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hatano A, Nagasao T, Shimizu Y, Jin H, Kaneko T, Cho Y, Jiang H, Kishi K. A biomechanical study regarding the effect of tissue harvesting from the thorax on its movement during inspiration. COMPUTER AIDED SURGERY : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR COMPUTER AIDED SURGERY 2013; 18:118-28. [PMID: 23480496 DOI: 10.3109/10929088.2013.777120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE In the practice of plastic surgery, ribs and cartilage are often harvested for use in auto-grafts. This study aimed to elucidate the effect of such harvesting on the inspiration movement of the thorax. MATERIALS AND METHODS Sixteen three-dimensional computer simulation models were produced by reference to the CT data of 16 patients. To simulate the harvesting of ribs and costal cartilages, parts were removed from these thorax models, thereby producing models with different types of defect. By performing finite element calculation after applying contracture forces on the external intercostal muscles and diaphragm, the movement patterns exhibited by the thoraces during inspiration were analyzed. The relationships between the defect types and the movement patterns were evaluated with reference to the dynamic behavior of the sternum and the increase in thoracic volume. RESULTS Although the removal of costal cartilage can cause asymmetric movement of the thorax, it did not affect the inspiration movement of the thorax. However, removal of two or more ribs not only caused asymmetric movement of the thorax, but also negatively affected that movement. Removal of two or three ribs impaired the expansion of the hemi-thorax on inspiration by 10% and 40%, respectively. CONCLUSION The present study is the first to clarify the quantitative effect of tissue harvesting from the thorax on inspiration. The findings will be useful for surgeons when planning operations requiring harvesting of tissue from the thorax.
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Affiliation(s)
- Asako Hatano
- Department of Plastic and Reconstructive Surgery, School of Medicine, Keio University , Tokyo , Japan
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Videothoracoscopic repair of pectus excavatum with sternal transection for adult patients with nonelastic deformity. J Thorac Cardiovasc Surg 2011; 142:942-3. [DOI: 10.1016/j.jtcvs.2011.02.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 02/01/2011] [Accepted: 02/18/2011] [Indexed: 11/22/2022]
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Willital GH, Saxena AK, Schütze U, Richter W. Chest-deformities: a proposal for a classification. World J Pediatr 2011; 7:118-23. [PMID: 21574027 DOI: 10.1007/s12519-011-0263-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 09/27/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND In this article we assess the significance of classifying chest-deformities based on morphological findings in type-related treatment and its results. DATA SOURCES Recent publications on chest-deformities in children and youth were retrieved from PubMed and Medline and from our clinical and intraoperative findings. RESULTS Chest-deformities are diagnosed by thorax-measurements using a flexible meter projected on a graph-paper by MR/CT investigations and color coded videorasterstereography. In addition an ultrasound guided mediastinal analysis is performed on the heart, the great vessels and mediastinal organs. These investigations could determine meticulously the morphology of the sternum, the sterno-costal segments and the costal arch, enabling to find different chest wall deformities, i.e., 11 different types. The clinical and surgical significance of such a classification can be shown by comparing postoperative results of non-classified chest-deformities with those of classified. Preoperatively non-classified chest-deformities often have postoperative asymmetric shapes, partial local recurrences, costal arch eversions and a platythorax. Such a classification can be used to analyze and predict socalled "secondary associated alterations" of the vertebral column or mediastinal organs. CONCLUSIONS Determining the specific type of a thorax deformity could be considered a type-related physiotherapy as conservative treatment or vacuum treatment and if surgery is indicated a type-related surgical correction can be performed. A type-related and adapted surgical correction can prevent subsequent mitral valve prolapse, recurrent infections, vertebral disturbances caused by kypho-scoliosis and increasing psychological irritation. Typing chest-deformities are an additional and essential help for the surgeon to perform specific surgical procedures: detorsion of the sternum, correction of the sterno-costal region, the costal arch bow and the kind of chest wall immobilization by metal struts. It can also compare the postoperative results more accurately in similar types of chest-deformities.
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Affiliation(s)
- Günter H Willital
- Pediatric Surgical Research Institute Münster, Am Getterbach 49e, D-48163 Münster, Germany.
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Esteves E, Paiva KCC, Calcagno-Silva M, Chagas CC, Barbosa-Filho H. Treatment of Pectus Excavatum in Patients over 20 Years of Age. J Laparoendosc Adv Surg Tech A 2011; 21:93-6. [DOI: 10.1089/lap.2010.0193] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Edward Esteves
- Department of Pediatric Surgery, University of Goias, Goiania, Brazil
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Dynamic effects of the Nuss procedure on the spine in asymmetric pectus excavatum. J Thorac Cardiovasc Surg 2010; 140:1294-9.e1. [PMID: 20650473 DOI: 10.1016/j.jtcvs.2010.06.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2010] [Revised: 05/17/2010] [Accepted: 06/20/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study aimed to elucidate dynamic effects of the Nuss procedure on the spine in the treatment of patients with pectus excavatum with asymmetric thoraces. METHODS Twenty-five patients with pectus excavatum who underwent the Nuss procedure were categorized into 4 groups by preoperative morphology of the spine and thoracic asymmetry. In group 1 (n = 8), the right side of the thorax was concave and the spine bowed to the right. In group 2 (n = 4), the right side of the thorax was concave and the spine bowed to the left. In group 3 (n = 5), the left side of the thorax was concave and the spine bowed to the right. In group 4 (n = 8), the left side of the thorax was concave and the spine bowed to the left. With computed tomographic data, finite-element models were produced to simulate each patient's thorax. Thereafter, dynamic response patterns of the spine to the Nuss procedure were examined. Validity of these biomechanical findings was verified by referring to clinical outcomes. RESULTS In group 1 and group 4 models, deformed spines were straightened; in group 2 and group 3 models, spinal bowing increased. These biomechanical findings were compatible with clinical evaluations. CONCLUSIONS Performance of the Nuss procedure for asymmetric pectus excavatum exerts dynamic influence on the spine. Response patterns of the spine are predictable from morphologic relationships between the asymmetric patterns of the anterior thoracic wall and the spine.
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Nagaso T, Miyamoto J, Kokaji K, Yozu R, Jiang H, Jin H, Tamaki T. Double-bar application decreases postoperative pain after the Nuss procedure. J Thorac Cardiovasc Surg 2010; 140:39-44, 44.e1-2. [DOI: 10.1016/j.jtcvs.2009.12.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 11/06/2009] [Accepted: 12/13/2009] [Indexed: 11/17/2022]
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Luu TD, Kogon BE, Force SD, Mansour KA, Miller DL. Surgery for Recurrent Pectus Deformities. Ann Thorac Surg 2009; 88:1627-31. [DOI: 10.1016/j.athoracsur.2009.06.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Revised: 06/01/2009] [Accepted: 06/04/2009] [Indexed: 11/27/2022]
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Fokin AA, Steuerwald NM, Ahrens WA, Allen KE. Anatomical, histologic, and genetic characteristics of congenital chest wall deformities. Semin Thorac Cardiovasc Surg 2009; 21:44-57. [PMID: 19632563 DOI: 10.1053/j.semtcvs.2009.03.001] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2009] [Indexed: 11/11/2022]
Abstract
There is a large and diverse group of congenital abnormalities of the thorax that manifest as deformities and/or defects of the anterior chest wall and, depending on the severity and concomitant anomalies, may have cardiopulmonary implications. Pectus excavatum, the most common anterior chest deformity, is characterized by sternal depression with corresponding leftward displacement and rotation of the heart. Pectus carinatum, the second most common, exhibits a variety of chest wall protrusions and very diverse clinical manifestations. The cause of these conditions is thought to be abnormal elongation of the costal cartilages. Collagen, as a major structural component of rib cartilage, is implicated by genetic and histologic analysis. Poland syndrome is a unique unilateral chest/hand deficiency that may include rib defects, pectoral muscle deficit, and syndactyly. Cleft sternum is a rare congenital defect resulting from nonfusion of the sternal halves, which leaves the heart unprotected and requires early surgical intervention.
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Affiliation(s)
- Alexander A Fokin
- Heineman Medical Research Laboratories, Carolinas Medical Center, Charlotte, NC 28203, USA.
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Pilegaard HK, Licht PB. Routine use of minimally invasive surgery for pectus excavatum in adults. Ann Thorac Surg 2008; 86:952-6. [PMID: 18721589 DOI: 10.1016/j.athoracsur.2008.04.078] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Revised: 04/20/2008] [Accepted: 04/23/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Nuss operation, a minimally invasive repair of pectus excavatum, is considered the treatment of choice in children. It is controversial in adults, but smaller series have been published. We have used the Nuss operation routinely in adults since 2003. METHODS The indication for operation was a patient-described disabling cosmetic appearance. We modified the operation by using a shorter pectus bar, which appears to be more stable. All patient records were available and analyzed retrospectively. RESULTS Operations for pectus excavatum were done in 475 patients (89% men) at Aarhus University Hospital. 180 patients (38%) were aged 18 years or older, median patient age was 22 years (range, 18 to 43 years). All but one patient achieved an excellent cosmetic result. Two pectus bars were required in 57 patients (32%), and 2 patients required 3 pectus bars. The median duration of the procedure was 41 minutes (range, 16 to 119 minutes), which was significantly longer compared with younger patients, but the difference was not clinically relevant (6 minutes). Pneumothorax occurred in 86 patients (48%), but only 4 (2%) required chest tube drainage. In 3 patients the pectus bar dislocated during follow-up. CONCLUSIONS Minimally invasive repair for pectus excavatum can be performed safely in adults, with excellent immediate cosmetic results. Adults often require more than 1 pectus bar. From the results of this large series, we conclude that patients aged younger than 50 years are eligible for minimally invasive surgical correction of pectus excavatum.
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Affiliation(s)
- Hans K Pilegaard
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby Aarhus, Denmark.
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Jaroszewski D. Invited Commentary. Ann Thorac Surg 2008; 86:957. [DOI: 10.1016/j.athoracsur.2008.05.069] [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: 05/19/2008] [Revised: 05/19/2008] [Accepted: 05/28/2008] [Indexed: 10/21/2022]
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