Child pectus excavatum: correction by minimally invasive surgery

The Musculoskeletal Manifestations of Marfan Syndrome: Diagnosis, Impact, and Management

Purpose of Review

Marfan syndrome (MFS) is an autosomal dominant heritable disorder of fibrillin-1 (FBN1) with predominantly ocular, cardiovascular, and musculoskeletal manifestations that has a population prevalence of approximately 1 in 5–10,000 (Chiu et al. Mayo Clin Proc. 89(1):34–42, 146, Dietz 3, Loeys et al. J Med Genet. 47(7):476–85, 4).

Recent Findings

The vascular complications of MFS still pose the greatest threat, but effective management options, such as regular cardiac monitoring and elective surgical intervention, have reduced the risk of life-threatening cardiovascular events, such as aortic dissection. Although cardiovascular morbidity and mortality remains high, these improvements in cardiovascular management have extended the life expectancy of those with MFS by perhaps 30–50 years from an estimated mean of 32 years in 1972 (Dietz 3, Gott et al. Eur J Cardio-thoracic Surg. 10(3):149–58, 147, Murdoch et al. N Engl J Med. 286(15):804–8, 148). The musculoskeletal manifestations of MFS, which to date have received less attention, can also have a significant impact on the quality of life and are likely to become more important as the age of the Marfan syndrome population increases (Hasan et al. Int J Clin Pract. 61(8):1308–1320, 127). In addition, musculoskeletal manifestations are often critically important in the diagnosis of MFS.

Summary

Here, we review the main clinically relevant and diagnostically useful musculoskeletal features of MFS, which together contribute to the “systemic features score” (referred to hereafter as systemic score), part of the revised Ghent nosology for MFS. We discuss current treatment strategies and highlight the need for a multidisciplinary approach to diagnosis and management. Finally, we review new pharmacological approaches that may be disease modifying and could help to improve the outcome for individuals with this syndrome.

Pectus excavatum and scoliosis: a review about the patient's surgical management

Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine. This review article aims to perform an updated overview of the literature about the effect of pectus excavatum correction at the spine and the management of patients with both pectus excavatum and scoliosis. Although acquired scoliosis has been rarely reported after a Nuss procedure, studies show that the Nuss procedure can have a beneficial effect in mild coexisting scoliosis especially when it is performed during the adolescence. The management of cases presented with both pectus excavatum and scoliosis depends on the severity of pre-operative scoliosis and demands detailed evaluation of the spine pre and postoperatively. In the rare condition of post-operative scoliosis following a Nuss procedure, the removal of the metallic bar and conservative measures may have satisfactory results on the spine.

Original bar fixation technique in minimally invasive repair of pectus excavatum in adolescents: A 36-case series

In pectus excavatum, minimally invasive endoscopic repair is the current gold standard in adolescents. The main postoperative pitfall is bar displacement, making fixation a major issue. We report an original transcostal technique using absorbable USP-2 suture in 36 patients. There was a single case of bar displacement (2.78%; 95% CI: 0.07-14.53). Bar stability was comparable to literature reports; but the present technique avoided the complications potentially incurred by use of metal wire, pericostal fixation points and stabilizers.

Acquired scoliosis following Nuss procedure for pectus excavatum: A case report

RATIONALE

Nuss procedure is a safe and popular minimally invasive surgical technique for the correction of pectus excavatum in adolescents. Acquired scoliosis over 50 degrees after Nuss procedure has never been reported.

PATIENT CONCERNS

A 14-year-old boy was referred to pediatric surgery for pectus excavatum deformity. He underwent a successful Nuss procedure. At follow up, the patient was noted having an asymmetric back whole spine X-ray showed a right-sided thoracic curve with a Cobb angle of 54 degrees.

INTERVENTIONS AND OUTCOMES

We obtained a satisfactory result by removing the pectus bar and prescribing the patient a brace.

LESSONS

This report demonstrates that the spine should be evaluated routinely before and after Nuss procedure. Besides, spinal fusion is not recommended for acquired scoliosis following pectus excavatum surgery.

Effect on Chest Deformation of Simultaneous Correction of Pectus Excavatum with Scoliosis

Objective

This paper is to understand the effect of simultaneous correction of pectus excavatum with scoliosis and to provide some useful information for clinical orthopedic surgery design.

Methods

The method of a three-dimensional reconstruction has been used to the reconstruction of the chest model of pectus excavatum with scoliosis, and the numerical stimulation has been conducted to the process of minimally invasive correction. Three kinds of correction methods have been considered in the numerical simulation, stretch spine, stretch spine and minimally invasive correction at the same time, and release stretch spine after stretch spine and minimally invasive correction of pectus excavatum at the same time.

Results

It is found that stretch spine may help to correction of scoliosis but aggravate the sternum collapse, and release stretch spine after stretch spine and minimally invasive correction at the same time could not only be good at scoliosis but also improve the collapse of the sternum, which could help to improve the heartbeat and breath of the patients.

Conclusion

Among the three kinds of correction methods, release stretch spine after stretch spine and minimally invasive correction at the same time could help to improve both the scoliosis and the collapse of the sternum.

Minimally invasive repair of pectus excavatum in children: Results of a modified Nuss procedure

INTRODUCTION

Pectus excavatum (PE) is the most common deformity of the anterior thoracic wall. The Nuss technique allows the thorax to be reshaped with the aid of a retrosternal metallic bar. The aim of this study is to evaluate and compare the complication rate between the original Nuss technique and a lightly modified approach.

MATERIAL AND METHOD

We performed a retrospective single-center observational study based on the medical files of patients operated for PE in the Pediatric Surgery Unit between July 2004 and July 2015. We divided two patient groups according to the operating technique employed: the Nuss group (NG) and the modified Nuss group (MNG) with supplementary subxiphoid incision and bilateral thoracoscopy.

RESULTS

Twenty-seven patients were included: sixteen in the NG and eleven in the MNG. No significant differences were found between the two groups for all kinds of complications: total complication rate (50% for the NG versus 54% for the MNG, P>0.05), early (31% vs 46%, P>0.05), late (19% vs 9%, P>0.05), non-serious (37% vs 36%, P>0.05) or serious (13 vs 18%, P>0.05). There was no life threatening complication in the MNG, contrary to the NG. In the two groups, a significant difference was found (P=0.029) regarding the operating time: longer operating times (80±25min) were correlated with a higher complication rate.

CONCLUSION

The modified Nuss technique does not cause more complications than the original technique described by Nuss and it has the advantage to minimize the risk of heart damage.

Minimally invasive repair of pectus excavatum using the Nuss technique in children and adolescents: indications, outcomes, and limitations

BACKGROUND

Pectus excavatum (PE) is a common congenital deformity. The Nuss technique for minimally invasive repair of PE involves thoracoscopy-assisted insertion of a bar or plate behind the deformity to displace the sternum anteriorly. Our objective here was to clarify the indications and limitations of the Nuss technique based on a review of 70 patients.

MATERIALS AND METHODS

A retrospective review of children managed at two centres identified 70 patients who had completed their growth and had their plate removed. Mean age was 13.8 years (range, 6-19 years). The reason for surgery was cosmetic disfigurement in 66 (95%) patients. The original Nuss technique was used in 63 patients, whereas 7 patients required an additional sub-xiphoid approach. Time to implant removal ranged from 8 months to 3 years.

RESULTS

The cosmetic outcome was considered satisfactory by the patients in 64 (91%) cases and by the surgeon in 60 (85.7%) cases. Major complications requiring further surgery occurred in 6 (8.5%) patients and consisted of haemothorax (n=2), chest wall sepsis (n=2, including 1 after implant removal), allergy (n=1), and implant displacement (n=1). Early or delayed minor complications occurred in 46 (65%) patients and resolved either spontaneously or after non-surgical therapy.

DISCUSSION

The minimal scarring and reliably good outcomes support the widespread use of the Nuss technique in children and adolescents. Our complication rates (minor, 65%; and major, 8.5%) are consistent with previous publications. In our opinion, contra-indications to thoracoscopic PE correction consist of a history of cardio-thoracic surgery and the finding by computed tomography of a sternum-to-spine distance of less than 5 cm or of sternum rotation greater than 35°. In these situations, we recommend a sub- and retro-xiphoid approach to guide implant insertion or a classic sterno-chondroplasty procedure.

LEVEL OF EVIDENCE

Level IV, retrospective descriptive cohort study.

Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum

This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric=0-21; adult 17-99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.

Comparison of the Nuss and sternal turnover procedures for primary repair of pectus excavatum

BACKGROUND

Pectus excavatum (PE) is a common chest wall deformity. There are several surgical alternatives for the repair of PE. In our practice, the sternal turnover (STO) procedure had been performed for decades. In 2008, we started treating PE patients with the Nuss procedure. Our objective of this study is to compare these two procedures.

METHODS

A retrospective chart review was conducted on 50 patients undergoing pectus excavatum repairs from March 2005 to January 2013, including 20 patients with the STO procedure and 30 patients with the Nuss procedure. Patients were evaluated for type of repair performed, operating time, drainage after operation, length of postoperative stay, complications, and cosmetic results.

RESULTS

The mean age of the STO group was 11.0 years and that of the Nuss group was 15.0 years (p = 0.353). The Nuss procedure had a much shorter mean operating time, a less mean drainage after operation, and a shorter mean time to drainage tube removal than those of the STO procedure. The rate of complication was 40.0% (8/20) in the STO group and 33.3% (10/30) in the Nuss group. Follow-up data indicated that 90% (18/20) of patients in the STO group and 96.7% (29/30) of patients in the Nuss group regarded the results as good or excellent (p = 0.965).

CONCLUSION

Our data suggests that both the STO and Nuss procedures are equally safe and effective correction methods. However, less trauma, faster recovery, and better cosmetic results are the benefits of the Nuss procedure.

Routine postoperative chest X-ray is unnecessary following the Nuss procedure for pectus excavatum

OBJECTIVES

Pneumothorax is the most common complication after the Nuss procedure for pectus excavatum. The majority of pneumothoraces are small, and the patients have no symptoms. The aim of this study was to evaluate the necessity for routine chest X-ray immediately after surgery.

METHODS

Group I consists of 644 patients who were operated on with a Nuss procedure for pectus excavatum between 2001 and 2009 (85% male, median age 16 [range 7-48 years]) at Aarhus University Hospital. The standard procedure included chest X-ray immediately after surgery and before discharge. Group II consists of 294 patients (88% male, median age 16 [range 11-54 years]) who had a Nuss procedure in the period January 2011 to October 2012, where the standard procedure only included chest X-ray before discharge.

RESULTS

In Group I, pneumothorax was found on the chest X-ray obtained immediately after surgery in 333 (52%) patients. Fifteen (4.5%) were treated with chest-tube drainage. Six of these patients had no symptoms, but a 2- to 3-cm pneumothorax, 2 had progression of the pneumothorax and 7 had respiratory symptoms. The median size of those drained was 3 (range 2-6 cm). At the normal 6-week control, no pneumothorax remained. Group II: Among the 294 patients, 1 (0.3%) had a chest tube.

CONCLUSIONS

Only patients with respiratory symptoms after the Nuss procedure need a chest X-ray. A routine chest X-ray can be limited to the time of discharge where the position of the bar(s) is also checked.

Simplified open repair for anterior chest wall deformities. Analysis of results in 205 patients

INTRODUCTION

Pectus deformities are the most frequently seen congenital thoracic wall anomalies. The cause of these conditions is thought to be abnormal elongation of the rib cartilages. We here report our clinical experience and the results of a sternochondroplasty procedure based on the subperichondrial resection of the elongated cartilages.

HYPOTHESIS

This technique is a valuable surgical strategy to treat the wide variety of pectus deformities.

PATIENTS AND METHODS

During the period from October 2001 through September 2009, 205 adult patients (171 men and 34 women) underwent pectus excavatum (181), carinatum (19) or arcuatum (5) repair. The patients' pre and postoperative data were collected using a computerized database, and the results were assessed with a minimum 2-year follow-up.

RESULTS

The postoperative morbidity rate was minimal and the mortality was nil. The surgeon graded cosmetic results as excellent (72.5%), good (25%) or fair (2.5%), while patients reported better results. Patients with pectus excavatum were found to have much more patent foramen ovale (PFO) than the normal adult population, which occluded after the procedure in 61% of patients, and significant improvement was found in exercise cardiopulmonary function and exercise tolerance at the 1-year follow-up.

DISCUSSION

Our sternochondroplasty technique based on the subperichondrial resection of the elongated cartilages allows satisfactory repair of both pectus excavatum and sternal prominence. It is a safe procedure that might improve the effectiveness of surgical therapy in patients with pectus deformities.

Initial surgical and pain management outcomes after Nuss procedure

PURPOSE

The purpose of this article was to report surgical and pain management outcomes of the initial Nuss procedure experience at the Children's Hospital of Wisconsin (Milwaukee) and to place this experience in the context of the published literature.

METHODS

The initial 118 consecutive Nuss procedures in 117 patients were retrospectively reviewed with approval of the Children's Hospital of Wisconsin human rights review board. Patient, surgical, complication, and pain descriptors were collected for each case. Statistical methods for comparison of pain strategies included the Kolmogorov-Smirnov test for normality, 1-way repeated measures analysis of variance, and paired t tests.

RESULTS

Patient, surgical, and complication descriptors were comparable to other large series. Complication rates were 7% early and 25% late. Epidural success rate was 96.4%. There was 1 episode of recurrence 2 years postbar removal (n = 114).

CONCLUSIONS

The institution of the Nuss procedure provides a highly desired result with significant complication rates. The ideal approach would deliver this result with lower risk. A pain service-driven epidural administration of morphine or hydromorphone with local anesthetic provides excellent analgesia for patients after Nuss procedure. The success of epidural analgesia is independent of catheter site and adjunctive medications. Ketorolac was an effective breakthrough medication.