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Stagnaro N, Trocchio G, Torre M, Rizzo F, Martucciello G, Marasini M. Cardiovascular MRI assessment of pectus excavatum in pediatric patients and postoperative simulation using vacuum bell. J Pediatr Surg 2021; 56:1600-1605. [PMID: 33256973 DOI: 10.1016/j.jpedsurg.2020.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The sternal lift by Vacuum Bell (VB) is effective, as largely demonstrated by its intraoperative use during surgical procedure to elevate the sternum during the Nuss procedure routinely. Indeed, the thoracic remodelling during VB application is comparable to post-surgical scenario, and suitable to compare cardiovascular parameters of the two different thoracic configurations immediately. OBJECTIVE We would quantify and correlate preoperative parameters which determine the severity of the pectus excavatum (PE), and the cardiovascular effects at the baseline. Than we would assess the cardiovascular changes during VB positioning, mimicking the immediate, temporary effect of Pectus-correction. MATERIALS AND METHODS We included 26 consecutive patients (mean age is 13,3 +/- 2,2 years) symptomatic and non, with a previous clinical diagnosis of PE. CMR was performed before and during application of VB, using the same imaging protocol. In both conditions, we measured thoracic indexes, and cardiac function as well as flow through main vessels. RESULTS Mean expiratory Haller Index (HI) was 5,4 (+/-1,4 SD; normal <3). During VB application, all patients showed improvement in the main morphologic parameters of the thorax (mean expiratory HI = 4,7 (+/-1,6 SD, delta -13%, P = 0,01). During VB application, a minimal but not significant increase of Right Ventricle End Diastolic Volume (RVEDVi) (delta +4,6%, P = 0,12), and Right Ventricle Ejection Fraction (RVEF) (delta +1,2%, P = 0,2) was observed. CONCLUSION In adolescents affected by PE, cardiacMRI (CMR) demonstrates normal values of biventricular volume and systolic function. During VB application, beside significative improvements in chest wall anatomy, CMR shows a minimal positive variation in right ventricle volume and function. A minority of patients showed some degree of diastolic dysfunction at baseline, unchanged after VB application, with possible correlation between valve inflow and sternal impingement.
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Affiliation(s)
- Nicola Stagnaro
- UOC Radiologia, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini, 5, 16147 Genova, Italy.
| | | | - Michele Torre
- Pediatric Thoracic and Airway Surgery Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Francesca Rizzo
- UOC Radiologia, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini, 5, 16147 Genova, Italy
| | - Giuseppe Martucciello
- DiNOGMI, Università degli Studi di Genova, Genova, Italy; Pediatric Surgery Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
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Eisinger RS, Islam S. Caring for People With Untreated Pectus Excavatum. Chest 2020; 157:590-594. [DOI: 10.1016/j.chest.2019.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/20/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022] Open
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Abstract
Chest wall disorders represent deformities and/or injuries that alter the rib cage geometry and result in pulmonary restriction, increased work of breathing, exercise limitations, and cosmotic concerns. These disorders are congenital or acquired and affect all ages. Disorders affecting the spine (kyphoscoliosis, ankylosing spondylitis), ribs (flail chest), and sternum (pectus excavatum) are discussed in this article, with emphasis on clinical presentations, pulmonary function abnormalities, diagnosis, and treatment.
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Affiliation(s)
- Mazen O Al-Qadi
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale-New Haven Hospital, Yale University School of Medicine, 20 York Street, New Haven, CT 06510, USA.
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Eisinger RS, Harris T, Rajderkar DA, Islam S. Against the Overgrowth Hypothesis: Shorter Costal Cartilage Lengths in Pectus Excavatum. J Surg Res 2019; 235:93-97. [PMID: 30691856 DOI: 10.1016/j.jss.2018.09.080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/28/2018] [Accepted: 09/25/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pectus excavatum is a common chest wall deformity with no known cause. A common hypothesis is that in patients with pectus excavatum, there is an overgrowth of costal cartilage relative to healthy individuals. MATERIALS AND METHODS We obtained radiological curvilinear three-dimensional measurements of the fourth to eighth costal cartilage and associated ribs in 16 patients with pectus excavatum and 16 age- and gender-matched controls between the ages of 6 and 32 y. An analysis of variance was used to compare bone length, cartilage length, and their ratios between patients and controls. RESULTS Relative to bone length, patients with pectus excavatum overall had shorter costal cartilage lengths (P < 0.001), especially on the left side (P < 0.05). We were unable to localize this observation to specific ribs during post hoc analysis. CONCLUSIONS This is the first study to empirically test the overgrowth hypothesis of pectus excavatum for ribs 4 through 8. Although we and others have found no evidence to support this hypothesis, we surprisingly found the alternate hypothesis to be true: patients with pectus excavatum tend to have shorter costal cartilages. Future studies should expand on these results with larger sample sizes and consider volumetric measurements longitudinally during thoracic development.
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Affiliation(s)
- Robert S Eisinger
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Travis Harris
- Department of Radiology, University of Florida College of Medicine, Gainesville, Florida
| | - Dhanashree A Rajderkar
- Department of Radiology, University of Florida College of Medicine, Gainesville, Florida
| | - Saleem Islam
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida.
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Velazco CS, Arsanjani R, Jaroszewski DE. Nuss procedure in the adult population for correction of pectus excavatum. Semin Pediatr Surg 2018; 27:161-169. [PMID: 30078487 DOI: 10.1053/j.sempedsurg.2018.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.
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Affiliation(s)
- Cristine S Velazco
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States.
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Koumbourlis AC. Pectus deformities and their impact on pulmonary physiology. Paediatr Respir Rev 2015; 16:18-24. [PMID: 25464892 DOI: 10.1016/j.prrv.2014.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 10/29/2014] [Indexed: 11/24/2022]
Abstract
Pectus excavatum (PE) and pectus carinatum (PC) are the most common anomalies of the thoracic cage and they have been recognized since ancient times [1-3]. The two conditions differ in their appearance, and their effect on lung function. There is no direct correlation between the appearance of the deformities and the clinical symptoms. Whether, and when these deformities should be corrected as well as with which method (surgical or conservative) remain controversial. The following article reviews the current concepts regarding the pathophysiology of both conditions as well as the advances in their evaluation and management.
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Affiliation(s)
- Anastassios C Koumbourlis
- Professor of Pediatrics, George Washington University, Chief, Pulmonary & Sleep Medicine, Children's National Medical Center.
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Redding GJ, Kuo W, Swanson JO, Phillips GS, Emerson J, Yung D, Swanson JW, Sawin RS, Avansino JR. Upper thoracic shape in children with pectus excavatum: impact on lung function. Pediatr Pulmonol 2013; 48:817-23. [PMID: 22912067 DOI: 10.1002/ppul.22660] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 07/26/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Pectus excavatum (PE) can present with respiratory complaints in childhood. However severity of the PE, measured by the Pectus Severity Index (PSI), correlates only modestly with reduced vital capacity (VC). We hypothesized that another upper thoracic feature, a pectus gracilis (PG) or slender chest, co-exists with PE, and impacts lung function. PATIENTS AND METHODS We developed the Pectus Gracilis Index (PGI) based on the chest width to depth ratio at the gladiolar-manubrial sternal junction on computerized tomographic (CT) scans, and measured PGI among 316 control children 10-20 years old. PG was defined by PGI values >2 z-scores above the mean normal value. We determined the prevalence of PG in 97 children with PE and correlated PGI and PSI with VC among the 86 that performed spirometry. RESULTS The mean and upper limit of normal for PGI averaged 2.73 and 3.55, respectively for control children. The prevalences of a PG among controls and children with PEs were 3.2% and 59%, respectively (OR = 45, P < 0.00001). Among the children with PEs, the PGI, and PSI correlated with one another (r = 0.77, P < 0.001). Both PSI and PGI significantly correlated inversely with VC. (r = -0.34, P < 0.001 and r = -0.38, P < 0.001, respectively). Importantly, PGI correlated with VC after adjusting for PSI among children with PE. (r = 0.20, P < 0.03). CONCLUSION The upper thoracic feature of a PG is common among children with PE and contributes to reductions in VC. Assessment of the thorax, using the PGI, may improve the structure-function correlations previously described for children with PE.
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Affiliation(s)
- Gregory J Redding
- Department of Pediatric Pulmonology, Radiology, Cardiology, and General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington, USA.
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Balci AE, Eren S, Ozyurtkan MO. Symmetrical excessive pectus excavatum in children. Asian Cardiovasc Thorac Ann 2013; 21:683-8. [PMID: 24569326 DOI: 10.1177/0218492312467538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The indications for repair of pectus excavatum are controversial. We present our surgical results in children with severe pectus excavatum. METHODS 27 children aged 6-15-years were included in the study. Pulmonary function tests and chest measurements were performed pre- and postoperatively. Deformed cartilages were resected subperichondrially, and a Kirchner wire was used to support the chest cage; it was removed 5 days after the operation. Fourteen children with restricted pulmonary function were considered to have excessive pectus excavatum. RESULTS 3 patients had asthma-like symptoms that resolved postoperatively. None suffered chest pain postoperatively. Postoperative hospital stay was 7.1 days. Only minor complications occurred postoperatively. The mean pectus severity index was 0.27 ± 0.2 preoperatively and 0.41 ± 0.1 postoperatively (p < 0.05). For children with restricted pulmonary function, it was 0.17 ± 0.3 preoperatively and 0.38 ± 0.2 postoperatively (p < 0.05). Mean percentage of predicted forced expiratory volume in 1 s changed significantly from 79.2% ± 17.8% preoperatively to 83.6% ± 12.2% by the 3rd postoperative month. For children with a pectus severity index <0.2, it changed from 68.5% ± 13.2% preoperatively to 82.3% ± 13.4%. Pulmonary restriction correlated with a worse pectus severity index (r = 0.8). After 6 and 13 months, a minor decrease in pulmonary function was noted. Significant increases in right and left ventricular function occurred in cases of severe deformity. CONCLUSIONS Surgery is recommended not only for cosmetic reasons but also to increase cardiorespiratory functional capacity and alleviate symptoms. Kirchner wires can be used safely.
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Affiliation(s)
- Akin Eraslan Balci
- Euphrates University School of Medicine, Department of Thoracic Surgery, Elaziğ, Turkey
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Jayaramakrishnan K, Wotton R, Bradley A, Naidu B. Does repair of pectus excavatum improve cardiopulmonary function? Interact Cardiovasc Thorac Surg 2013; 16:865-70. [PMID: 23449664 DOI: 10.1093/icvts/ivt045] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was 'Does repair of pectus excavatum (PE) improve cardiopulmonary function?' One hundred and sixty-eight papers were found using the reported search, 19 level III evidence papers and three meta-analyses were relevant. Studies were divided into four groups based on the surgical technique applied and pulmonary and cardiac functions in these groups were analysed. The meta-analyses show conflicting results for improvements in pulmonary and cardiac functions when comparing surgical techniques, while four more recent studies show improved long-term results using the Nuss technique. The best evidence of papers studying the PE repair using the minimally invasive Nuss technique demonstrates a decrease in pulmonary function during the early postoperative period, however, there is a small but significant improvement during the late postoperative period and after bar removal. The best evidence for cardiac function in this group suggests an early improvement that is sustained during further follow-up. The best evidence of papers studying the PE repair using the Ravitch technique shows that pulmonary function decreased during the early postoperative period, however, there is a small but significant improvement during the late postoperative period. The best evidence for cardiac function in this group suggests an early improvement that is sustained during further follow-up. The best evidence of papers studying the PE repair using other techniques (modified Daniel's technique, modified Baronofsky's technique, sterno-costal turn-over technique and sterno-costal elevation technique) or where surgical techniques used were not described (preceding year 1985) suggests that there is no improvement in pulmonary function after surgery. There is some evidence that certain aspects of cardiac function improved after surgery in this group.
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Chen Z, Amos EB, Luo H, Su C, Zhong B, Zou J, Lei Y. Comparative pulmonary functional recovery after Nuss and Ravitch procedures for pectus excavatum repair: a meta-analysis. J Cardiothorac Surg 2012; 7:101. [PMID: 23020904 PMCID: PMC3504562 DOI: 10.1186/1749-8090-7-101] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 09/23/2012] [Indexed: 12/05/2022] Open
Abstract
Background Pectus excavatum (PE) is a common chest wall malformation, with surgery being the only method known to correct the defect. Although the Nuss and Ravitch procedures are commonly used, there is no consensus as to whether surgical repair improves pulmonary function. We therefore investigated whether pulmonary function recovers after surgical repair, and if recovery is dependent on the type of procedure or time after surgery. Methods Literature searches were performed using PubMed, EMBASE, Health Periodicals Database, and CNKI (Chinese National Knowledge Index) from January 1990 to December 2007. The following keywords were used: pectus excavatum, chest wall deformity, funnel chest, pulmonary function, respiratory, lung function, and pectus severity index. The primary outcome of interest was possible changes in pulmonary function following surgical repair. Results Meta-analysis of 23 studies showed that, although there was evidence of statistically significant heterogeneity among studies (Chi-square, 17.11, p < 0.05), changes in pulmonary functional indices, including forced expiratory volume over 1 s (FEV1), forced vital capacity (FVC), vital capacity (VC), and total lung capacity (TLC), were similar 1 year after the Ravitch and Nuss procedures. Several years after surgery and bar removal, however, the changes in pulmonary functional indices significantly favored the Nuss procedure. Conclusions Pulmonary function tends to improve after the surgical correction of pectus excavatum. Although the Nuss procedure was not significantly better 1 year after surgery, long-term postoperative pulmonary function improvement was significantly better after bar removal.
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Affiliation(s)
- Zhenguang Chen
- Department of Thoracic Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.
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13
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Swanson JW, Avansino JR, Phillips GS, Yung D, Whitlock KB, Redding GJ, Sawin RS. Correlating Haller Index and cardiopulmonary disease in pectus excavatum. Am J Surg 2012; 203:660-664. [DOI: 10.1016/j.amjsurg.2011.12.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Revised: 12/14/2011] [Accepted: 12/14/2011] [Indexed: 11/29/2022]
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Abstract
Pectus excavatum most frequently involves the lower sternum and chest wall. Because the morphology varies, preoperative imaging for anatomic assessment and documentation of dimensions of the chest are important. Many modifications have been made to the minimally invasive procedure since it was first performed in 1987. As a result, there has been an increase in the number of patients seeking surgical correction. This article discusses the clinical features of pectus excavatum and reviews the preoperative considerations and the steps involved in the repair of the deformity.
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Airway deformation in patients demonstrating pectus excavatum with an improvement after the Nuss procedure. Pediatr Surg Int 2011; 27:61-6. [PMID: 21113603 DOI: 10.1007/s00383-010-2709-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE This study analyzed the inside appearance of the trachea and the main bronchus at the time of performing the Nuss procedure to test the hypothesis that the trachea and the main bronchus might be deformed by compression from great vessels due to sternal depression. METHODS A retrospective cohort study included 36 patients with pectus excavatum, who were treated using the Nuss procedure between July 2001 and December 2009. The primary outcome measures were the oblateness of the trachea and bilateral main bronchus. The oblateness in patients with pectus excavatum was compared with that of the control group. Their postoperative changes and the relationship between the Haller CT index were also analyzed. RESULTS The oblateness of the trachea and the left main bronchus in patients with pectus excavatum was significantly greater than that of the control group. A negative correlation was recognized between the percent vital capacity and the oblateness of the left main bronchus. The oblateness of the bilateral main bronchus significantly improved during the 2 years of bar placement. CONCLUSION A significant deformation of the airways was demonstrated in patients with pectus excavatum, which improved after correcting it by means of the Nuss procedure.
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Saleh RS, Finn JP, Fenchel M, Moghadam AN, Krishnam M, Abrazado M, Ton A, Habibi R, Fonkalsrud EW, Cooper CB. Cardiovascular magnetic resonance in patients with pectus excavatum compared with normal controls. J Cardiovasc Magn Reson 2010; 12:73. [PMID: 21144053 PMCID: PMC3022801 DOI: 10.1186/1532-429x-12-73] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Accepted: 12/13/2010] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To assess cardiothoracic structure and function in patients with pectus excavatum compared with control subjects using cardiovascular magnetic resonance imaging (CMR). METHOD Thirty patients with pectus excavatum deformity (23 men, 7 women, age range: 14-67 years) underwent CMR using 1.5-Tesla scanner (Siemens) and were compared to 25 healthy controls (18 men, 7 women, age range 18-50 years). The CMR protocol included cardiac cine images, pulmonary artery flow quantification, time resolved 3D contrast enhanced MR angiography (CEMRA) and high spatial resolution CEMRA. Chest wall indices including maximum transverse diameter, pectus index (PI), and chest-flatness were measured in all subjects. Left and right ventricular ejection fractions (LVEF, RVEF), ventricular long and short dimensions (LD, SD), mid-ventricle myocardial shortening, pulmonary-systemic circulation time, and pulmonary artery flow were quantified. RESULTS In patients with pectus excavatum, the pectus index was 9.3 ± 5.0 versus 2.8 ± 0.4 in controls (P < 0.001). No significant differences between pectus excavatum patients and controls were found in LV ejection fraction, LV myocardial shortening, pulmonary-systemic circulation time or pulmonary flow indices. In pectus excavatum, resting RV ejection fraction was reduced (53.9 ± 9.6 versus 60.5 ± 9.5; P = 0.013), RVSD was reduced (P < 0.05) both at end diastole and systole, RVLD was increased at end diastole (P < 0.05) reflecting geometric distortion of the RV due to sternal compression. CONCLUSION Depression of the sternum in pectus excavatum patients distorts RV geometry. Resting RVEF was reduced by 6% of the control value, suggesting that these geometrical changes may influence myocardial performance. Resting LV function, pulmonary circulation times and pulmonary vascular anatomy and perfusion indices were no different to controls.
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Affiliation(s)
- Roya S Saleh
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - J Paul Finn
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Biomedical Physics; David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Michael Fenchel
- Department of Diagnostic and Interventional Neuroradiology, University of Tuebingen, Germany
| | - Abbas Nasirae Moghadam
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Biomedical Engineering, Amirkabir University of Technology (Tehran Polytechnic),Tehran, Iran
| | - Mayil Krishnam
- Division of Cardiovascular and Thoracic Imaging; Department of Radiology, University of California, Irvine, USA
| | - Marlon Abrazado
- Exercise Physiology Research Laboratory, Department of Medicine; David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Anthony Ton
- Department of Radiology, Kaiser Permanente, San Diego, California, USA
| | - Reza Habibi
- Department of Radiology, Maricopa Medical Center, Phoenix, Arizona, USA
| | - Eric W Fonkalsrud
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Christopher B Cooper
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Physiology; David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Zeng Q, Lai JY, Wang CJ, Cheng HY, Chu CC, Chang CJ, Chiu PH, Chen ZC, Chang PY. A cross-sectional study of lung volume development in pectus excavatum patients: estimating the total lung volume from chest computed tomograph using 3-dimensional volumetric reconstruction. J Pediatr Surg 2010; 45:2322-7. [PMID: 21129538 DOI: 10.1016/j.jpedsurg.2010.08.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 08/12/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE This study quantified the lung volume development of pectus excavatum (PE) patients using chest computed tomography (CT) 3-dimensional volumetric reconstructions. The technique permits current and retrospective analyses of data from different institutions. PATIENTS AND METHODS We analyzed the records of PE patients who underwent chest CT preoperatively between 2005 and 2009 at 3 institutions. All patients were Chinese. A window of -992 to -198 Hounsfield units was chosen for calculating the CT total lung volume (TLV). The data were compared with the data for 73 microtia and other chest-wall tumor patients studied during the same period as a control group. RESULTS In total, 377 PE patients with Haller pectus index (PI) of at least 3.2 were identified for this study. Compared with the reported TLV data for 1050 healthy children and our control group, we found little evidence of a decreased TLV in PE patients at any age for either sex. The mean PI did not change significantly between the ages of 3 and 27 years. The PI was inversely correlated with the TLV (P < .001). CONCLUSION Our cross-sectional study provides evidence that the TLV of PE patients is within the reference range in children and adolescents.
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Affiliation(s)
- Qi Zeng
- Department of Pediatric Surgery, Beijing Children Hospital, Capital Medical University, Beijing, China
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Coskun ZK, Turgut HB, Demirsoy S, Cansu A. The prevalence and effects of Pectus Excavatum and Pectus Carinatum on the respiratory function in children between 7-14 years old. Indian J Pediatr 2010; 77:1017-9. [PMID: 20814837 DOI: 10.1007/s12098-010-0155-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 04/23/2010] [Indexed: 11/30/2022]
Abstract
The study involved 1342 primary school students aged 7-14 years who applied to Ankara, a primary care center for general health check-up between 2006 and 2007. Forty-three students, 35 of whom had PE and 8 of whom had PC, were subjected to thorax measurement. All 43 students underwent pulmonary function tests (PFT).The prevalence rate of PC was 0.6%, and of PE, 2.6%. The thorax widths of the groups were similar (P = 0.273). The thorax circumference and depth of PE group were lower than those of the controls (P < 0.05). The probability rate of abnormality in PFT scores of PE group was statistically significantly higher than that of the controls (P = 0.022) whereas absence of normal PFT scores the difference between PC group and the controls was not statistically significant (p = 0.095). The results indicate that more than half of the individuals with pectus deformity do not have any physical complaints and do not have statistically significant differences in their PFT parameters.
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Affiliation(s)
- Zafer Kutay Coskun
- Basic Science Department of Anatomy, Gazi University Faculty of Medicine, Ankara, Turkey.
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Abstract
Pectus Excavatum is the most common congenital abnormality of the chest wall. In the majority of the cases the condition is idiopathic. Affected patients tend to have lung volumes that are mildly decreased but within the normal range and they are often associated with mild air-trapping. Many patients show evidence of lower airway obstruction. Exercise intolerance is the most common symptom associated with pectus excavatum, and it is now believed to be due to cardiovascular rather than pulmonary causes. The psychological effect of the deformity often exceeds its actual physical effect. Several surgical techniques are available for the repair of the deformity, although the need for it is still considered controversial by many. The current article provides an in depth review of the pathophysiology and clinical characteristics of pectus excavatum, as well as an overview of the treatment options in order to help the practitioners caring of affected patients in their evaluation.
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Affiliation(s)
- Anastassios C Koumbourlis
- Division of Pediatric Pulmonary Medicine, Schneider Children's Hospital, North Shore-Long Island Jewish Health System, Albert Einstein College of Medicine, Great Neck, NY 11021, USA.
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Kelly RE. Pectus excavatum: historical background, clinical picture, preoperative evaluation and criteria for operation. Semin Pediatr Surg 2008; 17:181-93. [PMID: 18582824 DOI: 10.1053/j.sempedsurg.2008.03.002] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pectus excavatum is a depression of the sternum and costal cartilages which may present at birth, or more commonly during the teenage growth spurt. Symptoms of lack of endurance, shortness of breath with exercise, or chest pain are frequent. Although pectus excavatum may be a component of some uncommon syndromes, patients usually are healthy. Evaluation should include careful anatomic description with photographs, radiography to demonstrate the depth of the depression, extent of cardiac compression, or displacement, measurement of pulmonary function, and echocardiography to look for mitral valve prolapse (in 15%) or diminished right ventricular volume. Indications for surgical treatment include two or more of the following: a severe, symptomatic deformity; progression of deformity; paradoxical respiratory chest wall motion; computer tomography scan with a pectus index greater than 3.25; cardiac compression/displacement and/or pulmonary compression; pulmonary function studies showing restrictive disease; mitral valve prolapse, bundle branch block, or other cardiac pathology secondary to compression of the heart; or failed previous repair(s). The developmental factors, genetics, and physiologic abnormalities associated with the condition are reviewed.
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Affiliation(s)
- Robert E Kelly
- Department of Surgery, Children's Hospital of The King's Daughters, Eastern Virginia Medical School, 601 Children's Lane, Suite 5B, Norfolk, VA 23507, USA.
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Malek MH, Coburn JW. Strategies for cardiopulmonary exercise testing of pectus excavatum patients. Clinics (Sao Paulo) 2008; 63:245-54. [PMID: 18438580 PMCID: PMC2664209 DOI: 10.1590/s1807-59322008000200014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Accepted: 12/29/2007] [Indexed: 11/22/2022] Open
Abstract
The purpose of this paper is to provide strategies for cardiopulmonary exercise testing of pectus excavatum patients. Currently, there are no standardized methods for assessing cardiovascular and pulmonary responses in this population; therefore, making comparisons across studies is difficult if not impossible. These strategies are intended for physicians, pulmonary technicians, exercise physiologists, and other healthcare professionals who conduct cardiopulmonary exercise testing on pectus excavatum patients. By using the strategies outlined in this report, comparisons across studies can be made, and the effects of pectus excavatum on cardiopulmonary function can be assessed with greater detail.
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Affiliation(s)
- Moh H Malek
- Division of Physiology, School of Medicine, University of California, San Diego, CA, USA.
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Affiliation(s)
- Marlos de Souza Coelho
- Pontifícia Universidade Católica do Paraná; Sociedade Brasileira de Cirurgia Torácica; Pontifícia Universidade Católica do Paraná; Universidade Federal do Paraná; Hospital Universitário Cajuru; Santa Casa de Misericórdia de Curitiba
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Chang PY, Lai JY, Chen JC, Wang CJ. Quantitative evaluation of bone and cartilage changes after the Ravitch thoracoplasty by multislice computed tomography with 3-dimensional reconstruction. J Thorac Cardiovasc Surg 2007; 134:1279-83. [DOI: 10.1016/j.jtcvs.2007.05.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2006] [Revised: 04/29/2007] [Accepted: 05/11/2007] [Indexed: 10/22/2022]
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Abstract
INTRODUCTION Pectus excavatum or funnel chest is the most common anterior chest wall deformity seen in children and adults. The sternal depression appears to be caused by overgrowth of the costal cartilages, also the cause of the less common deformities: pectus carinatum (pigeon breast) and pectus arcuatum. BACKGROUND Usually the overgrowth involves the third to seventh costal cartilages but it can be more or less extensive. The cardiopulmonary functional consequences are insignificant in the protrusional deformities and inconsistent in pectus excavatum and the indications for surgery are mainly cosmetic. VIEWPOINT AND CONCLUSIONS The procedural modalities are guided by morphological study of the CT scan. We describe a surgical technique that comprise subperichondrial excision of all deformed costal cartilages followed by transverse sternotomy to correct the sternal deformity, anteriorly in the case of pectus excavatum and posteriorly for pectus carinatum and arcuatum. As the perichondrial sheaths are totally preserved they are sutured in continuous layers to give a shortening effect. In the case of pectus excavatum the sternum is then secured anteriorly for about 6 months by a retrosternal metallic strut in an overcorrected position. The partially resected seventh cartilages are then sutured to the xiphoid. Other surgical techniques are described, including modified Ravitch's procedure, modelling osteochondroplasty, prosthetic reconstruction and Nuss's procedure. Results of the more important series are reported and discussed.
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Affiliation(s)
- M Conti
- Clinique de Chirurgie Thoracique, Hôpital Albert Calmette, CHU Lille, France
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Kilda A, Basevicius A, Barauskas V, Lukosevicius S, Ragaisis D. Radiological assessment of children with pectus excavatum. Indian J Pediatr 2007; 74:143-7. [PMID: 17337826 DOI: 10.1007/s12098-007-0007-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess what degree of chest wall deformation changes statistically reliably after surgery, using pre- and postoperative radiological examination data. METHODS Radiological chest examinations were performed for 88 children before and after remedial operations. Pre- and postoperative chest radiograph and CT were performed to measure transversal chest width; sagittal left chest side depth, sagittal right chest side depth, sternovertebral distance and vertebral body length. Derivative indices were also estimated: Vertebral index (VI), Frontosagittal index (FI), Haller index (HI) and asymmetry index. Computerized assessment of data was used. For statistical analysis, the software "Statistica 6.0" was used. RESULTS Postoperatively VI increased approximately by 2.37+/-2.72, FI decreased by 4.60+/-4.34 and HI value increased approximately up by 0.45+/-0.49. Statistically significant deformation index difference before and after surgery was not detected when VI was below 26.2 (p=0.08), FI was above 32.9 (p=0.079) and HI was less than 3.12 (p=0.098). CONCLUSION Preoperative CT and X-ray assessment of chest wall deformation degree is important for pediatric patients. The following deformation indices are indications for surgical treatment: VI>26, FSI< 33 and HI>3.1.
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Affiliation(s)
- Arturas Kilda
- Department of Radiology, Kaunas University of Medicine, Lithuania.
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Genc O, Gurkok S, Gözübüyük A, Dakak M, Caylak H, Yücel O. Repair of pectus deformities: experience and outcome in 317 cases. Ann Saudi Med 2006; 26:370-4. [PMID: 17019098 PMCID: PMC6074110 DOI: 10.5144/0256-4947.2006.370] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The most common congenital chest wall deformities are pectus excavatum and pectus carinatum. Various techniques have been described for correction of pectus deformities. We describe our experience with surgical repair of pectus deformity (PD) in adults, including our new technique, which uses a resorbable plaque for fixation of the sternum. METHODS We reviewed the records of 317 patients who underwent surgical correction of PD between October 1997 and December 2005. RESULTS All of the patients were male and the median age was 21.3 years (range, 16-32 years). Of 317 patients, the type of deformity was a pectus excavatum in 230 patients and a pectus carinatum in 87 of the patients. Four different operative techniques were used. There were no intraoperative deaths or major perioperative morbidity. The complications rate was 17%. Overall mean hospital stay was 14.25 days. In 208 patients who underwent a mid-term outpatient follow up (mean, 8 months), there was no recurrence. Patient satisfaction was excellent in 234 patients, good in 79 patients and fair in 4 patients. CONCLUSION The majority of patients with pectus deformity had been operated on during childhood; therefore there is limited published information about the correction of pectus excavatum and pectus carinatum deformities in adults. The most important point in pectus correction is to achieve proper and long-term stability of the sternum following osteotomy. Various techniques can be used for this purpose.
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Affiliation(s)
- Onur Genc
- Gulhane Military Medical Academy, General Thoracic Surgery, Ankara, Turkey
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Abstract
One of the more common chest wall anomalies seen in children is pectus excavatum. Although some studies suggest a physiologic impact of this anomaly on cardiac function during exercise, this remains somewhat controversial. Regardless, a number of children are symptomatic from either the appearance of the deformity or from the standpoint of tolerance to exercise. Most are relieved of these symptoms with surgical repair. Several different operations have been utilized for repair of this anomaly, but two techniques now are the predominant methods in use today. These are the modified Ravitch procedure and the Nuss procedure. Both have been shown to provide satisfactory results.
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Herrmann KA, Zech C, Strauss T, Hatz R, Schoenberg S, Reiser M. CINE-MRT des Thorax bei Patienten mit Pectus excavatum. Radiologe 2006; 46:309-16. [PMID: 16550355 DOI: 10.1007/s00117-006-1354-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Morphologic and dynamic assessment of respiratory chest kinetics was performed in patients with pectus excavatum deformity (PE) using dynamic MRI: cine MRI. MATERIAL AND METHODS Seven consecutive patients with PE (aged 20.3 years+/-4.0) and ten healthy volunteers of comparable age underwent real-time cine MRI of the chest during breathing on a 1.5 T MR scanner (Magnetom Sonata, Siemens Medical Systems, Erlangen, Germany) using a standard phased array body coil and a half-Fourier single-shot turbo spin echo sequence (HASTE) for dynamic imaging. During deep inspiration and expiration, single-shot sequences were performed in one slice level over 20 s at a frequency of 1 image/s covering the entire thoracic cage in three orientations. Morphology and chest kinetics in patients with PE were analyzed and compared with normal values, and typical patterns of chest kinetics were noted. RESULTS Three different types of chest morphology in PE were identified: (1) the generally flattened thoracic cage, (2) the "tilted" sternum, and (3) the focally deepened sternum. Three patterns of motion correspond to these morphological types: (1) elevation of the sternum and the anterior thoracic wall, (2) angulated elevation of the parasternal rib cage with persistent deepening of the sternum resembling a "wing beat" movement, and (3) increased diaphragmatic movements with limited chest wall dynamics. CONCLUSIONS Cine MRI is an adequate radiation-free diagnostic modality for the dynamic imaging of both chest morphology and chest wall kinetics in patients with PE. The pectus severity index can easily be determined and three typical movement patterns of chest wall kinetics identified.
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Affiliation(s)
- K A Herrmann
- Institut für Klinische Radiologie, Klinikum Grosshadern der Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377 , München.
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Bawazir OA, Montgomery M, Harder J, Sigalet DL. Midterm evaluation of cardiopulmonary effects of closed repair for pectus excavatum. J Pediatr Surg 2005; 40:863-7. [PMID: 15937832 DOI: 10.1016/j.jpedsurg.2005.02.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND/PURPOSE Since the introduction of the closed technique for repair of pectus excavatum, increasing numbers of patients are presenting for surgery. However, controversy exists regarding the effects of repair on long-term cardiopulmonary outcome. This report details the effects over time of closed repair of pectus excavatum on pulmonary function, cardiac function, exercise tolerance, and the patient's perception of appearance and subjective ability to exercise. METHODS All patients undergoing closed repair of pectus excavatum were evaluated prospectively. Preoperative computed tomography scan, static pulmonary function studies, exercise tolerance, and echocardiographic evaluation of cardiac function were done. Studies were repeated at 3 and 21 months post-bar placement, and then 3 months after bar removal. RESULTS Pre- and postoperative data were available for an initial 48 patients, with 11 patients completing the full evaluation after bar removal. All measures of pulmonary function including forced expiratory volume in 1 second and forced vital capacity were reduced at 3 months postoperation, with a gradual increase during follow-up; however, pulmonary function remained below normative values for patients without pectus excavatum of similar age. Cardiac function as measured by cardiac output and index was increased at 3 months postoperation and maintained thereafter. Exercise tolerance declined initially and then increased by the 21-month evaluation point and after bar removal. Patients reported a subjective improvement in the ability to exercise immediately after bar insertion. CONCLUSIONS These results corroborate previous studies which suggested that after closed repair of pectus excavatum there is an immediate subjective improvement in the ability to exercise which is paralleled by an improvement in cardiac output. However, there is an early postoperative decline in pulmonary function which does improve over time; however, this does not reach normal values for similar weight. Further studies are needed to determine whether these results are maintained, or whether after bar removal there is a further improvement in pulmonary status. These results do support the use of the closed repair of pectus excavatum for maintaining and possibly improving cardiopulmonary function in this patient population.
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Affiliation(s)
- Osama A Bawazir
- Department of Surgery, Pediatric General Surgery, Alberta Children's Hospital, Calgary, AB, Canada T2T 5C7
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Koumbourlis AC, Stolar CJ. Lung growth and function in children and adolescents with idiopathic pectus excavatum. Pediatr Pulmonol 2004; 38:339-43. [PMID: 15334513 DOI: 10.1002/ppul.20062] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patterns of lung growth and function were studied retrospectively in 103 patients (73 male and 30 female) with idiopathic pectus excavatum in order to determine: 1) the prevalence of restrictive lung defect and/or other lung function abnormalities; 2) the possible association between type of lung function abnormalities and age of the patient; and 3) whether the type of lung function is associated with other clinical conditions. Forty-three patients (42%) were between 5-9 years of age; 36 (35%) were between 10-14 years; and 24 (23%) were between 15-19 years. Restrictive lung disease was detected only in 5 patients (5%), whereas 42 patients (41%) had evidence of obstructive pattern, and the remaining 56 patients (54%) had a normal pattern. The mean values for lung volume (total lung capacity (TLC) and/or forced vital capacity (FVC)) were lowest in the 10-14-year group, whereas the mean values of the indices of lower airway function (forced expiratory volume at 1 sec (FEV(1)), FEV(1)/FVC, forced expiratory flow at 25-75% of forced vital capacity (FEF(25-75)), and FEF(25-75)/FVC) were higher in the younger group. Residual volume (RV) and RV/TLC were elevated in all age groups, but they declined toward normalization with increasing age. There were no significant differences between groups (stratified either by pattern of lung function or by age) with regard to their demographics or clinical characteristics (scoliosis, direction of sternal rotation, history of asthma/reactive airways disease, or exercise intolerance). We conclude that idiopathic pectus excavatum may be associated with a variety of lung function abnormalities (in particular, lower airway obstruction) even in the absence of overt clinical symptoms. There was no evidence of significant worsening of lung function with increasing age.
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Affiliation(s)
- Anastassios C Koumbourlis
- Division of Pediatric Critical Care and Pulmonology, College of Physicians and Surgeons of Columbia University and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, New York, USA.
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Affiliation(s)
- A Casas
- Fundación Neumológica Colombiana. Bogotá. Colombia.
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Borowitz D, Cerny F, Zallen G, Sharp J, Burke M, Gross K, Glick PL. Pulmonary function and exercise response in patients with pectus excavatum after Nuss repair. J Pediatr Surg 2003; 38:544-7. [PMID: 12677562 DOI: 10.1053/jpsu.2003.50118] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE The Ravitch repair of pectus excavatum removes segments of abnormal costal cartilages after which the sternum is elevated and stabilized. Some investigators have found a worsening in total lung capacity postoperatively. Recently, a technique has been used in which the costal cartilages are preserved, and the sternum is elevated with an internal steel bar (Nuss repair). The authors hypothesized that placement of a substernal bar in the first stage of the Nuss repair will not adversely affect pulmonary and exercise function. METHODS Patients who presented to the Children's Hospital of Buffalo for surgical repair of pectus excavatum from June 1997 through June 2000 underwent pulmonary function and exercise testing before and 6 to 12 months after the first stage of a Nuss repair. RESULTS Ten patients were studied (all boys; mean age at operative repair, 13.4 +/- 3 years). Mean baseline pulmonary function was normal, and no significant differences were seen before and after placement of the intrathoracic bar. Peak oxygen consumption was near normal, although work at VO2max was less than predicted (mean, 68.2% before v. 71.8% after surgery). V(E) was below normal and Vt/FVC was below the expected 50% to 60% level both before and after surgery (41.3% +/- 3 SE and 41.6% +/- 3 SE pre- and postoperatively, respectively). CONCLUSIONS Placement of a substernal steel bar in the first stage of the Nuss procedure for repair of pectus excavatum does not cause adverse effects on either static pulmonary function or on the ventilatory response to exercise.
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Affiliation(s)
- Drucy Borowitz
- Department of Pediatrics, State University of New York at Buffalo, Buffalo, New York, USA
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Sigalet DL, Montgomery M, Harder J. Cardiopulmonary effects of closed repair of pectus excavatum. J Pediatr Surg 2003; 38:380-5; discussion 380-5. [PMID: 12632353 DOI: 10.1053/jpsu.2003.50112] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE Increasing numbers of patients with pectus excavatum defects are presenting for operative repair. Studies that follow-up with patients after open repair have found a decrease in pulmonary function with some improvement in cardiac output and exercise tolerance; however, these effects have not been examined systematically after closed or Nuss repair of pectus excavatum. This study examined the early postoperative effects of closed repair of pectus on pulmonary function, exercise tolerance, and cardiac function. METHODS Patients were followed up prospectively after initial evaluation for operation. All patients underwent preoperative computed tomography (CT) scan, and pre- and postoperative (3 months) pulmonary function studies, exercise tolerance, and echocardiographic evaluation of cardiac function. RESULTS Eleven patients underwent evaluation. Preoperative CT index was 4.1 +/- 0.9. Patients reported an improvement in subjective postoperative exercise tolerance (4.1 +/- 0.7; maximal, + 5). Pulmonary function studies (FVC and vital capacity) were significantly reduced at 3 months postsurgery: change in FVC, -0.67 +/- 0.92 L and VC, -0.5 +/- 0.72 L. Similarly, VO2 max was reduced: preoperative, 35.6 +/- 1.5 versus postoperative, 29.1 +/- 11.9 L/kg/min. Cardiac function was significantly improved postoperation (stroke volume preoperative, 61.6 +/- 25 versus 77.5 +/- 23 mL postoperative). All comparisons had a P value less than.05 by Student's paired t test. CONCLUSIONS These results show that closed repair of pectus excavatum is associated with a subjective improvement in exercise tolerance, which is paralleled by an increase in cardiac function and a decline in pulmonary function. These findings support the use of closed repair of pectus excavatum in patients who complain of subjective shortness of breath; further study is required to delineate the long-term cardiopulmonary implications after closed repair.
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Affiliation(s)
- David L Sigalet
- Division of Pediatric Surgery, Department of Surgery, Alberta Children's Hospital, Calgary, Alberta, Canada
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Länsman S, Serlo W, Linna O, Pohjonen T, Törmälä P, Waris T, Ashammakhi N. Treatment of pectus excavatum with bioabsorbable polylactide plates: Preliminary results. J Pediatr Surg 2002; 37:1281-6. [PMID: 12194117 DOI: 10.1053/jpsu.2002.34983] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE Pectus excavatum usually is corrected by thoracoplasty using metal plates. Recently bioabsorbabe polylactide plates have been developed. The aim of this study was to compare outcome after use of metal and bioasorbable plates in thoracoplasty performed for correction of pectus excavatum. METHODS Eighty-three children (<16 years old) underwent thoracoplasty (Sulamaa's technique). In 75 patients, metallic plates, and in 8 patients, self-reinforced poly-L-lactide (SR-PLLA) plates, were used. Seven patients in the SR-PLLA group and 13 patients in the metal plate group were assessed 0.5 to 13 years postoperatively. RESULTS The mean operating time was 121 minutes in the metal plate group, and 87 minutes in the SR-PLLA plate group. In the metal plate group, complications were pain caused by instability of the metal plates (n = 17), wound infection (n = 3), recurrence of deformity (n = 3), postoperative pain (n = 3), pneumothorax (n = 1), and nonspecific postoperative fever (n = 1). Thirteen patients underwent reoperation to refix the position of the metallic plates. In the SR-PLLA group, one case of pneumothorax occurred, and plate fragment palpability caused local pain in one patient. Cosmetic results and lung function values were similar. CONCLUSION Our preliminary results show that bioabsorbable plates are a useful option in the treatment of pectus excavatum in children.
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Affiliation(s)
- S Länsman
- Division of Plastic Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
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Raichura N, Entwisle J, Leverment J, Beardsmore CS. Breath-hold MRI in evaluating patients with pectus excavatum. Br J Radiol 2001; 74:701-8. [PMID: 11511494 DOI: 10.1259/bjr.74.884.740701] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pectus excavatum (PE) is a congenital condition in which the sternum is displaced posteriorly with associated changes in the adjacent costal cartilages. The aetiology of PE is uncertain although various underlying abnormalities of the diaphragm have been implicated. There is sparse information regarding the use of fast MRI in evaluating the deformity. Our aims were to use fast MRI to evaluate static and respiratory-related dynamic chest wall characteristics, the extent of cardiac displacement and diaphragmatic excursion in patients. FLASH and TurboFLASH MR sequences in axial and coronal planes were performed on the thoraces of six young patients with PE and six individually matched healthy controls during full inspiratory and full expiratory breath-holds. The Pectus Index was derived from chest wall measurements using axial images. The distances of the left and right cardiac borders from the midline were measured using axial images, and excursion of the dome of each hemidiaphragm was measured using coronal images. The degree of sternal depression worsened substantially in expiration. Anterior chest wall movement was similar in the two groups. Patients had significantly flatter chests than the controls. There was a trend towards leftward cardiac displacement in the patients (maximum distance between left heart border and midline during full expiration 99.5 mm in patients and 91.8 mm in controls). The right diaphragmatic dome excursion was greater than the left in the controls (53.6 mm and 47.4 mm, respectively), but this was not seen in the patients (50.2 mm and 50.4 mm, respectively). It is concluded that fast MRI is very informative in evaluating skeletal abnormalities, chest wall motion, and cardiac and diaphragmatic changes seen in PE.
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Affiliation(s)
- N Raichura
- Department of Child Health, University of Leicester, Clinical Sciences Building, Leicester Royal Infirmary, PO Box 65, Leicester LE2 7LX, UK
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Theerthakarai R, El-Halees W, Javadpoor S, Khan MA. Severe pectus excavatum associated with cor pulmonale and chronic respiratory acidosis in a young woman. Chest 2001; 119:1957-61. [PMID: 11399733 DOI: 10.1378/chest.119.6.1957] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Pectus excavatum has never been reported to cause hypercapnic respiratory failure. In this report, we describe the first such case in a young woman with severe pectus excavatum who presented with chronic respiratory acidosis, pulmonary hypertension, and chronic cor pulmonale. An extensive diagnostic workup failed to uncover any other cause of respiratory acidosis, which led us to conclude that the severe chest wall deformity and the resulting severe restrictive defect were responsible for the development of chronic respiratory acidosis and cor pulmonale.
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Affiliation(s)
- R Theerthakarai
- Pulmonary Division, St. Joseph's Hospital and Medical Center, Paterson, NJ 07503, USA
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Pretorius ES, Haller JA, Fishman EK. Spiral CT with 3D reconstruction in children requiring reoperation for failure of chest wall growth after pectus excavatum surgery. Preliminary observations. Clin Imaging 1998; 22:108-16. [PMID: 9543588 DOI: 10.1016/s0899-7071(97)00073-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pectus excavatum is the most common congenital chest wall deformity. Extensive corrective surgery prior to age 3 may disturb chest wall growth and result in a constricted thorax. We describe our surgical and radiologic experience with eight such cases, paying particular attention to the role of spiral computed tomography (CT) with 3D reconstruction in patient management. Spiral CT was performed on children who had developed restrictive chest walls following pectus excavatum surgery. These children then underwent a unique operation to elevate the sternum and attempt to correct their restrictive chest wall defects. In several cases, postoperative spiral CT was performed. Spiral CT with 3D reconstruction defined the orientation of the ribs and costal cartilages and their relationship to the sternum, allowing exact preoperative measurement of the bony rib cage and guiding individualized operative correction. Computed thoracic volumes in select cases correlated well with subjective patient reports of increased exercise capacity. Repair of pectus excavatum defects prior to age 3 may result in constrictive thoracic abnormalities. Surgical correction can increase thoracic volume and improve prospects for normal thoracic function. Three-dimensional reconstruction of spiral CT data is useful in both preoperative and postoperative evaluation.
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Affiliation(s)
- E S Pretorius
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Abstract
Pectus excavatum repair usually results in unchanged or improved pulmonary function. However, a small subset of patients will experience severely impaired pulmonary function after pectus repair caused by restrictive lung disease, and no adequate surgical approach has been described for this condition. A procedure is described that is a variation of an operation for Jeune's thoracic dystrophy, that resulted in marked respiratory improvement in this setting. A 14-year-old boy had undergone standard pectus excavatum repair at age 4, from which he recovered uneventfully. Beginning at age 10 to 12 years progressive restrictive pulmonary disease, recurrent pneumonia, and cor pulmonale developed, which resulted in almost constant shortness of breath and the need for continuous nasal positive pressure support. Pulmonary function test results were markedly abnormal and worsening. He underwent an operative procedure consisting of sternal split that was wedged open permanently with rib struts, opening of pleura bilaterally, and six rib resections bilaterally. His postoperative recovery was satisfactory, and his pulmonary functions have shown steady improvement. He is now completely off oxygen and pressure support, has improved exercise tolerance, and has returned to school. Severe restrictive lung disease after pectus repair can be successfully managed with aggressive operative procedures. Patients should have close follow-up after pectus repair for the development of this potentially debilitating disorder to allow earlier repair.
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Affiliation(s)
- T R Weber
- Department of Surgery, St Louis University Health Sciences Center and Cardinal Glennon Children's Hospital, MO 63104-1095, USA
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Quigley PM, Haller JA, Jelus KL, Loughlin GM, Marcus CL. Cardiorespiratory function before and after corrective surgery in pectus excavatum. J Pediatr 1996; 128:638-43. [PMID: 8627435 DOI: 10.1016/s0022-3476(96)80128-4] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine whether pectus excavatum (PE) results in cardiopulmonary abnormalities, and whether surgical repair results in improvement. METHODS We performed pulmonary function testing and incremental exercise testing in 36 adolescents with PE (aged 16 +/- 3 (SD) years) and 10 age-matched, healthy control subjects. Fifteen PE subjects were reexamined postoperatively, as were six control subjects. RESULTS Preoperatively, PE subjects had a significantly lower forced vital capacity than control subjects had (81% +/- 14% vs 98% +/- 9% of the predicted value; p < 0.001). Chest computed tomography ratios of internal transverse to antero-posterior diameters correlated inversely with total lung capacity (r = 0.56; p < 0.01). Fifty-eight percent of PE subjects had subjective complaints of exercise limitation. PE subjects exercised at a workload similar to that of control subjects. Maximal heart rate and O2 pulse did not differ between the two groups. Respiratory measurements during exercise were similar between the two groups. Respiratory measurements during exercise were similar between the two groups. Postoperatively there was no change in forced vital capacity (as a percentage of the predicted value). The PE subjects exercised for a slightly longer period and had a slightly higher O2 pulse, whereas control subjects showed no change. CONCLUSION Some subjects with PE have mild restrictive lung disease, which is not affected by surgical repair. Postoperatively they have a slight increase in exercise tolerance and O2 pulse, which suggests improved cardiac function during exercise. However, the clinical implications of this modest improvement are unclear.
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Affiliation(s)
- P M Quigley
- Eudowood Division, Johns Hopkins University, Baltimore, Maryland, USA
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Pircova A, Sekarski-Hunkeler N, Jeanrenaud X, Ruchat P, Sadeghi H, Frey P, Payot M. Cardiac perforation after surgical repair of pectus excavatum. J Pediatr Surg 1995; 30:1506-8. [PMID: 8786505 DOI: 10.1016/0022-3468(95)90423-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Five days after surgical repair of pectus excavatum, this 7-year-old boy had a right-sided Kirschner wire protruding beneath the skin. The wire was repositioned blindly. Severe congestive heart failure developed. Surgical exploration showed a pierced right atrium, a torn septal leaflet of the tricuspid valve and noncoronary aortic cusp, and a large traumatic ventricular septal defect. The outcome and the indications and possible complications of surgery are discussed.
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Affiliation(s)
- A Pircova
- Pediatric Cardiology Unit, Centre Hospitalier Universitaire Vaudoid, Lausanne, Switzerland
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Matsui T, Kitano M, Nakamura T, Shimizu Y, Hyon SH, Ikada Y. Bioabsorbable struts made from poly-l-lactide and their application for treatment of chest deformity. J Thorac Cardiovasc Surg 1994. [DOI: 10.1016/s0022-5223(94)70234-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Morshuis WJ, Folgering HT, Barentsz JO, Cox AL, van Lier HJ, Lacquet LK. Exercise cardiorespiratory function before and one year after operation for pectus excavatum. J Thorac Cardiovasc Surg 1994. [DOI: 10.1016/s0022-5223(94)70414-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Morshuis W, Folgering H, Barentsz J, van Lier H, Lacquet L. Pulmonary function before surgery for pectus excavatum and at long-term follow-up. Chest 1994; 105:1646-52. [PMID: 8205855 DOI: 10.1378/chest.105.6.1646] [Citation(s) in RCA: 86] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Pulmonary function tests were performed before surgery on 152 patients who were operated on for pectus excavatum between 1970 and 1987 and at long-term follow-up to assess the degree of impairment and to investigate any changes caused by surgical correction. The mean age at surgery was 15.3 +/- 5.5 years. Pulmonary function was found to be restricted preoperatively. Multivariate analysis showed that preoperative pulmonary function was not related to age, the severity of the deformity at physical examination, or to pulmonary complaints. Only the patients with obstructive disease showed significantly more pulmonary complaints (p = 0.042). The total lung capacity (TLC) and inspiratory vital capacity (IVC) were significantly related to the age-corrected (delta) anteroposterior diameter of the chest (lower vertebral index [LVI]) (p = 0.0001). At follow-up (mean, 8.1 +/- 3.6 years), the restriction of pulmonary function was increased despite improvement in the symptoms of most patients and despite a significant increase in the anteroposterior diameter of the chest (p = 0.0001): the TLC was decreased from 83.7 percent predicted (pred) preoperatively to 73.8 percent pred (p = 0.0001) and the IVC from 78.3 percent pred to 70.7 percent pred (p = 0.0001). The surgical results were satisfactory in 83.6 percent. No relation was found between the changes in pulmonary function measured at follow-up and the surgical results. Only the age at surgery and the changes in the TLC and IVC at follow-up were significantly related (p = 0.0036, 0.0043, respectively), although the correlation coefficients were low (r = 27 percent and 28 percent, respectively). The reduction in lung function at follow-up was most pronounced in the patients who had the least functional impairment (TLC > 75 percent pred) preoperatively. No correlation was found between the changes in the pulmonary function test results at follow-up and follow-up interval, preoperative delta LVI, and the change in delta LVI at follow-up.
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Affiliation(s)
- W Morshuis
- Department of Thoracic and Cardiac Surgery, University Hospital Nijmegen, The Netherlands
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