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Dunning J, Burdett C, Child A, Davies C, Eastwood D, Goodacre T, Haecker FM, Kendall S, Kolvekar S, MacMahon L, Marven S, Murray S, Naidu B, Pandya B, Redmond K, Coonar A. The pectus care guidelines: best practice consensus guidelines from the joint specialist societies SCTS/MF/CWIG/BOA/BAPS for the treatment of patients with pectus abnormalities. Eur J Cardiothorac Surg 2024; 66:ezae166. [PMID: 38964837 DOI: 10.1093/ejcts/ezae166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/26/2024] [Accepted: 04/30/2024] [Indexed: 07/06/2024] Open
Abstract
Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back towards the spine (excavatum), protrudes forwards (carinatum) or more rarely is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities (such as swimming, dancing) and from interactions that might 'expose' them (such as sleepovers, dating, going to the beach and wearing fashionable clothes). This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise (such as running) but can also limit moderate activity such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment usually also suffer from low self-esteem and depression. This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and non-surgical techniques including bracing and vacuum bell therapy. We also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants and other rare procedures such as Pectus Up. For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance and long-term support. All the interventions have risks and benefits that the patient, parents and clinicians need to carefully consider and discuss when deciding on the most appropriate course. We hope this evidence review of 'Best Practice for Pectus' will make a significant contribution to those considerations and help all involved, from patients to national policy makers, to deliver the best possible care.
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Affiliation(s)
- Joel Dunning
- Department of Cardiothoracic surgery, James Cook University Hospital, Middlesbrough, UK
| | - Clare Burdett
- Department of Cardiothoracic surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Carl Davies
- Royal College of Physicians and Surgeons of Glasgow, UK
| | | | - Tim Goodacre
- Royal College of Surgeons of England, London, UK
| | - Frank-Martin Haecker
- Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
- Department of Paediatric Surgery, Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Simon Kendall
- Society for Cardiothoracic Surgery in Great Britain and Ireland, London, UK
| | - Shyam Kolvekar
- National Pectus Centre, Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Lisa MacMahon
- Department of Thoracic Surgery, Phoenix Children's Hospital, Phoenix, USA
- Chest Wall International Group (CWIG), Switzerland
| | - Sean Marven
- British Association of Paediatric Surgeons Thoracic and Airway Group, London, UK
| | - Sarah Murray
- Clinical Research Collaborative BHF and Leicester University, National PPI Group, Leicester, UK
| | - Babu Naidu
- Department of Thoracic Surgery, Birmingham Heartlands Hospital, Birmingham, UK
| | - Bejal Pandya
- National Pectus Centre, Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Karen Redmond
- Department of Thoracic Surgery, School of Medicine, University College Dublin, National Thoracic Subcommittee Lead SCTS, The Mater Hospital, Dublin, Dublin, Ireland, UK
| | - Aman Coonar
- Thoracic Lead at NHS England, President of the Society for Cardiothoracic Surgery in Great Britain and Ireland, London, UK
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Walsh J, Walsh R, Redmond K. Systematic review of physiological and psychological outcomes of surgery for pectus excavatum supporting commissioning of service in the UK. BMJ Open Respir Res 2023; 10:e001665. [PMID: 37827806 PMCID: PMC10582895 DOI: 10.1136/bmjresp-2023-001665] [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: 02/09/2023] [Accepted: 07/28/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Pectus excavatum (PEx) is the most common congenital chest wall abnormality affecting 1 in 400 births in the UK. PEx is associated with significant physiological and psychological impairment. While readily surgically correctable, the benefits that surgery can bring have been debated and proven difficult to objectively measure. In the UK, this has led to the decommissioning of PEx surgery. The aim of this review is to conduct a systematic search of the literature on PEx surgery to assess physiological and psychological outcomes. METHODS A systematic review of the MEDLINE (PubMed), Embase and Cochrane databases was performed. Articles were sought which included patients undergoing surgery for PEx and reported on changes in cardiopulmonary measures, symptoms, quality of life and psychological assessments before and after surgical repair. Last search was performed in July 2022 and relevant findings were synthesised by narrative review. RESULTS Fifty-one articles were included in qualitative synthesis, with 34 studies relating to physiological outcomes and 17 studies relating to psychological and quality of life measures. Twenty-one studies investigated pulmonary function at rest. There was no change in forced vital capacity or forced expiratory volume in 1 second following open repair and transient reductions followed closed repair. In the 11 studies investigating echocardiography, transthoracic rarely demonstrated cardiac compression; however, transoesophageal demonstrated intraoperative relief in cardiac compression in severe cases. Sixteen studies investigated exercise testing (cardiopulmonary exercise testing, CPET), 12 of which demonstrated significant improvement following surgery, both in maximal oxygen consumption and oxygen pulse. Seventeen studies investigated quality of life, all but one of which showed improvement following repair of PEx. All papers that reported on patient satisfaction following surgery found high rates, between 80% and 97%. DISCUSSION While the majority of studies to date have been small and data heterogeneous, the literature shows that for many patients with PEx, there exists a cardiopulmonary limitation that while difficult to objectify, is likely to improve with surgical repair. Resting parameters offer little yield in aiding this except in the most severe cases. CPET therefore offers a better option for dynamic assessment of this limitation and improvements following repair. Surgery significantly improves psychological well-being and quality of life for patients with PEx.
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Affiliation(s)
- Jamie Walsh
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Ross Walsh
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Karen Redmond
- Cardiothoracic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Houle MC, Sjulin TJ, McInnis IC, Walter RJ, Morris MJ. Clinical Evaluation of Exertional Dyspnea in Adult Pectus Excavatum Patients. CURRENT RESPIRATORY MEDICINE REVIEWS 2022. [DOI: 10.2174/1573398x18666220128110107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abstract:
Evaluation of patients with pectus excavatum has primarily been focused on the pediatric population who undergo surgical correction of sternal defects mainly for cosmetic reasons combined with exercise-limiting symptoms. The extent of cardiopulmonary improvement in this population based on cardiac imaging, pulmonary function testing, and cardiopulmonary exercise testing may be highly variable. There is no current consensus on the limitations of cardiopulmonary impairment or potential improvement from surgical repair in pediatric patients. Limited data has published in the medical literature on the evaluation of adults with pectus excavatum who may also present with a variety of clinical symptoms. Adult patients with exercise limitation and pectus excavatum may present with exertional dyspnea, chest discomfort, palpitations/tachycardia, exercise-induced wheezing, and use of bronchodilators for asthma-like symptoms. While numerous published review articles outline clinical evaluation and surgical treatment for younger patients, comprehensive evaluation for these adult patients has not been fully elucidated. There is no current consensus on the underlying cause of cardiopulmonary impairment in adult patients or their potential improvement from surgical repair. This review focuses on the recommended evaluation of adult patients to discern the potential cardiopulmonary limitations to exercise due to pectus excavatum, especially in physically fit adults such as active duty military personnel. Two illustrative cases are presented to describe the complexity of the evaluation of adult patients and potential need for surgical correction.
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Affiliation(s)
- Mateo C. Houle
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX , USA
| | - Tyson J. Sjulin
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX , USA
| | - Ian C. McInnis
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX , USA
| | - Robert J. Walter
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX , USA
| | - Michael J. Morris
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX , USA
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Oleksak F, Spakova B, Durdikova A, Durdik P, Kralova T, Igaz M, Molnar M, Gura M, Murgas D. Correlation of anthropometric index and cardiopulmonary exercise testing in children with pectus excavatum. Respir Physiol Neurobiol 2021; 296:103790. [PMID: 34560293 DOI: 10.1016/j.resp.2021.103790] [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: 04/28/2021] [Revised: 08/09/2021] [Accepted: 09/19/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) is a method used to evaluate functional impairment of patients with various diseases. OBJECTIVE The objective was to use CPET to estimate the usability of anthropometric index (AI) in patients with pectus excavatum (PE) as a marker of functional impairment caused by chest deformity. METHODS The study included 32 paediatric patients (28 males) with PE. Patients underwent CPET using a breath-by-breath exhaled gas analysis method and continuous monitoring of cardiac parameters. RESULTS In both groups, two (overall four) patients met criteria for cardiogenic limitation (low VO2 and low O2Pulse). Mean VO2/WR was below two standard deviations (2SD) in patients with less severe PE; other observed parameters were within normal limits (Z-score ± 2 SD). The AI had no observed correlation with peak ventilation, VO2peak and peak workload. CONCLUSION The obtained CPET data do not correlate well with the severity of chest deformity expressed with AI. There were similar physical activity limitations in both examined groups of patients and they did not depend on the severity of the deformity.
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Affiliation(s)
- F Oleksak
- Clinic for Children and Adolescents, University Hospital in Martin, Jessenius Medical Faculty in Martin, Commenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovakia.
| | - B Spakova
- Clinic of Pediatric Surgery, University Hospital in Martin, Jessenius Medical Faculty in Martin, Commenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovakia
| | - A Durdikova
- Clinic for Children and Adolescents, University Hospital in Martin, Jessenius Medical Faculty in Martin, Commenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovakia
| | - P Durdik
- Clinic for Children and Adolescents, University Hospital in Martin, Jessenius Medical Faculty in Martin, Commenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovakia
| | - T Kralova
- Clinic for Children and Adolescents, University Hospital in Martin, Jessenius Medical Faculty in Martin, Commenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovakia
| | - M Igaz
- Clinic for Children and Adolescents, University Hospital in Martin, Jessenius Medical Faculty in Martin, Commenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovakia
| | - M Molnar
- Clinic of Pediatric Surgery, University Hospital in Martin, Jessenius Medical Faculty in Martin, Commenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovakia
| | - M Gura
- Clinic of Pediatric Surgery, University Hospital in Martin, Jessenius Medical Faculty in Martin, Commenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovakia
| | - D Murgas
- Clinic of Pediatric Surgery, University Hospital in Martin, Jessenius Medical Faculty in Martin, Commenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovakia
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Hardie W, Powell AW, Jenkins TM, Foster K, Tretter JT, Fleck RJ, Garcia VF, Brown RL. Ventilatory limitations are not associated with dyspnea on exertion or reduced aerobic fitness in pectus excavatum. Pediatr Pulmonol 2021; 56:2911-2917. [PMID: 34143574 DOI: 10.1002/ppul.25540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/22/2021] [Accepted: 06/13/2021] [Indexed: 11/12/2022]
Abstract
Exercise intolerance and chest pain are common symptoms in patients with pectus excavatum. To assess if the anatomic extent of pectus deformities determined by the correction index (CI) is associated with a pulmonary impairment at rest and during exercise we performed a retrospective review on pectus patients in our center who completed a symptom questionnaire, cardiopulmonary exercise test (CPET), pulmonary function tests (PFT), and chest magnetic resonance imaging. Of 259 patients studied, dyspnea on exertion and chest pain was reported in 64% and 41%, respectively. Peak oxygen uptake (VO2 ) was reduced in 30% and classified as mild in two-thirds. A pulmonary limitation during exercise was identified in less than 3%. Ventilatory limitations on PFT was found in 26% and classified as mild in 85%. Obstruction was the most common abnormal pattern (11%). There were no differences between patients with normal or abnormal PFT patterns for the CI, VO2, or percentage reporting dyspnea or chest pain. Scatter plots demonstrated significant but weak inverse relationships between the CI and lung volumes at rest and during exercise. Multivariable linear regression modeling evaluating predictors of VO2 demonstrated positive associations with the forced expiratory volume at one second and a negative association with the CI. We conclude that resting PFT patterns have poor correlation with the anatomic extent of the pectus defect, symptomatology or aerobic fitness. Pulmonary limitations on CPET are uncommon and lung volumes during exercise are only minimally associated with the CI.
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Affiliation(s)
- William Hardie
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adam W Powell
- Division of Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Todd M Jenkins
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Karla Foster
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Justin T Tretter
- Division of Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Robert J Fleck
- Division of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Victor F Garcia
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rebeccah L Brown
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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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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Rasihashemi SZ, Ramouz A. Pectus excavatum repair using Prolene polypropylene mesh. Asian Cardiovasc Thorac Ann 2016; 24:140-4. [PMID: 26744495 DOI: 10.1177/0218492315625160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We aimed to assess the clinical outcomes of our surgical technique for repair of pectus excavatum using Prolene polypropylene mesh. METHODS Among 29 patients with pectus excavatum, the major complaint was cosmetic dissatisfaction, and the main symptom was exercise dyspnea in 15 patients. The Haller index used to assess pectus excavatum severity; it was significant in 22 patients. In all patients, a 2-layer sheet of Prolene polypropylene mesh was placed behind the sternum. RESULTS No serious complication was observed postoperatively, and all patients were satisfied with the cosmetic result. Mitral valve prolapse improved in all cases after 3 months. Spirometry revealed improved pulmonary function after surgery. CONCLUSION With due attention to the advantages of Prolene polypropylene mesh, such as remaining permanently in place, adapting to various stresses encountered in the body, resisting degradation by tissue enzymes, and trimming without unraveling, we concluded that this mesh is suitable for use as posterior sternal support in pectus excavatum patients.
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Affiliation(s)
| | - Ali Ramouz
- Department of Cardiothoracic Surgery, Tabriz University of Medical Sciences, Tabriz, Iran
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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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Normalized cardiopulmonary exercise function in patients with pectus excavatum three years after operation. Ann Thorac Surg 2013; 96:272-8. [PMID: 23684487 DOI: 10.1016/j.athoracsur.2013.03.034] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 03/13/2013] [Accepted: 03/18/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND During exercise cardiac function is often limited in patients with pectus excavatum. Therefore, we hypothesized that cardiopulmonary exercise function would improve after the Nuss procedure. METHODS Seventy-five teenagers (49 patients, 26 controls) were investigated at rest and during bicycle exercise before surgery, and 1 year and 3 years postoperatively (after pectus-bar removal). Echocardiography and lung spirometry were performed at rest. Cardiac output, heart rate, and aerobic exercise capacity were measured using a photoacoustic gas-rebreathing technique during rest and exercise. RESULTS Forty-four patients and 26 controls completed 3 years follow-up. Preoperatively, patients had lower maximum cardiac index, mean ± SD, 6.6 ± 1.2 l·min(-1)·m(-2) compared with controls 8.1 ± 1.0 l·min(-1)·m(-2) during exercise (p = 0.0001). One year and 3 years postoperatively, patients' maximum cardiac index had increased significantly and after 3 years there was no difference between patients and controls (8.1 ± 1.2 l·min(-1)·m(-2) and 8.3 ± 1.6 l·min(-1)·m(-2), respectively [p = 0.572]). The maximum oxygen consumption was unchanged. Left ventricular dimensions increased in patients over 3 years; however, no difference was seen between the 2 groups. Preoperatively, patients had lower forced expiratory volume in the first second of expiration (FEV1; 86% ± 13%) as compared with controls (94% ± 10%), p = 0.009. Postoperatively, no difference was found in FEV1 between the 2 groups. CONCLUSIONS Before operation, FEV1 and maximum cardiac index were lower in patients compared with healthy, age-matched controls. One year after, both parameters had increased, although only FEV1 had normalized. After 3 years and bar removal, cardiopulmonary function in patients during exercise had normalized.
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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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Tang M, Nielsen HHM, Lesbo M, Frokiaer J, Maagaard M, Pilegaard HK, Hjortdal VE. Improved cardiopulmonary exercise function after modified Nuss operation for pectus excavatum. Eur J Cardiothorac Surg 2011; 41:1063-7. [DOI: 10.1093/ejcts/ezr170] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lesbo M, Tang M, Nielsen HH, Frokiaer J, Lundorf E, Pilegaard HK, Hjortdal VE. Compromised cardiac function in exercising teenagers with pectus excavatum. Interact Cardiovasc Thorac Surg 2011; 13:377-80. [DOI: 10.1510/icvts.2011.267054] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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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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Russell HM, Backer CL. Pediatric Thoracic Problems: Patent Ductus Arteriosus, Vascular Rings, Congenital Tracheal Stenosis, and Pectus Deformities. Surg Clin North Am 2010; 90:1091-113. [DOI: 10.1016/j.suc.2010.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Cavestri B, Wurtz A, Bart F, Nevière R, Aguilaniu B, Wallaert B. Exploration fonctionnelle à l’exercice des patients présentant un pectus excavatum. Rev Mal Respir 2010; 27:717-23. [DOI: 10.1016/j.rmr.2010.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 01/21/2010] [Indexed: 10/19/2022]
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Johnson JN, Hartman TK, Pianosi PT, Driscoll DJ. Cardiorespiratory function after operation for pectus excavatum. J Pediatr 2008; 153:359-64. [PMID: 18534622 DOI: 10.1016/j.jpeds.2008.03.037] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 01/17/2008] [Accepted: 03/17/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We performed a review of current data to determine the effect that operation has on pulmonary function, aerobic capacity, and stroke volume in patients with pectus excavatum. STUDY DESIGN Two reviewers independently assessed clinical trials and collected data on interventions and outcomes. To qualify for inclusion, a study had to include preoperative and postoperative assessment, provide outcomes in either a published percentile or qualified matched control form to control for interval growth, and include only original patient groups. RESULTS Postoperative total lung capacity for patients who had Ravitch repair was significantly lower (SMD, 0.71 [CI -1.06, -0.36]; I(2) = 19.6%) than preoperative. Based on 2 studies after removal of the Nuss bar, FEV(1) was significantly increased from preoperative values (SMD, 0.39 [CI, 0.03, 0.74]; I(2) = 0%). Stroke volume increased after surgery (SMD, 0.40 [CI, 0.10, 0.70]; I(2) = 0%) after Ravitch repair. There was a trend toward improved exercise tolerance, but it was not statistically significant. CONCLUSIONS Total lung capacity was decreased after Ravitch repair, and FEV(1) was increased after Nuss bar removal. Stroke volume may be increased after Ravitch repair. Exercise tolerance was not improved after either type of surgical repair.
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Affiliation(s)
- Jonathan N Johnson
- Department of Pediatrics, Mayo Clinic College of Medicine, Rochester, MN, 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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Kelly RE, Shamberger RC, Mellins RB, Mitchell KK, Lawson ML, Oldham K, Azizkhan RG, Hebra AV, Nuss D, Goretsky MJ, Sharp RJ, Holcomb GW, Shim WKT, Megison SM, Moss RL, Fecteau AH, Colombani PM, Bagley TC, Moskowitz AB. Prospective Multicenter Study of Surgical Correction of Pectus Excavatum: Design, Perioperative Complications, Pain, and Baseline Pulmonary Function Facilitated by Internet-Based Data Collection. J Am Coll Surg 2007; 205:205-16. [PMID: 17660066 DOI: 10.1016/j.jamcollsurg.2007.03.027] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Revised: 03/19/2007] [Accepted: 03/19/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND Given widespread adoption of the Nuss procedure, prospective multicenter study of management of pectus excavatum by both the open and Nuss procedures was thought desirable. Although surgical repair has been performed for more than 50 years, there are no prospective multicenter studies of its management. STUDY DESIGN This observational study followed pectus excavatum patients treated surgically at 11 centers in North America, according to the method of choice of the patient and surgeon. Before operation, all underwent evaluation with CT scan, pulmonary function tests, and body image survey. Data were collected about associated conditions, hospital complications, and perioperative pain. One year after completion of treatment, patients will repeat the preoperative evaluations. This article addresses early results only. RESULTS Of 416 patients screened, 327 were enrolled; 284 underwent the Nuss procedure and 43 had the open procedure. Median preoperative CT index was 4.4. Pulmonary function testing before operation showed mean forced vital capacity of 90% of predicted values; forced expiratory volume in 1 second (FEV(1)), 89% of predicted; and forced expiratory flow during the middle half of the forced vital capacity (FEF(25% to 75%)), 85% of predicted. Early postcorrection results showed that operations were performed without mortality and with minimal morbidity at 30 days postoperatively. Median hospital stay was 4 days. Postoperative pain was a median of 3 on a scale of 10 at time of discharge; the worst pain experienced was the same as was expected by the patients (median 8), and by 30 days after correction or operation, the median pain score was 1. Because of disproportionate enrollment and similar early complication rates, statistical comparison between operation types was limited. CONCLUSIONS Anatomically severe pectus excavatum is associated with abnormal pulmonary function. Initial operative correction performed at a variety of centers can be completed safely. Perioperative pain is successfully managed by current techniques.
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Affiliation(s)
- Robert E Kelly
- Department of Surgery, Suite 5B, Children's Lane, Norfolk, VA 23507, USA
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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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Guntheroth WG, Spiers PS. Cardiac function before and after surgery for pectus excavatum. Am J Cardiol 2007; 99:1762-4. [PMID: 17560891 DOI: 10.1016/j.amjcard.2007.01.064] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Revised: 01/22/2007] [Accepted: 01/22/2007] [Indexed: 11/19/2022]
Abstract
A 2006 meta-analysis concluded that thoracic surgery for pectus excavatum (PE) significantly improves cardiovascular function. However, that analysis was flawed by a high level of heterogeneity in the outcomes and inappropriate methods in 5 of the 8 publications analyzed. Therefore, a search of the published research from 1965 to the present was conducted, and only 5 publications were found that reported studies of cardiac function before and after operation, including 118 patients and 82 unoperated controls. Cardiac function was studied most frequently by echocardiography, despite the limitations imposed by the abnormal anatomy of pectus excavatum, but only studies that did not report cardiac or left ventricular dimensions or output were excluded. Studies using indirect estimates on the basis of oxygen pulse, which depends on several other variables, were not included. No improvements were found in left ventricular size, stroke volume, and cardiac output after surgery in 4 of 5 studies, using radionuclides, 2-dimensional echocardiography, radiographic planimetry, and cardiac output by the Fick method. Only a single study, with volumes calculated by squaring the diameter of the left ventricle from M-mode echocardiography, reported an increase (22%) in left ventricular stroke volume after operation, but that increased (17%) in the investigators' unoperated controls. This and 2 other studies used in this meta-analysis were also included in a meta-analysis conducted by Malek et al. In a fourth study, Malek et al included only the first study that found an improvement, but the final study reported no improvement. In conclusion, there is no reliable documentation of improved cardiac function from thoracic surgery for pectus excavatum.
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Affiliation(s)
- Warren G Guntheroth
- Department of Pediatrics, Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA.
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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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Malek MH, Berger DE, Housh TJ, Marelich WD, Coburn JW, Beck TW. Cardiovascular Function Following Surgical Repair of Pectus Excavatum. Chest 2006; 130:506-16. [PMID: 16899852 DOI: 10.1378/chest.130.2.506] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Despite numerous published reports, there is no consensus in the literature as to whether the surgical repair of the pectus excavatum improves cardiovascular function. As a result, it has been suggested that correction should be considered a cosmetic procedure, and therefore, many health insurance companies have questioned whether the repair of the pectus excavatum improves cardiovascular function and thus are reluctant to authorize the procedure. The purpose of this study was to apply metaanalysis methodology to generate a quantitative synthesis of the effects of surgical repair on cardiovascular function and to test the hypothesis that surgical repair of the pectus excavatum results in significant improvements in cardiovascular function. METHODS Studies were retrieved via computerized literature searches, cross-referencing from original and review articles, and a review of the reference list by a recognized authority in the area of pectus excavatum repair. The inclusion criteria were as follows: (1) reporting quantitative measures of preoperative and postoperative cardiovascular function; (2) published in the English language; (3) indexed between January 1960 and May 2005; (4) reporting the duration between which preoperative and postoperative assessments were conducted; and (5) describing the cardiovascular assessment procedures. RESULTS A comprehensive search of the literature identified eight studies that met all of the inclusion criteria. These studies, representing 169 pectus excavatum patients, were used for the metaanalysis. Random-effects modeling yielded a mean weighted effect size (ES) for cardiovascular function that was statistically significant (ES, 0.59; 95% confidence interval, 0.25 to 0.92; p = 0.0006). CONCLUSIONS The findings of the present study indicated that surgical repair of the pectus excavatum significantly improves cardiovascular function and contradicts arguments that surgical repair is primarily cosmetic yielding minimal physiologic improvement.
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Affiliation(s)
- Moh H Malek
- Human Performance Laboratory, Department of Nutrition and Health Sciences, University of Nebraska-Lincoln, Lincoln, 68583-0806, USA.
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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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Affiliation(s)
- Rebecca M McGuigan
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
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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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Luzzi L, Voltolini L, Zacharias J, Campione A, Ghiribelli C, Di Bisceglie M, Gotti G. Ten year experience of bioabsorbable mesh support in pectus excavatum repair. ACTA ACUST UNITED AC 2005; 57:733-40. [PMID: 15544770 DOI: 10.1016/j.bjps.2004.05.019] [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] [Received: 04/28/2003] [Accepted: 05/25/2004] [Indexed: 10/26/2022]
Abstract
INTRODUCTION We reviewed 10 years experience in the treatment of this deformity using a retro-sternal bioabsorbable mesh in place of a metallic device to lift and stabilise the sternum. Moreover, the mesh supports the thoracic and upper abdominal wall reconstruction. MATERIALS AND METHODS From January 1990 to December 2000, in our Thoracic Surgery Unit, 65 patients with PE were assessed for surgical repair, mean age 16+/- 3.5 years, fronto sagittal thoracic index (FSTI) 0.21, ranging from 0.15-0.33. Twenty-three of them underwent surgical correction after initial assessment, 22 were deferred and sent to physiotherapy. At a subsequent assessment, five of the patients sent to physiotherapy were deemed to require surgery. RESULTS Of the 28 patients who underwent surgery, 2 (10%) presented a mild recurrence of PE after 1 year (0.30<FSTI>0.34), meanwhile all other patients maintained a FSTI>0.34. For all patients the improvement in FSTI was statistically significant, p = 0.001. Patients satisfaction after 24 months was thus shared: excellent 18 patients (65%), good seven patients (25%), fair one patient (3.5%) and poor two patients (7%). No major complications were observed in preoperative period. Patients mobilisation was soon achieved thanks to the postoperative pain control and the absence of retro-sternal metallic support. CONCLUSIONS The introduction of bioabsorbable mesh in the Robicsek technique is a safe procedure related to a high percentage of success. The high tolerance of the material reduces the inflammatory reaction. Moreover, the procedure prevents patients from having complications caused by retro-sternal device dislodgment, avoiding a second intervention for device reposition and reducing the postoperative chest pain achieving an early patient mobilisation. In the end a complete reconstruction of the upper abdomen wall has been produced.
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Affiliation(s)
- L Luzzi
- Thoracic Surgery Unit, University Hospital of Siena, Viale Bracci 14, 53100 Siena, Italy.
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Lawson ML, Mellins RB, Tabangin M, Kelly RE, Croitoru DP, Goretsky MJ, Nuss D. Impact of pectus excavatum on pulmonary function before and after repair with the Nuss procedure. J Pediatr Surg 2005; 40:174-80. [PMID: 15868581 DOI: 10.1016/j.jpedsurg.2004.09.040] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Patient reports of preoperative exercise intolerance and improvement after surgical repair of pectus excavatum (Pex) have been documented but not substantiated in laboratory studies. This may be because no study has been large enough to determine if pulmonary function tests (PFTs) in the Pex population are significantly different from the normal population, and none has assessed improvement in pulmonary function after Nuss bar removal. METHODS The authors studied PFT results in 408 Pex patients before repair and in a subset of 45 patients after Nuss procedure and bar removal. Significance of differences in percent predicted (using Knudson's equations) was tested using t tests (parametric) or sign tests (nonparametric). Normal was defined as 100% of predicted for forced vital capacity (FVC), forced expired volume in 1 second (FEV1), and forced expiratory flow (FEF25%-75%). RESULTS Preoperatively, FVC and FEV1 medians were lower than the normal by 13%, whereas the FEF 25-75 median was lower than normal by 20% (all P < .01). The postoperative group had statistically significant improvement after surgery for all parameters. Patients older than 11 years at the time of surgery had lower preoperative values and larger mean post-bar removal improvement than the younger patients. An older patient with a preoperative FEF25-75 score of 80% of normal would be predicted by these data to have a postoperative FEF25-75 of 97%, indicating almost complete normalization for this function. CONCLUSIONS These results demonstrate that preoperatively Pex patients as a group have decreased lung function relative to normal patients. After Nuss procedure and bar removal, we show a small but significant improvement in pulmonary function. These results are consistent with patient reports of clinical improvement and indicate the need for more in-depth tests of cardiopulmonary function under exercise conditions to elucidate the mechanism.
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Affiliation(s)
- M Louise Lawson
- Center for Pediatric Research, Children's Hospital of The King's Daughters and Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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Malek MH, Fonkalsrud EW. Cardiorespiratory Outcome after Corrective Surgery for Pectus Excavatum: A Case Study. Med Sci Sports Exerc 2004; 36:183-90. [PMID: 14767238 DOI: 10.1249/01.mss.0000113704.43219.1b] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose of this case study was to examine the effect of pectus excavatum before and after surgical correction on ventilatory and cardiorespiratory responses to submaximal and maximal exercise. METHODS The patient was a 30-yr-old longshoreman who had mild pectus excavatum since infancy that became worse during his adolescent growth years. The deformity persisted into adulthood with increasing symptoms. Although he had a history of habitual aerobic exercise, the patient experienced frequent episodes of pain in the lower anterior chest, breathlessness, and reduced stamina when performing activities of daily living. He performed pulmonary function tests, submaximal and maximal incremental exercise testing, before and 6 months after corrective surgery. RESULTS Six months after corrective surgery, the patient demonstrated increases in FEV1 (13.0%), maximum voluntary ventilation (MVV, 32.3%), maximum power output (max, 15.5%), [OV0312]O2max (7.9%), metabolic threshold ([OV0312]O2theta, 30.8%), oxygen-pulse ([OV0312]O2/fc, 14.0%), and maximal tidal volume (VTmax, 11.7%). On submaximal testing, we found that the time constant for oxygen uptake kinetics was 46.8 s for the on-transit and 46.5 s for the off-transit before surgery and 33.6 s for the on-transit and 30.3 s for the off-transit six months after surgery. CONCLUSIONS The information derived from this case study supports the opinion that corrective surgery for pectus excavatum may alleviate the impaired ventilatory and cardiorespiratory performance seen preoperatively.
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Affiliation(s)
- Moh H Malek
- Human Performance Laboratory, Department of Nutrition and Health Sciences, 110 Ruth Leverton Hall, University of Nebraska-Lincoln, Lincoln, NE 68583-0806, USA.
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Malek MH, Fonkalsrud EW, Cooper CB. Ventilatory and cardiovascular responses to exercise in patients with pectus excavatum. Chest 2003; 124:870-82. [PMID: 12970011 DOI: 10.1378/chest.124.3.870] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
PURPOSE Uncertainty exists as to whether pectus excavatum causes true physiologic impairments to exercise performance as opposed to lack of fitness due to reluctance to exercise. The purpose of this study was to examine the effect of pectus excavatum on ventilatory and cardiovascular responses to incremental exercise in physically active patients. METHODS Twenty-one patients with pectus excavatum (age range, 13 to 50 years; mean [+/- SD] age, 23.6 +/- 8.9 years; severity index range, 3.7 to 8.0; mean severity index, 5.1 +/- 1.2) were referred for preoperative evaluation. Eighteen of the patients (85%) had a history of performing aerobic activity ranging from 30 min to 2 h per day (mean duration, 1.0 +/- 0.61 h per day) for 3 +/- 1.5 days per week. Patients performed pulmonary function tests, and submaximal and maximal incremental exercise testing. RESULTS On maximal exercise testing, the maximum oxygen uptake (O(2)max), and oxygen-pulse were significantly lower than the reference values (t(20) = 6.17 [p < 0.0001] and t(20) = 4.52 [p < 0.0001], respectively). Furthermore, patients exhibited cardiovascular limitation, but not ventilatory limitation. Despite their high level of habitual exercise activity, the overall metabolic threshold for lactate accumulation was abnormally low (ie, 41% of the reference value for O(2)max) especially in those with a pectus severity index (PSI) of > 4.0 (39% of the reference value of O(2)max), which is consistent with cardiovascular impairment rather than physical deconditioning. Patients with a PSI of > 4.0 were also eight times more likely to have reduced aerobic capacity than patients who had a low severity index, despite their level of exercise participation. On submaximal testing, we found that the time constant for O(2) uptake kinetics was 37.4 s for the on-transit and 41.6 s for the off-transit. The observed values for FVC, FEV(1), maximum voluntary ventilation, and diffusing capacity of the lung for carbon monoxide were significantly lower than reference values, but those for total lung capacity and residual volume were not significantly lower than reference values. CONCLUSIONS The information derived from this study supports the opinion that pectus excavatum is associated with true physiologic impairment and reduced exercise capacity, predominantly due to impaired cardiovascular performance rather than ventilatory limitation. Furthermore, the impairment is not explained by physical deconditioning.
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Affiliation(s)
- Moh H Malek
- The Exercise Physiology Research Laboratory, Department of Surgery, David Geffen School of Medicine at UCLA, University of California-Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
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Abstract
Chest wall anomalies are a heterogeneous group of malformations requiring repair. Recurrence and the need for secondary repair may occur. Congenital anomalies, including bifid sternum, pentalogy of Cantrell, Jeunes's syndrome and Poland's anomaly, rarely recur. Pectus carinatum may recur in the original surgical area or an adjacent area and most often recurs in patients who undergo repair before completion of teenage growth. Pectus excavatum may recur in approximately 5% of patients. Simple recurrence, floating sternum, or Acquired Jeune's syndrome may result. All of these would require reoperation. Each chest wall anomaly recurrence requires an individualized approach to timing and type of repair. Overall excellent results should be obtained for operative repair of recurrences.
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Affiliation(s)
- Paul M Colombani
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, CMSC 7-113, Baltimore, MD 21287, USA
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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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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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37
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Abstract
BACKGROUND Exercise capacity is often limited in subjects with pectus excavatum (PE), but the mechanism is unknown. OBJECTIVES We attempted to quantify exercise capacity and to investigate whether limitation of venous return to the heart contributes to exercise intolerance in PE. METHODS A total of 13 patients with PE (mean age, 19 +/- 6 years) and 20 control subjects (mean age, 25 +/- 11 years) underwent sitting and supine incremental cycling and exercise Doppler stroke volume (SV) measurements. RESULTS Supine peak oxygen uptake (V'O(2)max) for the patients (1351 +/- 345 mL/min) and control subjects (1505 +/- 330 mL/min) was not different. In contrast, sitting V'O(2)max was lower in the patients than in the control subjects, 1480 +/- 462 and 1994 +/- 581 mL/min, respectively (P =.02). Supine exercise SV was not different between groups. Moreover, only in the patients with PE was supine exercise SV, 70 +/- 18 mL, higher than sitting exercise SV, 55 +/- 14 mL (P =.015). The corresponding values for the control subjects were 70 +/- 18 mL and 65 +/- 19 mL (P = NS). CONCLUSIONS Patients with PE exercising in the sitting position have reduced V'O(2)max and SV, whereas during supine exercise they approached the control values. The supine advantage in PE suggests that upright exercise capacity in this disease is affected by reduced filling of the heart in the non-supine position.
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Affiliation(s)
- L Zhao
- Pulmonary and Heart Institutes, Sheba Medical Center, Tel-Hashomer, Israel; and Sackler Medical School, Tel-Aviv University, Tel-Aviv, Israel
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Xiao-Ping J, Ting-Ze H, Wen-Ying L, Fu-Kang W, Yu-Ru Y, Jie-Xiong F, Qi-Cheng L, Ming L, Yun-Man T. Pulmonary function for pectus excavatum at long-term follow-up. J Pediatr Surg 1999; 34:1787-90. [PMID: 10626855 DOI: 10.1016/s0022-3468(99)90313-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of this article was to assess whether and to what extent pulmonary function recovered to normal degree postoperatively and to investigate the changes in pulmonary function after surgical correction and the value of surgical correction. METHODS A total of 27 patients who could be questioned and examined in person at the outpatient department of our hospital were included in this study. Of these patents, 24 were boys and 3 were girls. Their ages ranged from 3 to 16 years (mean, 8.67) at follow-up. The mean age at surgery was 4 years, and mean years of follow-up was 6.8. Pulmonary functional measurements included in vital capacity (VC), total lung capacity (TLC), residual volume (RV), functional residual capacity (FRC), RV-TLC ratio, maximal voluntary ventilation (MVV), force ventilatory capacity (FVC), forced expiratory volume in one second (FEV1), maximal midexpiratory flow curve (MMEF), maximal expiratory flow in 75% vital capacity (V75), maximal expiratory flow in 50% vital capacity (V50), maximal expiratory flow in 25% vital capacity (V25), and breathing reserve ratio (BR). RESULTS TLC, FRC, MVV, MMEF, V75, and V50 values were not different from the normal values. IVC, FVC, FEV1, and V25 values were decreased significantly compared with the normal values. The RV and RV-TLC were high in 87.5% cases. CONCLUSIONS Preoperative symptoms obviously improved after operation. There was little airway obstruction in the patients postoperatively. The patients with pectus excavatum should be operated on as soon as possible.
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Affiliation(s)
- J Xiao-Ping
- Department of Pediatric Surgery, First University Hospital, WCUMS, Chengdu, China
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Kowalewski J, Brocki M, Dryjanski T, Zolyński K, Koktysz R. Pectus excavatum: increase of right ventricular systolic, diastolic, and stroke volumes after surgical repair. J Thorac Cardiovasc Surg 1999; 118:87-92; discussion 92-3. [PMID: 10384189 DOI: 10.1016/s0022-5223(99)70145-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The study was undertaken to assess how a surgical correction of funnel chest modifies right ventricular structure and function. METHODS Before and 6 months after surgery in 42 patients (27 male and 15 female patients, aged 5-31 years), a pectus index was calculated and echocardiographic examinations of the right ventricle were performed, with calculation of systolic, diastolic, and stroke volume indices. Right ventricular volume was estimated by subtracting the left ventricular volume from that of the entire heart. The values of the right ventricular volumes and the pectus index before and after the operation, as well as the changes in the indices, were compared. RESULTS Statistically significant changes in the pectus index and the right ventricular volume indices after surgery were noted. No correlation was observed between the changes in the pectus index and the changes in any right ventricular volume indices. CONCLUSION Surgical treatment of funnel chest causes an increase in right ventricular systolic, diastolic, and stroke volumes, although there is no correlation between these changes and the degree of sternocostal elevation.
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Affiliation(s)
- J Kowalewski
- First Department of General Surgery, Department of Cardiology, Department of Orthopedic and Field Surgery, and Patomorphology, The Military Medical Academy, Lodz, Poland
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Coln D. What's New in Pediatric Surgery? A Minimally Invasive Technique to Correct Pectus Excavatum. Proc (Bayl Univ Med Cent) 1999. [DOI: 10.1080/08998280.1999.11930138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Abstract
Pediatric chest lesions are usually either symptomatic or strikingly visible. The most common lesions, as well as the lesions that require prompt surgical treatment, are reviewed in this article. Careful imaging studies and diagnostic tests such as bronchoscopy can usually characterize these lesions and enable a safe, directed surgical approach. Although many chest lesions can be managed without surgery, primary care providers can expedite treatment of these problems by early referral to pediatric surgeons or pediatric thoracic surgeons.
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Affiliation(s)
- R S Sawin
- Children's Hospital and Regional Medical Center, University of Washington School of Medicine, Seattle, 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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44
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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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45
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Abstract
The use of a single CT scan to evaluate the severity of pectus excavatum has been popular since its inception. However, there is no objective data to address the evolution of the deformity. Using repeated CT scans taken an average of 1 year and 3 months apart, eight children with pectus excavatum were prospectively followed. The initial pectus indices ranged from 3.6 to 6.8 (mean 5.4 +/- 1.3) and the follow-up indices, from 3.5 to 6.7 (mean 5.3 +/- 1.0). No progress of pectus excavatum was found during the study period. Our routine five axial chest CT sections also helped to specify a pectus index based on the central section taken through the deepest part of the deformity, and provided useful information for further conservative or surgical management.
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Affiliation(s)
- J H Chuang
- Division of Pediatric Surgery, Chang Gung Memorial Hospital, No. 123, Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien, Taiwan, ROC
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46
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Abstract
Postoperative radiographic changes after pectus repair have not previously been described. We reviewed the chest radiographs of 65 children who underwent surgical repair of pectus excavatum between early 1985 and mid-1992. After operation, 64 children showed atelectasis, 38 had pleural effusions, 30 showed a congestion or edema pattern, 12 had pneumothorax, 21 showed fixation strut tilt or rotation, and 4 had pneumomediastinum. Despite the sometimes worrying radiographic appearance, these children uniformly did well clinically.
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Affiliation(s)
- L Lancaster
- Department of Radiology, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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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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49
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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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