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Clinker C, Scaife J, Martinez D, Kahan AM, Eldredge RS, Russell KW. Effect of cryoablation in Nuss bar placement on opioid utilization and length of stay. Pediatr Surg Int 2024; 40:260. [PMID: 39363012 DOI: 10.1007/s00383-024-05838-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2024] [Indexed: 10/05/2024]
Abstract
BACKGROUND Our institution recently transitioned from paravertebral nerve blocks (PVBs) to intercostal nerve cryoablation (INC) for pain control following minimally invasive repair of pectus excavatum (MIRPE). This study aimed to determine how INC affected the operative time, length of stay, complication rates, inpatient opioid use, and outpatient prescription of opioids at a single center. METHODS A retrospective review was performed at a single pediatric referral center of all patients who underwent MIRPE between 2018 and 2023. Patient demographics, operative details, and perioperative course were collected. The use of INC versus PVB was recorded. Univariate analyses were performed using Wilcoxon rank sum tests for continuous variables and chi-squared tests for categorical variables. RESULTS 255 patients were included with a median age of 15 years, median BMI of 18.50 kg/m2, and median Haller index of 4.40. INC was utilized in 41% (105/255), and 59% (150/255) received PVB. The two groups did not differ significantly in BMI, Haller index, or complications, though the INC patients were older by 1 year (15.0 vs. 16.0, p = 0.034). INC was associated with an increased operative time (INC: 92 min vs. PVB: 67 min, p < 0.001), decreased length of stay (3 vs. 4 days, p = < 0.001), more than twofold decrease in inpatient opioids per day (INC: 16 MME vs. PVB: 41 MME, p < 0.001), and a fourfold decrease in the amount of opioids prescribed at discharge (INC: 90 MME vs. PVB: 390 MME, p < 0.001). CONCLUSION INC after MIRPE significantly decreased both the inpatient opioid utilization and our outpatient prescribing practices while also decreasing our overall length of stay without increasing complications. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Christopher Clinker
- University of Utah School of Medicine, 100 North Mario Capechi Drive, Salt Lake City, UT, 84103-0000, United States
| | - Jack Scaife
- University of Utah School of Medicine, 100 North Mario Capechi Drive, Salt Lake City, UT, 84103-0000, United States
| | - Davian Martinez
- University of Utah School of Medicine, 100 North Mario Capechi Drive, Salt Lake City, UT, 84103-0000, United States
| | - Anastasia M Kahan
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, United States
| | | | - Katie W Russell
- University of Utah School of Medicine, 100 North Mario Capechi Drive, Salt Lake City, UT, 84103-0000, United States.
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, United States.
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Weinhandl AC, Ermerak NO, Yüksel M, Rebhandl W. 'Short Bars Crossed' to Remodel the Entire Chest Wall in Children and Adolescents with Pectus Excavatum. J Pediatr Surg 2024; 59:161590. [PMID: 38914508 DOI: 10.1016/j.jpedsurg.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/26/2024] [Accepted: 05/30/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND The cross-bar technique of minimally invasive pectus excavatum (PE) correction remains underreported, which is especially true of pediatric patients. We therefore reviewed the experience of a Turkish and an Austrian center. An additional novelty characterizing both pediatric cohorts was the use of short bars. METHODS In a retrospective study, pediatric PE corrections involving 'short bars crossed' were analyzed for complications and intra-/postoperative outcomes. Cases with two or three bars were included, given that a horizontal third bar was placed whenever considered useful for upper-chest elevation. All bars were fitted with a single stabilizer near the surgical entry point. In the Austrian center, intercostal nerve cryoablation was used for pain management. Descriptive statistics are presented. RESULTS Seventy-eight patients ≤18 years old were evaluable at the Turkish (n = 56) and Austrian (n = 22) centers. Total median values were 16.2 (IQR: 15.1-17.4) years for age and 4.60 (IQR: 3.50-6.11) for Haller index. Ten mild or moderate complications (12.8%) were observed, including just one revision requirement due to bar migration (1.28%). Intercostal nerve cryoablation (n = 13) was associated with longer surgical procedures at 150 (IQR: 137-171) versus 80 (IQR: 60-100) minutes but with shorter hospital stays, given an IQR of 3-4 days versus 4-5 days. CONCLUSION 'Short bars crossed'-with a single stabilizer in a ventral position close to the surgical entry point-ensure a wide distribution of forces, protect against bar migration, are safe and effective, and offer stability at an age characterized by growth and physical activity. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anja C Weinhandl
- University Clinic of Pediatric and Adolescent Surgery, Comprehensive Center for Pediatrics, Medical University of Vienna, Austria
| | - Nezih O Ermerak
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Mustafa Yüksel
- Department of Thoracic Surgery, Emeritus Prof of Marmara University Lecturer of TC, Demiroglu Bilim University Medical School, Istanbul, Turkey
| | - Winfried Rebhandl
- University Clinic of Pediatric and Adolescent Surgery, Comprehensive Center for Pediatrics, Medical University of Vienna, Austria.
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Raikot SR, Polites SF, Potter DD. Biocompatible Cable Ties Are an Alternative to Metal Stabilizers for Bar Securement During Minimally Invasive Pectus Excavatum Repair. J Laparoendosc Adv Surg Tech A 2024; 34:936-940. [PMID: 38634817 DOI: 10.1089/lap.2023.0417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Background: Bar stabilization during minimally invasive pectus excavatum repair (MIRPE) is critical to avoid dislodgement. Multiple techniques are described including stabilizers, wires, and sutures. This retrospective study compared bar movement and outcomes between existing techniques and ZipFix™, a biocompatible cable tie. Methods: Patients ≤20 years of age who underwent MIRPE with ZipFix between January 2021 and September 2022 were compared with historical controls who underwent repair by same surgeons between January 2018 and December 2020 using stabilizers or polydioxanone suture (PDS). Demographics, clinical details, and outcomes were compared using Kruskal-Wallis and chi-square tests. Results: Of the 116 patients who underwent repair, 45 had bars secured with ZipFix (39%) and 71 (61%) were historical controls (35 stabilizer, 36 PDS). Median (interquartile range) age was 15 (14-16) years and Haller index was 3.9 (3.6-4.5). Nine (8%) patients required two bars. Haller index and use of second bar were comparable between stabilization techniques (P > .05). In total, 49 patients (40%) reported any pain at 1 month and this was similar between stabilization techniques (P = .45). Median bar movement was greater for bars secured with PDS than with ZipFix or stabilizers at 1 month (5.5 versus 2.3 versus 3.3°, P = .010) and last follow-up (6.5 versus 2.1 versus 3.6°, P < .001). One patient whose bar was secured with PDS required revision for dislodgement. Conclusion: Pectus bar stabilization with ZipFix is a safe alternative to metal stabilizers and both techniques are superior to suture stabilization alone. The use of ZipFix may be preferred given its lower cost and ease of use.
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Affiliation(s)
- Swathi R Raikot
- Division of Pediatric Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephanie F Polites
- Division of Pediatric Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - D Dean Potter
- Division of Pediatric Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Carter M, Hua R, Pitt JB, Zeineddin S, Perez A, Sands L, Kujawa S, Lehane A, Stake C, Reynolds M, Abdullah F, Goldstein SD. Utility of White Light Scanning as an Alternative to Computed Tomography to Evaluate Severity of Pectus Excavatum Deformity. J Pediatr Surg 2024; 59:1694-1702. [PMID: 38772759 DOI: 10.1016/j.jpedsurg.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/15/2024] [Accepted: 04/23/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Pectus excavatum (PE) severity and surgical candidacy are determined by computed tomography (CT)-delineated Haller Index (HI) and Correction Index (CI). White light scanning (WLS) has been proposed as a non-ionizing alternative. The purpose of this retrospective study is to create models to determine PE severity using WLS as a non-ionizing alternative to CT. METHODS Between November 2015 and February 2023, CT and WLS were performed for children ≤18 years undergoing evaluation at a high-volume, chest-wall deformity clinic. Separate quadratic discriminate analysis models were developed to predict CT HI ≥ 3.25 and CT CI ≥ 28% indicating surgical candidacy. Two bootstrap forest models were trained on WLS measurements and patient demographics to predict CT HI and CT CI values then compared to actual index values by intraclass correlation coefficient (ICC). RESULTS In total, 242 patients were enrolled (86.4% male, mean [SD] age 15.2 [1.3] years). Quadratic discriminate analysis models predicted CT HI ≥ 3.25 with specificity = 91.7%, PPV = 97.7% (AUC = 0.91), and CT CI ≥ 28% with specificity = 92.3%, PPV = 93.5% (AUC = 0.84). Bootstrap forest model predicted CT HI with training dataset ICC (95% CI) = 0.91 (0.88-0.93, R2 = 0.85) and test dataset ICC (95% CI) = 0.86 (0.71-0.94, R2 = 0.77). For CT CI, training dataset ICC (95% CI) = 0.91 (0.81-0.93, R2 = 0.86) and test dataset ICC (95% CI) = 0.75 (0.50-0.88, R2 = 0.63). CONCLUSIONS Using noninvasive and nonionizing WLS imaging, we can predict PE severity at surgical threshold with high specificity obviating the need for CT. Furthermore, we can predict actual CT HI and CI with moderate-excellent reliability. We anticipate this point-of-care tool to obviate the need for most cross-sectional imaging during surgical evaluation of PE. LEVEL OF EVIDENCE Level III. STUDY TYPE Study of Diagnostic Test.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.
| | - Rui Hua
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Shirley Ryan AbilityLab, Chicago, IL, United States
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Amparo Perez
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Laurie Sands
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Suzanne Kujawa
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Alison Lehane
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Christine Stake
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Marleta Reynolds
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University's Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
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Vaishnav J, Sharma S, Balakrishnan S. Embryonic Thyroid Hormone Insufficiency Causes Structural Anomalies in the Embryo of Domestic Chick, Gallus domesticus. Anat Histol Embryol 2024; 53:e13106. [PMID: 39282744 DOI: 10.1111/ahe.13106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 08/09/2024] [Accepted: 08/31/2024] [Indexed: 09/26/2024]
Abstract
Thyroid hormone (TH) is essential for growth and development, yet its specific role during embryogenesis remains incompletely understood. This study investigates the impact of TH deficiency, induced by thiourea, a known inhibitor of thyroid peroxidase (TPO), on the development of domestic chicks. Thiourea was administered before thyroid gland formation, and its presence in treated embryos was confirmed through liquid chromatography-mass spectrometry. In silico docking revealed a strong interaction between thiourea and the CCP-like domain of TPO, which was corroborated by TPO activity assays showing reduced enzyme function. This reduction in enzyme activity led to lower embryonic TH levels and increased thyroid-stimulating hormone (TSH) secretion. Morphological analysis of newly hatched chicks revealed significant structural anomalies, particularly in lateral plate mesoderm-derived structures, including omphalocele, limb deformities, anophthalmia and craniofacial defects. Alcian blue and Alizarin red staining demonstrated reduced ossification in ribs and forelimbs, while histological analysis showed incomplete abdominal wall closure and abnormal vertebral column development. Haematological profiling of TH-deficient newly hatched chicks revealed significantly lower blood cell counts, highlighting TH's critical role in haematopoiesis. These findings emphasise the multifaceted role of TH in embryonic development, with potential implications for understanding congenital hypothyroidism and its developmental impacts, especially in regions with limited healthcare access.
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Affiliation(s)
- Juhi Vaishnav
- Dr. Vikram Sarabhai Institute of Cell and Molecular Biology, Faculty of Science, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India
| | - Shashikant Sharma
- Department of Zoology, Faculty of Science, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India
| | - Suresh Balakrishnan
- Dr. Vikram Sarabhai Institute of Cell and Molecular Biology, Faculty of Science, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India
- Department of Zoology, Faculty of Science, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India
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Wharton K, Chidiac C, Lopez C, Hunsberger J, Rhee D, Cappiello C, Garcia AV. Enhanced Recovery After Surgery 2.0: Optimizing Pain Management in Nuss Procedure: Cryoablation and Nerve Block Strategies for Reduced Opioid Use. J Surg Res 2024; 301:563-571. [PMID: 39053171 DOI: 10.1016/j.jss.2024.07.003] [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: 10/24/2023] [Revised: 06/24/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Our study assesses the association between cryoablation, with and without nerve block supplementation, post-Nuss procedure pain, and opioid use in pectus excavatum (PE) patients. METHODS We conducted a retrospective cohort study at a single center for PE patients who underwent the Nuss procedure from 2017 to 2022. Outcomes included postoperative opioid use (measured in oral morphine milligram equivalent per kilogram [OME/kg]), average pain score (scale 0-10), and length of stay (LOS). RESULTS One hundred sixty-four patients (146 males and 18 females) were included, with 79 (48.2%) receiving neither cryoablation nor nerve block, 60 (36.6%) receiving intraoperative cryoablation alone, and 25 (15.2%) receiving both cryoablation and nerve block. The median age was 16 y. Nerve block recipients consumed fewer opioids during hospitalization than cryoablation alone and nonintervention groups (1.5 versus 2.3 versus 5.8 OME/kg, respectively, P < 0.0001). Average pain scores over the total LOS were lower in nerve block recipients (3.5 versus 3.8 versus 4.2, P = 0.03), particularly on postoperative day 0 (P = 0.002). Nerve block recipients had a shorter LOS than cryoablation alone and nonintervention groups (43.4 versus 54.7 versus 66.2 h, P < 0.0001). On multivariate analysis, cryoablation alone resulted in significantly less opioid use compared to no intervention (3.32 OME/kg reduction, 95% confidence interval -4.16 to -2.47, P < 0.0001). Addition of nerve block further reduced opioid use by 1.10 OME/kg (95% confidence interval -2.07 to -0.14, P = 0.04). CONCLUSIONS Cryoablation with nerve block supplementation is associated with reduced pain, opioid use, and LOS post-Nuss for PE repair compared to cases without cryoablation or with cryoablation only. Cryoablation with regional nerve blocks should be considered for Nuss repair under the enhanced recovery after surgery pathway.
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Affiliation(s)
- Kristin Wharton
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charbel Chidiac
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carla Lopez
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joann Hunsberger
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel Rhee
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clint Cappiello
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Ran X, Shen W, Li X, Liao J, Yuan H, Wang H, Wu S, Rong S. The individualized treatment for minimally invasive repair of pectus carinatum in adolescent: a single center' s retrospective study. J Cardiothorac Surg 2024; 19:483. [PMID: 39148133 PMCID: PMC11328510 DOI: 10.1186/s13019-024-02910-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/15/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Pectus carinatum (PC) mainly present at the growth spurt time of the early teenage years or the puberty. Poor outer appearance is a major reason for seeking help for surgeons to increase self-confidence and self-esteem. At present, minimally invasive repair (MIR) is one of effective ways to correct the chest wall deformity. Therefore, there is great practical significance to conduct clinical research on MIR about the adolescent PC. METHODS We applied Abramson procedure in PC group or we applied Abramson procedure and Nuss procedure in PC/PE group. We retrospectively reviewed the results of 41 cases who underwent the surgical correction at our department from January 2020 to April 2023. RESULTS All the procedures were successfully done without severe complications. The median operation Time was 80 min in PC group while was 130 min in PC/PE group. The median LOS were 4 days in PC group while 5 days in PC/PE group. The median compression depth was 32 mm in PC group while 12 mm in PC/PE group. Postoperatively, there are some complications. All Pneumothorax patients being treated conservatively were found in 9 patients in two groups. One patient suffered overcorrection after operation. There were 3 patients suffered steel wires breakage in two groups. One patient reoperation postoperatively for the dislocation of the bar secondary to steel wires breakage. CONCLUSIONS The Abramson procedure or Abramson procedure and Nuss procedure have good short-term results in repair PC and PC/PE. Select one or two procedures should be done individually based on whether the lower plane over depressed after Abramson procedure.
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Affiliation(s)
- Xudong Ran
- Cardiothoracic surgery department, children' s hospital of Soochow university, No. 92 Zhongnan Street, Suzhou, 215000, Jiangsu Province, China.
| | - Weijia Shen
- Cardiothoracic surgery department, children' s hospital of Soochow university, No. 92 Zhongnan Street, Suzhou, 215000, Jiangsu Province, China
| | - Xin Li
- Cardiothoracic surgery department, children' s hospital of Soochow university, No. 92 Zhongnan Street, Suzhou, 215000, Jiangsu Province, China
| | - Jianyi Liao
- Cardiothoracic surgery department, children' s hospital of Soochow university, No. 92 Zhongnan Street, Suzhou, 215000, Jiangsu Province, China
| | - Hongliang Yuan
- Cardiothoracic surgery department, children' s hospital of Soochow university, No. 92 Zhongnan Street, Suzhou, 215000, Jiangsu Province, China
| | - Hao Wang
- Cardiothoracic surgery department, children' s hospital of Soochow university, No. 92 Zhongnan Street, Suzhou, 215000, Jiangsu Province, China
| | - Songhua Wu
- Cardiothoracic surgery department, children' s hospital of Soochow university, No. 92 Zhongnan Street, Suzhou, 215000, Jiangsu Province, China
| | - Shuhan Rong
- Cardiothoracic surgery department, children' s hospital of Soochow university, No. 92 Zhongnan Street, Suzhou, 215000, Jiangsu Province, China
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Billar R, Heyman S, Kant S, Wijnen R, Sleutels F, Demirdas S, Schnater JM. Early-Onset Pectus Excavatum Is More Likely to Be Part of a Genetic Variation. Eur J Pediatr Surg 2024; 34:325-332. [PMID: 37100424 PMCID: PMC11226330 DOI: 10.1055/a-2081-1288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/20/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Potential underlying genetic variations of pectus excavatum (PE) are quite rare. Only one-fifth of PE cases are identified in the first decade of life and thus are of congenital origin. The objective of this study is to test if early-onset PE is more likely to be part of genetic variations than PE that becomes apparent during puberty or adolescence. MATERIALS AND METHODS Children younger than 11 years who presented with PE to the outpatient clinic of the Department of Pediatric Surgery at our center between 2014 and 2020 were screened by two clinical geneticists separately. Molecular analysis was performed based on the differential diagnosis. Data of all young PE patients who already had been referred for genetic counseling were analyzed retrospectively. RESULTS Pathogenic genetic variations were found in 8 of the 18 participants (44%): 3 syndromic disorders (Catel-Manzke syndrome and two Noonan syndromes), 3 chromosomal disorders (16p13.11 microduplication syndrome, 22q11.21 microduplication syndrome, and genetic gain at 1q44), 1 connective tissue disease (Loeys-Dietz syndrome), and 1 neuromuscular disorder (pathogenic variation in BICD2 gene). CONCLUSION Early-onset PE is more likely to be part of genetic variations than PE that becomes apparent during puberty or adolescence. Referral for genetic counseling should therefore be considered. TRIAL REGISTRATION NCT05443113.
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Affiliation(s)
- Ryan Billar
- Department of Pediatric Surgery, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Stijn Heyman
- Department of Pediatric Surgery, ZNA, Antwerp Hospital Network, Queen Paola Children's Hospital, Antwerp, Belgium
| | - Sarina Kant
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - René Wijnen
- Department of Pediatric Surgery, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Frank Sleutels
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Serwet Demirdas
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J. Marco Schnater
- Department of Pediatric Surgery, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
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Norlander L, Anderzén-Carlsson A, Vidlund M, Sundqvist AS. Experiences of living with funnel chest prior to corrective surgery: An interview study. PLoS One 2024; 19:e0304968. [PMID: 38995912 PMCID: PMC11244765 DOI: 10.1371/journal.pone.0304968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/19/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVES Pectus excavatum, or funnel chest, causes both physical and psychosocial issues, affecting health-related quality of life. However, the literature on how funnel chest affects daily living prior to corrective surgery is sparse. Therefore, the study aimed to describe the experiences of living with funnel chest prior to correctional surgery. MATERIALS AND METHODS The study had a qualitative exploratory design. Consecutive sampling was applied in which all individuals from a single cardiothoracic department scheduled for the minimally invasive repair of pectus excavatum were asked to participate. Nineteen participants, 17 men and two women, participated in the study. Individual telephone interviews were conducted from February 2020 until April 2021. The interviews were analyzed with qualitative content analysis using an inductive approach. RESULTS The overall theme "To have or not to have a cavity in my chest, it could make a difference" was interpreted as the latent meaning of the participants' experiences. The theme included two subthemes with three categories each. The subtheme "The funnel chest puts a weight on my shoulders" describes the heavy burden the funnel chest places on the participants. The second subtheme, "This is me, but I want to change my future", describes that participants see the funnel chest as a part of themselves; nevertheless, they look forward to surgery and a life without it. CONCLUSION The results emphasize the heavy burden funnel chest causes and the great limitations it places on the individual. It also highlights the importance of surgery and the hope for a better future for individuals with funnel chest.
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Affiliation(s)
- Louise Norlander
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Anderzén-Carlsson
- University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mårten Vidlund
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Ann-Sofie Sundqvist
- University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Mete O, Işik H, Pirinççi CŞ, Yaşa ME, Sapmaz E. Spinal posture, mobility, and position sense in adolescents with chest wall deformities: a comparison of pectus excavatum, pectus carinatum and healthy peers. Pediatr Surg Int 2024; 40:178. [PMID: 38970642 PMCID: PMC11227458 DOI: 10.1007/s00383-024-05759-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/08/2024]
Abstract
PURPOSE The study aimed to compare spinal posture, mobility, and position sense in adolescents with pectus excavatum (PE), pectus carinatum (PC), and healthy control (HC). METHODS 22 with PE, 22 with PC, and 21 HC were included in the study. The spinal posture (thoracic kyphosis, lumbar lordosis, pelvic tilt, thoracic, lumbar, pelvic lateral tilt angles) and mobility (thoracic, lumbar, hip/sacral, and overall, in the sagittal and frontal plane) with the spinal mouse, and spinal position sense (repositing errors) with the inclinometer were assessed. RESULTS The thoracic kyphosis angle of PE and PC was higher than in HC (p < 0.001; p = 0.001). Hip/sacral mobility in the sagittal plane was lower in the PE and PC than control, respectively (p < 0.001; p < 0.001). Overall sagittal spinal mobility (p:0.007) and hip/sacral mobility in the frontal plane (p:0.002) were lower in the PC than in HC. Overall frontal spinal mobility was lower in the PE and PC than in HC (p:0.002; p:0.014). The PE and PC repositing errors were higher (p < 0.001; p:0.014). CONCLUSION The study found that adolescents with PE and PC had decreased spinal mobility, spinal alignment disorders, and a decline in spinal position sense. It is important not to overlook the spine during physical examinations of adolescents with chest wall deformities. In clinical practice, we suggest that adolescents with chest deformities should undergo a spine evaluation and be referred for physical therapy to manage spinal disorders.
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Affiliation(s)
- Oguzhan Mete
- Cardiopulmonary Physiotherapy and Rehabilitation Department, Gülhane Faculty of Physiotherapy and Rehabilitation, University of Health Sciences, Ankara, Turkey.
| | - Hakan Işik
- Department of Thoracic Surgery, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Cansu Şahbaz Pirinççi
- Cardiopulmonary Physiotherapy and Rehabilitation Department, Gülhane Faculty of Physiotherapy and Rehabilitation, University of Health Sciences, Ankara, Turkey
| | - Mustafa Ertuğrul Yaşa
- Cardiopulmonary Physiotherapy and Rehabilitation Department, Gülhane Faculty of Physiotherapy and Rehabilitation, University of Health Sciences, Ankara, Turkey
| | - Ersin Sapmaz
- Department of Thoracic Surgery, Gülhane Training and Research Hospital, Ankara, Turkey
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11
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Karamitros G, Kakogeorgou V, Chandler NM, Goulas S. Evaluating the web as a source of information for patients with chest wall deformities: insights into engagement and disparities. Pediatr Surg Int 2024; 40:150. [PMID: 38833023 DOI: 10.1007/s00383-024-05732-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Recent data highlight the internet's pivotal role as the primary information source for patients. In this study, we emulate a patient's/caregiver's quest for online information concerning chest deformities and assess the quality of available information. METHODS We conducted an internet search using combination of the terms "pectus excavatum," "pectus excavatum surgery," "funnel chest," "pectus excavatum repair" and identified the first 100 relevant websites from the three most popular search engines: Google, Yahoo, and Bing. These websites were evaluated using the modified Ensuring Quality Information for Patients (EQIP) instrument. RESULTS Of the 300 websites generated, 140 (46.7%) were included in our evaluation after elimination of duplicates, non-English websites, and those targeting medical professionals. The EQIP scores in the final sample ranged from 8 to 32/36, with a median score of 22. Most of the evaluated websites (32.8%) originated from hospitals, yet none met all 36 EQIP criteria. DISCUSSION None of the evaluated websites pertaining to pectus excavatum achieved a flawless "content quality" score. The diverse array of websites potentially complicates patients' efforts to navigate toward high-quality resources. Barriers in accessing high-quality online patient information may contribute to disparities in referral, patient engagement, treatment satisfaction, and overall quality of life. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Georgios Karamitros
- Division of Plastic Surgery, Department of Surgery, University Hospital of Ioannina, Ioannina, Greece.
- Medical School, Department of Plastic Surgery, University of Ioannina, Stavrou Niarchou Avenue, 45500, Ioannina, Greece.
| | - Vasiliki Kakogeorgou
- Department of Orthopaedics, General Hospital of Nea Ionia "Konstantopouleio", Nea Ionia, Greece
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Sofoklis Goulas
- Brookings Institution, Washington, DC, USA
- Hoover Institution, Stanford University, Stanford, CA, USA
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12
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Song WY, Zhou Y, Wu C, Pan ZX, Li YG. A preliminary study on the normal values of the thoracic Haller index in children. Eur J Cardiothorac Surg 2024; 65:ezae143. [PMID: 38588563 DOI: 10.1093/ejcts/ezae143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/21/2024] [Accepted: 04/06/2024] [Indexed: 04/10/2024] Open
Abstract
OBJECTIVES The Haller index (HI) is widely utilized as a quantitative indicator to assess the extent of the pectus excavatum (PE) deformity, which is the most common chest wall abnormality in children. Both preoperative correction planning and postoperative follow-up need to be based on the standard of normal thoracic growth and development. However, there is currently no established reference range for the HI in children. Consequently, the goal of this study was to conduct a preliminary investigation of normal HI values among children to understand thoracic developmental characteristics. METHODS Chest computed tomography images obtained from January 2012 to March 2022 were randomly selected from the imaging system of the Children's Hospital of Chongqing Medical University. We divided the images of children into a total of 19 groups: aged 0-3 months (1 group), 4-12 months (1 group) and 1 year to 17 years (17 groups), with 50 males and 50 females, totaling 100 children in each group. HI was measured in the plane where the lowest point of the anterior thoracic wall was located and statistically analysed using SPSS 26.0 software. RESULTS A total of 1900 patients were included in the study. Our results showed that HI, transverse diameter and anterior-posterior diameter were positively correlated with age (P < 0.05). Using age as the independent variable and HI as the dependent variable, the best-fit regression equations were HI-male = 2.047 * Age0.054(R2 = 0.276, P<0.0001) and HI-female = 2.045 * Age0.067(R2 = 0.398, P<0.0001). Males had significantly larger thoracic diameters than females, and there was little difference in the HI between the 2 sexes. CONCLUSIONS The HI rapidly increases during the neonatal period, slowly increases during infancy and stops increasing during puberty, with no significant differences between the sexes.
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Affiliation(s)
- Wan-Yi Song
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Zhou
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chun Wu
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng-Xia Pan
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yong-Gang Li
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
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13
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Galbis Caravajal JM, Estors Guerrero M, Martinez Hernández N. Pectus excavatum. Surgical treatment: Structural or aesthetic? Cir Esp 2024; 102:252-256. [PMID: 38492888 DOI: 10.1016/j.cireng.2024.02.005] [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: 12/23/2023] [Accepted: 02/02/2024] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Pectus excavatum is a wall deformity that often warrants medical evaluation. In most cases, it's a purely visual aesthetic alteration, while in others, it comes with symptoms. Several surgical techniques have been described, but their outcomes are difficult to assess due to the heterogeneity of presentations and the lack of long-term follow-up. We present our experience as thoracic surgeons, assessing correction as either structural (remodeling of the thoracic cage through open surgery) or aesthetic (design and implantation of a customized 3D prosthesis). MATERIAL AND METHODS Retrospective observational study of the indication for surgical treatment of pectus excavatum carried out by a team of thoracic surgeons and the short- to mid-term results. RESULTS Between 2021 and 2023, we treated 36 cases surgically, either through thoracic cage remodeling techniques or with 3D prostheses. There were few minor complications, and the short- to mid-term results were positive: alleviation of symptoms or compression of structures when present, or aesthetic correction of the defect in other cases. CONCLUSIONS Surgery for pectus excavatum should be evaluated for structural correction of the wall or aesthetics. In the former, thoracic cage remodeling requiring cartilage excision and possibly osteotomies is necessary. In the latter, the defect is corrected with a customized 3D prosthesis.
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Affiliation(s)
- José M Galbis Caravajal
- Cirugía Torácica, Hospital La salud, Valencia, Spain; Cirugía Torácica, Hospital Universitario de La Ribera, Alcira, Valencia, Spain.
| | - Miriam Estors Guerrero
- Cirugía Torácica, Hospital La salud, Valencia, Spain; Cirugía Torácica, Hospital Universitario de La Ribera, Alcira, Valencia, Spain
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14
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Glenski TA, Taylor CM, Weisberg EL, Doyle NM, Melanson A. The implementation of a pectus bar insertion enhanced recovery after surgery pathway: A quality improvement initiative. Paediatr Anaesth 2024; 34:422-429. [PMID: 38217340 DOI: 10.1111/pan.14838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Pectus excavatum repair is associated with significant discomfort, and pain is a primary contributor to postoperative hospital length of stay. Recent advances in postoperative pain control include the use of intercostal cryoablation techniques that may now make it possible to discharge patients on the day of surgery. Unnecessary variation in patient care and noncompliance with care bundles may be a factor in extended length of stay. The global aim of this quality improvement initiative was to successfully implement an enhanced recovery after surgery (ERAS) pathway on patients undergoing pectus excavatum repair. The SMART aim was to have a greater than 70% compliance for the perioperative bundle elements within 1 year of the pathway implementation. METHODS Multiple Plan-Do-Study-Act (PDSA) cycles were designed to create and implement an ERAS pathway for patients undergoing a pectus bar insertion procedure. This multidisciplinary pathway was designed, managed, and implemented with key stakeholders from the Departments of Evidence Based Practice, Surgery, Anesthesiology, and Perioperative Nursing. Patient characteristics, outcomes, and compliance with elements of the pathway were measured for analysis for both the baseline and post-intervention groups with monthly automated reports. RESULTS After implementation of the ERAS pathway, data on the first 50 patients showed a 90% compliance with the perioperative bundle elements. Mean length of stay was significantly decreased from 33 h (95% CI [28.76, 37.31]) to 18 h (95% CI [14.54, 21.70]). There were zero readmissions within 24 hours for patients who were discharged on the day of surgery. CONCLUSION Employing a multidisciplinary approach in both planning and execution that standardized clinician practices and minimized unnecessary variation in patient care, an ERAS pathway for pectus bar insertion has been successfully established at our institution.
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Affiliation(s)
- Todd A Glenski
- Department of Anesthesiology, Department of Evidence Based Practice, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Christian M Taylor
- Department of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Emily L Weisberg
- Department of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Nichole M Doyle
- Department of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Andrea Melanson
- Department of Evidence Based Practice, Children's Mercy Kansas City, Kansas City, Missouri, USA
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15
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Endo Y, Shimamura Y, Niinami H. Mitral Valve Regurgitation in Klippel-Feil Syndrome With Related Thoracic Deformity. Tex Heart Inst J 2024; 51:e238282. [PMID: 38665003 PMCID: PMC11075515 DOI: 10.14503/thij-23-8282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
Klippel-Feil syndrome, characterized by congenital fusion of any 2 or more cervical vertebrae, is a rare disorder in which skeletal and other organ system-related abnormalities have been reported. This article reports a case of mitral valve regurgitation in a patient with Klippel-Feil syndrome and related thoracic deformity who underwent mitral valvuloplasty. Postoperatively, the mitral valve regurgitation disappeared, and there has been no recurrence for 3 years. This case highlights mitral valvuloplasty via median sternotomy as an excellent treatment for mitral valve regurgitation in a patient with thoracic deformity related to Klippel-Feil syndrome.
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Affiliation(s)
- Yuki Endo
- Department of Cardiovascular Surgery, Saitama City Hospital, Saitama City, Saitama, Japan
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Yoshiei Shimamura
- Department of Cardiovascular Surgery, Saitama City Hospital, Saitama City, Saitama, Japan
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, Tokyo, Japan
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16
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Piro L, Lena F, Roggero A, Stagnaro N, Mattioli G, Torre M. Sternal cleft and pectus excavatum: an overlooked congenital association? Pediatr Surg Int 2024; 40:105. [PMID: 38602580 DOI: 10.1007/s00383-024-05686-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Sternal cleft (SC), a rare thoracic malformation, is associated with pectus excavatum (PE) in 2.6-5% of cases. It remains unclear if these conditions are congenitally linked or if SC repair triggers PE. To investigate the potential higher frequency of PE in SC cases, we conducted a retrospective study of our SC patients. METHODS We assessed PE incidence, progression, and management in SC patients treated at our institute from 2006 to 2022. When available, we collected pre-SC repair CT scan data, calculating the Haller Index (HI) and Correction Index (CI) and compared them to a selected control group. RESULTS Among 8 SC patients, 7 had concomitant PE (87.5%), varying in severity. PE management ranged from observation to thoracoplasty, depending on its degree. We observed a significant pre-operative CI difference between SC and control group patients (p < 0.00001). In the last two SC repair cases, we attempted concurrent PE prevention or treatment. CONCLUSION Our findings suggest an underestimated association between PE and SC in the existing literature. SC patients may exhibit a predisposition to PE from birth, which may become more apparent with growth after SC repair. Consequently, PE prevention or treatment should be considered during SC repair procedures.
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Affiliation(s)
- Liliana Piro
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy.
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science, University of Genoa, Genoa, Italy.
| | - Federica Lena
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science, University of Genoa, Genoa, Italy
| | - Arianna Roggero
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science, University of Genoa, Genoa, Italy
| | - Nicola Stagnaro
- Department of Radiology, IRCCS Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
| | - Girolamo Mattioli
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science, University of Genoa, Genoa, Italy
| | - Michele Torre
- Pediatric Surgery Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
- Pediatric Thoracic and Airway Surgery Unit, IRCCS Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
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17
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Keong DE, Tzeng IS, Htut N, Fan YJ, Hsieh MS, Cheng YL. Impact of delayed removal of pectus bar on outcomes following Nuss repair: a retrospective analysis. J Cardiothorac Surg 2024; 19:160. [PMID: 38549167 PMCID: PMC10976664 DOI: 10.1186/s13019-024-02685-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 03/24/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Usually, pectus bars are removed 3 years after the Nuss procedure in patients with pectus excavatum. However, the optimal timing for postoperative pectus bar removal remains undefined. Our study investigated the effects of delayed pectus bar removal after Nuss repairs. METHODS Retrospective data were collected on patients who underwent Nuss procedures for pectus excavatum and had their bars removed from August 2014 to December 2020. Patients with correction periods > 3 years were divided into group A (< 6 years) and group B (≥ 6 years). Propensity score matching was used to compare complications and radiological outcomes associated with bar removal. RESULTS Of the 542 patients who underwent bar removal, 451 (Group A: 419 patients, Group B: 32) had correction duration > 3 years. The average correction duration was 4.5 ± 1.4 years. After propensity score matching analysis, group B [median duration: 8.0 (6.0-16.2) years] exhibited significantly longer median operative times (85 vs. 55 min; P = 0.026), higher callus formation rates (68.8% vs. 46.9%; P = 0.029), and greater median intraoperative blood loss (35 vs. 10 mL; P = 0.017) than group A [median duration: 4.2 (3.0-5.9) years]. However, following bar removal, the groups showed no statistical differences in the surgical complication rates (group A: 6.3% vs. group B: 9.4%; P = 0.648) or median ratio of radiological improvement (an improvement on the Haller index on chest radiography; 21.0% vs. 22.2%; P = 0.308). CONCLUSIONS Delaying pectus bar removal after Nuss repair presents certain challenges but does not compromise overall outcomes. These findings suggest that a longer correction period may be unnecessary. However, further multicenter studies with long-term follow-up are warranted to assess long-term outcomes.
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Affiliation(s)
- Der-En Keong
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | | | - Nay Htut
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Yu-Jiun Fan
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Min-Shiau Hsieh
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Yeung-Leung Cheng
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.
- School of Medicine, Tzu Chi University, Hualien, Taiwan.
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18
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Htut N, Tzeng IS, Fan YJ, Cheng YL. Body measurement changes in adults with pectus excavatum after the Nuss procedure: a study of 272 patients. J Cardiothorac Surg 2024; 19:65. [PMID: 38321519 PMCID: PMC10845464 DOI: 10.1186/s13019-024-02573-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 01/30/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Pectus excavatum (PE) is the most common congenital abnormality of the chest wall. Most patients with PE have slim bodies. Some studies have been conducted on the physical growth of children and adolescents who underwent the Nuss procedure. This study aimed to evaluate body measurement changes in adult patients with PE after the Nuss procedure. METHODS A total of 272 adult PE patients, who underwent the Nuss procedure and pectus bars removal from August 2014 to December 2020, were evaluated retrospectively. Body measurement [body height (BH), body weight (BW), and body mass index (BMI)] of the patients were collected before Nuss repair and after bar removal. We used the interquartile range (IQR) to identify and exclude outliers. Associations between changes in body measurement and clinical and radiological features were evaluated. RESULTS The BH, BW and BMI showed significantly increased after pectus bar removal, compared to pre-Nuss procedure parameters (BH 173.8 ± 5.9 cm vs. 173.9 ± 5.9 cm, P < 0.001; BW 60.3 ± 8.1 kg vs. 61.1 ± 8.8 kg, P = 0.005; BMI 19.9 ± 2.2 kg/m2 vs. 20.1 ± 2.4 kg/m2, P = 0.02). The same result were observed in the male subgroup, the HI ≥ 4 group and the male subgroup within the HI ≥ 4 group. CONCLUSIONS The BH, BW and BMI were significantly increased after completing surgical correction of PE using the Nuss procedure, particularly in young males and patients with more pronounced deformities.
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Affiliation(s)
- Nay Htut
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - I-Shiang Tzeng
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- Department of Statistics, National Taipei University, New Taipei City, Taiwan
| | - Yu-Jiun Fan
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Yeung-Leung Cheng
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.
- School of Medicine, Tzu Chi University, Hualien, Taiwan.
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Masai K, Nakai T, Okubo Y, Kaseda K, Hishida T, Asakura K. Nuss procedure for the treatment of pectus excavatum with dyspnea following oropharyngeal cancer surgery: a case report. J Surg Case Rep 2024; 2024:rjad714. [PMID: 38250131 PMCID: PMC10799248 DOI: 10.1093/jscr/rjad714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Pectus excavatum (PE) causes cardiopulmonary dysfunction depending on the degree and form of the depression. The patient was a 74-year-old woman with a history of PE. Fourteen years ago, a total glossolaryngectomy was performed for oropharyngeal cancer. Two years later, the patient gradually experienced difficulty in breathing. Computed tomography (CT) revealed severe PE and right main bronchial stenosis. We performed a Nuss procedure for PE repair to surgically release the stenosis of the right main bronchus. Postoperative chest CT showed improvement in the sternal depression and right main bronchial stenosis. Furthermore, shortness of breath was relieved postoperatively. Oropharyngeal cancer surgery may cause tracheal support disruption, leading to leftward shift and severe stenosis of the right main bronchus due to sternum depression. This is an important report regarding respiratory distress caused by a combination of PE and post-oropharyngeal cancer surgery.
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Affiliation(s)
- Kyohei Masai
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Taketo Nakai
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yu Okubo
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Kaoru Kaseda
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Tomoyuki Hishida
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Keisuke Asakura
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
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Pitt JB, Zeineddin S, Carter M, Perez A, Sands L, Kujawa S, Reynolds M, Abdullah F, Goldstein SD. Demographics of Anterior Chest Wall Deformity Patients: A Tertiary Children's Hospital Experience. J Surg Res 2024; 293:451-457. [PMID: 37827024 DOI: 10.1016/j.jss.2023.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Anterior chest wall deformities consist of abnormal development of the chest, with the most common congenital deformities being pectus excavatum (PE) and pectus carinatum (PC). Surgical series are common, but less research is present assessing the demographics of all who present for initial evaluation. The purpose of this study is to describe the patient characteristics of those who present for ambulatory surgical evaluation. METHODS Data were collected from initial patient visits to an established multispecialty chest wall deformities program at a large Children's Hospital from 2017 to 2021. Variables assessed included primary diagnosis, age, sex, race/ethnicity, and whether surgical correction was performed. RESULTS A total of 1510 children were evaluated: 50.0% (n = 755) with PE, 43.3% (n = 653) with PC, 2.7% (n = 41) with mixed chest wall deformities, 0.7% (n = 10) with Poland syndrome, 1.1% (n = 17) with Currarino-Silverman syndrome, and 2.3% (n = 34) with other anterior chest wall deformities. Males and females presented at mean age of 12.8 (4.2) and 10.9 (5.5) years, respectively (P = 0.001). White children represented 61.1% of the overall population while Hispanic children represented 26.3%. White, non-Hispanic children represented 61.9% and 71.5% and Hispanic children represented 26.0% and 26.3% of the PE and PC populations, respectively. CONCLUSIONS Most patients seen in an urban chest wall deformities clinic were White, non-Hispanic; however, the proportion of other groups such as Hispanic and Asian is greater in this cohort than previously described. Further research is ongoing to ascertain the extent to which disease predisposition versus access to care play roles in this population.
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Affiliation(s)
- J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Amparo Perez
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Laurie Sands
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suzanne Kujawa
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Marleta Reynolds
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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21
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Oka N, Masai K, Okubo Y, Kaseda K, Hishida T, Asakura K. Combined Ravitch and Nuss procedure for pectus excavatum with dyspnea following scoliosis repair. J Surg Case Rep 2023; 2023:rjad618. [PMID: 37965534 PMCID: PMC10641290 DOI: 10.1093/jscr/rjad618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 10/23/2023] [Indexed: 11/16/2023] Open
Abstract
Pectus excavatum (PE) is often associated with scoliosis and can elicit cardiovascular disturbances under rare conditions. Here we report a patient who was treated with a combined Ravitch and Nuss procedure for PE with dyspnea following scoliosis repair to improve her symptoms. The patient was a 49-year-old woman with a history of PE and scoliosis. Right inferior pulmonary vein stenosis was caused by posterior spinal fusion for scoliosis prior to the PE repair. We could safely correct the chest wall deformity and treat dyspnea by performing a modified Ravitch repair in combination with the Nuss procedure.
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Affiliation(s)
- Naoyuki Oka
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kyohei Masai
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yu Okubo
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kaoru Kaseda
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomoyuki Hishida
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Keisuke Asakura
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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22
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Breglio AM, Fitzgerald TN, Moore CB, Einhorn LM. Evaluation of Analgesic Practice Changes Following the Nuss Procedure in Pediatric Patients. J Surg Res 2023; 291:289-295. [PMID: 37481964 PMCID: PMC10528185 DOI: 10.1016/j.jss.2023.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 05/26/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Pectus excavatum repair by the Nuss procedure results in severe postoperative pain. Regional blocks and intercostal nerve cryoablation (INC) have emerged as potential strategies to manage analgesia. This study compares pain-related outcomes following these perioperative interventions. METHODS We reviewed charts of patients <18 y who underwent the Nuss procedure at Duke Children's Hospital from July 2018 to June 2022. Patients were divided into three groups by analgesic strategy: no block, regional catheters, or INC, representing the chronologic change in our practice. The primary outcome was total and daily in-hospital opioid utilization measured by oral morphine equivalents (OMEs). Secondary outcomes included average daily pain scores, length of stay, opioid refills after discharge, and complications. RESULTS Twenty-one patients were included and analyzed: no block (n = 6), regional catheters (n = 7), and INC (n = 8). INC-treated patients required significantly lower total postoperative, in-hospital OMEs (64 ± 47 [mean ± standard deviation]) than those with no block (270 ± 217, P = 0.04) or those with regional catheters (273 ± 176, P = 0.03). INC was associated with longer average operative times (161 ± 36 min) than no block (105 ± 21 min, P = 0.005) or regional catheters (90 ± 11 min, P < 0.001). INC-treated patients had shorter hospital length of stays (median 68 h) than those with regional catheters (median 74 h, P = 0.006). CONCLUSIONS INC was associated with longer operative times but decreased in-hospital OMEs when compared to bilateral regional block catheters and multimodal analgesia alone.
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Affiliation(s)
- Andrew M Breglio
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Carrie B Moore
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Lisa M Einhorn
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
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23
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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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24
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AlHarbi Y. Anatomical Variations in the Pectoralis Minor Muscle Origin and Insertion: A Systematic Review. Cureus 2023; 15:e46329. [PMID: 37916251 PMCID: PMC10617980 DOI: 10.7759/cureus.46329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2023] [Indexed: 11/03/2023] Open
Abstract
The pathology of the shoulder is among the most widespread medical presentations and may be a result of existing anatomical variations. Therefore, the knowledge of the variations is vital for physicians and clinicians, tasked with treating patients presenting similar complaints to minimize misdiagnosis and prevent iatrogenic injuries. Therefore, the main objective of the present systematic review the variations in pectoralis minor muscle origin and insertion/attachment point. The study also seeks to better inform physicians and clinicians of the task of treating patients with various pathology problems and to ascertain that, upon identification, the pectoralis minor muscle variants are aptly appreciated. The search method used in this systematic review entails the use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, and the searching of several online databases, for studies focusing on variations in pectoralis minor muscles. The author reviewer evaluated the studies for eligibility, and the selection criteria for the studies used are described below. This systematic review has disclosed that, in some individuals, the pectoralis minor muscles have their origins in the second, third, and fourth ribs, even as others have their origin in the third and fourth ribs. Still, the systematic review has disclosed that, in certain individuals, the insertion of the pectoralis minor muscle occurs at the supraspinatus tendon, even as there are anomalies in the pectoralis minor insertion points linked to subacromial impingement, possible compression of the brachial plexus anteromedial and the axillary artery, and the subcoracoid impingement.
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Affiliation(s)
- Yasser AlHarbi
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Jeddah, SAU
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25
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Eldredge RS, McMahon L. Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review. Front Surg 2023; 10:1235120. [PMID: 37693640 PMCID: PMC10484532 DOI: 10.3389/fsurg.2023.1235120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature. Methods An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if p-value was <0.05. Results A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC. Conclusion The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE.
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Affiliation(s)
| | - Lisa McMahon
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ, United States
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26
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Katrancioglu O, Ozgel M, Inceoglu F, Katrancioglu N, Sahin E. Is there a relationship between Haller Index and cardiopulmonary function in children with pectus excavatum? TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:367-373. [PMID: 37664765 PMCID: PMC10472459 DOI: 10.5606/tgkdc.dergisi.2023.24088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/17/2022] [Indexed: 09/05/2023]
Abstract
Background This study aims to systematically examine the cardiopulmonary functions in children with pectus excavatum and to compare the obtained findings with the Haller Index. Methods Between September 2017 and June 2018, medical records of a total of 31 patients (27 males, 4 females; mean age: 14.8±2.0 years; range, 9 to 18 years) with pectus excavatum were retrospectively analyzed. The patients were divided into Group 1 (<2.5), Group 2 (2.5 to 3.19), and Group 3 (>3.2) according to the Haller Index. All groups were systematically evaluated based on pulmonary function tests and echocardiography. Forced vital capacity, forced expiratory volume in 1 second, and the forced expiratory volume in 1 second/ forced vital capacity ratio were calculated. Left ventricular enddiastolic diameter, ejection fraction, mitral valve prolapses, and right ventricular cavity in the apical four-chamber position were evaluated with echocardiography. Results Of the patients, 19.4% were in Group 1, 38.7% in Group 2, and 41.9% in Group 3. The mean Haller Index value was 3.09±0.64. According to pulmonary function test results, 16.1% of the patients had restrictive disease and 6.5% had obstructive disease. There was a negative correlation between the index and forced expiratory volume in 1 second and forced vital capacity, and there was a statistically significant decrease in these values, as the Haller Index increased (p<0.017). There was a significant difference in the ejection fraction among the groups (p<0.001) and, as the Haller Index increased, ejection fraction statistically significantly decreased. Conclusion Our study results show a negative correlation between the severity of pectus excavatum and pulmonary dysfunction and, as the severity increases, left ventricular function may be affected by the deformity. As a result, there seems to be a significant relationship between the severity of the deformity and cardiopulmonary functions.
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Affiliation(s)
- Ozgur Katrancioglu
- Department of Thoracic Surgery, Turgut Özal University Faculty of Medicine, Malatya, Türkiye
| | - Mehmet Ozgel
- Department of Thoracic Surgery, Turgut Özal University Faculty of Medicine, Malatya, Türkiye
| | - Feyza Inceoglu
- Department of Biostatistics, Turgut Özal University Faculty of Medicine, Malatya, Türkiye
| | - Nurkay Katrancioglu
- Department of Cardiovascular Surgery, Turgut Özal University Faculty of Medicine, Malatya, Türkiye
| | - Ekber Sahin
- Department of Thoracic Surgery, Medical Point Hospital, Gaziantep, Türkiye
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27
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What Is the Appropriate Timing for Bar Removal After the Nuss Repair for Pectus Excavatum? J Surg Res 2023; 285:136-141. [PMID: 36669392 DOI: 10.1016/j.jss.2022.12.029] [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: 04/02/2022] [Revised: 12/07/2022] [Accepted: 12/24/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The Nuss procedure for pectus excavatum requires that the sternal elevation be maintained by indwelling metal bars that are traditionally removed approximately 3 y after the repair. METHODS A retrospective cohort study was conducted of all patients who underwent primary Nuss repair from 2007 to 2018 in two institutions and had a follow-up of at least 24 mo. Pectus bars had been left in place beyond 3 y in patients concerned over possible recurrence after bar removal. Structured interviews were held to assess pain, chest tightness, or other discomfort, and any adverse events related to pectus bars. Results were compared between patients in whom pectus bars were removed after 3 y (standard group) and those in whom bars were left in place longer (extended bar duration group). RESULTS Two hundred and thirty-one patients (91% males, mean age 23.9 ± 8.3, mean Haller index 4.9 ± 2.3) were included. Bar duration was 30.6 ± 6.6 mo in the standard group (51 patients) versus 69.1 ± 26.3 mo in the extended group (180 patients). Some discomfort was reported by 81.6% in the standard group versus 62.9% in the extended group (P = 0.033), and discomfort occurring at least monthly or more often was only reported by 30% in the standard versus 30.3% in the extended group (P = 1.000). Quality of life improved in 92.6% of the standard group versus 94.7% of the extended group (P = 1.000). No significant adverse events were reported in either group. CONCLUSIONS Our data suggest that an extended bar duration after the Nuss repair may not cause any adverse event nor negatively affect quality of life.
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28
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Malan SH, Jaroszewski DE, Craner RC, Weis RA, Murray AW, Meinhardt JR, Girardo ME, Abdelrazek AS, Borah BJ, Dholakia R, Smith BB. Erector Spinae Plane Block With Liposomal Bupivacaine: Analgesic Adjunct in Adult Pectus Surgery. J Surg Res 2023; 289:171-181. [PMID: 37121043 DOI: 10.1016/j.jss.2023.03.016] [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: 04/29/2022] [Revised: 02/16/2023] [Accepted: 03/16/2023] [Indexed: 05/02/2023]
Abstract
INTRODUCTION Pain management may be challenging in patients undergoing pectus excavatum (PE) bar removal surgery. To enhance recovery, opioid sparing strategies with regional anesthesia including ultrasound-guided erector spinae plane block (ESPB) have been implemented. The purpose of this study was to evaluate the safety and efficacy of bilateral ESPB with a liposomal bupivacaine/traditional bupivacaine mixture as part of an enhanced patient recovery pathway. MATERIALS AND METHODS A retrospective review of adult patients who underwent PE bar removal from January 2019 to December 2020 was performed. Perioperative data were reviewed and recorded. Patients who received ESPB were compared to historical controls (non-ESPB patients). RESULTS A total of 202 patients were included (non-ESPB: 124 patients; ESPB: 78 patients). No adverse events were attributed to ESPB. Non-ESPB patients received more intraoperative opioids (milligram morphine equivalents; 41.8 ± 17.0 mg versus 36.7 ± 17.1, P = 0.05) and were more likely to present to the emergency department within 7 d postoperatively (4.8% versus 0%, P = 0.05) when compared to ESPB patients. No significant difference in total perioperative milligram morphine equivalents, severe pain in postanesthesia care unit (PACU), time from PACU arrival to analgesic administration, PACU length of stay, or postprocedure admission rates between groups were observed. CONCLUSIONS In patients undergoing PE bar removal surgery, bilateral ESPB with liposomal bupivacaine was performed without complications. ESPB with liposomal bupivacaine may be considered as an analgesic adjunct to enhance recovery in patients undergoing cardiothoracic procedures but further prospective randomized clinical trials comparing liposomal bupivacaine to traditional local anesthetics with and without indwelling nerve catheters are necessary.
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Affiliation(s)
- Shawn H Malan
- Adult Cardiothoracic Anesthesiology Fellow, Baylor Scott & White Medical Center, Texas A&M Health Science Center College of Medicine, Temple, Texas
| | - Dawn E Jaroszewski
- Professor of Surgery, Department of Cardiovascular Surgery, Mayo Clinic, Phoenix, Arizona
| | - Ryan C Craner
- Assistant Professor of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Ricardo A Weis
- Assistant Professor of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Andrew W Murray
- Assistant Professor of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | | | | | - Ahmad S Abdelrazek
- Research Fellow, Cardiovascular Surgery Research, Mayo Clinic, Rochester, Minnesota
| | - Bijan J Borah
- Mayo Clinic College of Medicine & Science Robert D. & Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Ruchita Dholakia
- Mayo Clinic College of Medicine & Science Robert D. & Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Bradford B Smith
- Assistant Professor of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona.
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29
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Perez Holguin RA, DeAngelo N, Sinha A, Shen C, Tsai AY. Cost and outcomes of intercostal nerve cryoablation versus thoracic epidural following the Nuss procedure. J Pediatr Surg 2023; 58:608-612. [PMID: 36646539 DOI: 10.1016/j.jpedsurg.2022.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pectus excavatum is the most common congenital chest wall abnormality, with the Nuss procedure being the most commonly performed repair. Pain control is the predominant factor in the postoperative treatment of these patients. This study aims to compare the cost and outcomes of intercostal nerve cryoablation (INC) and thoracic epidural (TE) in patients undergoing the Nuss procedure. METHODS A retrospective chart review was conducted at our institution for all patients who underwent the Nuss procedure for pectus excavatum from 2002 to 2020. Patients were stratified by pain management strategy, INC vs. TE. Chi-square and Fisher's exact were used to compare categorical variables. Wilcoxon tests were used to evaluate continuous variables and costs. RESULTS A total of 158 patients were identified. Of these, 80.4% (N = 127) were treated with epidural, while 19.6% (N = 31) were treated with intercostal nerve cryoablation. The INC group had lower rates of PCA use (35.5% vs. 93.7%, p < 0.001), lower total morphine milligram equivalent requirement (27.0 vs. 290.8, p < 0.001), and shorter length of stay (3.2 days vs. 5.3 days, p < 0.001) compared to the TE group. INC was also associated with longer operative times (153.0 min vs. 89.0 min, p < 0.001). The total hospitalization cost for the INC group was higher compared to the TE group ($24,742.5 vs $21,621.9, p = 0.001). CONCLUSIONS In patients undergoing the Nuss procedure, compared to thoracic epidural, INC was associated with lower opioid use and shorter length of stay but at the cost of longer operative time and increased hospitalization cost. LEVEL OF EVIDENCE Treatment Study, Level III.
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Affiliation(s)
- Rolfy A Perez Holguin
- Division of Outcomes Research and Quality, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA USA
| | - Noah DeAngelo
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC USA
| | | | - Chan Shen
- Division of Outcomes Research and Quality, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA USA
| | - Anthony Y Tsai
- Division of Pediatric Surgery, Penn State Health Children's Hospital, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA USA.
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30
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Sonaglioni A, Nicolosi GL, Trevisan R, Lombardo M, Grasso E, Gensini GF, Ambrosio G. The influence of pectus excavatum on cardiac kinetics and function in otherwise healthy individuals: A systematic review. Int J Cardiol 2023; 381:135-144. [PMID: 37003372 DOI: 10.1016/j.ijcard.2023.03.058] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/28/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND A number of anterior chest wall deformities, most notably pectus excavatum (PE), may have a detrimental effect on cardiac motion and function. Interpretation of transthoracic echocardiography (TTE) and speckle-tracking echocardiography (STE) results may be hampered by the possible influence of PE on cardiac kinetics. METHODS A comprehensive search of all articles assessing cardiac function in PE individuals was carried out. Inclusion criteria were: 1) individuals aged >10 years; 2) studies providing objective assessment of chest deformity (Haller index). Studies that measured myocardial strain parameters in PE patients were also included. RESULTS The search (EMBASE and Medline) yielded a total of 392 studies, 36 (9.2%) of which removed as duplicates; a further 339 did not meet inclusion criteria. The full-texts of 17 studies were then analyzed. All studies concordantly reported impaired right ventricular volumes and function. With respect to left ventricle (LV), TTE studies uniformly demonstrated a significant impairment in conventional echoDoppler indices in PE individuals, whereas STE studies provided conflicting results. Importantly, LV functional alterations promptly reverted upon surgical correction of chest defect. In subjects with PE of mild-to-moderate severity, we observed that degree of anterior chest wall deformity, as noninvasively assessed by modified Haller index (MHI), was strongly associated with myocardial strain magnitude, in heterogenous cohorts of otherwise healthy PE individuals. CONCLUSIONS Clinicians should be aware that in PE individuals, TTE and STE results may not always be indicative of intrinsic myocardial dysfunction, but may be, at least in part, influenced by artifactual and/or external chest shape determinants.
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Affiliation(s)
| | | | | | | | - Enzo Grasso
- Division of Cardiology, MultiMedica IRCCS, Milan, Italy
| | | | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Pathophysiology, Azienda Ospedaliero-Universitaria "S. Maria Della Misericordia", Perugia, Italy
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31
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Akinboro S, John R, Reyna T, Davis R, Ayoub C, Sangster R, Kim J, Nguyen H, Moreno C, Guner Y, Goodman L, Yu PT, Morphew T, Kabeer M. A pilot study of multi-modal pain management for same-day discharge after minimally invasive repair of pectus excavatum (Nuss procedure) in children. Pediatr Surg Int 2023; 39:159. [PMID: 36967421 PMCID: PMC10040230 DOI: 10.1007/s00383-023-05429-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND Despite advancements in minimally invasive repair of pectus excavatum (MIRPE), Nuss procedure, postoperative pain control remains challenging. This report covers a multimodal regimen using bilateral single-shot paravertebral block (PVB) and bilateral thoracoscopic intercostal nerve (T3-T7) cryoablation, leading to significant reduction in length of stay (LOS) and high rate of same-day discharge. METHODS This is a comparative study of pain management protocols for patients undergoing the Nuss procedure at a single center from 2016 through 2020. All patients underwent the the same surgical technique for the treatment of pectus excavatum at a single center. Patients received bilateral PVB with continuous infusion (Group 1, n = 12), bilateral PVB with infusion and right-side cryoablation (Group 2, n = 9), or bilateral single-shot PVB and bilateral cryoablation (Group 3, n = 17). The primary outcome was LOS with focus on same-day discharge, and the secondary outcome was decreased opioid usage. RESULTS Eleven of 17 patients in Group 3 (65%) (bilateral single-shot PVB and bilateral cryoablation) were discharged the same day as surgery. The remaining Group 3 patients were discharged the following day with no complications or interventions. Compared to Group 1 (no cryoablation), Group 3 had shorter LOS (median 4.4 days vs. 0.7 days, respectively, p < 0.001) and significantly decreased median opioid use on the day of surgery (0.92 mg/kg vs. 0.47 mg/kg, p = 0.006). CONCLUSION Findings demonstrate the feasibility of multimodal pain management for same-day discharge after the Nuss procedure. Future multisite studies are needed to investigate the superiority of this approach to established methods. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Rebecca John
- Children's Hospital of Orange County, Orange, USA.
| | - Troy Reyna
- Children's Hospital of Orange County, Orange, USA
| | - Rachel Davis
- Children's Hospital of Orange County, Orange, USA
| | | | | | - Joseph Kim
- Children's Hospital of Orange County, Orange, USA
| | - Hai Nguyen
- Children's Hospital of Orange County, Orange, USA
| | | | - Yigit Guner
- Children's Hospital of Orange County, Orange, USA
| | | | - Peter T Yu
- Children's Hospital of Orange County, Orange, USA
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32
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Thompson AR, Glick H, Rubalcava NS, Vernamonti JP, Speck KE. Implementation Science Fundamentals: Pediatric Surgery Enhanced Recovery After Surgery Protocol for Pectus Repair. J Surg Res 2023; 283:313-323. [PMID: 36423481 DOI: 10.1016/j.jss.2022.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/22/2022] [Accepted: 10/16/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Surgical repair of pectus excavatum and carinatum in children has historically been associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, multimodal approach designed to fast-track surgical care. However, obstacles to implementation have led to very few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol for pectus surgical repair using fundamental principles of implementation science. METHODS A multidisciplinary team of providers worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum and methods for identifying eligible patients. The surgical champion collaborated with all end users to review and revise the ERAS protocol, assessing all foreseeable barriers and facilitators prior to implementation. RESULTS Our entire pediatric surgery team, nurses at every stage (clinic/preoperative/recovery/floor), physical therapy, and information technology contributed to the creation and implementation of an ERAS protocol with seven phases of care. The finalized version was implemented by end users focusing on four main areas: pain control, ambulation, diet, and education. Barriers and facilitators were continually addressed with an iterative process to improve the success of implementation. CONCLUSIONS This is one of the first studies in children which details the step-by-step process of developing and implementing an ERAS protocol for pectus excavatum and carinatum. The process of development and implementation of an ERAS protocol as outlined in this manuscript can serve as a model for future ERAS protocols in pediatric surgery.
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Affiliation(s)
- Allison R Thompson
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan.
| | - Hannah Glick
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Nathan S Rubalcava
- Department of Surgery, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, Arizona; Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Jack P Vernamonti
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Maine Medical Center, Portland, Maine
| | - K Elizabeth Speck
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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Basic Strategies of Augmentation Mammoplasty in Patients with Tendencies of Pectus Excavatum and Carinatum. Aesthetic Plast Surg 2023; 47:54-60. [PMID: 35922671 DOI: 10.1007/s00266-022-02991-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/12/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND In this era of growing popularity of cosmetic surgeries, more women of various chest wall shapes are likely to receive augmentation mammoplasty. Pectus excavatum (PE) and pectus carinatum (PC) are the two most common chest wall deformities, and many asymptomatic patients visit the clinic. In this study, we presented various strategies for successfully performing breast augmentation in PE and PC patients without long-term complications such as symmastia. METHODS From January of 2019 to December of 2021, a total of 132 patients with tendencies of PE and PC received augmentation mammoplasty in our institute. We retrospectively reviewed data on demographics, surgical procedure, outcomes, and complications. RESULTS Among the 132 cases, 71.21% were done via inframammary approach, and 28.79% via transaxillary approach. The mean implant volume was 337.25 ± 51.46 ml, and the mean follow-up period was 16.48 ± 6.74 months. The Likert scale of outcome satisfaction scored 9.13 ± 0.48. No symmastia occurred. CONCLUSION We presented our basic strategies of breast surgery in patients with various chest wall anomalies. Augmentation mammoplasty can benefit PE and PC patients physically as well as psychologically, to carry out healthy positive lives. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Gräfe D, Lacher M, Martynov I, Hirsch FW, Voit D, Frahm J, Busse H, Sesia SB, Krämer S, Zimmermann P. Pectus excavatum in motion: dynamic evaluation using real-time MRI. Eur Radiol 2023; 33:2128-2135. [PMID: 36307555 PMCID: PMC9935721 DOI: 10.1007/s00330-022-09197-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/12/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The breathing phase for the determination of thoracic indices in patients with pectus excavatum is not standardized. The aim of this study was to identify the best period for reliable assessments of morphologic indices by dynamic observations of the chest wall using real-time MRI. METHODS In this prospective study, patients with pectus excavatum underwent morphologic evaluation by real-time MRI at 3 T between January 2020 and June 2021. The Haller index (HI), correction index (CI), modified asymmetry index (AI), and modified eccentricity index (EI) were determined during free, quiet, and forced breathing respectively. Breathing-related differences in the thoracic indices were analyzed with the Wilcoxon signed-rank test. Motion of the anterior chest wall was analyzed as well. RESULTS A total of 56 patients (11 females and 45 males, median age 15.4 years, interquartile range 14.3-16.9) were included. In quiet expiration, the median HI in the cohort equaled 5.7 (4.5-7.2). The median absolute differences (Δ) in the thoracic indices between peak inspiration and peak expiration were ΔHI = 1.1 (0.7-1.6, p < .001), ΔCI = 4.8% (1.3-7.5%, p < .001), ΔAI = 3.0% (1.0-5.0%, p < .001), and ΔEI = 8.0% (3.0-14.0%, p < .05). The indices varied significantly during different inspiratory phases, but not during expiration (p > .05 each). Furthermore, the dynamic evaluation revealed three distinctive movement patterns of the funnel chest. CONCLUSIONS Real-time MRI reveals patterns of chest wall motion and indicate that thoracic indices of pectus excavatum should be assessed in the end-expiratory phase of quiet expiration. KEY POINTS • The thoracic indices in patients with pectus excavatum depend on the breathing phase. • Quiet expiration represents the best breathing phase for determining thoracic indices. • Real-time MRI can identify different chest wall motion patterns in pectus excavatum.
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Affiliation(s)
- Daniel Gräfe
- Department of Pediatric Radiology, University Hospital, Leipzig, Germany.
| | - Martin Lacher
- Department of Pediatric Surgery, University Hospital, Leipzig, Germany
| | - Illya Martynov
- Department of Pediatric Surgery, University Hospital, Leipzig, Germany
| | | | - Dirk Voit
- Biomedizinische NMR, Max-Planck-Institut für Biophysikalische Chemie, Göttingen, Germany
| | - Jens Frahm
- Biomedizinische NMR, Max-Planck-Institut für Biophysikalische Chemie, Göttingen, Germany
| | - Harald Busse
- Department of Diagnostic and Interventional Radiology, University Hospital, Leipzig, Germany
| | - Sergio Bruno Sesia
- Division of General Thoracic Surgery, Bern University Hospital, Bern, Switzerland
| | - Sebastian Krämer
- Division of General Thoracic Surgery, Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital, Leipzig, Germany
| | - Peter Zimmermann
- Department of Pediatric Surgery, University Hospital, Leipzig, Germany
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Portnow LH, Pollock JL, Bay CP, Gombos EC. Mammographic positioning in women with pectus excavatum: An anatomic challenge. Clin Imaging 2022; 92:117-123. [DOI: 10.1016/j.clinimag.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/04/2022] [Accepted: 10/12/2022] [Indexed: 11/03/2022]
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Geraedts TCM, Daemen JHT, Vissers YLJ, Hulsewé KWE, Van Veer HGL, Abramson H, de Loos ER. Minimally invasive repair of pectus carinatum by the Abramson method: A systematic review. J Pediatr Surg 2022; 57:325-332. [PMID: 34969524 DOI: 10.1016/j.jpedsurg.2021.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this review is to provide an overview of the outcomes after minimally invasive pectus cartinatum repair (MIRPC) by the Abramson method to determine its effectiveness. METHODS The PubMed and Embase databases were systematically searched. Data concerning subjective postoperative esthetic outcomes after initial surgery and bar removal were extracted. In addition, data on recurrence, complications, operative times, blood loss, post-operative pain, length of hospital stay, planned time to bar removal and reasons for early bar removal were extracted. The postoperative esthetic result, was selected as primary outcome since the primary indication for repair in pectus carinatum is of cosmetic nature. RESULTS Six cohort studies were included based on eligibility criteria, enrolling a total of 396 patients. Qualitative synthesis showed excellent to satisfactory esthetic results in nearly all patients after correctional bar placement (99.5%, n = 183/184). A high satisfaction rate of 91.0% (n = 190/209) was found in patients after bar removal. Recurrence rates were low with an incidence of 3.0% (n = 5/168). The cumulative postoperative complication rate was 26.5% (n = 105/396), of whom 25% required surgical re-intervention. There were no cases of mortality. CONCLUSIONS Minimally invasive repair of pectus carinatum through the Abramson method is effective and safe. Its efficacy is demonstrated by the excellent to satisfactory esthetic results in 99.5% and 91.0% of patients after respectively correctional bar placement and implant removal. Future studies should aim to compare different treatment options for pectus carinatum in order to elucidate the approach of choice for different patient groups.
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Affiliation(s)
- Tessa C M Geraedts
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Jean H T Daemen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands; Faculty of Health, Medicine and Life Sciences (FHML), School for Oncology and Developmental Biology (GROW), Maastricht, the Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Hans G L Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium; BREATHE Laboratory, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Horacio Abramson
- Surgical Thoracic Service, Hospital Antonio Cetrángolo, Vicente Lopez, Buenos Aires, Argentina
| | - Erik R de Loos
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands.
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Neurolysis for analgesia following pectus repair in a national cohort. J Pediatr Surg 2022; 57:315-318. [PMID: 35339278 DOI: 10.1016/j.jpedsurg.2022.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Pectus excavatum and pectus carinatum are the most common chest wall deformities of childhood. Surgical repair can be complicated by post-operative analgesic challenges. Thoracic epidural analgesia, patient-controlled analgesia, and multimodal pain control are among the most common strategies. We sought to define the current utilization of intraoperative thoracic neurolysis, hypothesizing that this would minimize length of stay (LOS) and post-operative narcotic use with relatively higher proportion of non-narcotic post-operative analgesia. METHODS We performed a retrospective review of the Pediatric Health Information System (PHIS) database between 2017 and 2020. We first identified patients who underwent a pectus repair via ICD-10-PCS codes. We used ICD-10-PCS codes 01580ZZ and 01584ZZ to identify those patients who underwent concomitant thoracic neurolysis. Statistical analyses were performed using R; p value less than 0.05 was considered significant. RESULTS We identified 2979 patients who underwent a pectus repair. 184 underwent a concomitant thoracic nerve destruction procedure (6.7%); 13 were performed in 2017 (2.01%), 76 in 2018 (10.7%), and 84 in 2019 (9.6%). LOS was shorter in those patients who underwent neurolysis (mean=2.55 vs 3.73 days, SD=1.33 vs 1.78 days, p<0.001). There were fewer post-operative ICU admissions in neurolysis patients (3/184 vs. 193/2795, p = 0.003). The cost of procedures that included a neurolysis were higher, though not significantly so (mean=$24,885.64 vs $22,200.59). CONCLUSION Thoracic neurolysis may be a useful analgesic strategy, expediating post-operative discharge and potentially obviating the need for intensive care. Further larger-scale prospective trials should be considered to further elucidate the role of this analgesia method. LEVEL OF EVIDENCE Level III.
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de Beer S, Volcklandt S, de Jong J, Oomen M, Zwaveling S, van Heurn E. Dynamic compression therapy for pectus carinatum in children and adolescents: Factors for success. J Pediatr Surg 2022:S0022-3468(22)00601-7. [PMID: 36273920 DOI: 10.1016/j.jpedsurg.2022.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/07/2022] [Accepted: 09/18/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pectus carinatum (PC) is a congenital chest wall deformity. In childhood, it is increasingly treated with dynamic compression therapy. Factors for success for dynamic brace therapy are relatively unknown. METHODS Between 2013 and 2020, 740 patients treated with the Dynamic Compression System (DCS), were studied. This included the effect of age, gender, pectus height, symmetry and pectus rigidity on treatment time and symptoms with linear multiple regression analyses. RESULTS Carinatum height and high pressure of initial correction at the start of treatment were associated with a prolonged duration of treatment. For each cm increase in carinatum height, the total treatment duration increased with 1.9 months (p-value= 0.002, 95% CI: 0.70-3.13). An initial correction pressure of ≥7.6 pounds per square inch (psi), increased the treatment duration with 3.5 months (p-value 0.006, 95% CI: 1.04-6.01) compared to an initial correction pressure of ≤5.0 psi. A high initial pressure of correction of ≥7.6 psi increased the odds of having somatic symptoms with 1.19 (p-value= 0.012, 95% CI: 1.04-1.45) and psychosocial symptoms with 1.13 (p-value= 0.04, 95% CI: 1.01-1.27) compared to a low initial pressure of correction of ≤5.0 psi. An initial pressure of correction of 5.1-7.5 psi increased the odds of having somatic symptoms with 1.14 (p-value 0.046, 95% CI: 1.00-1.29) compared to an initial pressure of correction of ≤5.0 psi. Patients with asymmetric chests were more likely to abandon therapy CONCLUSIONS: High carinatum height and high initial pressure of correction are associated with prolonged bracing treatment and a higher failure rate. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sjoerd de Beer
- Amsterdam University Medical Center, Amsterdam, Netherlands.
| | - Sam Volcklandt
- Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Justin de Jong
- Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Matthijs Oomen
- Amsterdam University Medical Center, Amsterdam, Netherlands
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Rettig RL, Rudikoff AG, Lo HYA, Lee CW, Vazquez WD, Rodriguez K, Shaul DB, Conte AH, Banzali FM, Sydorak RM. Same day discharge for pectus excavatum-is it possible? J Pediatr Surg 2022; 57:34-38. [PMID: 33678403 DOI: 10.1016/j.jpedsurg.2021.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/04/2021] [Accepted: 02/03/2021] [Indexed: 01/12/2023]
Abstract
PURPOSE The use of intercostal nerve cryoablation (INC) has been an effective modality for treating pain in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate if PE patients undergoing Nuss procedures with INC and intercostal nerve block (INB) could safely be discharged the same day of surgery. METHODS A prospective study with IRB approval of 15 consecutive patients undergoing PE Nuss repair with INC, INB, and an enhanced recovery after surgery (ERAS) protocol was conducted. The primary outcome measure was hospital length of stay (LOS) in hours. Secondary variables included same day discharge, postoperative complications, emergency department (ED) visits, urgent care (UC) visits, opioid use, and return to the operating room (OR). RESULTS LOS averaged 11.9 h amongst 15 patients. Ten patients (66.7%) went home on postoperative day (POD) 0, and the rest went home on POD 1. No patients stayed in the hospital due to pain. Reasons for failure to discharge included urinary retention, drowsiness, vomiting, and anxiety, but not pain. No patients were readmitted to the ED. One patient visited UC for constipation. One patient had bar migration requiring return to the OR for revision. Ten (66.7%) patients did not use opioids after discharge. CONCLUSIONS Same day discharge is feasible and safe in PE patients undergoing Nuss procedure with INC and INB. INC with INB can adequately control pain without significant complications. Same day discharge can be safely considered for PE patients undergoing Nuss procedure with INC with INB. TYPE OF STUDY Prognosis study LEVEL-OF-EVIDENCE RATING: Level II.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Constance W Lee
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Walter D Vazquez
- Department of Pediatric Surgery, Kaiser Permanente San Diego Medical Center, 9455 Clairemont Mesa Blvd, San Diego 92123, CA, United States
| | - Karen Rodriguez
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States.
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Delay E, Nachaoui H. [Lipomodeling for congenital breast deformities: Technique, results and indications]. ANN CHIR PLAST ESTH 2022; 67:319-334. [PMID: 36031492 DOI: 10.1016/j.anplas.2022.07.022] [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: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 11/24/2022]
Abstract
Congenital breast deformities usually occur during adolescence and can disturb the self-development and affect the identity during this crucial stage. Several surgical techniques are now available to correct these different anomalies. The objective is to clarify the place of lipomodeling in thoraco-mammary malformations, resuming the different indications, the results, as well as the limits and potential complications. The adipose tissue was harvested by soft aspiration as to reduce adipocyte trauma and using a syringe fitted with a 3.5mm cannula. After centrifugation, fat was reinjected retrogradely and by making thin cylinders of fat similar to "spaghetti". Moderate to severe asymmetry is one of the best indications for lipomodeling using one or two sessions. Thus, a perfect and lasting symmetry is achieved, without the need of an implant, which would inevitably leads to asymmetry because of a dissimilar evolution of the breast all over the time. In Becker's nevus syndrome, lipomodeling has also been performant in bluring the hyperpigmentation of the nevus. The role of lipomodeling in pectus excavatum deformity (antero-posterior sternocostal depression) is also crucial. Lipomodeling can be used alone, or in combination with a rigid customed silicone implant. Tuberous breasts include various anomalies. Lipomodeling is currently used especially when the anomaly is unilateral (2 fat graft sessions are usually needed). Fasciotomies are frequently performed too. Lipomodeling is a real revolution in the management of Poland syndrome (anomaly characterized by the unilateral lack of the pectoralis major muscle, more or less associated with other ipsilateral anomalies). On average, 3 to 5 sessions are necessary to obtain a suitable symmetry. Lipomodeling is very unlikely to cause major surgical complications. Cytosteatonecrosis nodules mainly occur with novice practitioner and decrease as they become more experienced. However, the principle of the three-dimensional network, and the phenomenon of tissue saturation of the recipient site should be respected. The main limitation of lipomodeling is directly related to the amount of fat available. That's why it is very important to evaluate it during the first clinical consultation, and to carefully select the patients eligible in order to limit the risk of failure. Lipomodeling of congenital breast anomalies is a technique well established, with a precise algorithm to follow, and is a procedure with low surgical risk, less scarring, cosmetic and lasting results. This technique is to be suggested as a first line treatment in all indications of congenital breast deformities, alone or combined to an implant. Therefore, it seems essential that a plastic surgeon fully master the indications and the use of fat tissue transfer procedure, in order to obtain natural and harmonious results.
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Affiliation(s)
- E Delay
- Unité de chirurgie plastique et reconstructrice (Dr E Delay), centre Léon-Bérard, 28, rue Laënnec, 69373 Lyon cedex 08, France; Cabinet, 50, rue de la République, 69002 Lyon, France.
| | - H Nachaoui
- Unité de chirurgie plastique et reconstructrice (Dr E Delay), centre Léon-Bérard, 28, rue Laënnec, 69373 Lyon cedex 08, France
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Delay E, Nachaoui H, Frobert P. [Poland's syndrome]. ANN CHIR PLAST ESTH 2022; 67:358-373. [PMID: 35995703 DOI: 10.1016/j.anplas.2022.07.020] [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: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
Breast and thoracic deformities of Poland syndrome is a rare malformation known to be difficult to treat. Numerous descriptions of surgical corrections have been published but none achieved to correct severe cases before description of lipomodeling technique. The aim of this article is to present thoraco-mammary deformity of Poland syndrome, corrections techniques already available and therapeutical indications in primary and secondary cases. Constant anomaly of Poland syndrome is agenesis of sterno-costal part of pectoralis major muscle but other muscular anomalies can be associated. Skin and glandular anomalies present with a fine skin and an absent or hypoplasic subcutaneous fat with a glandular hypoplasia of various degree. Osteo-cartilaginous anomalies can be associated in very severe cases. Clinical sign of Poland syndrome is forced adduction manoeuvre highlighting pectoralis major agenesis. Functional impact of the deformity is low but psychological and psychosocial implications can be very important, supporting an early surgical correction. Therapeutic means are various and accurate descriptions are given in this article: thoracic bony reconstruction, thoracic implant made of silicone elastomer, breast implant, skin expansion, latissimus dorsi pedicled flap, free flaps, breast lipomodeling, Breast-pectoralis flap. Principles of each technique are described and balanced with their actual use in this malformation. Indications have been completely modified these last years due to lipomodeling contribution which represented a huge step in this deformity treatment. In our practice, if autologous reconstruction with lipomodeling is possible, we choose this solution at first. In case of severe thoracic deformity, a silicone elastomer implant made with the help of computed assisted conception can be an important adjunct, mainly by thin young man. In secondary cases, if implant is well tolerated, we found logical to stay in the same reconstruction path and do one or two sessions of lipomodeling in order to improve reconstruction. If implant tolerance is low and skin very thin at risk of exposure, we do recommend a conversion of implant reconstruction to autologous reconstruction. In conclusion, thoraco-mammary deformities of Poland syndrome are rare and hard to treat and should be managed by well trained and experimented surgeons. Breast lipomodeling is a huge step in the treatment of these deformities and should be regarded, in our opinion, as first line treatment if fat deposits are sufficient. In case of low fat provisions or in the thin young man, composite techniques should be used with silicone elastomer implant.
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Affiliation(s)
- E Delay
- Unité de chirurgie plastique et reconstructrice, Centre Léon Bérard, 28, rue Laënnec, 69373 Lyon cedex 08, France; Cabinet, 50, rue de la République, 69002 Lyon, France
| | - H Nachaoui
- Unité de chirurgie plastique et reconstructrice, Centre Léon Bérard, 28, rue Laënnec, 69373 Lyon cedex 08, France
| | - P Frobert
- Unité de chirurgie plastique et reconstructrice, Centre Léon Bérard, 28, rue Laënnec, 69373 Lyon cedex 08, France
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Song SH, Moon DH, Shim YH, Jung H, Lee S. Limited cryoablation reduces hospital stay and opioid consumption compared to thoracic epidural analgesia after minimally invasive repair of pectus excavatum. Medicine (Baltimore) 2022; 101:e29773. [PMID: 35945758 PMCID: PMC9351910 DOI: 10.1097/md.0000000000029773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
pain following minimally invasive repair of pectus excavatum (MIRPE) is a critical concern that leads to a prolonged hospital stay and high doses of opiates administered to the patients. This study aimed to evaluate the efficacy of intraoperative cryoanalgesia (cryoablation of the intercostal nerves) during MIRPE. We retrospectively analyzed the data of 64 patients who underwent MIRPE and received cryoanalgesia or epidural analgesia between January 2019 and January 2021. The oral morphine milligram equivalent (MME) was used to calculate the dosage of opioid agents. The median age was 15 years (range, 4-33 years). The median postoperative hospital stay was 4 days (range, 2-6 days), with a median oral MME consumption of 45 mg (ranging from 0 to 1360 mg). Cryoanalgesia was performed in 38 patients, and epidural analgesia was administered to the remaining 26 patients. The cryoanalgesia group had a significantly lesser pain score, shorter postoperative hospital stay and lower oral MME consumption than the epidural analgesia group (5 vs 2; P < .001, 3 days vs 5 days; P < .001, 19 mg vs 634 mg; P < .001). Cryoanalgesia appears to reduce postoperative hospital stay and opioid consumption compared with epidural analgesia. The outcomes of this study indicate that cryoanalgesia might be a safe and effective method for pain control following MIRPE.
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Affiliation(s)
- Seung Hwan Song
- Department of Thoracic and Cardiovascular Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Duk Hwan Moon
- Department of Thoracic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yon Hee Shim
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyunjoo Jung
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sungsoo Lee
- Department of Thoracic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- *Correspondence: Sungsoo Lee, Department of Thoracic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul, Republic of Korea, 06273 (e-mail: )
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Sertcakacilar G, Kose S. Bilateral PECS II block is associated with decreased opioid consumption and reduced pain scores for up to 24 hours after minimally invasive repair of pectus excavatum (Nuss procedure): a retrospective analysis. J Cardiothorac Vasc Anesth 2022; 36:3833-3840. [DOI: 10.1053/j.jvca.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/21/2022] [Accepted: 06/01/2022] [Indexed: 11/11/2022]
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Detection of Incidental Nonosseous Thoracic Pathology on State-of-the-Art Ultralow-Dose Protocol Computed Tomography in Pediatric Patients With Pectus Excavatum. J Comput Assist Tomogr 2022; 46:492-498. [DOI: 10.1097/rct.0000000000001285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Öztürk Ö, Çavdartepe BE, Bağış H. X-Linked Spinal Muscular Atrophy 2 due to a Synonymous Variant in the UBA1 Gene in a Family with Novel Findings from Turkey. Mol Syndromol 2022; 13:246-253. [PMID: 35707597 PMCID: PMC9149478 DOI: 10.1159/000519640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2023] Open
Abstract
Spinal muscular atrophy, X-linked 2 (SMAX2) is a rare type of spinal muscular atrophy characterized by muscle weakness, hypotonia, areflexia, myopathic face, tongue fibrillations, contractures, bone fractures, and cryptorchidism. Variants of the UBA1 gene lead to SMAX2. The UBA1 gene encodes a protein that activates the ubiquitin pathway which is responsible for protein degradation. Here, we describe a family presenting with hypotonia, muscle weakness, areflexia, contractures, weak cry, in association with other anomalies including myopathic face, scoliosis, tongue fibrillations, and cryptorchidism. Molecular analysis in 2 patients revealed a hemizygous pathogenic variant in the UBA1 gene (NM_153280.3, NP_695012.1: c.1731C>T [p.Asn577Asn]) inherited from their carrier mothers. Our study presents the first patients from Turkey, widening the phenotypic spectrum of SMAX2 by pectus carinatum, medullary sponge kidney, and frontal cyst.
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Affiliation(s)
- Özden Öztürk
- Department of Medical Genetics, Medical Faculty, Adiyaman University, Adiyaman, Turkey
| | - Büşra Eser Çavdartepe
- Department of Medical Genetics, Adiyaman University Training and Research Hospital, Adiyaman, Turkey
| | - Haydar Bağış
- Department of Medical Genetics, Medical Faculty, Adiyaman University, Adiyaman, Turkey
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Abstract
Chest wall pain affects many patients following chest surgery, fractures, or malignancies, and can be very difficult to manage with normal pharmacologic agents. Intercostal ablation provides one alternative treatment modality for patients suffering from intercostal pain. Intercostal cryoneurolysis involves using extreme cold to cause Wallerian degeneration of the targeted intercostal nerve. This article reviews the patient selection, technique, and complications in the utilization of intercostal neurolysis in the treatment of intractable chest pain.
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Affiliation(s)
- Junjian Huang
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kevin Delijani
- Georgetown University School of Medicine, Washington, District of Columbia
| | | | - Andrew J Gunn
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
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47
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Abbas AE. Commentary: Funneling the funnel chest debates into appropriate management of adult pectus excavatum. JTCVS Tech 2022; 12:220-221. [PMID: 35403024 PMCID: PMC8987600 DOI: 10.1016/j.xjtc.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/06/2022] [Accepted: 02/15/2022] [Indexed: 11/02/2022] Open
Affiliation(s)
- Abbas E. Abbas
- Warren Alpert Medical School of Brown University, Providence, RI
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48
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David VL. Current Concepts in the Etiology and Pathogenesis of Pectus Excavatum in Humans-A Systematic Review. J Clin Med 2022; 11:jcm11051241. [PMID: 35268332 PMCID: PMC8911421 DOI: 10.3390/jcm11051241] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/16/2022] [Accepted: 02/21/2022] [Indexed: 01/16/2023] Open
Abstract
Pectus excavatum (PE) is the most common deformity of the chest wall and is characterized by the posterior depression of the sternum and the lower costal cartilages. To date, the etiology of PE in humans remains enigmatic. Several etiologic hypotheses have been proposed over the past two centuries. However, most of them have been scientifically dismissed and now have only historic value. In this systematic review, we assess scientific publications of the past two centuries addressing the issue of the origin of PE in humans. We present and discuss the histologic, genetic, biomechanical, and experimental scientific achievements that contributed to the clarification of its etiology and pathogenesis. With no clear consensus over the exact mechanism, most recent studies agree that the primordial defect leading the deformation of the anterior chest wall in PE is related to the costal hyaline cartilage structure and function. Further studies on this subject must be carried out. Genetic studies seem to be the most promising way to understand the exact mechanism of PE's origin and pathogenesis.
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Affiliation(s)
- Vlad Laurentiu David
- Department of Pediatric Surgery and Orthopedics, "Victor Babes" University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
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49
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Luo D, Cheng K, Yuan M, Xu C, He T. Efficacy and determinants of vacuum bell treatment in preschool children with pectus excavatum. Front Pediatr 2022; 10:1008437. [PMID: 36313864 PMCID: PMC9607926 DOI: 10.3389/fped.2022.1008437] [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: 07/31/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The outcome of vacuum bell (VB) treatment for preschool patients with pectus excavatum (PE) is poorly understood. We aim to investigate the short-term treatment effect of VB with a three-dimensional scanner and assess the clinical and demographic factors that might influence treatment outcomes. METHODS We conducted a chart review study to review the records of preschool patients with PE who received VB treatment in a tertiary hospital from January 1, 2021, through January 1, 2022. Demographic data and chest wall deformity assessments were recorded at follow-up, including the anterior chest wall depths and depth ratio (DR). The demographic and clinical factors influencing treatment outcomes were tested using a logistic regression model. RESULTS 139 patients who accepted vacuum bell treatment were included in the final study analysis, with a mean age of 4.6 years and a BMI of 14.9. Forty-three patients (30.9%) with a depth of less than 3 mm met the termination criteria and showed cosmetic results. The changes in depths (P < 0.001) and DR (P < 0.001) were statistically significant in 55 patients with three or four follow-ups. Multifactor logistic regression analysis showed that initial depth (OR 0.69, 95% CI 0.58-0.84, P < 0.001) and treatment period (OR 1.58, 95% CI 1.23-2.04, P < 0.001) were independent predictors of achieving complete correction. CONCLUSION VB is an effective treatment modality in preschool patients in the short-term follow-up, which is influenced by the depth of depression and the duration of treatment. However, further prospective studies are needed to confirm these results.
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Affiliation(s)
- Dengke Luo
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Kaisheng Cheng
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Miao Yuan
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Chang Xu
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Taozhen He
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
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50
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Rettig RL, Rudikoff AG, Annie Lo HY, Lee CW, Vazquez WD, Rodriguez K, Shaul DB, Conte AH, Banzali FM, Sydorak RM. Same-day discharge following the Nuss repair: A comparison. J Pediatr Surg 2022; 57:135-140. [PMID: 34670678 DOI: 10.1016/j.jpedsurg.2021.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB). METHODS In June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017-2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR). RESULTS The characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation. CONCLUSIONS The majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital. LEVEL-OF-EVIDENCE Level II.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Constance W Lee
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Walter D Vazquez
- Department of Pediatric Surgery, Kaiser Permanente San Diego Medical Center, 9455 Clairemont Mesa Blvd, San Diego, CA 92123 USA
| | - Karen Rodriguez
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA.
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