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Toselli L, Bellia-Munzon G, Sanjurjo D, Martinez-Ferro M. Novel techniques and future developments in minimally invasive pectus repair. J Thorac Dis 2024; 16:4807-4815. [PMID: 39144309 PMCID: PMC11320257 DOI: 10.21037/jtd-23-1676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 06/24/2024] [Indexed: 08/16/2024]
Abstract
After the paradigm shift in the treatment of excavated deformities caused by the introduction of the Nuss technique in 1998, several innovative technical modifications and new treatment modalities have radically changed the surgical approach of pectus excavatum in the last couple of years. These new trends attain different topics. On one hand, the use of three-dimensional (3D) printing and implant customization surge as a possibility for a wider audience as 3D printers become available with lower costs. They provide the surgeon with new elements that enable precise planning, simulation, and customized prostheses amidst a tendency to abandon standardization and incorporate personalized medicine. Another topic comprises mandatory sternal elevation, in the continuous search for safety first always. Complete thoracic remodeling as a goal of repair instead of addressing only focal depressions, leaving the upper chest or focal protrusions unresolved. Finally, although the current surgical approach has evolved significantly, many groups still use lateral stabilizers or direct implant fixation with sutures or wires to the ribs. These systems continue to prove unreliable in preventing implant displacement. Fortunately, the bridge technique, described in this review, has come to address this sometimes fatal issue with encouraging results. We provide an updated overview of the latest developments regarding these concepts, related to the current state-of-the-art of the treatment of pectus excavatum.
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Affiliation(s)
- Luzia Toselli
- Department of Pediatric Surgery, Fundacion Hospitalaria, Buenos Aires, Argentina
| | - Gaston Bellia-Munzon
- Department of Chest Wall Malformations, Clínica Mi Pectus, Buenos Aires, Argentina
| | - Daniela Sanjurjo
- Department of Chest Wall Malformations, Clínica Mi Pectus, Buenos Aires, Argentina
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Şirazi S, Heydar AM, Bezer M, Yüksel M. Correlation of anterior chest wall anomalies and spinal deformities: a comprehensive descriptive study. Spine Deform 2024:10.1007/s43390-024-00918-8. [PMID: 38900408 DOI: 10.1007/s43390-024-00918-8] [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: 12/16/2023] [Accepted: 06/09/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE To investigate the association and evaluate the characteristics between different types of anterior chest wall and spinal deformities. METHODS A total of 548 patients with anterior chest wall deformities were included in this study. Clinical and radiological examinations were performed to determine spinal deformities. The type and severity of the spinal deformities were evaluated and their relationships with chest wall deformity subtypes were statistically analyzed. RESULTS Spinal deformities were identified in 93 (16.97%) patients. The patients were subdivided into 71 (76.3%) male and 22 (23.7%) female patients. A spinal deformity was detected in 57 (13%) of 418 pectus excavatum (PE) patients, in 23 (19%) of 117 pectus carinatum (PC) patients, and in all patients with mixed pectus deformity (PE + PC), syndromic deformity and rib anomalies. In the PE group, scoliosis, and kyphosis were observed at 57.9 and 31.6%, respectively. In the PC group, these rates were 43.5 and 47.8%, respectively. Idiopathic scoliosis was observed in 42 (77.7%) and constituted the most common scoliosis subgroup. The main thoracic curvature was the most common curve pattern, which was observed in 15 (35.7%) patients with idiopathic scoliosis. CONCLUSIONS Idiopathic scoliosis with main thoracic curvature is the most common deformity in patients with anterior chest wall deformity. Spinal deformities are more common in male patients with chest deformities. Kyphosis is found in a significant number of PE and PC patients. Patients with mixed PE and PC, rib anomalies, and syndromic disease are more likely to have spinal deformities.
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Affiliation(s)
- Serdar Şirazi
- Private Orthopaedic Office, Mustafa Kemal Paşa, Firuzköy Blv. Kayabaşı Sk. No:1/3 Avcılar, Istanbul, Turkey
| | - Ahmed Majid Heydar
- Memorial Bahçelievler Hospital, Orthopedic and Traumatology Clinic, Bahçelievler Merkez, Adnan Kahveci Blv. No: 227 Bahçelievler, 34180, Istanbul, Turkey.
| | - Murat Bezer
- Marmara University Hospital, Fevzi Çakmak Mah. Muhsin Yazıcıoğlu Cad. No: 10 Üst Kaynarca/Pendik, Istanbul, Turkey
| | - Mustafa Yüksel
- Marmara University Hospital, Fevzi Çakmak Mah. Muhsin Yazıcıoğlu Cad. No: 10 Üst Kaynarca/Pendik, Istanbul, Turkey
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Zhang R, Wang J, Chen C. Automatic implant shape design for minimally invasive repair of pectus excavatum using deep learning and shape registration. Comput Biol Med 2023; 158:106806. [PMID: 37019009 DOI: 10.1016/j.compbiomed.2023.106806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/05/2023] [Accepted: 03/20/2023] [Indexed: 04/05/2023]
Abstract
Minimally invasive repair of pectus excavatum (MIRPE) is an effective method for correcting pectus excavatum (PE), a congenital chest wall deformity characterized by concave depression of the sternum. In MIRPE, a long, thin, curved stainless plate (implant) is placed across the thoracic cage to correct the deformity. However, the implant curvature is difficult to accurately determine during the procedure. This implant depends on the surgeon's expert knowledge and experience and lacks objective criteria. Moreover, tedious manual input by surgeons is required to estimate the implant shape. In this study, a novel three-step end-to-end automatic framework is proposed to determine the implant shape during preoperative planning: (1) The deepest depression point (DDP) in the sagittal plane of the patient's CT volume is automatically determined using Sparse R-CNN-R101, and the axial slice containing the point is extracted. (2) Cascade Mask R-CNN-X101 segments the anterior intercostal gristle of the pectus, sternum and rib in the axial slice, and the contour is extracted to generate the PE point set. (3) Robust shape registration is performed to match the PE shape with a healthy thoracic cage, which is then utilized to generate the implant shape. The framework was evaluated on a CT dataset of 90 PE patients and 30 healthy children. The experimental results show that the average error of the DDP extraction was 5.83 mm. The end-to-end output of our framework was compared with surgical outcomes of professional surgeons to clinically validate the effectiveness of our method. The results indicate that the root mean square error (RMSE) between the midline of the real implant and our framework output was less than 2 mm.
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Matsuura R, Tazuke Y, Ueno T, Watanabe M, Nomura M, Masahata K, Kamiyama M, Zenitani M, Usui N, Okuyama H. Factors reducing psychological satisfaction after the Nuss procedure in pediatric patients. Asian J Endosc Surg 2023; 16:28-34. [PMID: 35962604 DOI: 10.1111/ases.13111] [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: 04/11/2022] [Revised: 06/16/2022] [Accepted: 07/07/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE We examined patient satisfaction with postoperative chest appearance after Nuss procedure and analyzed the factors for postoperative low satisfaction. METHODS We retrospectively reviewed data of 133 patients who underwent the Nuss procedure from 2000 to 2016. Their medical records, X-rays, and computed tomography scans were evaluated. Haller index and concave rate were used as objective indices of the deformity. The questionnaires were used to evaluate satisfaction with the chest appearance by a linear scale including five markers (1: dissatisfaction, 5: satisfaction). The patients were divided into two groups: the low satisfaction (score = 1, 2) and the high satisfaction (score = 3-5). RESULTS The median age during the Nuss procedure was 7.6 (interquartile range, 5.8-12.8) years. Out of 133, 65 patients replied, and the mean postoperative satisfaction score was 3.8 ± 0.2. Out of the 65 respondents, 16 patients (24.6%) were classified as low satisfaction group. Haller index and concave rate were significantly higher and the previous instances of chest operation history were more frequent in the low satisfaction group than in the high satisfaction group, although there was no significant intergroup difference in terms of the postoperative concave rate. CONCLUSIONS Severe deformity and previous chest operation history were considered to be factors for low satisfaction.
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Affiliation(s)
- Rei Matsuura
- Department of Pediatric Surgery, Graduate School of Medicine Osaka University, Osaka, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Graduate School of Medicine Osaka University, Osaka, Japan
| | - Takehisa Ueno
- Department of Pediatric Surgery, Graduate School of Medicine Osaka University, Osaka, Japan
| | - Miho Watanabe
- Department of Pediatric Surgery, Graduate School of Medicine Osaka University, Osaka, Japan
| | - Motonari Nomura
- Department of Pediatric Surgery, Graduate School of Medicine Osaka University, Osaka, Japan
| | - Kazunori Masahata
- Department of Pediatric Surgery, Graduate School of Medicine Osaka University, Osaka, Japan
| | - Masafumi Kamiyama
- Department of Pediatric Surgery, Graduate School of Medicine Osaka University, Osaka, Japan
| | - Masahiro Zenitani
- Department of Pediatric Surgery, Hyogo College of Medicine, Osaka, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Graduate School of Medicine Osaka University, Osaka, Japan
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van Es LJ, van Royen BJ, Oomen MW. Clinical significance of concomitant pectus deformity and adolescent idiopathic scoliosis: systematic review with best evidence synthesis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 11:100140. [PMID: 35814492 PMCID: PMC9256832 DOI: 10.1016/j.xnsj.2022.100140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/19/2022] [Accepted: 06/21/2022] [Indexed: 05/14/2023]
Abstract
BACKGROUND A misbalance in forces is proposed for causing adolescent idiopathic scoliosis (AIS). AIS is therefore correlated to adjacent musculoskeletal pathologies. Its concomitance with idiopathic pectus deformities (PD) is underexposed. This systematic review analyzes the clinical significance and predictive factors of PD-associated AIS. METHODS A search was performed in PubMed, UpToDate, Embase, and Cochrane. A study was included if it: assessed the association between PD and scoliosis (category I), reported a prevalence of scoliosis in PD patients (category II), or addressed other topics about PD-associated AIS (category III). Studies in category I discussing predictive factors were appraised using the Quality in Prognosis Studies tool. Because of heterogeneity among the studies, predictive factors were analyzed according to a best evidence synthesis. A mean prevalence of scoliosis in PD patients was calculated using category I and II. Category III was narratively reviewed. RESULTS Forty-eight studies were included (I:19, II:21, III:8). Category I comprised 512 patients with PD-concomitant scoliosis. Thirteen studies reported predictive factors, of which 15 concerned the prevalence of scoliosis in PD patients and 12 Cobb Angle (CA) change after PD correction. Compared with AIS, PD seems to develop earlier in adolescence, and PD with concomitant AIS was more frequently reported in older patients. Evidence remained conflicting regarding the association between the severity of PD and that of scoliosis. As opposed to at a younger age, late PD correction is not associated with a postoperative increase of CA. Limited evidence showed that patients with a high CA undergoing PD correction do not experience an increase in CA, though, strong evidence indicated that it would not lead to a decrease in CA. The mean probable prevalence of AIS in PD patients was 13.1%. CONCLUSION Current literature confirms the association between PD and AIS in patients with an indication for PD correction.Level of evidence: III.
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Key Words
- AIS, Adolescent Idiopathic Scoliosis
- Adolescent idiopathic scoliosis (AIS)
- BES, Best Evidence Synthesis
- BMI, Body Mass Index
- CA, Cobb Angle
- CT, Computed Tomography
- Chest wall deformities
- Funnel chest
- HI, Haller Index
- PC, Pectus Carinatum
- PD, Pectus Deformity
- PE, Pectus Excavatum
- Pectus carinatum
- Pectus excavatum
- Pigeon breast
- STA, Sternal Tilt Angle
- Scoliosis
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Affiliation(s)
- Laurian J.M. van Es
- Department of Orthopaedic Surgery, Noordwest Ziekenhuis, Wilhelminalaan 12 1815 JD Alkmaar, The Netherlands
| | - Barend J. van Royen
- Department of Orthopedic Surgery, Amsterdam UMC, University of Amsterdam and Vrije Universiteit, Amsterdam Movement Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
- Corresponding author: Prof. Dr. B.J. van Royen, Department of Orthopedic Surgery, Meibergdreef 9, 1105 AZ, Amsterdam.
| | - Matthijs W.N. Oomen
- Department of Pediatric surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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Kloth K, Klohs S, Bhullar J, Boettcher M, Hempel M, Trah J, Reinshagen K. The Epidemiology behind Pectus Excavatum: Clinical Study and Review of the Literature. Eur J Pediatr Surg 2022; 32:316-320. [PMID: 34126636 DOI: 10.1055/s-0041-1729898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Pectus excavatum (PE) is a funnel-shaped indentation of the sternum and is the most common deformity of the chest wall. It is associated with syndromic diseases but can occur as an isolated form. Familial occurrence is assumed in up to 40% of cases, but large-scale studies are lacking. Most of the data are obtained from case reports which postulate autosomal recessive, dominant with reduced penetrance, X-linked, and multifactorial patterns of inheritance. No monogenetic cause has been identified to date. This study was designed to provide basic information on the epidemiology, family history, and comorbidity for a large cohort of isolated PE and to show that there is an inheritance pattern for PE that indicates a genetic background. MATERIALS AND METHODS A retrospective study was done using a paper-based questionnaire for all PE patients attending two specialized centers for chest wall deformities. Patients with isolated PE were included and asked to provide information on family history and comorbidities. RESULTS Family history was available for 78 patients. A positive family history was found in 42 patients (54%) with a total of 53 affected family members. CONCLUSION The described family histories indicate an underlying genetic cause for PE. Identification of the genetic factors may contribute to characterize patients who are at risk of inheriting isolated PE.
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Affiliation(s)
- Katja Kloth
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Klohs
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jasmin Bhullar
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maja Hempel
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Trah
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Pechetov AA, Volchanskiy DA, Makov MA. [Correction of pectus excavatum and long-term outcome in adult]. Khirurgiia (Mosk) 2022:84-89. [PMID: 35080832 DOI: 10.17116/hirurgia202201184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pectus excavatum is the most common congenital chest malformation characterized by symmetrical or asymmetric depression of the chest with deformation of the sternocostal complex. Pectus excavatum is often associated with other dysplastic diseases of connective tissue. Ravitch thoracoplasty and Nuss minimally invasive correction are the most common today. The authors report surgical correction of PE in a 50-years-old male who underwent Ravitch modified thoracoplasty with implantation of shape memory plate. Long-term treatment outcomes and technical properties of the plate after removing are analyzed.
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Affiliation(s)
- A A Pechetov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - D A Volchanskiy
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - M A Makov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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Silva B, Pessanha I, Correia-Pinto J, Fonseca JC, Queiros S. Automatic assessment of Pectus Excavatum severity from CT images using deep learning. IEEE J Biomed Health Inform 2021; 26:324-333. [PMID: 34152992 DOI: 10.1109/jbhi.2021.3090966] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Pectus excavatum (PE) is the most common abnormality of the thoracic cage, whose severity is evaluated by extracting three indices (Haller, correction and asymmetry) from computed tomography (CT) images. To date, this analysis is performed manually, which is tedious and prone to variability. In this paper, a fully automatic framework for PE severity quantification from CT images is proposed, comprising three steps: (1) identification of the sternue's greatest depression point; (2) detection of 8 anatomical keypoints relevant for severity assessment; and (3) measurements' geometric regularization and extraction. The first two steps rely on heatmap regression networks based on the Unet++ architecture, including a novel variant adapted to predict 1D confidence maps. The framework was evaluated on a database with 269 CTs. For comparative purposes, intra-observer, inter-observer and intra-patient variability of the estimated indices were analyzed in a subset of patients. The developed system showed a good agreement with the manual approach (a mean relative absolute error of 4.41%, 5.22% and 1.86% for the Haller, correction, and asymmetry indices, respectively), with limits of agreement comparable to the inter-observer variability. In the intrapatient analysis, the proposed framework outperformed the expert, showing a higher reproducibility between indices extracted from distinct CTs of the same patient. Overall, these results support the feasibility of the developed framework for the automatic, accurate and reproducible quantification of PE severity in a clinical context.
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