Pulmonary function before surgery for pectus excavatum and at long-term follow-up

Systematic review of physiological and psychological outcomes of surgery for pectus excavatum supporting commissioning of service in the UK

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.

Clinical Evaluation of Exertional Dyspnea in Adult Pectus Excavatum Patients

Abstract:

Evaluation of patients with pectus excavatum has primarily been focused on the pediatric population who undergo surgical correction of sternal defects mainly for cosmetic reasons combined with exercise-limiting symptoms. The extent of cardiopulmonary improvement in this population based on cardiac imaging, pulmonary function testing, and cardiopulmonary exercise testing may be highly variable. There is no current consensus on the limitations of cardiopulmonary impairment or potential improvement from surgical repair in pediatric patients. Limited data has published in the medical literature on the evaluation of adults with pectus excavatum who may also present with a variety of clinical symptoms. Adult patients with exercise limitation and pectus excavatum may present with exertional dyspnea, chest discomfort, palpitations/tachycardia, exercise-induced wheezing, and use of bronchodilators for asthma-like symptoms. While numerous published review articles outline clinical evaluation and surgical treatment for younger patients, comprehensive evaluation for these adult patients has not been fully elucidated. There is no current consensus on the underlying cause of cardiopulmonary impairment in adult patients or their potential improvement from surgical repair. This review focuses on the recommended evaluation of adult patients to discern the potential cardiopulmonary limitations to exercise due to pectus excavatum, especially in physically fit adults such as active duty military personnel. Two illustrative cases are presented to describe the complexity of the evaluation of adult patients and potential need for surgical correction.

The physiologic impact of pectus excavatum repair

The adverse physiologic effects of pectus excavatum and subsequent resolution following correction have been a subject of controversy. There are numerous accounts of patients reporting subjective improvement in exercise tolerance after surgery, but studies showing clear and consistent objective data to corroborate this phenomenon physiologically have been elusive. This is partially due to a lack of consistent study methodologies but even more so due to a mere paucity of data. As experts in the repair of pectus excavatum, it is not uncommon for pediatric surgeons to operate on adult patients. For this reason, this review evaluates the contemporary literature to provide an understanding of the physiologic impact of repairing pectus excavatum on pediatric and adult patients separately.

Evaluating interest in narrative therapy for decision making about pectus excavatum treatment

OBJECTIVES

The decision to proceed with surgical treatment for pectus excavatum (PE) is rarely clear-cut. Patients interested in treatment are referred for evaluation by numerous different specialists, but psychosocial counselling is currently not included in this process. Our objective was to assess whether PE patients would be interested in formal assistance with the decision-making process surrounding PE surgery using narrative therapy principles.

METHODS

Ninety-seven untreated PE patients at 5 different institutions in 4 countries completed a questionnaire consisting of 13 questions, with 3 questions specifically evaluating interest in narrative therapy.

RESULTS

Eighty-two percent of participants were interested in narrative therapy to assist with the decision-making process surrounding PE surgery. Individuals most interested in narrative therapy tend to be more interested in correction (P < 0.05) to improve the way they feel about their body (P < 0.05).

CONCLUSIONS

The majority of PE patients are interested in narrative therapy to aid the decision-making process about treatment. We propose that narrative therapy should be offered to PE patients during the treatment evaluation process to address the psychosocial difficulties associated with PE and the surgical decision-making process overall. Future studies should assess the effectiveness of this interdisciplinary model.

Diminished pulmonary function in pectus excavatum: from denying the problem to finding the mechanism

BACKGROUND

Recently, technical improvement in the ability to measure lung function and the severity of chest deformity have enabled progress in understanding the mechanism of limitations of lung function in pectus excavatum.

METHODS

After establishing that most patients with pectus excavatum do have symptoms of exercise intolerance, easy fatigability, and shortness of breath with exertion, lung function has been evaluated by a variety of methods in different centers. Spirometry, plethysmography, exercise testing, oculo electronic plethysmography, and imaging methods have been used to assess lung function in pectus excavatum and its response to surgery.

RESULTS

Not all patients with pectus excavatum have subnormal static pulmonary function testing; some have above-average values. However, in more than 1500 adult and pediatric surgical patients with anatomically severe pectus excavatum at a single center, the bell curve of FVC, FEV1, and FEF 25-75 is shifted to significantly lower values in pectus excavatum. The curve is shifted to higher values after operation by approximately one standard deviation. Previous work has demonstrated that patients with more anatomically severe pectus excavatum are more likely to have diminished PFT's. A mechanism for this effect is seen by oculo electronic plethysmography, which demonstrates that the depressed portion of the chest does not move on respiration. After Nuss procedure, the chest wall motion used to create suction to draw air into the lungs is indistinguishable from that of persons with a normal chest, and the intrathoracic volume is markedly increased.

CONCLUSIONS

Pectus excavatum is accompanied in most patients by diminished static pulmonary function. Correction by Nuss procedure results in improvement in chest wall motion; this improvement in the thoracic bellows action is accompanied by improvement in pulmonary function testing.

Pectus deformities and their impact on pulmonary physiology

Pectus excavatum (PE) and pectus carinatum (PC) are the most common anomalies of the thoracic cage and they have been recognized since ancient times [1-3]. The two conditions differ in their appearance, and their effect on lung function. There is no direct correlation between the appearance of the deformities and the clinical symptoms. Whether, and when these deformities should be corrected as well as with which method (surgical or conservative) remain controversial. The following article reviews the current concepts regarding the pathophysiology of both conditions as well as the advances in their evaluation and management.

Longer term effects of closed repair of pectus excavatum on cardiopulmonary status

BACKGROUND

The "Nuss" repair is done for correction of moderate to severe pectus excavatum (PE). The long term cardiopulmonary and psychosocial effects of repair are uncertain. The objective of this study was to compare cardiopulmonary function and subjective evaluation of appearance and exercise tolerance pre-bar insertion with post-bar removal.

METHODS

All patients underwent preoperative and post-bar (3 month) removal evaluation with complete pulmonary function tests, exercise stress testing, echocardiogram, and self-rated appearance and exercise tolerance scoring. The protocol was approved by the regional ethics board, and all families gave informed consent.

RESULTS

Sixty-seven patients underwent pre and post testing. Preoperative CT index was 4.4 ± 1.3. Cardiopulmonary outcomes, standardized for height and weight, showed significant improvements in FEV-1 as (pre) 81.1 ± 17.0 vs post 89.8 ± 20.5*, FVC: 91.2 ± 18.6 vs 98.9 ± 22.9*, O2 pulse: 75.8 ± 14.4 vs 80.5 ± 18.3* (each as % predicted). Both the self-ratings of appearance (2.5 ± 0.8 vs 4.4 ± 0.5) and ability to exercise (3.3 ± 0.7 vs 4.3 ± 0.6, scale 1-5) increased significantly. (All data: mean ± St Dev, *p<0.05) CONCLUSIONS: Closed repair of PE results in improvements in pulmonary and aerobic exercise function and perceived appearance and exercise tolerance. Our data suggest that the impact on appearance and self-perceived well being is greater than the physical effect.

Does repair of pectus excavatum improve cardiopulmonary function?

A best evidence topic was written according to a structured protocol. The question addressed was 'Does repair of pectus excavatum (PE) improve cardiopulmonary function?' One hundred and sixty-eight papers were found using the reported search, 19 level III evidence papers and three meta-analyses were relevant. Studies were divided into four groups based on the surgical technique applied and pulmonary and cardiac functions in these groups were analysed. The meta-analyses show conflicting results for improvements in pulmonary and cardiac functions when comparing surgical techniques, while four more recent studies show improved long-term results using the Nuss technique. The best evidence of papers studying the PE repair using the minimally invasive Nuss technique demonstrates a decrease in pulmonary function during the early postoperative period, however, there is a small but significant improvement during the late postoperative period and after bar removal. The best evidence for cardiac function in this group suggests an early improvement that is sustained during further follow-up. The best evidence of papers studying the PE repair using the Ravitch technique shows that pulmonary function decreased during the early postoperative period, however, there is a small but significant improvement during the late postoperative period. The best evidence for cardiac function in this group suggests an early improvement that is sustained during further follow-up. The best evidence of papers studying the PE repair using other techniques (modified Daniel's technique, modified Baronofsky's technique, sterno-costal turn-over technique and sterno-costal elevation technique) or where surgical techniques used were not described (preceding year 1985) suggests that there is no improvement in pulmonary function after surgery. There is some evidence that certain aspects of cardiac function improved after surgery in this group.

Effects of the Nuss procedure on chest wall kinematics in adolescents with pectus excavatum

No data are available on the effects of the Nuss procedure on volumes of chest wall compartments (the upper rib cage, lower rib cage and abdomen) in adolescents with pectus excavatum. We used optoelectronic plethysmography to provide a quantitative description of chest wall kinematics before and 6 months after the Nuss procedure at rest and during maximal voluntary ventilation in 13 subjects with pectus excavatum. An average 11% increase in chest wall volume was accommodated within the upper rib cage (p=0.0001) and to a lesser extent within the abdomen and lower rib cage. Tidal volumes did not significantly change during the study. The repair effect on chest wall kinematics did not correlate with the Haller index of deformity at baseline. Six months of the Nuss procedure do increase chest wall volume without affecting chest wall displacement and rib cage configuration.

Pectus excavatum (funnel chest): a historical and current prospective

Pectus excavatum (PE) is a relatively common deformity involving the anterior chest wall. It is represented clinically as a conical depression of the sternum and costal cartilages with the apex at the xiphoid process. Associated features and symptoms vary but generally involve respiratory and cardiac abnormalities. Since it's initial description, numerous surgical techniques have been developed to correct PE, with the Ravtich (open) and Nuss (minimally invasive) procedures being the most commonly employed. Although the etiology remains unclear, the pathogenesis of PE is currently thought to involve the overgrowth of the costochondral region of the ribs. In addition, documented case reports of familial pectus excavatum exist, suggesting a heritable form of the defect. Numerous genetic markers have also been discovered, linking PE to various genetic syndromes.

Chest wall kinematics in young subjects with Pectus excavatum

Quantifying chest wall kinematics and rib cage distortion during ventilatory effort in subjects with Pectus excavatum (PE) has yet to be defined. We studied 24 patients: 19 during maximal voluntary ventilation (MVV) and 5 during MVV and cycling exercise (CE). By optoelectronic plethysmography (OEP) we assessed operational volumes in upper rib cage, lower rib cage and abdomen. Ten age-matched healthy subjects served as controls. Patients exhibited mild restrictive lung defect. During MVV end-inspiratory and end-expiratory volumes of chest wall compartments increased progressively in controls, whereas most patients avoided dynamic hyperinflation by setting operational volumes at values lower than controls. Mild rib cage distortion was found in three patients at rest, but neither in patients nor in controls did MVV or CE consistently affect coordinated motion of the rib cage. Rib cage displacement was not correlated with a CT-scan severity index. Conclusions, mild rib cage distortion rarely occurs in PE patients with mild restrictive defect. OEP contributes to clinical evaluation of PE patients.

Cardiopulmonary response following surgical repair of pectus excavatum in adult patients

OBJECTIVE

Severe pectus excavatum are common in adult patients, often causing psychological complaints and physiological impairments. Although lung function at rest may minimally deteriorate after surgical correction, it remains unclear if surgery improves exercise capacity. The objective of present study is to assess whether the surgical repair of pectus excavatum in adults would improve exercise tolerance.

METHODS

A prospective study was performed to compare pulmonary and cardiovascular function at rest and at maximal exercise, before, and at 1 year after pectus excavatum repair.

RESULTS

From December 2005 to May 2009, 120 adult patients underwent pectus excavatum repair. Of these patients, 70 (nine women, 61 men) underwent thorough preoperative, 6-, and 12-month postoperative assessments, and were included in the present study. Age ranged from 18 to 62 years (mean 27 years). The pectus index (Haller index) was 4.5 ± 1.1. Lung function tests at rest were within the normal range, whereas maximal oxygen uptake (peak VO₂) was only 77 ± 2% of the predicted value. At 1-year follow-up, the pectus excavatum repair was associated with minor changes in lung function tests and significant increase (p=0.0005) in VO₂ (87 ± 2% of the predicted value). Postoperative O₂ pulse increase at maximal exercise suggested that aerobic capacity improvement was the result of better cardiovascular adaptation at maximal workload.

CONCLUSION

These results demonstrate sustained improvement in exercise cardiopulmonary function at 1-year follow-up of pectus excavatum surgical repair in adult patients.

Indications and technique of Nuss procedure for pectus excavatum

Pectus excavatum most frequently involves the lower sternum and chest wall. Because the morphology varies, preoperative imaging for anatomic assessment and documentation of dimensions of the chest are important. Many modifications have been made to the minimally invasive procedure since it was first performed in 1987. As a result, there has been an increase in the number of patients seeking surgical correction. This article discusses the clinical features of pectus excavatum and reviews the preoperative considerations and the steps involved in the repair of the deformity.

Airway deformation in patients demonstrating pectus excavatum with an improvement after the Nuss procedure

PURPOSE

This study analyzed the inside appearance of the trachea and the main bronchus at the time of performing the Nuss procedure to test the hypothesis that the trachea and the main bronchus might be deformed by compression from great vessels due to sternal depression.

METHODS

A retrospective cohort study included 36 patients with pectus excavatum, who were treated using the Nuss procedure between July 2001 and December 2009. The primary outcome measures were the oblateness of the trachea and bilateral main bronchus. The oblateness in patients with pectus excavatum was compared with that of the control group. Their postoperative changes and the relationship between the Haller CT index were also analyzed.

RESULTS

The oblateness of the trachea and the left main bronchus in patients with pectus excavatum was significantly greater than that of the control group. A negative correlation was recognized between the percent vital capacity and the oblateness of the left main bronchus. The oblateness of the bilateral main bronchus significantly improved during the 2 years of bar placement.

CONCLUSION

A significant deformation of the airways was demonstrated in patients with pectus excavatum, which improved after correcting it by means of the Nuss procedure.

A cross-sectional study of lung volume development in pectus excavatum patients: estimating the total lung volume from chest computed tomograph using 3-dimensional volumetric reconstruction

BACKGROUND/PURPOSE

This study quantified the lung volume development of pectus excavatum (PE) patients using chest computed tomography (CT) 3-dimensional volumetric reconstructions. The technique permits current and retrospective analyses of data from different institutions.

PATIENTS AND METHODS

We analyzed the records of PE patients who underwent chest CT preoperatively between 2005 and 2009 at 3 institutions. All patients were Chinese. A window of -992 to -198 Hounsfield units was chosen for calculating the CT total lung volume (TLV). The data were compared with the data for 73 microtia and other chest-wall tumor patients studied during the same period as a control group.

RESULTS

In total, 377 PE patients with Haller pectus index (PI) of at least 3.2 were identified for this study. Compared with the reported TLV data for 1050 healthy children and our control group, we found little evidence of a decreased TLV in PE patients at any age for either sex. The mean PI did not change significantly between the ages of 3 and 27 years. The PI was inversely correlated with the TLV (P < .001).

CONCLUSION

Our cross-sectional study provides evidence that the TLV of PE patients is within the reference range in children and adolescents.

The prevalence and effects of Pectus Excavatum and Pectus Carinatum on the respiratory function in children between 7-14 years old

The study involved 1342 primary school students aged 7-14 years who applied to Ankara, a primary care center for general health check-up between 2006 and 2007. Forty-three students, 35 of whom had PE and 8 of whom had PC, were subjected to thorax measurement. All 43 students underwent pulmonary function tests (PFT).The prevalence rate of PC was 0.6%, and of PE, 2.6%. The thorax widths of the groups were similar (P = 0.273). The thorax circumference and depth of PE group were lower than those of the controls (P < 0.05). The probability rate of abnormality in PFT scores of PE group was statistically significantly higher than that of the controls (P = 0.022) whereas absence of normal PFT scores the difference between PC group and the controls was not statistically significant (p = 0.095). The results indicate that more than half of the individuals with pectus deformity do not have any physical complaints and do not have statistically significant differences in their PFT parameters.

Correlation between sternal depression and cardiac rotation in pectus excavatum: Evaluation with helical CT

OBJECTIVE

The purpose of this study was to investigate the effect of the degree of sternal depression on the cardiac rotation of pectus excavatum as depicted with helical CT.

MATERIALS AND METHODS

Sixty-three patients (53 boys, 10 girls; mean age, 9.7 +/- 7 years) with pectus excavatum who underwent helical chest CT and surgical correction were included in this study. Depth of sternal depression, CT depression index, cardiac rotation angle, and pulmonary vein angle were measured, and the correlation of these parameters was analyzed.

RESULTS

The mean sternal depression was 21 +/- 7 mm; CT depression index, 2.7 +/- 1.4; cardiac rotation angle, 55 degrees +/- 9 degrees ; and pulmonary vein angle, 52 degrees +/- 12 degrees . The sternal depression (18 mm) in patients with a CT depression index less than 2.4 was less than that in patients with a CT depression index of 2.4-2.9 (sternal depression, 21 mm) or greater than 2.9 (sternal depression, 28 mm) (p < 0.01). Similarly, the cardiac rotation angle (49 degrees +/- 5 degrees ) in patients with a CT depression index less than 2.4 was smaller than that in patients with a CT depression index of 2.4-2.9 (55 degrees +/- 6 degrees ) or greater than 2.9 (64 degrees +/- 12 degrees ) (p < 0.01). The pulmonary vein angle in patients with a CT depression index less than 2.4 (59 degrees +/- 11 degrees ) was larger than that in patients with a CT depression index of 2.4-2.9 (50 degrees +/- 12 degrees ) or a CT depression index greater than 2.9 (45 degrees +/- 8 degrees ) (p < 0.01). Cardiac rotation angle had a positive correlation with CT depression index (r = 0.75, p < 0.01).

CONCLUSION

The degree of sternal depression has a positive correlation with the degree of cardiac rotation in pectus excavatum. Helical CT is a valuable technique for evaluating the chest deformity and resultant cardiac rotation.

Exercise performance testing in patients with pectus excavatum before and after Nuss procedure

PURPOSE

To assess the changes in lung function and exercise performance due to minimal invasive pectus repair.

METHODS

Fifty-nine patients with an average age of 16 years were included in this prospective investigation. After determination of body mass index (BMI) and body fat patients were subjected to pre-OP, post-OP and post-implant removal spirometry and bicycle ergospirometry. Forced vital capacity (FVC), performance capacity (PC) and relative oxygen uptake were determined.

RESULTS

Post-OP FVC significantly decreased from 91% of normal value to 79%, but again increased to 88% after implant removal. PC showed a significant reduction (105-97% of normal value). Likewise, the relative oxygen uptake showed a significant decrease (43.8-42.2 ml/kg per min). These findings correlated to a significant increase of BMI and body fat. When calculating oxygen uptake per kilogram lean body weight, there were no significant changes (49.8 to 49.8 ml/kg per min).

CONCLUSIONS

Pectus repair resulted in a temporary reduction of FVC, which resolved after implant removal. The drop in oxygen uptake and PC could be related to a significant increase of BMI and body fat. According to our data pectus repair is not followed by improvements in lung function and exercise performance.

Prevalence of pectus carinatum and pectus excavatum in students in the city of Manaus, Brazil

OBJECTIVE

To determine the prevalence of congenital anterior chest wall deformities in 11- to 14-year-old students.

METHODS

Students participating in the study were recruited from public schools in the city of Manaus, Brazil. The statistically significant sample (precision, 1%; 95% CI) comprised 1,332 students. Pectus deformities were identified by physical examination of the chest, and the individuals with one of these deformities completed a questionnaire regarding heredity and symptoms resulting from the chest abnormality.

RESULTS

The mean age of the participants was 11.7 years. The prevalence of pectus abnormalities was 1.95% (pectus excavatum: 1.275%; pectus carinatum: 0.675%). Of the 26 students with a pectus deformity, 17 (65.4%) had pectus excavatum, and 18 (69.2%) were male. Concomitant scoliosis was observed in 3 cases (11.5%). A family history of pectus was reported by 17 students (65.4%), and 17 (65.4%) reported chest pain, dyspnea or palpitations.

CONCLUSIONS

In this study, the prevalence of pectus deformities (1.95%) was lower than that reported in other studies conducted in Brazil (3.6-4.9%) but was higher than that reported in the literature (mean, 1%).

Pectus excavatum: pathophysiology and clinical characteristics

Pectus Excavatum is the most common congenital abnormality of the chest wall. In the majority of the cases the condition is idiopathic. Affected patients tend to have lung volumes that are mildly decreased but within the normal range and they are often associated with mild air-trapping. Many patients show evidence of lower airway obstruction. Exercise intolerance is the most common symptom associated with pectus excavatum, and it is now believed to be due to cardiovascular rather than pulmonary causes. The psychological effect of the deformity often exceeds its actual physical effect. Several surgical techniques are available for the repair of the deformity, although the need for it is still considered controversial by many. The current article provides an in depth review of the pathophysiology and clinical characteristics of pectus excavatum, as well as an overview of the treatment options in order to help the practitioners caring of affected patients in their evaluation.

The long-term follow-up of patients with a congenital diaphragmatic hernia: a broad spectrum of morbidity

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly with a mortality rate of approximately 40-50%, depending on case selection. It has been suggested that new therapeutic modalities such as nitric oxide (NO), high frequency oxygenation (HFO) and extracorporal membrane oxygenation (ECMO) might decrease mortality associated with pulmonary hypertension and the sequelae of artificial ventilation. When these new therapies indeed prove to be beneficial, a larger number of children with severe forms of CDH might survive, resulting in an increase of CDH-associated complications and/or consequences. In follow-up studies of infants born with CDH, many complications including pulmonary damage, cardiovascular disease, gastro-intestinal disease, failure to thrive, neurocognitive defects and musculoskeletal abnormalities have been described. Long-term pulmonary morbidity in CDH consists of obstructive and restrictive lung function impairments due to altered lung structure and prolonged ventilatory support. CDH has also been associated with persistent pulmonary vascular abnormalities, resulting in pulmonary hypertension in the neonatal period. Long-term consequences of pulmonary hypertension are unknown. Gastro-esophageal reflux disease (GERD) is also an important contributor to overall morbidity, although the underlying mechanism has not been fully understood yet. In adult CDH survivors incidence of esophagitis is high and even Barrett's esophagus may ensue. Yet, in many CDH patients a clinical history compatible with GERD seems to be lacking, which may result in missing patients with pathologic reflux disease. Prolonged unrecognized GERD may eventually result in failure to thrive. This has been found in many young CDH patients, which may also be caused by insufficient intake due to oral aversion and increased caloric requirements due to pulmonary morbidity. Neurological outcome is determined by an increased risk of perinatal and neonatal hypoxemia in the first days of life of CDH patients. In patients treated with ECMO, the incidence of neurological deficits is even higher, probably reflecting more severe hypoxemia and the risk of ECMO associated complications. Many studies have addressed the substantial impact of the health problems described above, on the overall well-being of CDH patients, but most of them concentrate on the first years after repair and only a few studies focus on the health-related quality of life in CDH patients. Considering the scattered data indicating substantial morbidity in long-term survivors of CDH, follow-up studies that systematically assess long-term sequelae are mandatory. Based on such studies a more focused approach for routine follow-up programs may be established.

Cardiorespiratory function after operation for pectus excavatum

OBJECTIVE

We performed a review of current data to determine the effect that operation has on pulmonary function, aerobic capacity, and stroke volume in patients with pectus excavatum.

STUDY DESIGN

Two reviewers independently assessed clinical trials and collected data on interventions and outcomes. To qualify for inclusion, a study had to include preoperative and postoperative assessment, provide outcomes in either a published percentile or qualified matched control form to control for interval growth, and include only original patient groups.

RESULTS

Postoperative total lung capacity for patients who had Ravitch repair was significantly lower (SMD, 0.71 [CI -1.06, -0.36]; I(2) = 19.6%) than preoperative. Based on 2 studies after removal of the Nuss bar, FEV(1) was significantly increased from preoperative values (SMD, 0.39 [CI, 0.03, 0.74]; I(2) = 0%). Stroke volume increased after surgery (SMD, 0.40 [CI, 0.10, 0.70]; I(2) = 0%) after Ravitch repair. There was a trend toward improved exercise tolerance, but it was not statistically significant.

CONCLUSIONS

Total lung capacity was decreased after Ravitch repair, and FEV(1) was increased after Nuss bar removal. Stroke volume may be increased after Ravitch repair. Exercise tolerance was not improved after either type of surgical repair.

Pectus excavatum: historical background, clinical picture, preoperative evaluation and criteria for operation

Pectus excavatum is a depression of the sternum and costal cartilages which may present at birth, or more commonly during the teenage growth spurt. Symptoms of lack of endurance, shortness of breath with exercise, or chest pain are frequent. Although pectus excavatum may be a component of some uncommon syndromes, patients usually are healthy. Evaluation should include careful anatomic description with photographs, radiography to demonstrate the depth of the depression, extent of cardiac compression, or displacement, measurement of pulmonary function, and echocardiography to look for mitral valve prolapse (in 15%) or diminished right ventricular volume. Indications for surgical treatment include two or more of the following: a severe, symptomatic deformity; progression of deformity; paradoxical respiratory chest wall motion; computer tomography scan with a pectus index greater than 3.25; cardiac compression/displacement and/or pulmonary compression; pulmonary function studies showing restrictive disease; mitral valve prolapse, bundle branch block, or other cardiac pathology secondary to compression of the heart; or failed previous repair(s). The developmental factors, genetics, and physiologic abnormalities associated with the condition are reviewed.

Strategies for cardiopulmonary exercise testing of pectus excavatum patients

The purpose of this paper is to provide strategies for cardiopulmonary exercise testing of pectus excavatum patients. Currently, there are no standardized methods for assessing cardiovascular and pulmonary responses in this population; therefore, making comparisons across studies is difficult if not impossible. These strategies are intended for physicians, pulmonary technicians, exercise physiologists, and other healthcare professionals who conduct cardiopulmonary exercise testing on pectus excavatum patients. By using the strategies outlined in this report, comparisons across studies can be made, and the effects of pectus excavatum on cardiopulmonary function can be assessed with greater detail.

[Malformations of the anterior chest wall]

INTRODUCTION

Pectus excavatum or funnel chest is the most common anterior chest wall deformity seen in children and adults. The sternal depression appears to be caused by overgrowth of the costal cartilages, also the cause of the less common deformities: pectus carinatum (pigeon breast) and pectus arcuatum.

BACKGROUND

Usually the overgrowth involves the third to seventh costal cartilages but it can be more or less extensive. The cardiopulmonary functional consequences are insignificant in the protrusional deformities and inconsistent in pectus excavatum and the indications for surgery are mainly cosmetic.

VIEWPOINT AND CONCLUSIONS

The procedural modalities are guided by morphological study of the CT scan. We describe a surgical technique that comprise subperichondrial excision of all deformed costal cartilages followed by transverse sternotomy to correct the sternal deformity, anteriorly in the case of pectus excavatum and posteriorly for pectus carinatum and arcuatum. As the perichondrial sheaths are totally preserved they are sutured in continuous layers to give a shortening effect. In the case of pectus excavatum the sternum is then secured anteriorly for about 6 months by a retrosternal metallic strut in an overcorrected position. The partially resected seventh cartilages are then sutured to the xiphoid. Other surgical techniques are described, including modified Ravitch's procedure, modelling osteochondroplasty, prosthetic reconstruction and Nuss's procedure. Results of the more important series are reported and discussed.

Lung function after the minimal invasive pectus excavatum repair (Nuss procedure)

Background

The Nuss procedure was introduced at our center in 1999. The operation was mainly performed for cosmesis. Little information is available regarding the influence of this operation on lung function.

Methods

The aim of this study, a prospective analysis, was to analyze the effect of the Nuss procedure on lung function variables. Between 1999 and 2007 a total of 203 patients with pectus excavatum were treated with the Nuss procedure, of whom 145 (104 male, 41 female) were located at Emma Children’s Hospital. In the latter subset of consecutive patients, static lung function variables [total lung capacity (TLC), functional residual capacity (FRC), vital capacity (VC)] and dynamic lung function variables [forced expired volume in 1 s (FEV₁), maximum expiratory flow (MEF₅₀)] were performed using spirometry and body box measurements at four time points: prior to operation (T0), 6 months after the Nuss procedure (T1, n = 111), prior to removal of the Nuss bar (T2, n = 74), and 6 months after removal (T3, n = 53). All values were expressed as a percent of normal values for sex, age, and height. Results were compared with a paired-samples t-test, with the level of significance at p = 0.05.

Results

At 6 months after bar insertion the TLC, FRC, VC, FEV₁, and MEF₅₀ showed a significant increase; and prior to bar removal the FRC and MEF₅₀ showed significantly increased values. At 6 months after Nuss bar removal, none of the lung function variables showed any significant change compared to the preoperative values.

Conclusion

After the Nuss procedure for pectus excavatum, there was no improvement of pulmonary function, but neither was the patient’s pulmonary function harmed by resolving a largely cosmetic problem.

Long term cardiopulmonary effects of closed repair of pectus excavatum

The closed or "Nuss" repair of pectus excavatum is widely accepted for correction of moderate to severe deformities. Patients typically report significant subjective improvements in pulmonary symptoms, and short and medium term evaluations (up to 2 years with the bar in place) suggest modest improvement to cardiac function but a decrease in pulmonary function. This study examined the effects at 3 months post-bar removal of closed repair of pectus on pulmonary function, exercise tolerance and cardiac function. Patients were followed prospectively after initial evaluation for operation. All patients underwent preoperative and post-bar removal evaluation with CT scan, complete pulmonary function and exercise testing to anaerobic threshold, as well as echocardiogram. Twenty-six patients have completed the follow up protocol. Preoperative CT index was 4.5 +/- 1.3, average age at operation was 13.2 years, and average tanner stage was 3.5 +/- 0.5. At 3 months or greater follow-up post-bar removal, patients reported an improvement in subjective ability to exercise and appearance (P < 0.05 by wilcoxin matched pairs). Objective measures of FEV1, total lung capacity, diffusing lung capacity, O(2) pulse, VO(2max), and respiratory quotient all showed significant improvement compared to preoperative values, while normalized values of cardiac index at rest did not (All values normalized for height and age, comparisons P < 0.05 by student's paired t test). These results demonstrate a sustained improvement in cardiopulmonary function after bar removal following closed repair of pectus excavatum. These findings contrast with results from previous studies following the open procedure, or with the closed procedure at earlier time points; the long term physiological effects of closed repair of pectus excavatum include improved aerobic capacity, likely through a combination of pulmonary and cardiac effects.

Pectus excavatum

One of the more common chest wall anomalies seen in children is pectus excavatum. Although some studies suggest a physiologic impact of this anomaly on cardiac function during exercise, this remains somewhat controversial. Regardless, a number of children are symptomatic from either the appearance of the deformity or from the standpoint of tolerance to exercise. Most are relieved of these symptoms with surgical repair. Several different operations have been utilized for repair of this anomaly, but two techniques now are the predominant methods in use today. These are the modified Ravitch procedure and the Nuss procedure. Both have been shown to provide satisfactory results.

Cardiovascular Function Following Surgical Repair of Pectus Excavatum

BACKGROUND

Despite numerous published reports, there is no consensus in the literature as to whether the surgical repair of the pectus excavatum improves cardiovascular function. As a result, it has been suggested that correction should be considered a cosmetic procedure, and therefore, many health insurance companies have questioned whether the repair of the pectus excavatum improves cardiovascular function and thus are reluctant to authorize the procedure. The purpose of this study was to apply metaanalysis methodology to generate a quantitative synthesis of the effects of surgical repair on cardiovascular function and to test the hypothesis that surgical repair of the pectus excavatum results in significant improvements in cardiovascular function.

METHODS

Studies were retrieved via computerized literature searches, cross-referencing from original and review articles, and a review of the reference list by a recognized authority in the area of pectus excavatum repair. The inclusion criteria were as follows: (1) reporting quantitative measures of preoperative and postoperative cardiovascular function; (2) published in the English language; (3) indexed between January 1960 and May 2005; (4) reporting the duration between which preoperative and postoperative assessments were conducted; and (5) describing the cardiovascular assessment procedures.

RESULTS

A comprehensive search of the literature identified eight studies that met all of the inclusion criteria. These studies, representing 169 pectus excavatum patients, were used for the metaanalysis. Random-effects modeling yielded a mean weighted effect size (ES) for cardiovascular function that was statistically significant (ES, 0.59; 95% confidence interval, 0.25 to 0.92; p = 0.0006).

CONCLUSIONS

The findings of the present study indicated that surgical repair of the pectus excavatum significantly improves cardiovascular function and contradicts arguments that surgical repair is primarily cosmetic yielding minimal physiologic improvement.

CINE-MRT des Thorax bei Patienten mit Pectus excavatum

BACKGROUND

Morphologic and dynamic assessment of respiratory chest kinetics was performed in patients with pectus excavatum deformity (PE) using dynamic MRI: cine MRI.

MATERIAL AND METHODS

Seven consecutive patients with PE (aged 20.3 years+/-4.0) and ten healthy volunteers of comparable age underwent real-time cine MRI of the chest during breathing on a 1.5 T MR scanner (Magnetom Sonata, Siemens Medical Systems, Erlangen, Germany) using a standard phased array body coil and a half-Fourier single-shot turbo spin echo sequence (HASTE) for dynamic imaging. During deep inspiration and expiration, single-shot sequences were performed in one slice level over 20 s at a frequency of 1 image/s covering the entire thoracic cage in three orientations. Morphology and chest kinetics in patients with PE were analyzed and compared with normal values, and typical patterns of chest kinetics were noted.

RESULTS

Three different types of chest morphology in PE were identified: (1) the generally flattened thoracic cage, (2) the "tilted" sternum, and (3) the focally deepened sternum. Three patterns of motion correspond to these morphological types: (1) elevation of the sternum and the anterior thoracic wall, (2) angulated elevation of the parasternal rib cage with persistent deepening of the sternum resembling a "wing beat" movement, and (3) increased diaphragmatic movements with limited chest wall dynamics.

CONCLUSIONS

Cine MRI is an adequate radiation-free diagnostic modality for the dynamic imaging of both chest morphology and chest wall kinetics in patients with PE. The pectus severity index can easily be determined and three typical movement patterns of chest wall kinetics identified.

THE LEARNING CURVE IN LEARNING THE CURVE: A REVIEW OF NUSS PROCEDURE IN TEENAGERS

BACKGROUND

The Nuss procedure is a new minimally invasive repair for pectus excavatum that was first published in 1998. Modifications in technique are constantly evolving to minimize complications, especially bar displacement, which are higher in adolescents and adults. The present study reviews our early experience with this procedure in a much older group of children than previously reported and suggests an alternative method of avoiding bar displacement.

METHODS

Retrospective chart review was carried out on 78 consecutive patients who underwent the Nuss procedure between December 1999 and January 2004. All patients underwent a uniform technique using bilateral lateral stabilisers and thoracoscopy was not used. Operative details, subjective cosmetic results and complication rates were assessed.

RESULTS

The mean age was 15.4 +/- 3.2 years. Single bars were used in 95%, double bars in 5%. The defect was asymmetrical in 26%. The defect was mild in 7%, moderate in 59% and severe in 34%. The median length of stay was 6.0 days (range 4-11). Total operating time was 58 min (range 35-95). Patient controlled analgesia (morphine) for pain relief was used for 105 h (range 61-169) or 4.4 days; the epidural infusion was stopped 1 day earlier. Cosmetic results were excellent in 80.3%. There was residual asymmetry in 75% of the asymmetrical defects although all were improved. Complications included eight (10%) reoperations for bar displacement. This was related to the learning curve as seven of these occurred in the first 2 years of the series. Removal of the bar has been accomplished in 31 (40%) patients. This was elective in all but four patients (three early removals for pain and one for infection).

CONCLUSIONS

The Nuss procedure gives good results even in teenagers. Modification of technique and increased experience has reduced complications. The use of bilateral lateral stabilisers without additional wire fixation is an alternative method to avoid bar displacement.

Midterm evaluation of cardiopulmonary effects of closed repair for pectus excavatum

BACKGROUND/PURPOSE

Since the introduction of the closed technique for repair of pectus excavatum, increasing numbers of patients are presenting for surgery. However, controversy exists regarding the effects of repair on long-term cardiopulmonary outcome. This report details the effects over time of closed repair of pectus excavatum on pulmonary function, cardiac function, exercise tolerance, and the patient's perception of appearance and subjective ability to exercise.

METHODS

All patients undergoing closed repair of pectus excavatum were evaluated prospectively. Preoperative computed tomography scan, static pulmonary function studies, exercise tolerance, and echocardiographic evaluation of cardiac function were done. Studies were repeated at 3 and 21 months post-bar placement, and then 3 months after bar removal.

RESULTS

Pre- and postoperative data were available for an initial 48 patients, with 11 patients completing the full evaluation after bar removal. All measures of pulmonary function including forced expiratory volume in 1 second and forced vital capacity were reduced at 3 months postoperation, with a gradual increase during follow-up; however, pulmonary function remained below normative values for patients without pectus excavatum of similar age. Cardiac function as measured by cardiac output and index was increased at 3 months postoperation and maintained thereafter. Exercise tolerance declined initially and then increased by the 21-month evaluation point and after bar removal. Patients reported a subjective improvement in the ability to exercise immediately after bar insertion.

CONCLUSIONS

These results corroborate previous studies which suggested that after closed repair of pectus excavatum there is an immediate subjective improvement in the ability to exercise which is paralleled by an improvement in cardiac output. However, there is an early postoperative decline in pulmonary function which does improve over time; however, this does not reach normal values for similar weight. Further studies are needed to determine whether these results are maintained, or whether after bar removal there is a further improvement in pulmonary status. These results do support the use of the closed repair of pectus excavatum for maintaining and possibly improving cardiopulmonary function in this patient population.

Ten year experience of bioabsorbable mesh support in pectus excavatum repair

INTRODUCTION

We reviewed 10 years experience in the treatment of this deformity using a retro-sternal bioabsorbable mesh in place of a metallic device to lift and stabilise the sternum. Moreover, the mesh supports the thoracic and upper abdominal wall reconstruction.

MATERIALS AND METHODS

From January 1990 to December 2000, in our Thoracic Surgery Unit, 65 patients with PE were assessed for surgical repair, mean age 16+/- 3.5 years, fronto sagittal thoracic index (FSTI) 0.21, ranging from 0.15-0.33. Twenty-three of them underwent surgical correction after initial assessment, 22 were deferred and sent to physiotherapy. At a subsequent assessment, five of the patients sent to physiotherapy were deemed to require surgery.

RESULTS

Of the 28 patients who underwent surgery, 2 (10%) presented a mild recurrence of PE after 1 year (0.30<FSTI>0.34), meanwhile all other patients maintained a FSTI>0.34. For all patients the improvement in FSTI was statistically significant, p = 0.001. Patients satisfaction after 24 months was thus shared: excellent 18 patients (65%), good seven patients (25%), fair one patient (3.5%) and poor two patients (7%). No major complications were observed in preoperative period. Patients mobilisation was soon achieved thanks to the postoperative pain control and the absence of retro-sternal metallic support.

CONCLUSIONS

The introduction of bioabsorbable mesh in the Robicsek technique is a safe procedure related to a high percentage of success. The high tolerance of the material reduces the inflammatory reaction. Moreover, the procedure prevents patients from having complications caused by retro-sternal device dislodgment, avoiding a second intervention for device reposition and reducing the postoperative chest pain achieving an early patient mobilisation. In the end a complete reconstruction of the upper abdomen wall has been produced.

Further experience with the operative management of asphyxiating thoracic dystrophy after pectus repair

BACKGROUND/PURPOSE

Asphyxiating thoracic dystrophy (ATD) can occur years after a Ravitch-type repair of pectus excavatum, resulting in debilitating alteration in pulmonary function (PFT). An operation was devised to attempt repair of this deformity.

METHODS

After institutional review board approval, the records of 10 children (ages 9-18 years) with ATD that developed 4 to 12 years postpectus operation who underwent attempted repair of ATD were reviewed. Data obtained before ATD operation and at 6, 12, and 24 months afterward included chest computed tomography, pulmonary functions (PFT), and a quality of life questionnaire. The operation consisted of sternal split with rib graft placement to permanently hold the sternum apart.

RESULTS

All children survived and the bone grafts healed solidly. Computed tomography showed a change from a flat to a round chest contour on cross section, with increased anteroposterior dimension. Two patients had no change in PFT at 24 months whereas the other 8 had 21% to 30% improvement in PFT parameters. All patients reported improved exercise tolerance, and 3 began sports activities who were previously unable to do so. Two patients on oxygen, essentially bedridden, are now active, breathing only room air. Seven of 10 patients continue to have cosmetic concerns.

CONCLUSIONS

A small population of patients who had postoperative pectus repair developed severe, debilitating ATD. The repair described improves most patients, some dramatically, but does not significantly improve cosmetic appearance. The operation is undergoing further refinement to address these issues.

Índice antropométrico para classificação quantitativa do pectus excavatum

INTRODUÇÃO: O pectus excavatum caracteriza-se por uma depressão do esterno e das cartilagens para-esternais inferiores. Medidas clínicas para classificar essas depressões são poucas e de difícil aplicação. OBJETIVO: Criar medidas clínicas para quantificar a deformidade e poder comparar os resultados entre os períodos pré e pós-operatório. MÉTODO: Dez pacientes portadores de pectus excavatum, foram operados utilizando-se a técnica de Robicsek modificada pelo grupo de Cirurgia Torácica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, sendo também medidos clínica e radiologicamente nos periodos pré e pós operatõrio. Dez pacientes controles que não apresentavam anormalidades torácicas clínicas e ou radiológicas foram medidos da mesma forma. O defeito foi avaliado no nível do manúbrio e da maior deformidade através do índice antropométrico e do índice de Haller. RESULTADOS: A análise multivariada para as médias do índice antropométrico mostrou diferenças significativas entre o pré operatório e o grupo controle e entre as médias do pré e do pós operatório, e diferença não significativa entre o pós operatório e o grupo controle. A mesma análise, aplicada às médias do índice de Haller, demonstrou os mesmos resultados. O estudo pareado entre as médias do pré e do pós operatório mostrou tratarem-se de grupos diferentes. A correlação canônica evidenciou que o índice antropométrico e o índice de Haller têm correlação de 86%. CONCLUSÃO: Pacientes portadores de pectus excavatum podem ter a deformidade quantificada através de medidas do índice antropométrico no pré e no pós operatório, as quais permitem uma avaliação objetiva e comparativa dos resultados, e são de fácil realização.

Lung growth and function in children and adolescents with idiopathic pectus excavatum

Patterns of lung growth and function were studied retrospectively in 103 patients (73 male and 30 female) with idiopathic pectus excavatum in order to determine: 1) the prevalence of restrictive lung defect and/or other lung function abnormalities; 2) the possible association between type of lung function abnormalities and age of the patient; and 3) whether the type of lung function is associated with other clinical conditions. Forty-three patients (42%) were between 5-9 years of age; 36 (35%) were between 10-14 years; and 24 (23%) were between 15-19 years. Restrictive lung disease was detected only in 5 patients (5%), whereas 42 patients (41%) had evidence of obstructive pattern, and the remaining 56 patients (54%) had a normal pattern. The mean values for lung volume (total lung capacity (TLC) and/or forced vital capacity (FVC)) were lowest in the 10-14-year group, whereas the mean values of the indices of lower airway function (forced expiratory volume at 1 sec (FEV(1)), FEV(1)/FVC, forced expiratory flow at 25-75% of forced vital capacity (FEF(25-75)), and FEF(25-75)/FVC) were higher in the younger group. Residual volume (RV) and RV/TLC were elevated in all age groups, but they declined toward normalization with increasing age. There were no significant differences between groups (stratified either by pattern of lung function or by age) with regard to their demographics or clinical characteristics (scoliosis, direction of sternal rotation, history of asthma/reactive airways disease, or exercise intolerance). We conclude that idiopathic pectus excavatum may be associated with a variety of lung function abnormalities (in particular, lower airway obstruction) even in the absence of overt clinical symptoms. There was no evidence of significant worsening of lung function with increasing age.

Haemopericardium causing cardiac tamponade: a late complication of pectus excavatum repair

A 24 year old man presented to the emergency department with clinical signs of cardiac tamponade requiring emergency surgery. The cause was a sternal wire from a pectus excavatum repair two years previously that had fractured and migrated through the pericardium causing an epicardial injury and a haemopericardium.

Ventilatory and cardiovascular responses to exercise in patients with pectus excavatum

PURPOSE

Uncertainty exists as to whether pectus excavatum causes true physiologic impairments to exercise performance as opposed to lack of fitness due to reluctance to exercise. The purpose of this study was to examine the effect of pectus excavatum on ventilatory and cardiovascular responses to incremental exercise in physically active patients.

METHODS

Twenty-one patients with pectus excavatum (age range, 13 to 50 years; mean [+/- SD] age, 23.6 +/- 8.9 years; severity index range, 3.7 to 8.0; mean severity index, 5.1 +/- 1.2) were referred for preoperative evaluation. Eighteen of the patients (85%) had a history of performing aerobic activity ranging from 30 min to 2 h per day (mean duration, 1.0 +/- 0.61 h per day) for 3 +/- 1.5 days per week. Patients performed pulmonary function tests, and submaximal and maximal incremental exercise testing.

RESULTS

On maximal exercise testing, the maximum oxygen uptake (O(2)max), and oxygen-pulse were significantly lower than the reference values (t(20) = 6.17 [p < 0.0001] and t(20) = 4.52 [p < 0.0001], respectively). Furthermore, patients exhibited cardiovascular limitation, but not ventilatory limitation. Despite their high level of habitual exercise activity, the overall metabolic threshold for lactate accumulation was abnormally low (ie, 41% of the reference value for O(2)max) especially in those with a pectus severity index (PSI) of > 4.0 (39% of the reference value of O(2)max), which is consistent with cardiovascular impairment rather than physical deconditioning. Patients with a PSI of > 4.0 were also eight times more likely to have reduced aerobic capacity than patients who had a low severity index, despite their level of exercise participation. On submaximal testing, we found that the time constant for O(2) uptake kinetics was 37.4 s for the on-transit and 41.6 s for the off-transit. The observed values for FVC, FEV(1), maximum voluntary ventilation, and diffusing capacity of the lung for carbon monoxide were significantly lower than reference values, but those for total lung capacity and residual volume were not significantly lower than reference values.

CONCLUSIONS

The information derived from this study supports the opinion that pectus excavatum is associated with true physiologic impairment and reduced exercise capacity, predominantly due to impaired cardiovascular performance rather than ventilatory limitation. Furthermore, the impairment is not explained by physical deconditioning.

Pulmonary function and exercise response in patients with pectus excavatum after Nuss repair

BACKGROUND/PURPOSE

The Ravitch repair of pectus excavatum removes segments of abnormal costal cartilages after which the sternum is elevated and stabilized. Some investigators have found a worsening in total lung capacity postoperatively. Recently, a technique has been used in which the costal cartilages are preserved, and the sternum is elevated with an internal steel bar (Nuss repair). The authors hypothesized that placement of a substernal bar in the first stage of the Nuss repair will not adversely affect pulmonary and exercise function.

METHODS

Patients who presented to the Children's Hospital of Buffalo for surgical repair of pectus excavatum from June 1997 through June 2000 underwent pulmonary function and exercise testing before and 6 to 12 months after the first stage of a Nuss repair.

RESULTS

Ten patients were studied (all boys; mean age at operative repair, 13.4 +/- 3 years). Mean baseline pulmonary function was normal, and no significant differences were seen before and after placement of the intrathoracic bar. Peak oxygen consumption was near normal, although work at VO2max was less than predicted (mean, 68.2% before v. 71.8% after surgery). V(E) was below normal and Vt/FVC was below the expected 50% to 60% level both before and after surgery (41.3% +/- 3 SE and 41.6% +/- 3 SE pre- and postoperatively, respectively).

CONCLUSIONS

Placement of a substernal steel bar in the first stage of the Nuss procedure for repair of pectus excavatum does not cause adverse effects on either static pulmonary function or on the ventilatory response to exercise.