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Dunning J, Burdett C, Child A, Davies C, Eastwood D, Goodacre T, Haecker FM, Kendall S, Kolvekar S, MacMahon L, Marven S, Murray S, Naidu B, Pandya B, Redmond K, Coonar A. The pectus care guidelines: best practice consensus guidelines from the joint specialist societies SCTS/MF/CWIG/BOA/BAPS for the treatment of patients with pectus abnormalities. Eur J Cardiothorac Surg 2024; 66:ezae166. [PMID: 38964837 DOI: 10.1093/ejcts/ezae166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/26/2024] [Accepted: 04/30/2024] [Indexed: 07/06/2024] Open
Abstract
Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back towards the spine (excavatum), protrudes forwards (carinatum) or more rarely is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities (such as swimming, dancing) and from interactions that might 'expose' them (such as sleepovers, dating, going to the beach and wearing fashionable clothes). This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise (such as running) but can also limit moderate activity such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment usually also suffer from low self-esteem and depression. This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and non-surgical techniques including bracing and vacuum bell therapy. We also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants and other rare procedures such as Pectus Up. For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance and long-term support. All the interventions have risks and benefits that the patient, parents and clinicians need to carefully consider and discuss when deciding on the most appropriate course. We hope this evidence review of 'Best Practice for Pectus' will make a significant contribution to those considerations and help all involved, from patients to national policy makers, to deliver the best possible care.
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Affiliation(s)
- Joel Dunning
- Department of Cardiothoracic surgery, James Cook University Hospital, Middlesbrough, UK
| | - Clare Burdett
- Department of Cardiothoracic surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Carl Davies
- Royal College of Physicians and Surgeons of Glasgow, UK
| | | | - Tim Goodacre
- Royal College of Surgeons of England, London, UK
| | - Frank-Martin Haecker
- Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
- Department of Paediatric Surgery, Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Simon Kendall
- Society for Cardiothoracic Surgery in Great Britain and Ireland, London, UK
| | - Shyam Kolvekar
- National Pectus Centre, Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Lisa MacMahon
- Department of Thoracic Surgery, Phoenix Children's Hospital, Phoenix, USA
- Chest Wall International Group (CWIG), Switzerland
| | - Sean Marven
- British Association of Paediatric Surgeons Thoracic and Airway Group, London, UK
| | - Sarah Murray
- Clinical Research Collaborative BHF and Leicester University, National PPI Group, Leicester, UK
| | - Babu Naidu
- Department of Thoracic Surgery, Birmingham Heartlands Hospital, Birmingham, UK
| | - Bejal Pandya
- National Pectus Centre, Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Karen Redmond
- Department of Thoracic Surgery, School of Medicine, University College Dublin, National Thoracic Subcommittee Lead SCTS, The Mater Hospital, Dublin, Dublin, Ireland, UK
| | - Aman Coonar
- Thoracic Lead at NHS England, President of the Society for Cardiothoracic Surgery in Great Britain and Ireland, London, UK
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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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Benes GA, Hunsberger JB, Dietz HC, Sponseller PD. Opioid Utilization After Scoliosis Surgery is Greater in Marfan Syndrome Than Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 2024; 49:E80-E86. [PMID: 37294802 DOI: 10.1097/brs.0000000000004741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/29/2023] [Indexed: 06/11/2023]
Abstract
STUDY DESIGN Retrospective matched case cohort. OBJECTIVE Compare postoperative opioid utilization and prescribing behaviors between patients with Marfan syndrome (MFS) and adolescent idiopathic scoliosis (AIS) after posterior spinal fusion (PSF). SUMMARY OF BACKGROUND DATA Opioids are an essential component of pain management after PSF. However, due to the potential for opioid use disorder and dependence, current analgesic strategies aim to minimize their use, especially in younger patients. Limited information exists on opioid utilization after PSF for syndromic scoliosis. PATIENTS AND METHODS Twenty adolescents undergoing PSF with MFS were matched with patients with AIS (ratio, 1:2) by age, sex, degree of spinal deformity, and the number of vertebral levels fused. Inpatient and outpatient pharmaceutical data were reviewed for the quantity and duration of opioid and adjunct medications. Prescriptions were converted to morphine milligram equivalents (MMEs) using CDC's standard conversion factor. RESULTS Compared with patients with AIS, patients with MFS had significantly greater total inpatient MME use (4.9 vs . 2.1 mg/kg, P ≤ 0.001) and longer duration of intravenous patient-controlled anesthesia (3.4 vs . 2.5 d, P = 0.001). Within the first 2 postop days, MFS patients had more patient-controlled anesthesia boluses (91 vs . 52 boluses, P = 0.01) despite similar pain scores and greater use of adjunct medications. After accounting for prior opioid use, MFS was the only significant predictor of requesting an opioid prescription after discharge (odds ratio: 4.1, 95% CI: 1.1-14.9, P = 0.03). Patients with MFS were also more likely to be discharged with a more potent prescription (1.0 vs . 0.72 MME per day/kg, P ≤ 0.001) and to receive a longer-duration prescription (13 vs . 8 d, P = 0.005) with a greater MME/kg (11.6 vs . 5.6 mg/kg, P ≤ 0.001) as outpatients. CONCLUSION Despite a similar intervention, patients with MFS and AIS seem to differ in their postoperative opioid usage after PSF, presenting an opportunity for further research to assist clinicians in better anticipating the analgesic needs of individual patients, particularly in light of the ongoing opioid epidemic.
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Affiliation(s)
- Gregory A Benes
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Joann B Hunsberger
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD
| | - Harry C Dietz
- Institute of Genetic Medicine, The Johns Hopkins University, Baltimore, MD
| | - Paul D Sponseller
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, MD
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Media AS, Christensen TD, Katballe N, Juhl-Olsen P, Vad H, Petersen RH, Højsgaard A, Vincenzo de Paoli F. Complication rates rise with age and Haller index in minimally invasive correction of pectus excavatum: A high-volume, single-center retrospective cohort study. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00107-7. [PMID: 38340954 DOI: 10.1016/j.jtcvs.2024.01.047] [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: 05/05/2023] [Revised: 01/09/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVES The study objectives were to describe the compounded complication rate of minimally invasive repair of pectus excavatum, identify predisposing risk factors, and evaluate the optimal timing of correction. Minimally invasive repair of pectus excavatum is the standard treatment for pectus excavatum and consists of 2 invasive procedures, for example, correction with bar insertion followed by bar removal after 2 to 3 years. METHODS A retrospective cohort study identifying children, adolescents, and adults of both genders corrected for pectus excavatum with minimally invasive repair of pectus excavatum between 2001 and 2022. Information on complications related to bar insertion and removal procedures for each individual patient was compiled into a compounded complication rate. Complication severities were categorized according to the Clavien-Dindo classification. RESULTS A total of 2013 patients were corrected by minimally invasive repair of pectus excavatum with a median age (interquartile range) for correction of 16.6 (5) years. Overall compounded complication rate occurred at a frequency of 16.4%, of which 9.3% required invasive reinterventions (Clavien-Dindo classification ≥IIIa). The complication rate related to bar insertion was 2.6-fold higher compared with bar removal (11.8% vs 4.5%, respectively). Multivariable analysis revealed age (adjusted odds ratio, 1.05; P < .001), precorrection Haller Index (adjusted odds ratio, 1.10; P < .033), and early-phase institutional experience (adjusted odds ratio, 1.59; P < .002) as independent predisposing risk factors. The optimal age of correction was 12 years, and the compounded complication rate correlated exponentially with age with a doubling time of 7.2 years. Complications increased 2.2-fold when the Haller index increased to 5 or more units. CONCLUSIONS Minimally invasive repair of pectus excavatum is associated with a high compounded complication rate that increases exponentially with age and high Haller Index. Consequently, we recommend repair during late childhood and early adolescence, and emphasize the importance of informing patients and relatives about the significant risks of adult correction as well as the need of 2 consecutive procedures taking the complication profile into account before planning surgery.
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Affiliation(s)
- Ara S Media
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Katballe
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Vad
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Anette Højsgaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Frank Vincenzo de Paoli
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark.
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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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Dupuis M, Daussy L, Noel-Savina E, Dahan M, Didier A, Chavoin JP, Guibert N. Impact of pectus excavatum on pulmonary function and exercise capacity in patients treated with 3D custom-made silicone implants. ANN CHIR PLAST ESTH 2024; 69:53-58. [PMID: 36737354 DOI: 10.1016/j.anplas.2023.01.002] [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: 02/04/2023]
Abstract
BACKGROUND Pectus excavatum (PE) is the most common congenital chest wall deformity, whose cardiopulmonary consequences are controversial. PE surgery is in our experience usually performed for aesthetic reasons. OBJECTIVES The aim of this study was to evaluate the impact of PE on respiratory function and exercise capacity in patients with PE before patient-specific silicone implant correction. METHODS This monocentric prospective study conducted at Toulouse University Hospital included sixty patients scheduled for custom-made silicone implants correction. Respiratory function (pulmonary function tests (FPTs)) and exercise capacity (VO2 max) were measured before surgery. RESULTS Before surgery, no (0/60) restrictive lung disease was detected, with a mean total lung capacity (TLC) of 98.5% of predicted value (IC 95%; 80.4-137). Median VO2 max (n=56) was normal (89% predicted), with no cardiac limitation. CONCLUSION In this cohort, PE had no impact on respiratory function nor exercise capacity. In patients without cardiac or respiratory effects of PE, silicone implants should be considered the preferred approach as it adequately addressed patients' main complaint of low self-esteem.
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Affiliation(s)
- M Dupuis
- Pulmonology Department, University Hospital of Toulouse, 24, chemin de Pouvourville, 31059 Toulouse, France
| | - L Daussy
- Pulmonology Department, Albi Hospital, Albi, France
| | - E Noel-Savina
- Pulmonology Department, University Hospital of Toulouse, 24, chemin de Pouvourville, 31059 Toulouse, France
| | - M Dahan
- Thoracic surgery Department, Toulouse University Hospital, Toulouse, France
| | - A Didier
- Pulmonology Department, University Hospital of Toulouse, 24, chemin de Pouvourville, 31059 Toulouse, France
| | - J P Chavoin
- Plastic surgery Department, Toulouse University Hospital, Toulouse, France
| | - N Guibert
- Pulmonology Department, University Hospital of Toulouse, 24, chemin de Pouvourville, 31059 Toulouse, France.
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Mohamed JS, Tan JW, Tam JKC. Quality of life with minimally invasive repair of pectus excavatum: a systematic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:407. [PMID: 38213813 PMCID: PMC10777225 DOI: 10.21037/atm-23-1647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/17/2023] [Indexed: 01/13/2024]
Abstract
Background Minimally invasive repair of pectus excavatum (MIRPE) is a popular method for surgical correction of PE, and its impact on quality of life is a growing area of interest. We performed a systematic review and meta-analysis to evaluate the impact of MIRPE on the quality of life of patients. Methods This study was registered with PROSPERO under reference number CRD42020222061. A literature search of PubMed, Cochrane Library, EMBASE and Scopus was conducted from the date of inception till November 23, 2020. We included studies which administered one or more questionnaires on patients up to 60 years old, parents or both, to assess the quality of life before and after MIRPE. Studies not written in English, abstracts, articles without primary data, reviews and studies which combined data on PE and other deformities were excluded. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions and the Cochrane risk of bias tool. A random-effects meta-analysis was performed to obtain mean differences for key themes of quality of life before and after MIRPE. Responses from the same questionnaires, as well as common themes across different questionnaires, were compared. Results Of the 20 studies identified for systematic review, 7 studies that reported the responses of 478 patients were included in the meta-analysis. Patients who underwent MIRPE experienced an increased self-esteem [standardized mean difference (SMD): 1.38, 95% confidence interval (CI): 0.95 to 1.81, P<0.00001] and a smaller degree of chest interference with their social activities (SMD: 0.84, 95% CI: 0.60 to 1.08, P<0.00001). These findings were consistent even after the implanted bar was removed. Conclusions MIRPE may be associated with a better quality of life for patients with PE as self-esteem and extent of chest interference with social activities are improved after the procedure. The key limitations of this study are the lack of high-quality evidence due to paucity of randomized trials, and the significant heterogeneity in reported outcomes due to variations in the questionnaires and timepoints of administration.
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Affiliation(s)
- Jameelah Sheik Mohamed
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jian Wei Tan
- Department of Cardiac, Thoracic & Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - John Kit Chung Tam
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic & Vascular Surgery, National University Heart Centre, Singapore, Singapore
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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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Aly MR, Farina JM, Botros MM, Jaroszewski DE. Minimally invasive repair of pectus excavatum in adults: a review article of presentation, workup, and surgical treatment. J Thorac Dis 2023; 15:5150-5173. [PMID: 37868874 PMCID: PMC10587002 DOI: 10.21037/jtd-23-87] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/29/2023] [Indexed: 10/24/2023]
Abstract
Pectus excavatum (Pex) is one of the most common congenital deformities of the chest wall, with pectus constituting 90% of all chest wall deformities and excavatum being reported in almost 1:400 to 1:1,000 live births with predominant occurrence in males up to five times more than in females. Depending on the severity, presentation varies from mild cosmetic complaints to life limiting cardiopulmonary symptoms. Patients may develop symptoms as they age, and these symptoms may worsen over the years. A technique for minimally invasive repair for pectus excavatum (MIRPE) was introduced with the concept of temporarily implanting metal bars to correct the deformity. This has rapidly become the standard of care for the pediatric and adolescent patients. The use of MIRPE in adults, however, has been slower to adopt and more controversial. This is largely due to the increased calcification and rigidity of the chest wall in adults which can make the repair more complex and lead to a higher risk of complications. We present a literature review of the presentation, workup, and surgical treatment of adult patients with Pex undergoing MIRPE. Adult patients can, with advanced preoperative evaluations and technique modifications, undergo a highly successful repair resulting in symptom resolution and satisfying results.
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Affiliation(s)
- Mohamed R Aly
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Juan M Farina
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Michael M Botros
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
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Dreher C, Reinsberg M, Oetzmann von Sochaczewski C, Siebert S, Strohm J, Kurz R, Ziegler AM, Heydweiller A, Yavuz ST. Changes in Pulmonary Functions of Adolescents with Pectus Excavatum Throughout the Nuss Procedure. J Pediatr Surg 2023; 58:1674-1678. [PMID: 36935229 DOI: 10.1016/j.jpedsurg.2023.02.057] [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: 10/16/2022] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND We aimed to determine the longitudinal changes in pulmonary functions of adolescents with Pectus Excavatum who underwent the Nuss procedure, the minimally invasive repair of pectus excavatum (MIRPE). METHODS Lung function measurements were performed before bar implantation (T0), at least six weeks to ten months after implantation (T1a), at least eleven months to sixty-one months after bar implantation (T1b) and at least two weeks after bar explantation (T2). RESULTS Data of 114 patients (83.3% male) whose median age at implantation was 15.6 years and at explantation 18.7 years were analyzed. Shortly after implantation at T1a a significant decline of vital capacity (VC; n = 82), forced vital capacity (FVC; n = 78) and forced expiratory volume in 1 second (FEV1; n = 80) compared to T0 was seen. At T1b a significant decline for the residual volume (RV; n = 83), the residual volume/total lung capacity ratio (RV/TLC; n = 81), the total specific airway resistance (sRaw; n = 80) and the total airway resistance (Raw; n = 84) also compared to T0 was measured. In the comparison of T1b to T2 a significant increase of VC, FVC (n = 67), FEV1 (n = 69), TLC (n = 67) and a significant decrease of Raw (n = 66), sRaw, RV (n = 65) and the RV/TLC (n = 64) ratio could be observed. In the direct analysis between T0 and T2, after the explantation of the bar a significant increase in VC (n = 54), FVC (n = 52), and TLC (n = 55) and a significant decrease of RV (n = 51) and the RV/TLC index (n = 50), and in airway resistance parameters like Raw (n = 52) and sRaw (n = 51) could be detected. CONCLUSIONS Lung function values along with markers of airway resistance improve in patients after the complete procedure of MIRPE. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Charlotte Dreher
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany
| | - Max Reinsberg
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany
| | | | - Stephanie Siebert
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany
| | - Joanna Strohm
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Ralf Kurz
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Anna-Maria Ziegler
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Andreas Heydweiller
- Department of Pediatric Surgery, Children's Hospital, University of Bonn, Bonn, Germany
| | - Suleyman Tolga Yavuz
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany.
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11
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Johnstone AD, Davis C, Roberts NJ, Sharp K. Quality of life of children and young people with anterior chest wall deformity: a systematic review of the literature. Arch Dis Child 2023:archdischild-2022-324948. [PMID: 37185083 DOI: 10.1136/archdischild-2022-324948] [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: 09/29/2022] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the current evidence regarding the quality of life (QoL) of children and young people with anterior chest wall deformity (ACWD). METHODS Using a defined search strategy, a systematic review of the literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. RESULTS The search identified 305 articles, after refinement, the full text of 51 studies were reviewed and 10 included in the review. A total of eight studies described QoL associated with the correction of ACWD and two studies reported on QoL without correction. The surgical correction of ACWD was reported in six studies and non-surgical correction in two studies. A total of three disease-specific and 24 generic QoL measures were used. The variation in QoL outcome measures, together with a lack of consistency in the time scales of data collection, did not allow for direct comparison between studies. However, the improvement in psychosocial QoL following correction of ACWD is clear. The impact of ACWD on physical QoL is less defined and the influence of age, gender, severity and type of deformity is uncertain. The literature identified primarily surrounds QoL outcomes in relation to surgical correction and is therefore not representative of all children and young people with ACWD. CONCLUSIONS Correction of ACWD is associated with significant improvement in the psychosocial QoL of children and young people. Further work is required to standardise QoL data collection for all children with ACWD to achieve a greater understanding of the impact and guide future management.
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Affiliation(s)
- Ashley D Johnstone
- Physiotherapy, Royal Hospital for Children, Glasgow, UK
- School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Carl Davis
- Paediatric Surgery, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Nicola J Roberts
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Kath Sharp
- School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, UK
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12
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Li H, Fan S, Kong X, Pan Z, Wu C, Li Y, Wang G, Dai J, He D, Wang Q. Academic performance in children with pectus excavatum: a real-world research with propensity score matching. Ther Adv Respir Dis 2023; 17:17534666231155779. [PMID: 36846947 PMCID: PMC9972046 DOI: 10.1177/17534666231155779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/23/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND The optimal timing of surgery for pectus excavatum (PE) is controversial. A large proportion of children will not undergo surgery before puberty. However, untimely surgery may lead to a decline in the children's social adaptation and competitiveness because the children have already developed psychological and physiological impairments due to PE at an early age. The study retrospectively compared the academic performance in PE children undergoing the Nuss procedure versus nonsurgical observation. METHODS This retrospective real-world research study included 480 PE patients with definite surgical indications, in whom it was first recommended that they undergo surgery between the ages of 6 and 12 years old. Academic performance was collected at baseline and 6 years later. A generalized linear regression was calculated to screen the factors affecting the performance. A propensity score matching (PSM) analysis was conducted to reduce the potential for confounding factors between surgical and nonsurgical PE patients. RESULTS Haller index (HI) and pulmonary function were recognized as factors affecting baseline performance according to the generalized linear regression. For PE children with surgical indications, their academic performance significantly declined after 6 years of nonsurgical observation (52.1% ± 17.1% versus 58.3% ± 16.7%, p = 0.042). The academic performance in the surgery group was better than that in the nonsurgery group 6 years after PSM (60.7% ± 17.7% versus 52.1% ± 17.1%, p = 0.008). CONCLUSIONS The severity of PE will affect the academic performance of children.For PE children with definite surgical indications between the ages of 6 and 12 years old, surgical intervention rather than nonsurgical observation is more conducive to the development of children's academic performance.
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Affiliation(s)
- Hongbo Li
- Department of Cardiothoracic Surgery, Ministry
of Education Key Laboratory of Child Development and Disorders, National
Clinical Research Center for Child Health and Disorders, China International
Science and Technology Cooperation Base of Child Development and Critical
Disorders, Children’s Hospital of Chongqing Medical University, Chongqing,
China
- Chongqing Higher Institution Engineering
Research Center of Children’s Medical Big Data Intelligent Application,
Chongqing, China
- Chongqing Key Laboratory of Pediatrics,
Chongqing Medical University, Chongqing, China
| | - Shulei Fan
- Department of Respiratory Medicine, Second
Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiangpan Kong
- Department of Cardiothoracic Surgery, Ministry
of Education Key Laboratory of Child Development and Disorders, National
Clinical Research Center for Child Health and Disorders, China International
Science and Technology Cooperation Base of Child Development and Critical
Disorders, Children’s Hospital of Chongqing Medical University, Chongqing,
China
| | - Zhengxia Pan
- Department of Cardiothoracic Surgery, Ministry
of Education Key Laboratory of Child Development and Disorders, National
Clinical Research Center for Child Health and Disorders, China International
Science and Technology Cooperation Base of Child Development and Critical
Disorders, Children’s Hospital of Chongqing Medical University, Chongqing,
China
| | - Chun Wu
- Department of Cardiothoracic Surgery, Ministry
of Education Key Laboratory of Child Development and Disorders, National
Clinical Research Center for Child Health and Disorders, China International
Science and Technology Cooperation Base of Child Development and Critical
Disorders, Children’s Hospital of Chongqing Medical University, Chongqing,
China
| | - Yonggang Li
- Department of Cardiothoracic Surgery, Ministry
of Education Key Laboratory of Child Development and Disorders, National
Clinical Research Center for Child Health and Disorders, China International
Science and Technology Cooperation Base of Child Development and Critical
Disorders, Children’s Hospital of Chongqing Medical University, Chongqing,
China
| | - Gang Wang
- Department of Cardiothoracic Surgery, Ministry
of Education Key Laboratory of Child Development and Disorders, National
Clinical Research Center for Child Health and Disorders, China International
Science and Technology Cooperation Base of Child Development and Critical
Disorders, Children’s Hospital of Chongqing Medical University, Chongqing,
China
| | - Jiangtao Dai
- Department of Cardiothoracic Surgery, Ministry
of Education Key Laboratory of Child Development and Disorders, National
Clinical Research Center for Child Health and Disorders, China International
Science and Technology Cooperation Base of Child Development and Critical
Disorders, Children’s Hospital of Chongqing Medical University, Chongqing,
China
| | - Dawei He
- Chongqing Higher Institution Engineering
Research Center of Children’s Medical Big Data Intelligent Application,
Chongqing, China
- Chongqing Key Laboratory of Pediatrics,
Chongqing Medical University, Chongqing, China
| | - Quan Wang
- Department of Cardiothoracic Surgery, Ministry
of Education Key Laboratory of Child Development and Disorders, National
Clinical Research Center for Child Health and Disorders, China International
Science and Technology Cooperation Base of Child Development and Critical
Disorders, Children’s Hospital of Chongqing Medical University, No.136
Zhongshan Second Road, Yuzhong District, Chongqing 400014, China
- Chongqing Higher Institution Engineering
Research Center of Children’s Medical Big Data Intelligent Application,
Chongqing, China
- Chongqing Key Laboratory of Pediatrics,
Chongqing Medical University, Chongqing, China
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13
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Chavoin JP, Facchini F, Leyx P, Hunt I, Benjoar MD, Molins L, Tiffet O, Ratdke C, Dornseifer U, Giovannini M, Chaput B, Redmond K. [Place of 3D custom-made implants after failure of modeling steno-chondro-plasties]. ANN CHIR PLAST ESTH 2022; 67:414-424. [PMID: 35933312 DOI: 10.1016/j.anplas.2022.07.011] [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: 11/01/2022]
Abstract
Most common congenital malformation of the thorax, Pectus Excavatum affects about one in 500 people. Several surgical or medical techniques have been proposed. Some are followed by complications or insufficient results even though their constant functional value is highly controversial. Secondary surgery with a deep customized 3D elastomer implant, may be an elegant effective and safe solution compared to others; it allows a good aesthetic result expected by patients in the absence of any respiratory or cardio-vascular functional context.
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Affiliation(s)
- J-P Chavoin
- Service de chirurgie plastique reconstructrice et esthétique, CHU Toulouse Rangueil, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France.
| | - F Facchini
- Service de chirurgie infantile, Hopital pédiatrique Meyer, Viale Gaetano Pieraccini 24, 50139 Florence, Italie
| | - P Leyx
- Recherche et développement, Anatomik Modeling SAS, 19, rue Jean Mermoz, 31100 Toulouse, France
| | - I Hunt
- Pectus Clinic, service de chirurgie thoraciqueSpire St. Anthony's Hospital Worcester Park, Sutton SM3, 9DW Londres, Royaume Uni
| | | | - L Molins
- Hôpital Clinique universitaire du Sacré-cœur, C. de Viladomat 288, 08029 Barcelone, Espagne
| | - O Tiffet
- Service de chirurgie Thoracique, CHU de St.Etienne, hôpital Nord, avenue Albert Raimond, 42270 Saint-Etienne, France
| | - C Ratdke
- Service de chirurgie plastique reconstructrice et esthétique, clinique universitaire de Vienne, 18-20 Waringer Gurtel, 1090 Vienne, Autriche
| | - U Dornseifer
- Service de chirurgie plastique reconstructrice et esthétique, Isar Klinikum, Sonnenstrasse 24-26, 80331 Munich, Allemagne
| | - M Giovannini
- Chirurgie Générale et thoracique, via di Roncrio 25, 40100 Bologne, Italie
| | - B Chaput
- Service de chirurgie plastique reconstructrice et esthétique, CHU Toulouse Rangueil, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France
| | - K Redmond
- Service de Chirurgie cardio-thoracique Hôpital Universitaire Mater Misericordia, Ecole street, Dublin 7, Irlande
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14
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Fraser JA, Briggs KB, Svetanoff WJ, Aguayo P, Juang D, Fraser JD, Snyder CL, Oyetunji TA, St Peter SD. Short and long term outcomes of using cryoablation for postoperative pain control in patients after pectus excavatum repair. J Pediatr Surg 2022; 57:1050-1055. [PMID: 35277249 DOI: 10.1016/j.jpedsurg.2022.01.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/31/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We report the findings of a three-year prospective observational study elucidating long-term symptoms and complications of patients who underwent minimally invasive pectus excavatum repair with intercostal nerve cryoablation with specific attention to postoperative pain control associated with the cryoablation technique. METHODS Surveys were administered to patients who underwent bar placement for pectus excavatum with intercostal nerve cryoablation from 2017 to 2021 regarding pain scores, pain medication usage, and limitations to activity beginning on the day of surgery, on the day of discharge, and at two-week and three-month follow-up. RESULTS Of 110 patients, forty-eight (44%) completed the discharge survey; sharp pain and pressure on the first postoperative night were the most described pain characteristics, most frequently in the middle of the chest. On follow-up, 55% of patients reported tolerable residual pain at two weeks and 41% at three months, with 25% requiring intermittent pain medication at three months. There were three readmissions for inadequate pain control and 110 calls to the surgery clinic by three-month follow-up, most commonly for persistent pain and frequent popping sensation with movement. DISCUSSION Although cryoablation is an excellent pain control modality, these data suggest that patients underreport functional symptoms and experience more frequent discomfort and alteration of daily living activities.
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Affiliation(s)
- James A Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA.
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Andersen NH, Hauge EM, Baad-Hansen T, Groth KA, Berglund A, Gravholt CH, Stochholm K. Musculoskeletal diseases in Marfan syndrome: a nationwide registry study. Orphanet J Rare Dis 2022; 17:118. [PMID: 35248143 PMCID: PMC8898450 DOI: 10.1186/s13023-022-02272-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 02/20/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Marfan syndrome is associated with abnormalities in the musculoskeletal system including scoliosis, pectus deformities, protrusio acetabuli, and foot deformities. Over a life span, many patients with Marfan syndrome will need treatment; however, the musculoskeletal morbidity over a life span is not well described. The aim of the present study was to assess the overall burden of musculoskeletal disease in patients with Marfan syndrome.
Materials and methods
A registry-based, nationwide epidemiological study of patients with a Ghent II verified Marfan syndrome diagnosis from 1977 to 2014. Each patient was matched on age, and sex with up to 100 controls from the background population.
Results
We identified 407 patients with Marfan syndrome and 40,700 controls and compared their musculoskeletal diagnoses and surgical treatments using Cox proportional hazards ratio (HR). The risk of a registration of a musculoskeletal diagnosis in patients with Marfan syndrome was significantly increased compared to controls (HR: 1.94 (1.69–2.24). One out of six with Marfan syndrome was registered with scoliosis (HR: 36.7 (27.5–48.9). Scoliosis was more common in women with Marfan syndrome compared to men (HR: 4.30 (1.73–1.08)). One out of 11 were registered with a pectus deformity HR: 40.8 (28.1–59.3), and one out of six with a deformity of the foot. Primarily pes planus (HR: 26.0 (15.2–44.3). The proportion of patients with Marfan syndrome (94/407) that underwent musculoskeletal surgery was also significantly higher (HR: 1.76 (1.43–2.16)). The major areas of surgery were the spine, pectups correction, and surgery of the foot/ankle. Ten patients with Marfan syndrome had elective orthopedic surgery without being recognized and diagnosed with Marfan syndrome until later in life. None of these had scoliosis, pectus deformity or a foot deformity. Among patients with an aortic dissection, the age at dissection was 34.3 years in those with at least one major musculoskeletal abnormality. In patients without a major abnormality the age at dissection was 45.1 years (p < 0.01).
Conclusions
The extent of musculoskeletal disease is quite significant in Marfan syndrome, and many will need corrective surgery during their life span. Surgeons should be aware of undiagnosed patients with Marfan syndrome when treating patients with a Marfan syndrome like-phenotype.
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16
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Skoczyński S, Kudela G, Brożek G, Lawson J, Tobor S, Skoczyńska A, Swinarew A, Trejnowska E, Winnicki IR, Repetowska K, Paluch J, Barczyk A, Koszutski T. Pulmonary function, exercise capacity and dyspnea in patients 7 years after Nuss surgery. Adv Med Sci 2022; 67:179-186. [PMID: 35306355 DOI: 10.1016/j.advms.2022.02.008] [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: 07/21/2021] [Revised: 01/23/2022] [Accepted: 02/28/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE Pectus excavatum is a frequent thoracic malformation increasingly treated with minimally invasive methods (MIRPE), which are performed for cardio-respiratory problems and in some centers also for esthetic considerations. Theoretically, MIRPE may increase thoracic elastic recoil, work of breathing and cause emphysema. The aim of the present study was to determine whether teenagers who underwent MIRPE may expect normal thoracic cage development, cardio-respiratory function, exercise capacity and asymptomatic functioning. MATERIAL AND METHODS Fifty five patients (21.1 ± 3.0 years) who underwent MIRPE between 2000 and 2010 were assessed 6.8 (±2.4) years after surgery. Controls were matched for sex, age and height to the intervention participants. Spirometry, body plethysmography, diffusion capacity and the 6 min walking test (6MWT) were performed. Anteroposterior (AP) and transverse chest diameters were measured. RESULTS Participants who underwent MIRPE had normal pulmonary function, and exercise capacity. After adjustment for potential confounders, the intervention group had lower mean BMI [-1.88 ± 0.56 (kg/m2); p = 0.001] and chest AP diameter [-2.79 ± 0.57 (cm); p < 0.001], but higher residual volume (RV%) [12.98 ± 5.31 (%); p = 0.001], RV% total lung capacity (TLC) [5.56 ± 0.92 (%); p < 0.001], forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) [2.64 ± 1.28 (%); p = 0.039] and 6MWT distance [29.10 ± 13.02 (m); p = 0.025]. CONCLUSIONS Young adults who undergo MIRPE may expect normal pulmonary function and exercise capacity. Observed differences in air trapping require further assessment in terms of emphysema development risk.
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17
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Norlander L, Sundqvist AS, Anderzén-Carlsson A, Dreifaldt M, Andreasson J, Vidlund M. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6526194. [PMID: 35142354 PMCID: PMC9252118 DOI: 10.1093/icvts/ivac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/17/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Louise Norlander
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Corresponding author. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Södra Grev Rosengatan, 701 85 Örebro, Sweden. Tel: 0046-196025118; e-mail: (L. Norlander)
| | - Ann-Sofie Sundqvist
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Agneta Anderzén-Carlsson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mats Dreifaldt
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
| | - Jesper Andreasson
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Mårten Vidlund
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
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Alqadi GO, Saxena AK. Analysis of Psychological Assessments Affecting Patients Undergoing Treatment for Chest Wall Deformities. Am Surg 2021:31348211038585. [PMID: 34382882 DOI: 10.1177/00031348211038585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM This study aimed to review the literature with regard to the psychological aspects in patients with pectus excavatum (PE) and pectus carinatum (PC). METHODS The literature was reviewed by analyzing articles on PubMed using the search terms "psychology" and "pectus." RESULTS The literature search revealed 22 articles that offered a total of 2214 patients for analysis. Regarding chest wall deformities (CWD), there were 15 articles referring to PE, 4 articles on PC, and 3 pertaining to both PE and PC. Authors used various types of questionnaires and 14 studies which also included a parent questionnaire. There are 14 reports which analyzed both the preoperative and postoperative psychological status and 4 reports in which a control group was used. Treatment of CWD was shown to have consistently positive results. There is no consensus regarding the correlation between severity of CWD and psychological issues. Only 2 studies found no statistically significant results after treatment. CONCLUSIONS The literature reveals a great concern for psychosocial issues in CWD patients. Most articles describe improvement in overall quality of life (QOL) after surgery. An increase in social and physical function, body image, and self-esteem was observed in CWD patients, which is supported by parent responses.
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Affiliation(s)
- Gratiana O Alqadi
- Department of Pediatric Surgery, Chelsea Children's Hospital, 9762Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, London, UK.,Department of Pediatric Surgery, 87267University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Amulya K Saxena
- Department of Pediatric Surgery, Chelsea Children's Hospital, 9762Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, London, UK
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Laín A, Giralt G, Giné C, García Martínez L, Villaverde I, López M. Transesophageal echocardiography during pectus excavatum correction in children: What happens to the heart? J Pediatr Surg 2021; 56:988-994. [PMID: 32660778 DOI: 10.1016/j.jpedsurg.2020.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Cardiac compression in pectus excavatum remains difficult to evaluate. We describe the findings with intraoperative transesophageal echocardiography during pectus excavatum correction in pediatric patients. METHODS We studied right heart changes during surgical correction of pectus excavatum by transesophageal echocardiograph. Four-D echo was associated to assess morphology of the tricuspid annulus. RESULTS Twenty patients were included, mean age 13.5 (+/- 2.9). Mean preoperative Haller Index was 6.3 (+/- 2.63) and mean Correction Index 47.63% (+/- 12.4%). Preoperative transthoracic echocardiography at rest showed mild right heart compression in 6. Correction was gained by Nuss technique in 19, and Taulinoplasty in one. Initial transesophageal echocardiography showed compression of the right heart and deformation of the tricuspid annulus in all. During the sternal elevation, diameters of right atrium, ventricle and tricuspid annulus significantly improved: mean augmentation of right ventricle was 5.78 mm (+/- 3.56 p < 0.05), right atrium 6.64 mm (+/- 5.55 p < 0.05) and tricuspid annulus 6.02 mm (+/- 3.29 p < 0.05). The morphology of the tricuspid annulus in 4D normalized. CONCLUSIONS Preoperative transthoracic echocardiography at rest underestimates right chamber compression in pediatric patients with pectus excavatum. Surgical correction improves diameters of the right ventricle, right atrium and tricuspid annulus and normalizes the morphology of the tricuspid annulus (4D). LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ana Laín
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain.
| | - Gemma Giralt
- Pediatric Cardiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Giné
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain
| | | | - Iván Villaverde
- Pediatric Anesthesiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Manuel López
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain
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20
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de Carvalho RLC, Tedde ML, de Campos JRM, Hamilton NN, Guilherme GF, Sousa VM, Junior VFS, Savazzi FH, Pego-Fernandes PM. Quality of life outcomes after minimally invasive repair of pectus excavatum utilizing a new set of metallic bars and stabilizers. J Pediatr Surg 2021; 56:545-549. [PMID: 32711943 DOI: 10.1016/j.jpedsurg.2020.06.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/10/2020] [Accepted: 06/23/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE The aim of the study was to evaluate the postoperative quality of life (QoL) of patients who underwent minimally invasive repair of pectus excavatum (MIRPE) with a newly designed bar and bar stabilizers. METHODS We conducted a prospective randomized study in which patients were operated either with standard perpendicular stabilizers (control group) or with the newly designed oblique stabilizers (intervention group). All patients were evaluated 6 months after the operation with the Pectus Excavatum Evaluation Questionnaire (PEEQ). RESULTS There were 16 patients in the control group and 14 in the intervention group. Mean age was 17 (SD: 3.3, range 14-27) years. There were no demographic differences between groups. Two patients in the control group and one in the intervention group were repaired with two bars instead of one. There was one reoperation in each group. There was a significant difference between the pre- and postoperative scores, in both groups, in the patient body image domain (control group: 9.5 to 3; p < 0.01; intervention group 10 to 3; p < 0.01), as well as in the psychosocial domain (control group: 13.5 to 24, p < 0.01; intervention group: 15 to 24, p < 0.01). With regards to the patients' perception of physical difficulties before and after MIRPE, the difference between pre- and postoperative scores was greater in the intervention group (8 to 12, p < 0.01) than in the control group (10 to 11, p = 0.04). The mean length of stay was 4.5 and 5 days in the intervention group and the control group, respectively. CONCLUSION Our study showed that patients who underwent MIRPE with the newly designed bars and stabilizers had non-inferior outcomes than patients reported in the literature who underwent MIRPE with standard bars and stabilizers. We found slightly better outcomes in patients in the intervention group compared to the control group, but larger studies will be needed to confirm if those differences are statistically significant. LEVEL OF EVIDENCE II.
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Affiliation(s)
| | - Miguel Lia Tedde
- Heart Institute (InCor), University of Sao Paulo, R. Dr. Eneas de Carvalho Aguiar, 44, 05403-000, Sao Paulo, Brazil; Hospital Alemão Oswaldo Cruz, R Treze de Maio, 1815, 01327-001, Sao Paulo, Brazil.
| | | | - Niura Noro Hamilton
- Heart Institute (InCor), University of Sao Paulo, R. Dr. Eneas de Carvalho Aguiar, 44, 05403-000, Sao Paulo, Brazil; Hospital Alemão Oswaldo Cruz, R Treze de Maio, 1815, 01327-001, Sao Paulo, Brazil
| | - Gustavo Falavigna Guilherme
- Heart Institute (InCor), University of Sao Paulo, R. Dr. Eneas de Carvalho Aguiar, 44, 05403-000, Sao Paulo, Brazil
| | - Vanessa Moreira Sousa
- Heart Institute (InCor), University of Sao Paulo, R. Dr. Eneas de Carvalho Aguiar, 44, 05403-000, Sao Paulo, Brazil
| | | | - Flavio Henrique Savazzi
- Heart Institute (InCor), University of Sao Paulo, R. Dr. Eneas de Carvalho Aguiar, 44, 05403-000, Sao Paulo, Brazil
| | - Paulo Manuel Pego-Fernandes
- Heart Institute (InCor), University of Sao Paulo, R. Dr. Eneas de Carvalho Aguiar, 44, 05403-000, Sao Paulo, Brazil
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Media AS, Christensen TD, Katballe N, Pilegaard HK, de Paoli FV. Prevalence of comorbidities in a surgical pectus excavatum population. J Thorac Dis 2021; 13:1652-1657. [PMID: 33841956 PMCID: PMC8024824 DOI: 10.21037/jtd-20-3352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Pectus excavatum is the most common chest wall deformity and is associated to various connective tissue, cardiopulmonary, and skeletal abnormalities. Several conditions and syndromes have been associated to pectus excavatum, although the overall health implications of the pectus excavatum phenotype are unclear. Therefore, in this study we aimed to examine the health implications of the pectus excavatum phenotype by assessing all comorbidities and previous medical conditions in a cohort of patients undergoing pectus excavatum surgery. Methods This single-centre retrospective prevalence study included 1,046 patients undergoing minimal invasive repair of pectus excavatum from 2001 to 2012. Hospital medical charts were assessed and comorbidities and previous medical conditions were registered systematically and categorized according to the affected organ system. Results In our study population of 1,046 patients, we registered 623 conditions. The median age was 17 years and the majority of patients (56%) had no previous or present conditions. Notable prevalence of asthma (8.8%), allergies (12.3%), previous hernia surgery (5.2%), and psychiatric conditions (4.9%) were found. Conclusions The majority of patients undergoing pectus excavatum surgery have no comorbidities or previous medical conditions. It seems that this patient category is comparable to the background population in this regard and our findings do not support screening this patient category for associated conditions.
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Affiliation(s)
- Ara Shwan Media
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Niels Katballe
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Frank Vincenzo de Paoli
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Physiology, Aarhus University, Aarhus, Denmark
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22
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Norlander L, Karlsson J, Anderzén-Carlsson A, Vidlund M, Dreifaldt M, Andreasson J, Sundqvist AS. Translation and psychometric evaluation of the Swedish versions of the Nuss Questionnaire modified for Adults and the Single Step Questionnaire. J Patient Rep Outcomes 2021; 5:21. [PMID: 33629190 PMCID: PMC7904978 DOI: 10.1186/s41687-021-00293-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pectus excavatum (PE) is the most common congenital chest wall deformity. Most individuals with PE suffer from psychosocial problems, with low self-esteem and poor body image. Correctional surgery for PE is available, the most widely used is the Nuss procedure. The Nuss procedure has previously been reported to improve self-esteem, body image and health-related quality of life (HRQoL). To assess HRQoL among individuals with PE, the Nuss Questionnaire modified for Adults (NQ-mA) and Single Step Questionnaire (SSQ) has been developed. The aim of the current study was to translate and culturally adapt NQ-mA and SSQ to fit a Swedish context, and to evaluate the psychometric properties, and validate the culturally adapted versions. METHODS Individuals who had undergone the Nuss procedure for pectus excavatum were invited to participate in a multicentre study with cross-sectional design. HRQoL was assessed by NQ-mA, SSQ and RAND-36. Psychometric properties for NQ-mA and SSQ were evaluated by content validity index and construct validity (exploratory factor analysis, confirmatory factor analysis, and inter-scale correlations). Known-groups validity, as well as floor and ceiling effects, were evaluated. Internal consistency reliability was examined using Cronbach's alpha. RESULTS In total 236 individuals participated in the study. Content validity index for NQ-mA showed satisfactory results, except for two items. Factor analysis for NQ-mA suggested a two-factor model, with exclusion of two items. Subscales correlated adequately with RAND-36's domains. Known-groups validity for NQ-mA demonstrated high sensitivity for between-group differences. Ceiling effects were present in several items. Cronbach's alpha for NQ-mA was .89. Confirmatory factor analysis for SSQ resulted in a three-factor model, with exclusion of five items. However, this model was shown to be unstable through further exploratory factor analysis testing, and no further psychometric tests were conducted for SSQ. CONCLUSION The 10-item Swedish version of NQ-mA was shown to be valid for research and clinical assessment of HRQoL in individuals with pectus excavatum. The Swedish version of SSQ requires revision of items before further validation can be performed.
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Affiliation(s)
- Louise Norlander
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden. .,Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
| | - Jan Karlsson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Agneta Anderzén-Carlsson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mårten Vidlund
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
| | - Mats Dreifaldt
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
| | - Jesper Andreasson
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Ann-Sofie Sundqvist
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.,University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Rodriguez-Granillo GA, Raggio IM, Deviggiano A, Bellia-Munzon G, Capunay C, Nazar M, Martinez JL, Carrascosa P, Martinez-Ferro M. Impact of pectus excavatum on cardiac morphology and function according to the site of maximum compression: effect of physical exertion and respiratory cycle. Eur Heart J Cardiovasc Imaging 2020; 21:77-84. [DOI: 10.1093/ehjci/jez061] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
Aims
Previous studies have demonstrated diverse cardiac manifestations in patients with pectus excavatum (PEX), although mostly addressing morphological or physiological impact as separate findings. Using multimodality imaging, we evaluated the impact of PEX on cardiac morphology and function according to the site of maximum compression, and the effect of exertion and breathing.
Methods and results
All patients underwent chest computed tomography, cardiac magnetic resonance (CMR), and stress echocardiography (echo) in order to establish surgical candidacy. We evaluated diastolic function and trans-tricuspid gradient during stress (echo); and systolic function and respiratory-related septal wall motion abnormalities (CMR). Patients were classified according to the site of cardiac compression as type 0 (without cardiac compression); type 1 (right ventricle); and type 2 [right ventricle and atrioventricular (AV) groove]. Fifty-nine patients underwent multimodality imaging, with a mean age of 19.5 ± 5.9 years. Compared with a sex and age matched control group, peak exercise capacity was lower in patients with PEX (8.4 ± 2.0 METs vs. 15.1 ± 4.6 METs, P < 0.0001). At stress, significant differences were found between groups regarding left ventricular E/A (P = 0.004) and e/a ratio (P = 0.005), right ventricular E/A ratio (P = 0.03), and trans-tricuspid gradient (P = 0.001). At CMR, only 9 (15%) patients with PEX had normal septal motion, whereas 17 (29%) had septal flattening during inspiration. Septal motion abnormalities were significantly related to the cardiac compression classification (P < 0.0001).
Conclusions
The present study demonstrated that patients with PEX, particularly those with compression affecting the right ventricle and AV groove, manifest diverse cardiac abnormalities that are mostly related to exertion, inspiration, and diastolic function.
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Affiliation(s)
- Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, Diagnostico Maipu, Av. Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Ignacio M Raggio
- Department of Cardiology, Clinica Olivos and CEMIC, Av. Maipú 1660, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Alejandro Deviggiano
- Department of Cardiovascular Imaging, Diagnostico Maipu, Av. Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Gaston Bellia-Munzon
- Department of Surgery, Fundacion Hospitalaria, Private Children's Hospital, Av. Crámer 4601, C1429AKK, Buenos Aires, Argentina
| | - Carlos Capunay
- Department of Cardiovascular Imaging, Diagnostico Maipu, Av. Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Maximiliano Nazar
- Department of Surgery, Fundacion Hospitalaria, Private Children's Hospital, Av. Crámer 4601, C1429AKK, Buenos Aires, Argentina
| | - Jorge Luis Martinez
- Department of Surgery, Fundacion Hospitalaria, Private Children's Hospital, Av. Crámer 4601, C1429AKK, Buenos Aires, Argentina
| | - Patricia Carrascosa
- Department of Cardiovascular Imaging, Diagnostico Maipu, Av. Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Marcelo Martinez-Ferro
- Department of Surgery, Fundacion Hospitalaria, Private Children's Hospital, Av. Crámer 4601, C1429AKK, Buenos Aires, Argentina
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24
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Taylor JS, Madhavan S, Szafer D, Pei A, Koppolu R, Barnaby K, Wall JK, Chao SD. Three-Dimensional Optical Imaging for Pectus Excavatum Assessment. Ann Thorac Surg 2019; 108:1065-1071. [DOI: 10.1016/j.athoracsur.2019.04.074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 04/03/2019] [Accepted: 04/17/2019] [Indexed: 11/16/2022]
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25
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Li H, Jin X, Fan S, Wang D, Wu C, Pan Z, Li Y, An Y, Wang G, Dai J, Wang Q. Behavioural disorders in children with pectus excavatum in China: a retrospective cohort study with propensity score matching and risk prediction model. Eur J Cardiothorac Surg 2019; 56:596-603. [PMID: 30824916 DOI: 10.1093/ejcts/ezz038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Surgical repair of pectus excavatum is typically carried out immediately prior to puberty. However, at the time of surgery, some psychosocial issues, such as behavioural disorders may already have developed and the likelihood of these psychosocial disorders resolving after surgery is unclear. For this reason, some surgeons choose to perform surgical repair at an earlier age in some children. The study retrospectively compares the rate of behavioural disorders in children undergoing the Nuss procedure at 4 vs. 10 years of age. We also attempted to develop a model to predict the risk of behavioural disorders in 10 year-old patients. METHODS The current study included children receiving Nuss procedure for pectus excavatum at either 4 or 10 years of age. The presence/absence of behavioural disorder was assessed preoperatively, and in the third year, after removal of the bar. A propensity score matching (PSM) analysis was conducted to reduce the potential for confounding by baseline factors. Multivariable logistic regression was conducted to establish a model to predict the risk of behavioural disorders in the third year after the removal of the bar. The model was accessed by discrimination and calibration. A formula and a nomogram were developed based on the results. RESULTS The number of patients in each group was 45 after PSM. The rate of behavioural disorders at the baseline was significantly higher in the children undergoing Nuss procedure at 10 years of age [36% vs 20%, odds ratio (OR) 2.21, 95% confidence interval (CI) 0.85-5.72; P = 0.157]. The rate of behavioural disorders in the third year after the removal of the bar was 36% and 18% in children undergoing surgery at 10 and 4 years of age, respectively (OR 2.55, 95% CI 0.96-6.79; P = 0.094). The rate of persistent behavioural disorders, defined as continuing to have behavioural disorders in the third year after the removal of the bar in those with behavioural disorders at the baseline, was 88% vs 56% (OR 3.47, 95% CI 0.56-21.36; P = 0.204). Two patients (4%) relapsed in each group. A risk prediction model by variables of gender, Haller index, pulmonary function and score of Child Behaviour Checklist at the baseline was provided. CONCLUSIONS The rate of behavioural disorders was considerably lower in children who underwent the Nuss procedure at 4 years of age than at 10 years of age. Behavioural disorders may not readily resolve after surgery. Performing surgery at an early age rather than just before puberty may be better for psychosocial development. Psychosocial aid is necessary in addition to surgery to address behavioural disorders.
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Affiliation(s)
- Hongbo Li
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Xianqing Jin
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Shulei Fan
- Department of Respiratory Medicine, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Daoxin Wang
- Department of Respiratory Medicine, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chun Wu
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Zhengxia Pan
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yonggang Li
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yong An
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Gang Wang
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Jiangtao Dai
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Quan Wang
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
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26
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Preoperative multimodality imaging of pectus excavatum: State of the art review and call for standardization. Eur J Radiol 2019; 117:140-148. [DOI: 10.1016/j.ejrad.2019.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/10/2019] [Accepted: 06/13/2019] [Indexed: 02/03/2023]
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Shi R, Xie L, Chen G, Zeng Q, Mo X, Tang J, Zhou H, Zhang D, Ye X, Zhou Z, Tian D, Deng C, Ben X, Qiao G. Surgical management of pectus excavatum in China: results of a survey amongst members of the Chinese Association of Thoracic Surgeons. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:202. [PMID: 31205920 DOI: 10.21037/atm.2019.05.03] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background At present, there are no randomized trial or higher levels of evidence than case studies to guide thoracic surgeons in the field of thoracic deformities, typically for pectus excavatum. This study investigates the current clinical practices amongst the Chinese Association of Thoracic Surgeon (CATS) members in order to seek potential consensus and divergence. Methods A web-based questionnaire was designed by a subgroup of CATS Pectus Excavatum Management Working Group and was sent to all of the CATS members. The questionnaire was composed of 27 questions concerning debatable sections, including preoperative evaluations, indications, timings of surgery, anesthesia and analgesia methods, rehabilitations. Results A total of 385 questionnaires were mailed to available CATS members. Moreover, 208 questionnaires were retrieved, of them 170 were finally available for analysis. Results of high consensus were extracted. Besides well-known factors such as complaints of symptoms, a moderate to severe deformity by physical exam, a Haller CT index >3.2, pulmonary function deviance, and cardiology evaluation abnormality, cosmetic requests and severe social-psychological problems from deformity come to be the most common reasons (17.34% and 56.89%) for PE patients' demands for surgery, and also occupy high percentages (49.41% and 89.41%) in indications of surgery. Concerning CT scan, 3D reconstruction of the chest is performed additionally by two thirds (64.12%) of the investigated cohort. Two surgeons out of three (66.47%) responders consider the optimal age for surgery is 6-12 years old. After the Nuss procedure, the majority of responders (79.41%) agree on the removal of the bar 2-3 years after surgery. To deal with complicated or severe deformities, 84.71% of surgeons utilize the double bar or multiple bar techniques. The majority of responders (92.35%) prefer general anesthesia combined with intubation in PE surgery, as well as in the procedure of the Nuss bar removal (72.35%). Conclusions The survey reveals a remarkable consistency of practice patterns in several aspects. Adequate preoperative evaluations are needed. Cosmetic request and psychological discomfort from deformity are crucial indications for surgery. We had better perform PE surgery before patients' puberty and bar removal 3 years after surgery. Several surgical skills are fully debated to enhance orthopedic effect and diminish complications. General anesthesia combined with intubation is considered as a standard maneuver. Surgeons now pay more and more attention to perioperative rehabilitations. The given results can be used as evidence in guiding clinical practice in circumstances where no evidence of higher levels exists, although divergences exist. Future studies, especially randomized trials, are needed to establish clinical practice guidelines for thoracic surgeons in PE surgery.
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Affiliation(s)
- Ruiqing Shi
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Liang Xie
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Gang Chen
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Qi Zeng
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Jiming Tang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Haiyu Zhou
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Dongkun Zhang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiong Ye
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Zihao Zhou
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Dan Tian
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Cheng Deng
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiaosong Ben
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Guibin Qiao
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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28
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Viña NA, Carrascosa P, Mogensen VC, Deviggiano A, Bellia-Munzon G, Martinez-Ferro M, Rodriguez-Granillo GA. Evaluation of pectus excavatum indexes during standard cardiac magnetic resonance: Potential for single preoperative tool. Clin Imaging 2019; 53:138-142. [DOI: 10.1016/j.clinimag.2018.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/10/2018] [Accepted: 10/12/2018] [Indexed: 11/26/2022]
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Abstract
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.
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Affiliation(s)
- Robert J Obermeyer
- Children's Hospital of The King's Daughters, Norfolk, VA, USA ; Eastern Virginia Medical School, Norfolk, VA, USA.
| | - Nina S Cohen
- Eastern Virginia Medical School, Norfolk, VA, USA
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30
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Kelly RE, Daniel A. Outcomes, quality of life, and long-term results after pectus repair from around the globe. Semin Pediatr Surg 2018; 27:170-174. [PMID: 30078488 DOI: 10.1053/j.sempedsurg.2018.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The procedure introduced by Donald Nuss in 1997 at the American Pediatric Surgical Association meeting has now been adopted by pediatric, thoracic, and plastic surgeons around the globe. Since its introduction, the Nuss procedure has been the subject of intense scrutiny. More than 20 years since the original publication, medical centers from around the world have reported their experience with the procedure and robust evidence now supports its safety and efficacy. Additionally, in collaboration with psychologists in Norfolk, a methodology was devised to measure the psychosocial as well as the physical benefits of the procedure. Extensive independent multinational and multi-institutional data demonstrate repair of pectus excavatum using the Nuss procedure results in marked improvement in both physical function and body image. This report reviews the outcomes, quality of life, and long-term results of numerous centers worldwide since the introduction of the procedure.
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Affiliation(s)
- Robert E Kelly
- Department of Surgery, Children's Hospital of The King's Daughters, 601 Children's Lane, Norfolk, VA 23507, United States; Clinical Surgery and Pediatrics, Eastern Virginia Medical School, Norfolk, VA, United States.
| | - Antarius Daniel
- Department of Surgery, Children's Hospital of The King's Daughters, 601 Children's Lane, Norfolk, VA 23507, United States
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31
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Ewais MM, Chaparala S, Uhl R, Jaroszewski DE. Outcomes in adult pectus excavatum patients undergoing Nuss repair. PATIENT-RELATED OUTCOME MEASURES 2018; 9:65-90. [PMID: 29430201 PMCID: PMC5796466 DOI: 10.2147/prom.s117771] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.
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Affiliation(s)
- MennatAllah M Ewais
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Shivani Chaparala
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Rebecca Uhl
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
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32
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Man JY, Gurnaney HG, Dubow SR, DiMaggio TJ, Kroeplin GR, Adzick NS, Muhly WT. A retrospective comparison of thoracic epidural infusion and multimodal analgesia protocol for pain management following the minimally invasive repair of pectus excavatum. Paediatr Anaesth 2017; 27:1227-1234. [PMID: 29063665 DOI: 10.1111/pan.13264] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pain management following minimally invasive repair of pectus excavatum is variable. We recently adopted a comprehensive multimodal analgesic protocol that standardizes perioperative analgesic management. We hypothesized that patients managed with this protocol would use more opioids postoperatively, have similar pain control, and shorter length of stay compared to patients managed with thoracic epidural infusion. AIMS We retrospectively compared opioid consumption, pain scores, and length of stay between a cohort of patients managed with our multimodal analgesic protocol and a cohort managed with a thoracic epidural infusion. METHODS This retrospective cohort comparison includes patients, 8 to 21 years of age, managed with either thoracic epidural infusion (n = 21) or multimodal analgesic protocol (n = 29) following minimally invasive repair of pectus excavatum from January 1, 2011 through September 15, 2015. The primary outcome, total daily opioid consumption in morphine equivalents, is presented as an average by postoperative day. Secondary outcomes included median daily pain score and length of stay. RESULTS Patients were similar in age, weight, sex, and physical status. Patients managed with thoracic epidural infusion received less opioid (morphine equivalents-mg/kg) intraoperatively compared to multimodal analgesic protocol (difference of mean [95% confidence interval] 0.22 [0.16-0.28] P ≤ .01) but required more total opioid through postoperative day 3 (difference of mean [95% confidence interval] 1.2 [0.26-2.14] P = .01). We did not observe a difference in pain scores. Median length of stay was 1 day less in patients managed with multimodal analgesic protocol (difference of median [95% confidence interval] 1 [0.3-1.7] P = .003). CONCLUSION Implementation of a standardized comprehensive multimodal analgesic protocol following minimally invasive repair of pectus excavatum resulted in equivalent analgesia with a modest reduction in length of stay when compared to thoracic epidural. We did not observe an opioid sparing effect in our thoracic epidural which may reflect technique variability.
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Affiliation(s)
- Janice Y Man
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pediatric Anesthesiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA, USA.,Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Harshad G Gurnaney
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott R Dubow
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Theresa J DiMaggio
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gina R Kroeplin
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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