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Pitt JB, Carter M, Zeineddin S, Sands L, Kujawa S, Perez A, Liszewski WJ, Abdullah F, Goldstein SD. Chest Wall Dermatitis Patterns Following Thoracoscopic Intercostal Nerve Cryoablation for Surgical Correction of Pectus Excavatum. J Pediatr Surg 2024; 59:1687-1693. [PMID: 38403489 DOI: 10.1016/j.jpedsurg.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/09/2024] [Accepted: 02/12/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Intercostal nerve cryoablation (INC) has been shown to reduce postoperative pain and length of stay following surgical correction of pectus excavatum (SCOPE). Some patients have developed chest wall dermatological symptoms after INC that can be mistaken for metal allergy or infection. The purpose of this study is to report the symptoms, severity, incidence, and treatment of post-cryoablation dermatitis. METHODS A retrospective single institution review was performed for patients who underwent SCOPE with and without INC between June 2016 and March 2023 to assess for incidence of postoperative dermatological findings. Characteristics associated with these findings were evaluated. RESULTS During study period, 383 patients underwent SCOPE, 165 (43.1%) without INC and 218 (56.9%) with. Twenty-three (10.6%) patients who received INC developed exanthems characteristic of post-cryoablation dermatitis with two distinct phenotypes identified. No patients who underwent SCOPE without INC developed similar manifestations. Early dermatitis, characterized by a painless, erythematous, and blanching rash across the anterior thorax, was observed in 16 patients, presenting on median postoperative day 6.0 [IQR 6.0-8.5], with median time to resolution of 23.0 [IQR 12-71.0] days after symptom onset. Late dermatitis, characterized by hyperpigmentation spanning the anterior thorax, was observed in 7 patients, presenting on median postoperative day 129.0 [IQR 84.5-240.0], with median time to resolution of 114.0 [IQR 48.0-314.3] days. CONCLUSION This is the first report of dermatological manifestations following SCOPE with INC, a phenomenon of unknown etiology and no known long-term sequela. In our experience, it is self-resolving and lacks systemic symptoms suggesting observation alone is sufficient for resolution. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.
| | - Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Laurie Sands
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Suzanne Kujawa
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Amparo Perez
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Walter J Liszewski
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
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Lukish A, Kovler M, Shah A, Gosztyla C, Lukish J. Simultaneous Bilateral Thoracoscopy During the Nuss Procedure is Safe, Effective and Allows for Optimal Visualization of the Bar Passer Throughout the Substernal Dissection. J Pediatr Surg 2024:161666. [PMID: 39217004 DOI: 10.1016/j.jpedsurg.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/29/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Cardiac injury during the Nuss procedure is a rare risk that can lead to a catastrophic outcome. The specific aim of this pilot study was to evaluate the safety and efficacy of simultaneous bilateral thoracoscopy (SBT) compared to standard unilateral right thoracoscopy (RT) in children undergoing the Nuss procedure in order to mitigate that risk. METHODS IRB approval was obtained to analyze data on children who underwent SBT and RT during the Nuss procedure. Data retrieval included age, gender, Haller index (HI), operative time (OT), length of stay (LOS), complications and follow up. RESULTS From August 2022 to August 2023, 10 children who underwent SBT were compared to 10 children who underwent RT. Both groups underwent intercostal nerve cryoablation. Following completion of cryoablation, SBT or RT was carried out during the Nuss procedure. SBT allowed for the tip of the bar passer to be visualized during the entire dissection in both thoraces. There was no significant difference in either group with respect to age, HI, OT, LOS. There were no anesthetic or surgical complications in either group. CONCLUSION We found that SBT is safe, effective and allows for 100% visualization of the tip of the bar passer during the entire critical phase of the Nuss procedure. It does not impact OT or LOS compared to children who underwent only RT. SBT may benefit children who undergo the Nuss procedure by reducing the risk of cardiac injury. TYPE OF STUDY Original Research Retrospective Case-control study.
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Affiliation(s)
- Annamarie Lukish
- Kansas City University, School of Medicine and Biosciences, Kansas City, MO, USA
| | - Mark Kovler
- Division of Pediatric Surgery, Children's National Hospital, Washington, D.C, USA
| | - Adil Shah
- Division of Pediatric Surgery, Children's Nebraska, University of Nebraska College of Medicine, Omaha, NE, USA
| | - Carolyn Gosztyla
- Division of Pediatric Surgery, Children's National Hospital, Washington, D.C, USA
| | - Jeffrey Lukish
- Division of Pediatric Surgery, Children's National Hospital, Washington, D.C, USA; Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, D.C, USA.
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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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Huerta CT, Cobler-Lichter MD, Lynn R, Ramsey WA, Delamater JM, Alligood DM, Parreco JP, Sola JE, Perez EA, Thorson CM. Outcomes After Pectus Excavatum Repair: Center Volume Matters. J Pediatr Surg 2024; 59:935-940. [PMID: 38360451 DOI: 10.1016/j.jpedsurg.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE Pectus excavatum (Pectus) repair may be offered for those with significant cardiopulmonary compromise or severe cosmetic defects. The influence of hospital center volume on postoperative outcomes in children is unknown. This study aimed to investigate the outcomes of children undergoing Pectus repair, stratified by hospital surgical volume. METHODS The Nationwide Readmission Database was queried (2016-2020) for patients with Pectus (Q67.6). Patients were stratified into those who received repair at high-volume centers (HVCs; ≥20 repairs annually) versus low-volume centers (LVCs; <20 repairs annually). Demographics and outcomes were analyzed using standard statistical tests. RESULTS A total of 9414 patients with Pectus underwent repair during the study period, with 69% treated at HVCs and 31% at LVCs. Patients at LVCs experienced higher rates of complications during index admission, including pneumothorax (23% vs. 15%), chest tube placement (5% vs. 2%), and overall perioperative complications (28% vs. 24%) compared to those treated at HVCs, all p < 0.001. Patients treated at LVCs had higher readmission rates within 30 days (3.8% vs. 2.8% HVCs) and overall readmission (6.8% vs. 4.7% HVCs), both p < 0.010. Among readmitted patients (n = 547), the most frequent complications during readmission for those initially treated at LVCs included pneumothorax/hemothorax (21% vs. 8%), bar dislodgment (21% vs. 12%), and electrolyte disorders (15% vs. 9%) compared to those treated at HVCs. CONCLUSION Pediatric Pectus repair performed at high-volume centers was associated with fewer index complications and readmissions compared to lower-volume centers. Patients and surgeons should consider this hospital volume-outcome relationship. TYPE OF STUDY Retrospective Comparative. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Royi Lynn
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | - Jessica M Delamater
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | - Daniel M Alligood
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | | | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA; Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA; Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA; Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Keong DE, Tzeng IS, Htut N, Fan YJ, Hsieh MS, Cheng YL. Impact of delayed removal of pectus bar on outcomes following Nuss repair: a retrospective analysis. J Cardiothorac Surg 2024; 19:160. [PMID: 38549167 PMCID: PMC10976664 DOI: 10.1186/s13019-024-02685-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 03/24/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Usually, pectus bars are removed 3 years after the Nuss procedure in patients with pectus excavatum. However, the optimal timing for postoperative pectus bar removal remains undefined. Our study investigated the effects of delayed pectus bar removal after Nuss repairs. METHODS Retrospective data were collected on patients who underwent Nuss procedures for pectus excavatum and had their bars removed from August 2014 to December 2020. Patients with correction periods > 3 years were divided into group A (< 6 years) and group B (≥ 6 years). Propensity score matching was used to compare complications and radiological outcomes associated with bar removal. RESULTS Of the 542 patients who underwent bar removal, 451 (Group A: 419 patients, Group B: 32) had correction duration > 3 years. The average correction duration was 4.5 ± 1.4 years. After propensity score matching analysis, group B [median duration: 8.0 (6.0-16.2) years] exhibited significantly longer median operative times (85 vs. 55 min; P = 0.026), higher callus formation rates (68.8% vs. 46.9%; P = 0.029), and greater median intraoperative blood loss (35 vs. 10 mL; P = 0.017) than group A [median duration: 4.2 (3.0-5.9) years]. However, following bar removal, the groups showed no statistical differences in the surgical complication rates (group A: 6.3% vs. group B: 9.4%; P = 0.648) or median ratio of radiological improvement (an improvement on the Haller index on chest radiography; 21.0% vs. 22.2%; P = 0.308). CONCLUSIONS Delaying pectus bar removal after Nuss repair presents certain challenges but does not compromise overall outcomes. These findings suggest that a longer correction period may be unnecessary. However, further multicenter studies with long-term follow-up are warranted to assess long-term outcomes.
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Affiliation(s)
- Der-En Keong
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | | | - Nay Htut
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Yu-Jiun Fan
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Min-Shiau Hsieh
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Yeung-Leung Cheng
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.
- School of Medicine, Tzu Chi University, Hualien, Taiwan.
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Roostaei G, Amini H, Abtahi H, Kazemizadeh H, Edalatifard M, Rahimi B, Asadi S, Khoshnam‐Rad N. Post-operative arrest following pectus excavatum repair: A case report with a systematic review of the published case reports. Clin Case Rep 2024; 12:e8650. [PMID: 38464576 PMCID: PMC10920322 DOI: 10.1002/ccr3.8650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024] Open
Abstract
Key Clinical Message Common complications after PE surgery include ventricular tachycardia, cardiac arrest, pneumothorax, and bar displacement. These can lead to severe outcomes, emphasizing the need for caution and meticulous post-operative monitoring. Patients and their families should be well-informed about potential risks during the consent process. Abstract The objective of this study was to raise awareness among medical staff and surgeons about potential complications, particularly rare and life-threatening ones, associated with pectus excavatum (PE) surgery. PE is the most common chest wall deformity, characterized by sternal depression. Patients primarily seek treatment for cosmetic concerns, but some also report exercise intolerance and shortness of breath. Although surgical repair is the standard treatment, the incidence and nature of severe complications remain unclear and underreported. This study presents a case of a lethal cardiac event following PE surgery and conducts a systematic review of published case reports. This study describes a case of a lethal complication of ventricular fibrillation and cardiac arrest following the Ravitch procedure for correction of PE in a 10-year-old boy. A systematic review of relevant cases of PE surgery complications was conducted. Of the 506 initial records retrieved, 93 case reports from 83 articles were identified over the 23 years. Among them, 72 patients were male, and 20 cases were female. The average age of patients was 19.2 ± 7.7 years (range: 5-53). Complications had occurred up to 37 years from the time of surgery, with most of the cases (22.5%) occurring during the operation. The most frequent complications included cardiothoracic issues and displacement of the implanted steel bar. In nine patients, complications led to fatal outcomes. Due to the possible risks of PE surgery, particularly in cosmetically motivated cases, surgeons must exercise extreme caution and remain vigilant for rare and potentially life-threatening complications.
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Affiliation(s)
- Ghazal Roostaei
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hesam Amini
- Department of Thoracic Surgery, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hamidreza Abtahi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hossein Kazemizadeh
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Maryam Edalatifard
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Besharat Rahimi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Sanaz Asadi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Niloofar Khoshnam‐Rad
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
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Pitt JB, Zeineddin S, Carter M, Perez A, Sands L, Kujawa S, Reynolds M, Abdullah F, Goldstein SD. Demographics of Anterior Chest Wall Deformity Patients: A Tertiary Children's Hospital Experience. J Surg Res 2024; 293:451-457. [PMID: 37827024 DOI: 10.1016/j.jss.2023.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Anterior chest wall deformities consist of abnormal development of the chest, with the most common congenital deformities being pectus excavatum (PE) and pectus carinatum (PC). Surgical series are common, but less research is present assessing the demographics of all who present for initial evaluation. The purpose of this study is to describe the patient characteristics of those who present for ambulatory surgical evaluation. METHODS Data were collected from initial patient visits to an established multispecialty chest wall deformities program at a large Children's Hospital from 2017 to 2021. Variables assessed included primary diagnosis, age, sex, race/ethnicity, and whether surgical correction was performed. RESULTS A total of 1510 children were evaluated: 50.0% (n = 755) with PE, 43.3% (n = 653) with PC, 2.7% (n = 41) with mixed chest wall deformities, 0.7% (n = 10) with Poland syndrome, 1.1% (n = 17) with Currarino-Silverman syndrome, and 2.3% (n = 34) with other anterior chest wall deformities. Males and females presented at mean age of 12.8 (4.2) and 10.9 (5.5) years, respectively (P = 0.001). White children represented 61.1% of the overall population while Hispanic children represented 26.3%. White, non-Hispanic children represented 61.9% and 71.5% and Hispanic children represented 26.0% and 26.3% of the PE and PC populations, respectively. CONCLUSIONS Most patients seen in an urban chest wall deformities clinic were White, non-Hispanic; however, the proportion of other groups such as Hispanic and Asian is greater in this cohort than previously described. Further research is ongoing to ascertain the extent to which disease predisposition versus access to care play roles in this population.
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Affiliation(s)
- J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Amparo Perez
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Laurie Sands
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suzanne Kujawa
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Marleta Reynolds
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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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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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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Stephens EH, Dearani JA, Jaroszewski DE. Pectus Excavatum in Cardiac Surgery Patients. Ann Thorac Surg 2023; 115:1312-1321. [PMID: 36781097 DOI: 10.1016/j.athoracsur.2023.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Pectus excavatum frequently accompanies congenital heart disease and connective tissue diseases requiring cardiac surgery. Sometimes the indication is cardiac repair, with the pectus being incidentally noticed; other times, the pectus subsequently develops or becomes more significant after cardiac surgery. This review arms cardiac and congenital surgeons with background about the physiologic impact of pectus, indications for repair and repair strategies, and outcomes for cardiac surgery patients requiring pectus repair. METHODS A comprehensive literature review was performed using keywords related to pectus excavatum, pectus repair, and cardiac/congenital heart surgery within the PubMed database. RESULTS The risks of complications related to pectus repair, including in the setting of cardiac surgery or after cardiac surgery, are low in experienced hands, and patients demonstrate cardiopulmonary benefits and symptom relief. Concomitant pectus and cardiac surgery should be considered if it is performed in conjunction with those experienced in pectus repair, particularly given the increased cardiopulmonary impact of pectus after bypass. In the setting of potential bleeding or hemodynamic instability, delayed sternal closure is recommended. For those with anticipated pectus repair after cardiac surgery, the pericardium should be reconstructed for cardiac protection. For those undergoing pectus repair after cardiac surgery without a membrane placed, a "hybrid" approach is safe and effective. CONCLUSIONS Patients undergoing cardiac surgery noted to have pectus should be considered for possible concomitant or staged pectus repair. For those who will undergo a staged procedure, a barrier membrane should be placed before chest closure.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dawn E Jaroszewski
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona.
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11
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Khairallah S, Chow OS, Mick SL. Combined minimally invasive repair of pectus excavatum and robotically assisted mitral valve repair: A case report and considerations. J Card Surg 2022; 37:5571-5574. [PMID: 36316821 DOI: 10.1111/jocs.17070] [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: 06/13/2022] [Revised: 09/21/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Severe pectus excavatum (PE) is considered a relative contraindication to robotic cardiac surgery and information is lacking on surgical solutions to allow for a robotic approach in this setting. OBJECTIVE We present a case of concomitant minimally invasive treatment of severe PE with initial pectus correction with Nuss bar insertion followed by robotically assisted mitral valve repair. METHODS A multidisciplinary team planned and executed the operation. Thoracoscopic assessment at the onset of the case demonstrated mediastinal exposure was inadequate for robotic repar without PE correction. Forced sternal elevation demonstrated sternal laxity sufficient to provide adequate exposure. Nuss bars were placed and robotic repair proceeded uneventfully. RESULTS The patient underwent successful concomitant minimally invasive PE and robotically assisted mitral repair. CONCLUSION Successful combined minimally invasive pectus repair and robotic mitral valve can be achieved if sufficient chest wall laxity is present on forced sternal elevation and access sites are planned properly in a multidisciplinary approach.
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Affiliation(s)
- Sherif Khairallah
- Cardiothoracic Surgery Department, Weill Cornell Medicine New York Presbyterian Hospital (WCM), New York, New York, USA
| | - Oliver S Chow
- Cardiothoracic Surgery Department, Weill Cornell Medicine New York Presbyterian Hospital (WCM), New York, New York, USA
| | - Stephanie L Mick
- Cardiothoracic Surgery Department, Weill Cornell Medicine New York Presbyterian Hospital (WCM), New York, New York, USA
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12
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Grunfeld M, Ohira S, Choe J, Lanier GM, Martin K, Spielvogel D, Kai M. Heart recovery from a brain-dead donor with a history of Ravitch procedure for repair of pectus excavatum. J Card Surg 2022; 37:5531-5533. [PMID: 36273420 DOI: 10.1111/jocs.17065] [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: 05/03/2022] [Revised: 09/06/2022] [Accepted: 10/15/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND We describe the successful heart transplantation of a brain-dead male donor with a remote history of pectus excavatum repair. METHOD AND RESULTS On computed tomography, the ascending aorta was in close proximity to metallic struts from the donor's sternal repair. Before harvesting the heart, visual and digital inspections revealed minimal space between the sternum and ascending aorta, complicated by severe adhesions in the lower sternum. After the pericardium was opened, the subsequent recovery of the heart was performed in a standard fashion. At one-year post-transplant, the recipient continues to have normal graft function. CONCLUSIONS Careful evaluation, intraoperative consideration, and coordination with other transplant teams were essential in the successful recovery of the heart during a time of organ shortages.
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Affiliation(s)
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Joshua Choe
- New York Medical College, Valhalla, New York, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Kathryn Martin
- Division of Pediatric Surgery, Department of Surgery, Maria Fareri Children's Hospital, Valhalla, New York, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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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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Use of Biomaterials for Pectus Excavatum Surgery. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03480-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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15
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Tedde ML, de Beer SA. Correspondence on Should the Ravitch Procedure to Correct Pectus Excavatum Be Avoided in Young Children? J Chest Surg 2022; 55:252-254. [PMID: 35638124 PMCID: PMC9178302 DOI: 10.5090/jcs.22.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/18/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Miguel Lia Tedde
- Thoracic Surgery Department, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Brazil
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Sjoerd A. de Beer
- Pediatric Surgical Center Amsterdam (Kinderchirurgisch Centrum Amsterdam, KCCA), Amsterdam, Netherlands
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Linton SC, Ghomrawi HMK, Tian Y, Many BT, Vacek J, Bouchard ME, De Boer C, Goldstein SD, Abdullah F. Association of Operative Volume and Odds of Surgical Complication for Patients Undergoing Repair of Pectus Excavatum at Children's Hospitals. J Pediatr 2022; 244:154-160.e3. [PMID: 34968500 DOI: 10.1016/j.jpeds.2021.12.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether procedure-specific provider volume is associated with outcomes for patients undergoing repair of pectus excavatum at tertiary care children's hospitals. STUDY DESIGN We performed a cohort study of patients undergoing repair of pectus excavatum between January 1, 2013 and December 31, 2019, at children's hospitals using the Pediatric Health Information System database. The main exposures were the pectus excavatum repair volume quartile of the patient's hospital and the pectus excavatum repair volume category of their surgeon. Our primary outcome was surgical complication, identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification codes from Pediatric Health Information System. Secondary outcomes included high-cost admission and extended length of stay. RESULTS In total, 7183 patients with an average age of 15.2 years (SD 2.0), 83% male, 74% non-Hispanic White, 68% no comorbidities, 72% private insurance, and 82% from metro areas were analyzed. Compared with the lowest-volume (≤10 cases/year) quartile of hospitals, patients undergoing repair of pectus excavatum at hospitals in the second (>10-18 cases/year), third (>18-26 cases/year), and fourth (>26 cases/year) volume quartiles had decreased odds of complication of OR 0.52 (CI 0.34-0.82), 0.51 (CI 0.33-0.78), and 0.41 (CI 0.27-0.62), respectively. Patients with pectus excavatum who underwent repair by surgeons in the second (>1-5 cases/year), third (>5-10 cases/year), and fourth (>10 cases/year) volume categories had decreased odds of complication of OR 0.91 (CI 0.68-1.20), OR 0.73 (CI 0.51-1.04), and OR 0.55 (CI 0.39-0.76), respectively, compared with the lowest-volume (≤1 case/year) category of surgeons. CONCLUSIONS Procedure-specific case volume is an important factor when considering providers for elective surgery, even among specialized centers providing comprehensive patient care.
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Affiliation(s)
- Samuel C Linton
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Hassan M K Ghomrawi
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Yao Tian
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Benjamin T Many
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jonathan Vacek
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Megan E Bouchard
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Christopher De Boer
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Seth D Goldstein
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Fizan Abdullah
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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Pechetov AA, Volchanskiy DA, Makov MA. [Correction of pectus excavatum and long-term outcome in adult]. Khirurgiia (Mosk) 2022:84-89. [PMID: 35080832 DOI: 10.17116/hirurgia202201184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pectus excavatum is the most common congenital chest malformation characterized by symmetrical or asymmetric depression of the chest with deformation of the sternocostal complex. Pectus excavatum is often associated with other dysplastic diseases of connective tissue. Ravitch thoracoplasty and Nuss minimally invasive correction are the most common today. The authors report surgical correction of PE in a 50-years-old male who underwent Ravitch modified thoracoplasty with implantation of shape memory plate. Long-term treatment outcomes and technical properties of the plate after removing are analyzed.
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Affiliation(s)
- A A Pechetov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - D A Volchanskiy
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - M A Makov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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18
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Wang L, Bi R, Xie X, Xiao H, Hu F, Jiang L. A Modfied Nuss Procedure for Recurrent Pectus Excavatum of Adults. Front Surg 2022; 8:814837. [PMID: 35155553 PMCID: PMC8825472 DOI: 10.3389/fsurg.2021.814837] [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: 11/14/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background Limited data exist for adults with recurrent pectus excavatum (PE) treated with minimally invasive surgical repair. Methods Between July 2008 and December 2020, forty-two adult patients with recurrent PE underwent a modified Nuss procedure with a newly designed bar in our center. A small vertical subxiphoid incision was used to separate severe adhesions when necessary. Multiple steel wires were sutured, and the rib space was narrowed to firmly fix the bar. The primary end point was Haller index change after operation. The secondary end points included length of stay after operation, short-term and long-term complications. Results The mean patient age was 22.02 ± 3.49 years. The mean Haller index was 4.59 ± 1.09. A subxiphoid incision was performed in 12 patients. Thirty-nine patients had one bar placed, and 3 patients required two bars. Sixteen patients had 3 or more wires fixation, and 4 patients needed to have their intercostal space narrowed. There was no perioperative death, and the mean hospitalization was 5.57 ± 2.47 days. The Haller index reduced to 3.03 ± 0.41 after the operation (t = 11.85, p < 0.001). During the follow-up, there were 3 patients who developed non-infective wound effusion; bar rotations occurred in 3 patients. Twenty patients had the bar removed, post-bar removal Haller index was significantly reduced compared to the preoperative Haller index (2.89 ± 0.37 vs. 4.72 ± 1.05, t = 8.96, p < 0.001). Conclusions The modified Nuss procedure with a new titanium alloy bar can achieve good results for adult patients with recurrent PE.
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19
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Chen T, Chen C, Zeng Q, Zhang Y, Jiao J, Zhang X, Zhang N, Yu J. Use of caliper-based external measurement of body surface in assessing the severity of pectus excavatum. Front Pediatr 2022; 10:1015026. [PMID: 36186654 PMCID: PMC9521316 DOI: 10.3389/fped.2022.1015026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/30/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Objective assessment of the severity of pectus excavatum (PE) mainly depends on internal imaging examination, which poses radiation exposure risks and high financial costs. Our study explores the feasibility of caliper-based external measurements of the body surface to assess PE severity. MATERIALS AND METHODS Patients with PE aged 4-18 years who underwent both internal imaging examinations and external measurements were chosen for the study. Overall, 176 patients underwent surgery and 21 underwent regular observation. The Haller index (HI) and correction index (CI) were used to derive the external measurement indices, HI-caliper and CI-caliper. Receiver-operator characteristic analysis provided the optimal cut-off values and compared the diagnostic values of HI-caliper and CI-caliper. Spearman's correlation coefficient and Cohen's kappa coefficient were used to analyze the correlation and consistency between HI-caliper or CI-caliper and HI-CT or CI-CT, respectively. Also, a paired samples t-test was used to compare the differences of HI-caliper or CI-caliper before and after surgery. RESULTS HI-caliper and CI-caliper measurements had strong correlations with HI-CT and CI-CT results (rs = 0.70, p < 0.001; rs = 0.69, p < 0.001), respectively. The optimal cut-off values of HI-caliper and CI-caliper were 1.83 (sensitivity = 0.841, specificity = 0.905) and 12% (sensitivity = 0.881, specificity = 0.857), exhibiting comparable diagnostic values with HI-CT and CI-CT. HI-caliper > 1.83 or CI-caliper > 12% had medium intensity consistency with HI-CT ≥ 3.25 or CI-CT ≥ 28% (k = 0.545, 95% confidence interval: 0.374-0.716, p < 0.001). The HI-caliper and CI-caliper values were significantly different before and after surgery. CONCLUSION Caliper-based external measurement is a feasible method to screen patients who require surgical intervention and for monitoring the progression of PE severity.
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Affiliation(s)
- Tian Chen
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Chenghao Chen
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Qi Zeng
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yan Zhang
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jinghua Jiao
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xu Zhang
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Na Zhang
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jie Yu
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Núñez García B, Álvarez García N, Aquino-Esperanza J, Esteva Miró C, Pérez-Gaspar M, Jiménez Gómez J, Betancourth Alvarenga JE, Santiago Martínez S, Jiménez-Arribas P, Güizzo JR. Efficacy and Safety of Taulinoplasty Compared with the Minimally Invasive Repair of Pectus Excavatum Approach to Correct Pectus Excavatum. J Laparoendosc Adv Surg Tech A 2021; 31:1402-1407. [PMID: 34847730 DOI: 10.1089/lap.2021.0216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Background: Minimally invasive repair of pectus excavatum (MIRPE) technique is the current most used surgical method for pectus excavatum (PE) correction. To avoid MIRPE-required invasion of the mediastinum or pleural cavity, we developed taulinoplasty approach as an alternative option for the reduction of the sunken chest. Materials and Methods: This is a single-center unblind nonrandomized prospective pilot study, involving 26 MIRPE and 23 taulinoplasty patients. The primary safety endpoint was the presence of surgical complications, and the primary efficacy endpoint was Haller index measured postoperatively in taulinoplasty patients. Secondary endpoints were intensive care unit (ICU) and hospital length of stay (LOS), duration of surgical procedure, and postoperative pain management. Chi-square, Mann-Whitney, or Student "t" tests were used for comparison as appropriate. Results: There were no difference in median age (14.5 and 14 years), Haller index (4.63 and 4.17), or comorbidities. MIRPE and taulinoplasty procedures showed no difference regarding major or minor surgical complications. The efficacy endpoint of taulinoplasty was measured 5.5 (1.5-12) months after the procedure, exhibiting a significant reduction in the Haller index [4.17 (3.7-4.7) at baseline and 3.7 (2.9-4.1) postoperatively, P = .03]. Taulinoplasty required less surgical time (60.4 ± 15.5 versus 70.7 ± 15.9 minutes, P < .01); shorter ICU and hospital LOS (P < .01, respectively); and required fewer days of peridural, intravenous, and oral analgesia (P < .01, respectively). Conclusions: In this pilot study, taulinoplasty technique was as safe as the MIRPE approach and effective for the correction of PE, reducing surgical time, ICU and hospital LOS, and achieving better postoperative pain control.
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Affiliation(s)
| | | | - José Aquino-Esperanza
- Institut d'Investigació i Innovació Parc Taulí I3PT, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Clara Esteva Miró
- Department of Pediatric Surgery, Parc Taulí University Hospital, Sabadell, Spain
| | - Mireia Pérez-Gaspar
- Department of Pediatric Surgery, Parc Taulí University Hospital, Sabadell, Spain
| | - Javier Jiménez Gómez
- Department of Pediatric Surgery, Parc Taulí University Hospital, Sabadell, Spain
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21
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Minimally Invasive Modified Nuss Procedure for Repair of Pectus Excavatum in Pediatric Patients: Single-Centre Retrospective Observational Study. CHILDREN 2021; 8:children8111071. [PMID: 34828784 PMCID: PMC8624072 DOI: 10.3390/children8111071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 11/17/2022]
Abstract
Background: The treatment of pectus excavatum can be conservative or surgical. The aim of this study was to determine the factors influencing the outcomes of treatment after a minimally invasive Nuss corrective surgery procedure in pediatric patients. Methods: A total of 30 patient who underwent a minimally invasive Nuss corrective procedure for pectus excavatum from 1 January 2014 to 31 December 2020 were included in thisretrospective study. The collected data included thepatient’s demographic characteristics (age, sex, height, weight, body mass index—BMI, Haller index), treatment outcomes (duration of surgery, length of hospital stay, intraoperative complications, early and late complications, postoperative analgesia), and overall patient and legal guardian satisfaction two years after the procedure. Results: A total of 22 male and 8 female patients were included in the study. The median age was 15 years (interquartile range—IQR 14, 16), and the median BMI was 18.5 kg/m2 (IQR 17.7, 20.4) and 18.2 kg/m2 (IQR 16.9, 18.6) for males and females, respectively. The median CT Haller index was 3.67 (IQR 3.48, 4.09) for male and 3.69 (IQR 3.45, 3.9) for female patients. The median surgery duration was 120 min (IQR 100, 130), and the median hospital stay length was 8.5 days (IQR 8, 9.75). Indications for surgery were psychological (47%), followed by respiratory (30%) and combined respiratory-cardiac (20%) and respiratory-psychological disorders (3%). Early complications were observed in 18 patients (60%), and late complications were observed in 7 patients (23.3%). Intraoperative complications were not recorded. The most common early complications were pneumothorax and subcutaneous emphysema (30%), while late complications included bar displacement (10%) and deformity recurrence (6.6%). Overall, the procedure was successful in 93.1% of patients. Upon arrival home, 22 patients (81.5%) used analgesics for at least one day, up to a maximum of six months. A total of 23 (76.7%) operated patients determined that the surgical procedure had excellent results (grade 5), 4 (13.3%) patients report a good result (grade 4), 1(3.3%) patient reported a mediocre result, and one patient (3.3%) reported a bad result (grades 3 and 2, respectively). Conclusion: The Nuss procedure is a safe and effective method for treating funnel chest in children and adolescents. It also providesexcellent cosmetic and aesthetic results as well as subjective satisfaction with the outcome of surgical treatment.
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22
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Greberski K, Jarząbek R, Perek B, Łuczak M, Bugajski P. Exceptional life-threatening complication 19 years after Ravitch correction of pectus excavatum. J Card Surg 2021; 36:3971-3972. [PMID: 34339529 DOI: 10.1111/jocs.15889] [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: 05/04/2021] [Revised: 06/13/2021] [Accepted: 07/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ravitch technique of chest correction has been considered, although invasive, as a safe and efficacious surgical method. CASE We describe a case of a 35-year-old woman with cardiac tamponade and in cardiogenic shock due to exceptional late complication after pectus excavatum reconstruction by means of classic Ravitch technique 19 years earlier. This very late adverse event was caused by a broken metal sternal wire that injured the wall of the ascending aorta. The patient underwent salvage repair of this segment of the aorta in cardiopulmonary bypass. Postoperative course and postdischarge 3-year follow-up have been uneventful. CONCLUSION Therefore, life-threatening cardiovascular complications may occur even many years after reconstructive surgery for chest deformity.
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Affiliation(s)
- Krzysztof Greberski
- Department of Cardiac Surgery, J Strus Multidisciplinary Hospital, Poznan, Poland.,Department of the Prevention of Cardiovascular Diseases, Faculty of Health Sciences, Poznan University of Medical Sciences, Poznan, Poland
| | - Radosław Jarząbek
- Department of Cardiac Surgery, J Strus Multidisciplinary Hospital, Poznan, Poland
| | - Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Maciej Łuczak
- Department of Medical, Faculty of Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Paweł Bugajski
- Department of Cardiac Surgery, J Strus Multidisciplinary Hospital, Poznan, Poland.,Department of the Prevention of Cardiovascular Diseases, Faculty of Health Sciences, Poznan University of Medical Sciences, Poznan, Poland
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Chirurgische Techniken zur Behandlung der Trichterbrust (Pectus excavatum). ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2021. [DOI: 10.1007/s00398-021-00435-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Xie Y, Ning J. Application of Polydioxanone Sutures in the Nuss Procedure. Thorac Cardiovasc Surg 2021; 70:77-82. [PMID: 33601470 PMCID: PMC8828300 DOI: 10.1055/s-0041-1723847] [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] [Indexed: 10/31/2022]
Abstract
BACKGROUND/PURPOSE The Nuss procedure is the most common surgical repair for pectus excavatum (PE). Surgical steel wires are used in some modifications of the Nuss procedure to attach one or both ends of a support bar to the ribs. During follow-up, wire breakage was found in some cases. Patients with wire breakage may undergo prolonged bar removal surgery and may be exposed to excessive radiation.In this study, we had a series of patients who received polydioxanone suture (PDS) fixations instead of steel wires. This retrospective study was conducted to explore the differences between these two fixation materials in the incidence of related complications and efficacies. Furthermore, we attempted to observe whether the two materials lead to similar surgical efficacy in the Nuss procedure, whether they have divergent effects on the bar removal surgery, and whether PDS can reduce the risks due to steel wire breakage as expected. METHODS We retrospectively studied PDS and surgical steel wires as fixation materials for the Nuss procedure in children with congenital PE and reviewed the outcomes and complications. A total of 75 children who had undergone Nuss procedure repairs and bar removals from January 2013 to December 2019 were recruited to participate in this study. They were divided into three groups: the PDS group, the unbroken wire (UBW) group, and the broken wire (BW) group, according to the fixation materials and whether the wires had broken or not. Moreover, we selected the duration of operation (DO), intraoperative blood loss (BL), bar displacement (BD), postoperative pain score (PPS), and incision infection as the risk indicators and the postrepair Haller index (HI) as the effectiveness indicator. These indicators were statistically compared to determine whether there were differences among the three groups. RESULTS One BD occurred in the PDS and BW groups while none took place in the UBW group. No incision infection was found in any of the groups. The PDS group had the shortest DO, while the DO in the UBW group was shorter than that in the BW group (p < 0.05). BL in the PDS group was less than that in the other two groups (p < 0.05). Additionally, no difference was observed in BL between the BW and UBW groups (p > 0.05). The PPS of the PDS group was less than that of the BW group (p < 0.05), whereas no differences were found between the other two groups. No statistical difference emerged in HI among the groups (p > 0.05). CONCLUSION PDS fixation results in a similar repair outcome and shows certain advantages in the DO, BL, and PPS; also, PDSs are safe and effective in the Nuss procedure. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yimin Xie
- Department of Pediatric Surgery, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Jinbo Ning
- Department of Pediatric Surgery, Chongqing University Three Gorges Hospital, Chongqing, China
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Kurkov A, Guller A, Fayzullin A, Fayzullinа N, Plyakin V, Kotova S, Timashev P, Frolova A, Kurtak N, Paukov V, Shekhter A. Amianthoid transformation of costal cartilage matrix in children with pectus excavatum and pectus carinatum. PLoS One 2021; 16:e0245159. [PMID: 33493174 PMCID: PMC7833175 DOI: 10.1371/journal.pone.0245159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 12/22/2020] [Indexed: 11/21/2022] Open
Abstract
Background It is unclear if amianthoid transformation (AT) of costal cartilage extracellular matrix (ECM) has an impact on the development of pectus excavatum (PE) and pectus carinatum (PC). Methods AT foci were examined in intrasurgical biopsy specimens of costal cartilages of children (8–17 years old) with PE (n = 12) and PC (n = 12) and in age-matching autopsy control samples (n = 10) using histological and immunohistochemical staining, atomic force and nonlinear optical microscopy, transmission and scanning electron microscopy, morphometry and statistics. Results AT areas were identified in the costal cartilage ECM in children with normal chest, PE and PC. Each type of the AT areas (“canonical”, “intertwined”, “fine-fibred” and “intralacunary”) had a unique morphological pattern of thickness and alignment of amianthoid fibers (AFs). AFs were formed via lateral aggregation of collagen type II fibrils in the intact ECM. Foci of the AT were observed significantly more frequently in the PE and PC groups. The AT areas had unique quantitative features in each study group. Conclusion AT is a structurally diverse form of ECM alteration present in healthy and pathological costal cartilage. PE and PC are associated with specific AT disorders.
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Affiliation(s)
- Alexandr Kurkov
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- A.I. Strukov Department of Anatomical Pathology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Anna Guller
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- The Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
| | - Alexey Fayzullin
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- World-Class Research Center "Digital Biodesign and Personalized Healthcare", Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- * E-mail:
| | - Nafisa Fayzullinа
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Named After Academician V.I. Kulakov of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Vladimir Plyakin
- Clinical and Research Institute of Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| | - Svetlana Kotova
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Department of Polymers and Composites, N.N. Semenov Institute of Chemical Physics, Moscow, Russia
| | - Petr Timashev
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- World-Class Research Center "Digital Biodesign and Personalized Healthcare", Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Department of Polymers and Composites, N.N. Semenov Institute of Chemical Physics, Moscow, Russia
- Chemistry Department, Lomonosov Moscow State University, Moscow, Russia
| | - Anastasia Frolova
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Nikita Kurtak
- FSBI “Academician V.I. Shumakov Federal Research Center of Transplantology and Artificial Organs”, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Vyacheslav Paukov
- A.I. Strukov Department of Anatomical Pathology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Anatoly Shekhter
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Jawitz OK, Raman V, Thibault D, Yerokun B, Zwischenberger BA, Kosinski AS, Allen MS, Harpole DH. Complications after Ravitch versus Nuss repair of pectus excavatum: A Society of Thoracic Surgeons (STS) General Thoracic Surgery Database analysis. Surgery 2021; 169:1493-1499. [PMID: 33494946 DOI: 10.1016/j.surg.2020.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are conflicting reports in the literature comparing outcomes after open Ravitch and minimally invasive Nuss procedures for pectus excavatum repair, and there is relatively little data available comparing the outcomes of these procedures performed by thoracic surgeons. METHODS The 2010 to 2018 Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients age 12 or greater undergoing open or minimally invasive repair of pectus excavatum. Patients were stratified by operative approach. Multivariable logistic regression was performed with a composite outcome of 30-day complications. RESULTS A total of 1,767 patients met inclusion criteria, including 1,017 and 750 patients who underwent minimally invasive pectus repair and open repair, respectively. Open repair patients were more likely to be American Society of Anesthesiologists (ASA) class III or greater (24% vs 14%; P < .001), have a history of prior cardiothoracic surgery (26% vs 14%; P < .001), and require longer operations (median 268 vs 185 minutes; P < .001). Open repair patients were more likely to require greater than 6 days of hospitalization (18% vs 7%; P < .001), undergo transfusion (7% vs 2%; P < .001), and be readmitted (8% vs 5%; P = .004). After adjustment, open repair was not associated with an increased risk of a composite of postoperative complications (odds ratio 0.99, 95% confidence interval 0.67-1.46). This finding persisted after propensity score matching (odds ratio 1.11, 95% confidence interval 0.74-1.67). CONCLUSION Pectus excavatum repair procedure type was not associated with the risk of postoperative complications after adjustment. Further investigation is necessary to determine the impact of pectus excavatum repair type on recurrence and patient reported outcomes, including satisfaction, quality of life, and pain control.
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Affiliation(s)
- Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Babatunde Yerokun
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Brittany A Zwischenberger
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Mark S Allen
- Department of Thoracic Surgery, Mayo Clinic, Rochester, MN
| | - David H Harpole
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Long-term results after the modified Ravitch procedure performed in children and adolescents - a one-time procedure without the need to use additional support of the sternum. A retrospective study. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 17:173-177. [PMID: 33552179 PMCID: PMC7848616 DOI: 10.5114/kitp.2020.102336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/15/2020] [Indexed: 12/04/2022]
Abstract
Introduction Pectus excavatum is a depression of the sternum. Pectus carinatum, in contrast, is the convexity of the sternum. The mixed form is an intermediate condition. Surgical intervention is the treatment of choice. The techniques most commonly used include the Ravitch and the Nuss procedures. Aim To assess the immediate and long-term results of the original modification of the surgical treatment for anterior chest wall deformation. Material and methods The modification is based on the Ravitch procedure. The difference is that the ends of the resected cartilages are shaped like a blade in order to be inserted into the previously prepared wedge-shaped hollows located on both edges of the sternum. The result is long lasting without the need to use additional brackets. Results The follow-up examinations performed in 72 patients, including 57 boys and 15 girls, were the basis to produce long-term results. As for the type of deformity, out of 57 patients operated on due to pectus excavatum, 43 expressed satisfaction with the very good result. Similar satisfaction was reported in 7 out of 11 patients operated on due to pectus carinatum. There were 4 cases with the mixed form who had very good long-term results. Wound dehiscence was observed in 13 subjects, with one documented recurrence. Conclusions The alternative treatment we propose is a one-time procedure without the need to use additional support of the sternum. Good long-term results make the procedure suitable to be used more frequently in all types of deformities.
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Purrman KC, Ziazadeh D, Loria A, Jones C. Pectus Bar Displacement Causing Right Ventricular Outflow Tract Obstruction. Ann Thorac Surg 2021; 112:e267-e270. [PMID: 33412139 DOI: 10.1016/j.athoracsur.2020.10.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 09/30/2020] [Accepted: 10/03/2020] [Indexed: 10/22/2022]
Abstract
Pectus excavatum is the most common congenital anomaly of the chest wall. Surgical management of this problem has evolved to encompass many modifications of Dr. Ravitch's initial groundbreaking repair to include the insertion of mesh, metal struts and bars to bolster the repair through open and minimally invasive approaches. We present the first reported case of Right Ventricular Outflow Tract obstruction from a dislodged pectus bar following a modified Ravitch procedure. Herein, we describe the presentation, diagnosis, and management of this exceedingly rare complication and provide clinical pearls and inspiration for future research directions based on our unique experience.
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Affiliation(s)
- Kyle C Purrman
- Division of Thoracic and Foregut Surgery, University of Rochester Medical Center, Rochester, New York 14620.
| | - Daniel Ziazadeh
- Division of Thoracic and Foregut Surgery, University of Rochester Medical Center, Rochester, New York 14620
| | - Anthony Loria
- Department of Surgery, University of Rochester Medical Center, Rochester, New York 14620
| | - Carolyn Jones
- Division of Thoracic and Foregut Surgery, University of Rochester Medical Center, Rochester, New York 14620; Department of Surgery, University of Rochester Medical Center, Rochester, New York 14620
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Can plain chest X-ray replace computed tomography for the follow-up of children who have undergone the Nuss procedure? Surg Today 2020; 50:1249-1254. [PMID: 32458233 DOI: 10.1007/s00595-020-02020-8] [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] [Received: 03/25/2019] [Accepted: 03/27/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To establish whether new indices on plain chest X-ray (CXR) can replace those on computed tomography (CT) for the follow-up of children who have undergone the Nuss procedure. METHODS The subjects of this retrospective study were 45 children who underwent the Nuss procedure between 2000 and 2016. The Haller index (HI) was measured by preoperative CT. Preoperative and postoperative chest deformities were evaluated by two CXR measurements: the concave rate on the lateral view (CR; the depth of the concavity divided by the anterior-posterior diameter of the rib cage) and the tracheal bifurcation angle (TBA) on the anterior view. Data are expressed as the median with range. RESULTS The median age and HI of the children, when they underwent the Nuss procedure, was 9.3 (3.8-17.3) years and 4.5 (3.2-10.1), respectively. The preoperative CR was correlated significantly with the HI. The postoperative CR was significantly lower than the preoperative CR [pre: 0.17 (0.08-0.37), post: 0.09 (0.01-0.18), p < 0.05], and the low value was sustained after bar removal. The TBA decreased significantly after the Nuss procedure from 74.2° (55-104) preoperatively to 65.0° (45-92) postoperatively (p < 0.05). CONCLUSIONS These results suggest that CXR can replace CT for the follow-up of patients after the Nuss procedure, with lower radiation exposure.
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Aramini B, Morandi U, De Santis G, Baccarani A. Pectus excavatum correction enhanced by pectoralis muscle transposition: A new approach. Int J Surg Case Rep 2020; 70:106-109. [PMID: 32416478 PMCID: PMC7226633 DOI: 10.1016/j.ijscr.2020.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Indications for the surgical correction of pectus excavatum include functional/physiological, cosmetic, and psychosocial reasons. The most popular open technique for pectus excavatum repair was proposed by Ravitch in 1949 as an open approach that requires partial resection of the costal cartilage, xiphoid excision, and osteotomy of the sternum. The goal is to remove abnormal rib cartilage while preserving the perichondrium, allowing regrowth of the rib cartilage to the sternum in a more anatomic manner. OPERATIVE TECHNIQUE We present a case of bilateral pectoralis muscle flap transposition during a modified Ravitch procedure is presented herein. CONCLUSION This approach allows for a significant reduction in late complications and improves both functional and aesthetic outcomes.
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Affiliation(s)
- Beatrice Aramini
- Division of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Via Largo del Pozzo, 71, 41124, Modena, Italy.
| | - Uliano Morandi
- Division of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Via Largo del Pozzo, 71, 41124, Modena, Italy.
| | - Giorgio De Santis
- Division of Plastic Surgery, University of Modena and Reggio Emilia, Largo Pozzo 71, 41124 Modena, Italy.
| | - Alessio Baccarani
- Division of Plastic Surgery, University of Modena and Reggio Emilia, Largo Pozzo 71, 41124 Modena, Italy.
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von Kodolitsch Y, Demolder A, Girdauskas E, Kaemmerer H, Kornhuber K, Muino Mosquera L, Morris S, Neptune E, Pyeritz R, Rand-Hendriksen S, Rahman A, Riise N, Robert L, Staufenbiel I, Szöcs K, Vanem TT, Linke SJ, Vogler M, Yetman A, De Backer J. Features of Marfan syndrome not listed in the Ghent nosology – the dark side of the disease. Expert Rev Cardiovasc Ther 2020; 17:883-915. [DOI: 10.1080/14779072.2019.1704625] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Yskert von Kodolitsch
- German Aorta Center Hamburg at University Hospital Hamburg Eppendorf University Heart Centre, Clinics for Cardiology and Heart Surgery, VASCERN HTAD European Reference Centre
| | - Anthony Demolder
- Center for Medical Genetics and Department of Cardiology, Ghent University Hospital, VASCERN HTAD European Reference Centre, Ghent, Belgium
| | - Evaldas Girdauskas
- German Aorta Center Hamburg at University Hospital Hamburg Eppendorf University Heart Centre, Clinics for Cardiology and Heart Surgery, VASCERN HTAD European Reference Centre
| | - Harald Kaemmerer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich of the Free State of Bavaria, Munich
| | - Katharina Kornhuber
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich of the Free State of Bavaria, Munich
| | - Laura Muino Mosquera
- Department of Pediatric Cardiology and Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Shaine Morris
- Department of Pediatrics-Cardiology, Texas Children’s Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Enid Neptune
- Division of Pulmonary and Critical Care Medicine and Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Reed Pyeritz
- Departments of Medicine and Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Svend Rand-Hendriksen
- TRS, National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | - Alexander Rahman
- Department of Conservative Dentistry, Periodontology and Preventive Dentistry, Hannover Medical School, Hannover
| | - Nina Riise
- TRS, National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | - Leema Robert
- Department of Clinical Genetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Ingmar Staufenbiel
- Department of Conservative Dentistry, Periodontology and Preventive Dentistry, Hannover Medical School, Hannover
| | - Katalin Szöcs
- German Aorta Center Hamburg at University Hospital Hamburg Eppendorf University Heart Centre, Clinics for Cardiology and Heart Surgery, VASCERN HTAD European Reference Centre
| | - Thy Thy Vanem
- TRS, National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Stephan J. Linke
- Clinic of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Ophthalmological practice at the University Clinic Hamburg-Eppendorf, zentrumsehstärke, Hamburg, Germany
| | - Marina Vogler
- German Marfan Association, Marfan Hilfe Deutschland e.V, Eutin, Germany
| | - Anji Yetman
- Vascular Medicine, Children’s Hospital and Medical Center, Omaha, USA
| | - Julie De Backer
- Center for Medical Genetics and Department of Cardiology, Ghent University Hospital, VASCERN HTAD European Reference Centre, Ghent, Belgium
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Cheng YL, Lee FJ, Lo PC, Wu MY, Hsieh MS. Modified bilateral thoracoscopy-assisted Nuss procedure for repair of pectus excavatum after previous thoracic procedure. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_9_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Aramini B, Morandi U, De Santis G, Brugioni L, Stefani A, Ruggiero C, Baccarani A. Wound complication after modified Ravitch for pectus excavatum: A case of conservative treatment enhanced by pectoralis muscle transposition. Int J Surg Case Rep 2019; 66:322-325. [PMID: 31901741 PMCID: PMC6948225 DOI: 10.1016/j.ijscr.2019.12.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/23/2019] [Accepted: 12/20/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Multiple surgical debridement sessions are mandatory before wound closure in cases of infection after a modified Ravitch procedure for pectus excavatum. Vacuum-assisted closure (VAC) is a well-established technical resource for treating complicated wounds; however, in cases of suspicion of bone infection, this approach is not enough to prevent bar removal. PRESENTATION OF THE CASE We present a case of surgical wound dehiscence with hardware exposure in a patient who had undergone chondrosternoplasty for pectus excavatum. Several sessions of debridement (three) and VAC were applied every time. The final result was achieved without the necessity to remove the hardware; however, to avoid the risk of infection, a bilateral pectoralis muscle flap mobilization was performed as the final step after the surgical wound revisions, although this approach is suggested to be used during the modified Ravitch procedure. This approach allows for a significant reduction in late complications and improves morphological outcomes. DISCUSSION In summary, the pectoralis muscle flap transposition is very useful not only for aesthetical results but also in combination with multiple surgical revisions for conservative management in case of wound infection during a modified Ravitch procedure. In our case, this technique was adopted after accurate care of the wound and before the final closure, which helps to maintain good vascularization and a very satisfying result. CONCLUSION It is important to consider this approach during the modified Ravitch procedure, not only for better aesthetical results but also to prevent infections or wound dehiscence at the level of the bar.
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Affiliation(s)
- Beatrice Aramini
- Division of Thoracic Surgery, Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Via Largo del Pozzo 71- 41124 Modena, Italy.
| | - Uliano Morandi
- Division of Thoracic Surgery, Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Via Largo del Pozzo 71- 41124 Modena, Italy.
| | - Giorgio De Santis
- Division of Plastic Surgery, Department of General Surgery and Surgical Specialties. University of Modena and Reggio Emilia, Via Largo del Pozzo 71, 41124 Modena, Italy.
| | - Lucio Brugioni
- Internal Medicine and Critical Care Unit, Department of Integrated Medicine, Emergency Medicine and Medical Specialties, University of Modena and Reggio Emilia, Via Largo del Pozzo 71, 41124 Modena, Italy.
| | - Alessandro Stefani
- Division of Thoracic Surgery, Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Via Largo del Pozzo 71- 41124 Modena, Italy.
| | - Ciro Ruggiero
- Division of Thoracic Surgery, Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Via Largo del Pozzo 71- 41124 Modena, Italy.
| | - Alessio Baccarani
- Division of Plastic Surgery, Department of General Surgery and Surgical Specialties. University of Modena and Reggio Emilia, Via Largo del Pozzo 71, 41124 Modena, Italy.
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Tomaszek L, Fenikowski D, Gawron D, Komotajtys H. Comparative efficacy of continuous infusion of bupivacaine/fentanyl and ropivacaine/fentanyl for paediatric pain control after the Ravitch procedure and thoracotomy. A prospective randomized study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019; 163:366-373. [DOI: 10.5507/bp.2018.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 11/05/2018] [Indexed: 02/08/2023] Open
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Holmes DM, Polites SF, Roskos PL, Moir CR. Opioid use and length of stay following minimally invasive pectus excavatum repair in 436 patients - Benefits of an enhanced recovery pathway. J Pediatr Surg 2019; 54:1976-1983. [PMID: 30922685 DOI: 10.1016/j.jpedsurg.2019.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/29/2019] [Accepted: 02/03/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE The purpose of this study was to determine outcomes of an enhanced recovery pathway (ERP) for minimally invasive repair of pectus excavatum (MIRPE) at a high volume center, hypothesizing it is associated with decreased opioid requirement and shorter hospital stay. METHODS Patients were categorized into pre-ERP (1998-2006), transition (2007-2011), and ERP (2012-2017) cohorts. Data were abstracted from medical records. Univariate and multivariable analyses compared opioid utilization, length of stay (LOS), and complications between cohorts. Opioids were converted to morphine daily dose per kilogram (MEDD/kg). RESULTS Of 436 patients, 186 were ERP, 104 were transition, and 146 were pre-ERP. ERP was associated with decreased hospital opioid utilization (mean MEDD/kg 0.5 ± 0.2 vs 0.7 ± 0.4 vs 0.7 ± 0.8 p < .001) and shorter median LOS (3 vs 4 vs 5 days, p < .001) despite equivalent pain scores at discharge (2.7 ± 0.1 vs 2.8 ± 0.2 vs 2.9 ± 0.3, p = .73). Most ERP patients (76%) had LOS ≤3 days. Differences in LOS between ERP, transition, and pre-ERP persisted on multivariable analysis after adjusting for confounding factors. Post-operative complications were rare and not different between groups (p > .05). CONCLUSIONS Implementation of our ERP was associated with decreased opioid requirement and shorter hospital stay. ERPs are a valuable tool in pediatric surgery given the current emphasis on optimizing opioid and resource utilization. LEVELS OF EVIDENCE Level III (Retrospective comparative study).
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Affiliation(s)
- David M Holmes
- University of Illinois at Chicago College of Medicine, Chicago, IL.
| | | | - Penny L Roskos
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN
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Pectoralis Muscle Transposition in Association with the Ravitch Procedure in the Management of Severe Pectus Excavatum. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2378. [PMID: 31942373 PMCID: PMC6908393 DOI: 10.1097/gox.0000000000002378] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/14/2019] [Indexed: 11/26/2022]
Abstract
Pectus excavatum (PE) is the most common congenital chest wall deformity. PE is sometimes associated with cardiorespiratory impairment, but is often associated with psychological distress, especially for patients in their teenage years. Surgical repair of pectus deformities has been shown to improve both physical limitations and psychosocial well-being in children. The most common surgical approaches for PE treatment are the modified Ravitch technique and the minimally invasive Nuss technique. A technical modification of the Ravitch procedure, which includes bilateral mobilization and midline transposition of the pectoralis muscle flap, is presented here. Methods From 2010 to 2016, 12 patients were treated by a modified Ravitch procedure with bilateral mobilization and midline transposition of the pectoralis muscle flap for severe PE. Outcomes, morphological results, and complications were analyzed with respect to this new combined surgical approach. Results There was a statistically significant difference between pre- and postoperative values (P = 0.0025) of the Haller index at the 18-month follow-up, showing a significant morphological improvement for all treated patients. After surgery, no morbidity and mortality were noted. The mean hospital stay was 7 days, and all patients were discharged without major complications. Conclusion This technique significantly improved patients' postoperative morphological outcomes and significantly reduced long-term complications, such as wound dehiscence, skin thinning, and hardware exposure.
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Kauffman JD, Benzie AL, Snyder CW, Danielson PD, Chandler NM. Short-term Outcomes After Pectus Excavatum Repair in Adults and Children. J Surg Res 2019; 244:231-240. [PMID: 31301479 DOI: 10.1016/j.jss.2019.06.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/30/2019] [Accepted: 06/14/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pectus excavatum is a common congenital chest wall deformity often repaired during adolescence, although a subset of patients undergo repair as adults. The goal of our study was to determine the effects of age at repair and repair technique on short-term surgical outcomes. MATERIALS AND METHODS We performed a cohort study of patients in the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project pediatric (age<18 y) and adult databases who underwent pectus excavatum repair. The primary outcome was the incidence of 30-d complications. Secondary outcomes included length of stay, reoperation, and readmission. Multivariable logistic regression was used to estimate the independent effects of patient age and type of repair on postoperative outcomes. RESULTS Of the 2268 subjects included, 2089 (92.1%) were younger than 18 y. Overall, 3.4% of patients suffered a 30-d complication, and the risk was similar between age groups (risk ratio [RR], 0.69; 95% confidence interval [CI], 0.08-5.03; P = 0.731). Steroid therapy was an independent risk factor for complications (RR, 8.0; 95% CI, 1.9-19.7; P = 0.006). Median length of stay was 4 d (interquartile range, 3-5) and was similar between age groups. Risk for readmission and reoperation were 2.8% and 1.5%, respectively, and were similar for pediatric and adult patients. When comparing minimally invasive repair with and without thoracoscopy, risk for 30-d complications was lower among patients repaired with thoracoscopy (RR, 0.56; CI, 0.32-0.96; P = 0.034). CONCLUSIONS Pediatric and adult patients experience comparable rates of postoperative complications, readmission, and reoperation after pectus excavatum repair. Use of thoracoscopy during minimally invasive repair is associated with lower risk of complications. These findings suggest that thoracoscopy should be used routinely for minimally invasive repair of pectus excavatum.
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Affiliation(s)
- Jeremy D Kauffman
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Annie Laurie Benzie
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Christopher W Snyder
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Paul D Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.
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Huang YJ, Lin KH, Chen YY, Wu TH, Huang HK, Chang H, Lee SC, Chen JE, Huang TW. Feasibility and Clinical Effectiveness of Three-Dimensional Printed Model-Assisted Nuss Procedure. Ann Thorac Surg 2018; 107:1089-1096. [PMID: 30389445 DOI: 10.1016/j.athoracsur.2018.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 08/03/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The Nuss procedure is a minimally invasive technique for correcting pectus excavatum. We hypothesized that three-dimensional (3D) simulation may shorten operation time and provide better morphologic outcome. This study aimed to demonstrate the feasibility of the 3D model-assisted Nuss procedure and to compare its potential benefits with those of the traditional Nuss procedure. METHODS We simulated the targeted curvature, length, and planned intercostal space of a metallic bar, based on the preoperative chest computed tomographic images. After the use of a 3D printing technique, a plastic template bar was produced and sterilized. The metallic bar was bent and placed at the planned intercostal space accordingly. The patients' characteristics, total number of pectus bar placement, total operation time, and improvement percentage of Haller indices were compared with patients who underwent the traditional Nuss procedure. RESULTS A total of 419 patients underwent the Nuss procedure from January 2010 to July 2017 in our hospital, and 357 patients were eligible and enrolled for the following analysis. Fifteen patients underwent 3D simulation. After performing propensity-score matching analysis, the 3D printing group had a shorter operative time (60.36 versus 74.34 minutes, p < 0.001), fewer metallic bar placements (1.00 versus 1.36 bars, p < 0.001), and better improvement percentages in the Haller indices (20.34% versus 10.06%, p < 0.001) compared with the traditional Nuss procedure. CONCLUSIONS In this preliminary study, 3D-printed model-assisted Nuss procedure may provide benefits of shorter operative time, fewer metallic bar insertions, and comparable morphologic outcome by preoperative simulation.
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Affiliation(s)
- Yi-Jhih Huang
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Kuan-Hsun Lin
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Ying-Yi Chen
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Ti-Hui Wu
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Hsu-Kai Huang
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Hung Chang
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Shih-Chun Lee
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Jia-En Chen
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Tsai-Wang Huang
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China.
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Davari H, Rahim MB, Ershadi R, Rafieian S, Mardani P, Vakili MR, Shirinzadeh A. First Iranian Experience of the Minimally Invasive Nuss Procedure for Pectus Excavatum Repair: A Case Series and Literature Review. IRANIAN JOURNAL OF MEDICAL SCIENCES 2018; 43:554-559. [PMID: 30214110 PMCID: PMC6123557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Pectus excavatum is the most common congenital deformity of the chest wall. The most frequently used techniques include Ravitch (costochondral resection) and Nuss (minimally invasive pectus repair of pectus excavatum [MIRPE]). The Nuss technique includes using temporary metallic bars without costochondral resection to correct the chest wall deformity. Modified MIRPE can be learned easily and performed safely with few complications. There are no reports of successful MIRPE in Iran, although the Ravitch technique is well known. In the present study, we report the first Iranian experience with the modified Nuss procedure in 5 patients with pectus excavatum (age range=13-48 y). All the patients suffered from low self-esteem, and one of them complained of low exercise capacity and occasional chest pain. With single-lung ventilation and sternal elevation, an introducer was entered into the right thoracic cavity and retrosternal tunneling was performed under thoracoscopic vision. The introducer was passed to the left thoracic cavity and exited on the left thoracic wall. A titanium plate bar was implanted and fixed with stabilizers. There were no cases of mortality, and all the patients were discharged in good conditions within 2 weeks. Postoperative complications consisted of 1 case of pneumothorax and 2 cases of fixed bar protrusion. The present case series indicated that a skilled thoracoscopic surgeon is able to do the Nuss procedure in Iranian patients with symmetrical pectus excavatum with few complications. However, mixed or redo cases require more expertise.
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Affiliation(s)
- Hamidreza Davari
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
| | - Mohammad Bagher Rahim
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
| | - Reza Ershadi
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
| | - Shahab Rafieian
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
| | - Parviz Mardani
- General Thoracic Surgeon, General Surgery Ward, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Rahim Vakili
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
| | - Ahmad Shirinzadeh
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
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Song IH, Lee SJ, Kim SS, Lee SY. Surgical Outcomes of Double Compression and Complete Fixation Bar System in Pectus Excavatum. Ann Thorac Surg 2018; 106:1025-1031. [PMID: 29890147 DOI: 10.1016/j.athoracsur.2018.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/26/2018] [Accepted: 05/14/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Minimally invasive repair of pectus excavatum is a widely used technique for correction of pectus excavatum. Yet despite the advancement in the surgical techniques, it is still associated with various complications, including bar displacement leading to reoperation. To overcome this problem, we developed the double compression and complete fixation bar (DCCF) system that consists of 2 metal bars that are inserted above and below the sternum and compressed to correct pectus excavatum. METHODS Patients who underwent pectus excavatum correction surgery at this center between April 2006 and March 2017 were divided into a DCCF system group and a conventional Nuss procedure group and their demographic, clinical, and surgical characteristics were compared. RESULTS A total of 220 patients underwent the DCCF system procedure and 306 patients underwent the conventional Nuss procedure. The DCCF system group had significantly shorter operation time (p < 0.001) and postoperative hospital admission time (p < 0.001) compared with the conventional Nuss procedure group. There were only 2 cases (0.9%) of postoperative complications in the DCCF system group, which was significantly less than that of the conventional Nuss procedure group (n = 64, 20.9%; p < 0.001). In particular, there were no cases of bar displacement in the DCCF system group. CONCLUSIONS The DCCF system was applied to surgical correction of pectus excavatum, which led to significant reduction in the operation time and postoperative hospital admission period, as well as reduced minimally invasive repair of pectus excavatum complication and bar displacement rates. Therefore, we recommend the application of the DCCF system to the surgical correction of pectus excavatum.
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Affiliation(s)
- In-Hag Song
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang, Republic of Korea
| | - Seung Jin Lee
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang, Republic of Korea.
| | - Seung Soo Kim
- Department of Pediatrics, Soonchunhyang University Cheonan Hospital, Soonchunhyang, Republic of Korea
| | - Seock Yeol Lee
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang, Republic of Korea
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Tetteh O, Rhee DS, Boss E, Alaish SM, Garcia AV. Minimally invasive repair of pectus excavatum: Analysis of the NSQIP database and the use of thoracoscopy. J Pediatr Surg 2018; 53:1230-1233. [PMID: 29602550 DOI: 10.1016/j.jpedsurg.2018.02.089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/27/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The minimally invasive repair of pectus excavatum (MIRPE) has been widely accepted and has become a viable alternative to the open Ravitch technique. MIRPE has evolved over time with some advocating that a safe repair can be accomplished without direct visualization utilizing thoracoscopy. The MIRPE with and without a thoracoscopic approach has not been previously analyzed from a nationwide database to determine differences in safety and short-term outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) 2012-2015 database was used in identifying patients that had MIRPE using Current Procedural Terminology (CPT) codes and ICD-9CM/ICD-10CM postoperative diagnosis codes. Outcomes of interest were readmissions, reoperations, complications, cardiothoracic injury, operative time, and duration of hospital stay after surgery for MIRPE with and without thoracoscopy. Descriptive statistics, simple and multivariable logistic regressions, Fisher's exact, and Wilcoxon rank sum test were used to determine any differences in 30-day postoperative outcomes. RESULTS There were 1569 MIRPE cases included. 15.9% (N=249) of MIRPE were done without thoracoscopy. There were no significant differences with the use of thoracoscopy compared to without thoracoscopy in the rate of readmissions (2.5 vs 4.8%; p=0.06), reoperations (1.4 vs 2.0%; p=0.57), postoperative complications (2.6% vs 3.2%; p=0.52), and cardiothoracic injuries (0.2% vs 0.0%; p=1.00). Unadjusted odds ratios (ORs) for readmission and reoperation comparing MIRPE with thoracoscopy to MIRPE without thoracoscopy were 0.51 (p<0.05) and 0.71 (p=0.50), respectively. Adjusted ORs were 0.49 (p=0.04) and 0.71 (p=0.50), respectively. There were no reported deaths, but two cardiothoracic injuries were recorded in the group with thoracoscopy. MIRPE with thoracoscopy was associated with longer operative time (mean 13.0min; p=0.00) and longer hospital stay (mean 0.37days; p<0.01) compared to MIRPE without thoracoscopy. No data were available for the severity of the pectus defect. CONCLUSION MIRPE has a low adverse event rate with no difference in reoperations, postoperative complications, and cardiothoracic injuries with or without the use of thoracoscopy. There may be a higher rate of readmissions in the nonthoracoscopic group. While the technique used remains the surgeon's decision, the use of thoracoscopy may be unnecessary and is at an added cost. TYPE OF STUDY Treatment study (retrospective comparative study). LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Oswald Tetteh
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Daniel S Rhee
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Emily Boss
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Samuel M Alaish
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
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Song IH, Lee SJ, Lee SY. The usefulness of a trans-illuminated introducer during the Nuss procedure. Asian Cardiovasc Thorac Ann 2018; 26:377-381. [PMID: 29719984 DOI: 10.1177/0218492318772226] [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: 11/15/2022]
Abstract
Background There has been an increase in the number of patients undergoing the Nuss procedure for cosmetic purposes, thus increasing the need for safer surgery. However, there are reports of massive hemorrhage and organ damage during the Nuss procedure which involves dissection of the anterior mediastinum. We have developed the trans-illuminated introducer that allows safe surgery while maintaining a small surgical incision of less than 1 cm. Methods This study was a retrospective review of 306 patients aged 3-40 years who underwent the Nuss procedure using the trans-illuminated introducer at our hospital between April 2006 and December 2014. Results There were 29 (9.5%) early postoperative complications. The most common early complication was pneumothorax (15 cases, 4.9%). Five (1.6%) patients developed hemothorax in the early postoperative period, which occurred independently of the dissection process of the anterior mediastinum. None of these patients required reoperation or blood transfusion. There were no complications caused by the introducer during dissection of the anterior mediastinum. Conclusions Using the trans-illuminated introducer, we were able to dissect the anterior mediastinum without a major complication, such as massive hemorrhage from the mediastinum, while maintaining a small surgical incision for cosmetic purposes. Therefore, we consider that the trans-illuminated introducer is useful for improving the outcome of the Nuss procedure.
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Affiliation(s)
- In-Hag Song
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Hospital Cheonan, Seoul, Korea
| | - Seung Jin Lee
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Hospital Cheonan, Seoul, Korea
| | - Seock Yeol Lee
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Hospital Cheonan, Seoul, Korea
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Are Foley catheters needed after minimally invasive repair of pectus excavatum? Surgery 2018; 163:854-856. [PMID: 29397201 DOI: 10.1016/j.surg.2017.10.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 09/20/2017] [Accepted: 10/18/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND High narcotic requirements after minimally invasive repair of pectus excavatum (MIRPE) can increase the risk of urinary retention. Placement of intraoperative Foley catheters to minimize this risk is variable. This study determines the rate of urinary retention in this population to guide future practice. MATERIALS AND METHODS We reviewed retrospectively all patients who underwent MIRPE from January 2012 to July 2016 at 2 academic children's hospitals. Data collected included demographics, BMI, severity of the pectus defect, postoperative pain management, and the incidence of urinary retention and urinary tract infection (UTI). RESULTS Of 360 total patients who underwent MIRPE, 218 had an intraoperative Foley catheter. Patients with epidural pain control were more likely to receive a Foley catheter. The urinary retention rate was 34% for patients without an intraoperative Foley, and 1% in patients after removal of an intraoperatively placed Foley. Urinary retention was greater with an epidural compared with patient-controlled anesthesia (55% vs 26%, P = .002) in the no intraoperative Foley group. No urinary tract infections were identified. Epidural pain control was the only risk factor on multivariate analysis for retention in patients without an intraoperatively Foley catheter. CONCLUSION Intraoperative Foley catheters obviate urinary retention without increasing the risk of urinary tract infection after MIRPE. These results will allow surgeons to better counsel patients regarding Foley placement.
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Ashfaq A, Beamer S, Ewais MM, Lackey J, Jaroszewski D. Revision of Failed Prior Nuss in Adult Patients With Pectus Excavatum. Ann Thorac Surg 2018; 105:371-378. [DOI: 10.1016/j.athoracsur.2017.08.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/28/2017] [Accepted: 08/25/2017] [Indexed: 11/26/2022]
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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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Anesthesia for Nuss Procedures (Pectus Deformity). Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Fraser S, Child A, Hunt I. Pectus updates and special considerations in Marfan syndrome. Pediatr Rep 2017; 9:7277. [PMID: 29383220 PMCID: PMC5768089 DOI: 10.4081/pr.2017.7227] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 10/02/2017] [Accepted: 10/20/2017] [Indexed: 11/23/2022] Open
Abstract
Congenital chest wall or pectus deformities including pectus excavatum (funnel chest) and pectus carinatum (pigeon chest) affect a significant proportion of the general population and up to 70% of patients with Marfan syndrome. Patients often experience significant morbidity and psychological distress, which can worsen with age. Here we discuss new techniques for both operative and non-operative treatment of pectus deformity, the importance of a welltimed intervention and special considerations in patients with Marfan syndrome.
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Mao YZ, Tang S, Li S. Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis. J Pediatr Surg 2017; 52:1545-1552. [PMID: 28606386 DOI: 10.1016/j.jpedsurg.2017.05.028] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/16/2017] [Accepted: 05/29/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE To evaluate surgical outcomes of Nuss versus Ravitch repair of pectus excavatum via a systematic review and meta-analysis. METHODS Medline, PubMed, Cochrane, EMBASE, and Google Scholar databases were searched up to September 5, 2016 using the following search terms: pectus excavatum, funnel chest, Nuss; Ravitch, minimally invasive, and open surgery. Randomized controlled trials, two-arm prospective, and two-arm retrospective studies were eligible for inclusion. RESULTS Nineteen studies were included with a total of 1731 patients: 989 treated with Nuss and 742 treated with Ravitch. The overall analysis revealed that patients in the Nuss group had significantly shorter operation time (pooled SMD=-2.83, 95% CI=-3.76 to -1.90, p<0.001) and less blood loss (pooled SMD=-1.68, 95% CI=-2.28 to -1.09, P<0.001) than the Ravitch group. However, the length of hospital stay was similar between groups (pooled SMD=-0.55, 95% CI=-1.44 to 0.35, p=0.230). These findings were similar in the subgroup analysis for randomized and non-randomized controlled studies. Complications were not assessed due to inconsistent reporting across the included studies. CONCLUSIONS Our meta-analysis demonstrate that the Nuss procedure has a shorter operative time and less operative blood loss than the Ravitch procedure while the postoperative length of stay was similar. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Yong Zhong Mao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China..
| | - ShaoTao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Erratum to ravitch versus Nuss procedure for pectus excavatum: systematic review and meta-analysis. Ann Cardiothorac Surg 2016; 5:593. [PMID: 27942495 DOI: 10.21037/acs.2016.11.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
[This corrects the article DOI: 10.21037/acs.2016.08.06.].
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