The use of intravenous indocyanine green in minimally invasive segmental lung resections: a systematic review

Background

To identify intersegmental planes (ISPs) in video/robot-assisted thoracoscopic segmentectomies, indocyanine green (ICG) is commonly used. The aim of this systematic review is to evaluate the efficacy of intravenous ICG in the identification of ISP.

Methods

A systematic search was performed. Studies evaluating patients who underwent a video/robot-assisted thoracoscopic segmentectomy using intravenous ICG were included. The primary outcome measure was the frequency and percentage of patients in whom the ISP was adequately visualized. Secondary outcomes encompassed the ICG dose, time to visualization, time to maximum ICG visualization, time to disappearance of ICG effect and adverse reactions to ICG.

Results

Eighteen studies were included for systematic review, enrolling a total of 1,090 patients. Irrespective of the injected dose, intravenous ICG identified the ISP in 94% of the cases (range, 30-100%). Overall, there was a considerable amount of heterogeneity regarding the injected dose of ICG (range, 5-25 mg or 0.05-0.5 mg/kg). The mean time before first effect of ICG was visible ranged from 10 to 40 seconds. The mean total time of ICG visibility ranged from 90 to 140 seconds after a bolus injection and was 170 seconds after continuous infusion. No adverse reactions were reported.

Conclusions

After administration of intravenous ICG, visualization of the ISP is successful in up to 94% of cases, even after administration of a low dose (0.05 mg/kg) of ICG. The use of intravenous ICG is safe with no reported adverse effects in the immediate peri-operative period.

Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive Nuss repair of pectus excavatum: a protocol for a randomised clinical trial (ICE trial)

INTRODUCTION

Epidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve block) fail in accomplishing adequate prolonged pain management. Furthermore, the continuous use of opioids, often prescribed in addition to all pain management strategies, comes with side effects. Intercostal nerve cryoablation seems a promising novel technique. Hence, the primary objective of this study is to determine the impact of intercostal nerve cryoablation on postoperative length of hospital stay compared with standard pain management of young pectus excavatum patients treated with the minimally invasive Nuss procedure.

METHODS AND ANALYSIS

This study protocol is designed for a single centre, prospective, unblinded, randomised clinical trial. Intercostal nerve cryoablation will be compared with thoracic epidural analgesia in 50 young pectus excavatum patients (ie, 12-24 years of age) treated with the minimally invasive Nuss procedure. Block randomisation, including stratification based on age (12-16 years and 17-24 years) and sex, with an allocation ratio of 1:1 will be performed.Postoperative length of hospital stay will be recorded as the primary outcome. Secondary outcomes include (1) pain intensity, (2) operative time, (3) opioid usage, (4) complications, including neuropathic pain, (5) creatine kinase activity, (6) intensive care unit admissions, (7) readmissions, (8) postoperative mobility, (9) health-related quality of life, (10) days to return to work/school, (11) number of postoperative outpatient visits and (12) hospital costs.

ETHICS AND DISSEMINATION

This protocol has been approved by the local Medical Ethics Review Committee, METC Zuyderland and Zuyd University of Applied Sciences. Participation in this study will be voluntary and informed consent will be obtained. Regardless of the outcome, the results will be disseminated through a peer-reviewed international medical journal.

TRIAL REGISTRATION NUMBER

NCT05731973.

Pectus excavatum and carinatum: a narrative review of epidemiology, etiopathogenesis, clinical features, and classification

Background and Objective

A wide variety of congenital chest wall deformities that manifest in infants, children and adolescents exists, among which are pectus excavatum and pectus carinatum. Numerous studies have been conducted over the years aiming to better understand these deformities. This report provides a brief overview of what is currently known about the epidemiology, etiopathogenesis, clinical presentation, and classification of these deformities, and highlights the gaps in knowledge.

Methods

A search was conducted for all the above-described domains in the PubMed and Embase databases.

Key Content and Findings

A total of 147 articles were included in this narrative review. Estimation of the true incidence and prevalence of pectus excavatum and carinatum is challenging due to lacking consensus on a definition of both deformities. Nowadays, several theories for the development of pectus excavatum and carinatum have been suggested which focus on intrinsic or extrinsic pathogenic factors, with the leading hypothesis focusing on overgrowth or growth disturbance of costal cartilages. Furthermore, genetic predisposition to the deformities is likely to exist. Pectus excavatum is frequently associated with cardiopulmonary symptoms, while pectus carinatum patients mostly present with cosmetic complaints. Both deformities are classified based on the shape or severity of the deformity. However, each classification system has its limitations.

Conclusions

Substantial progress has been made in the past few decades in understanding the development and symptomatology of pectus excavatum and carinatum. Current hypotheses on the etiology of the deformities should be confirmed by biomedical and genetic studies. For clinical purposes, the establishment of a clear definition and classification system for both deformities based on objective morphologic features is eagerly anticipated.

Advancements in preoperative imaging of pectus excavatum: a comprehensive review

Pectus excavatum, the most common pectus deformity, varies in severity and has been associated with cardiopulmonary impairment and psychological distress. Since its initial documentation, a multitude of imaging techniques for preoperative evaluation (i.e., diagnosis, severity classification, functional assessment, and surgical planning) have been reported. Conventional imaging techniques encompass computed tomography (CT), chest radiography, magnetic resonance imaging (MRI), echocardiography and medical photography, while three dimensional (3D) optical surface imaging is a promising emerging technique in the preoperative assessment of pectus excavatum. This narrative review explores the current insights and advancements of these imaging modalities. CT imaging allows for the calculation of pectus indices and evaluation of cardiac compression and displacement. Recent developments focus on automated calculations, minimizing radiation exposure and improving surgical planning. Chest radiography offers a radiation-reducing alternative for pectus index measurement, but is unsuitable for disproportionally asymmetric chest deformations. MRI is a radiation-free imaging method, and allows for the calculation of pectus indices as well as the assessment of cardiac function. Real-time MRI provides dynamic insights, while exercise MRI shows promise for comprehensive evaluation of cardiac function but requires additional developments. Using echocardiography, structural cardiac changes can be identified, but its use in evaluating cardiac function in pectus excavatum patients is limited. Medical photography combined with caliper measurements complements other imaging methods for qualitative and quantitative documentation of pectus excavatum. Emerging as an innovative technique, 3D optical surface imaging offers a rapid, radiation-free assessment of the deformity which correlates with conventional pectus indices. Potential applications include quantifying other morphological features and predicting cardiac compression. However, standardization and validation are needed for its widespread use. This review provides an overview of preoperative imaging of pectus excavatum, highlighting the current developments in conventional methods and the potential of the emerging 3D optical surface imaging technique. These advancements hold promise for the future of the assessment and surgical planning of pectus excavatum.

Chest wall reconstruction after the Clagett procedure and other types of open-window thoracostomy: a narrative review

Background and Objective

The Clagett procedure is one of the last treatment options for chronic stage pleural empyema. It involves the formation of an open-window in the thoracic wall to allow for continuous drainage and irrigation of the pleural cavity. Once the empyema has been resolved, reconstruction of the chest wall is sometimes challenging. This review aims to identify and summarize the options for reconstructing soft tissue defects of the chest wall following the Clagett procedure and other types of open-window thoracostomy.

Methods

A narrative review was performed of the literature on PubMed, Cochrane Library, ClinicalTrials.gov, and Google Scholar, including all relevant studies published until January 2023.

Key Content and Findings

This review contains an overview of the reconstruction methods and the outcomes of the included studies on reconstructive options after the Clagett procedure and other types of open-window thoracostomy. A subdivision was made based on reconstruction type: pedicled flaps, free flaps, and the use of a vacuum-assisted closure (VAC) device. The advantages of pedicled flaps are reliable vascularization, better tissue match, reduced scarring, and shorter operation time compared to free flaps. However, when pedicled flaps are not available due to damage during previous surgeries or offer insufficient volume to obliterate the cavity, free flaps might be a solution.

Conclusions

In cases where an open-window thoracostomy necessitates chest wall reconstruction, a pedicled flap is the preferred choice, followed by free flaps. Additionally, vacuum-assisted negative pressure wound therapy (VANPWT) techniques have shown potentially promising results (as an adjunct to surgical treatment).

Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia

OBJECTIVES

In patients undergoing video-assisted thoracoscopic surgery for pneumothorax, the benefits and risks of single-shot intercostal nerve block as loco-regional analgesia are not well known. We retrospectively compared the effectiveness of intercostal nerve blocks as a viable alternative to thoracic epidural analgesia (TEA) regarding pain control and enhanced recovery.

METHODS

A retrospective multicentre analysis with single-centre propensity score matching was performed in patients undergoing video-assisted thoracoscopic surgery for pneumothorax receiving either TEA or intercostal nerve block. The primary outcome was a proportion of pain scores ≥4 (scale 0-10) until postoperative day (POD) 3. Secondary outcomes included variation in pain over time, additional opioid use, length of stay, mobility, complications and recurrence rate.

RESULTS

In 218 patients, TEA was compared to intercostal nerve block and showed no difference in the proportion of pain scores ≥4 {14.3% [interquartile range (IQR) 0.0-33.3] vs 11.1% (IQR 0.0-27.3) respectively, P = 0.24}, more frequently needed additional opioids on the day of surgery (18% vs 48%) and first POD (20% vs 42%), had a shorter length of stay (4.0 days [IQR 3.0-7.0] vs 3.0 days [IQR 2.8-4.0]) and were significantly more mobile until POD 3, while having similar recurrences. Intercostal nerve block had higher pain scores early in the course whereas TEA had higher late (rebound) pain scores.

CONCLUSIONS

In a multimodal analgesic setting with additional opioids, intercostal nerve block shows comparable moments of unacceptable pain from POD 0-3 compared to TEA and is linked to improved mobility. Results require randomized confirmation.

Delayed presentation of manubriosternal dislocation after thoracolumbar spondylodesis in a polytrauma patient - a case report

BACKGROUND

Manubriosternal dislocations are a rare entity and frequently associated with thoracic spine fractures and, in minority of cases, with cervical or thoracolumbar fractures.

METHODS

Our case represents a 38-year-old male who fell from a height resulting in multiple fractures, amongst others of the first lumbar vertebra. At primary survey and computed tomography scan no manubriosternal injury was apparent. After posterior stabilization of the thoracolumbar vertebrae a manubriosternal dislocation was identified and stabilized using plate-and-screw fixation.

RESULTS

Clinical findings of a manubriosternal dislocation are not always obvious, allowing them to be missed at initial assessment.

CONCLUSIONS

Manubriosternal dislocations can be missed at the initial investigation, even on cross-sectional imaging, and only become visible after spine stabilization because of the tight relationship between sternum and vertebrae in the thoracic cage. There is no unanimity in literature for surgical treatment of manubriosternal dislocations, although plate fixation is generally considered a safe and effective treatment option.

The relationship between plate prominence and need for removal after volar plate osteosynthesis of distal radius fractures

PURPOSE

This study aimed to assess the incidence of plate-related complications and the need for plate removal after volar plate osteosynthesis of the distal radius in relation to Soong classification.

METHODS

All consecutive patients (age > 16 years) in our level II trauma center treated with plate osteosynthesis for distal radius fractures from January 2017 until June 2019 were retrospectively evaluated. The main outcome measures were volar plate positioning according to Soong classification and incidence of plate removal. In addition, the incidence of tendon ruptures, reasons for volar plate removal, and improvement of complaints after removal were evaluated.

RESULTS

The overall incidence of plate removal in the 336 included patients was 16.9% (n = 57). Removal incidence in Soong 2 plates (28.2%) was significantly higher compared to Soong 0 and 1 plates (8.0% and 14.4%, respectively), P = 0.003. Multivariable binary logistic regression analysis showed Soong grade 2 as an independent predictor for plate removal, OR 4.3 (95% CI 1.4-13.7, P = 0.013). Four cases of flexor and four cases of extensor tendon rupture were reported, all in Soong 2 grade plating. The main reasons for volar plate removal were pain (42%) and reduced functionality (12%). In cases where pain was the main reason for removal, 81% of patients reported a decrease in pain during follow-up after surgery.

CONCLUSIONS

This study suggests an association between plate prominence graded by Soong and plate removal using a single plating system. Plate prominence should be reduced in volar plating whenever technically feasible.

Uniportal video-assisted thoracoscopic surgery for lobectomy: the learning curve

OBJECTIVES

Prior reported learning curves for uniportal video-assisted thoracoscopic lobectomy were predominantly based on surgery duration, while reports on complications are limited. Therefore, our study assessed the learning curve based on both technique-related complications and surgery duration.

METHODS

We retrospectively collected data from patients who had undergone uniportal video-assisted thoracoscopic lobectomy between 2015 and 2020. Exclusion criteria were concomitant procedures other than ipsilateral wedge resection, discontinued procedures, or lost to follow-up (less than 30 days). Learning curves were constructed per surgeon who performed over 20 procedures using non-risk adjusted cumulative sum (CUSUM) analysis for technique-related complications and cumulative sum analysis for surgery duration. Based on the literature, an acceptable complication rate was set at 30%, an unacceptable complication rate at 45%, and a mean surgery duration of 145 min.

RESULTS

Learning curves were constructed for three thoracic surgeons and one fellow who performed 324 uniportal video-assisted thoracoscopic lobectomies in total. Each surgeon was experienced in multiportal video-assisted thoracoscopic lobectomy, the fellow was familiar with basic multiportal video-assisted thoracoscopic procedures. Cumulative sum charts of three surgeons reached a statistically significant technique-related complication rate below 30% between 50 and 96 procedures. Regarding surgery duration, typical learning curves were observed for three surgeons with a transition point between 14 and 26 procedures.

CONCLUSIONS

Learning of uniportal video-assisted thoracoscopic surgery for lobectomy is safe without unacceptable complication rates and has a declining surgery duration over time for thoracic surgeons with experience in multiportal video-assisted thoracoscopic lobectomies. However, it remains unknown when the different stages of mastery are completed.

Modification of the Abramson procedure for minimally invasive repair of pectus carinatum: introduction of a pectus carinatum compression system

Pectus carinatum is characterized by a protruding sternum. This deformity can be surgically corrected through the minimally invasive Abramson technique. In this procedure, a presternal metal correctional bar, secured to rib-attached stabilizers, is implanted to redress the sternum to a neutral position. To anticipate the intended position of the sternum, manual compression is applied over the sternal deformity. We describe a modified version of the Abramson procedure, encompassing a table-mounted PectusAssist™ System which generates a constant mechanical compression over the protruding sternum. The PectusAssist™ System, most importantly, eliminates the necessity of manually applying repetitive pressure on the deformity, and therefore maintains a more stable sternal position. This will ensure accuracy of the template used to bend the bar into its desired configuration. The modification we propose also simplifies presternal tunnel creation as the two bilateral retromuscular tunnels, that need to be connected presternally, are potentially better aligned due to a more stable and reduced position of the sternum. The PectusAssist™ System makes the procedure less labor intensive and reduces variability without interfering with the safety of the procedure. Therefore, we advise standard use of the PectusAssist™ System during minimally invasive repair of pectus carinatum by the Abramson procedure.

Pectus Excavatum: Consensus and Controversies in Clinical Practice

BACKGROUND

Pectus excavatum is the most common congenital anterior chest wall deformity. Currently, a wide variety of diagnostic protocols and criteria for corrective surgery are being used. Their use is predominantly based on local preferences and experience. To date, no guideline is available, introducing heterogeneity of care as observed in current daily practice. The aim of this study was to evaluate consensus and controversies regarding the diagnostic protocol, indications for surgical correction, and postoperative evaluation of pectus excavatum.

METHODS

The study consisted of 3 consecutive survey rounds evaluating agreement on different statements regarding pectus excavatum care. Consensus was achieved if at least 70% of participants provided a concurring opinion.

RESULTS

All 3 rounds were completed by 57 participants (18% response rate). Consensus was achieved on 18 of 62 statements (29%). Regarding the diagnostic protocol, participants agreed to routinely include conventional photography. In the presence of cardiac impairment, electrocardiography and echocardiography were indicated. Upon suspicion of pulmonary impairment, spirometry was recommended. In addition, consensus was reached on the indications for corrective surgery, including symptomatic pectus excavatum and progression. Participants moreover agreed that a plain chest radiograph must be acquired directly after surgery, whereas conventional photography and physical examination should both be part of routine postoperative follow-up.

CONCLUSIONS

Through a multiround survey, international consensus was formed on multiple topics to aid standardization of pectus excavatum care.

Risk assessment for postoperative venous thromboembolism using the modified Caprini risk assessment model in lung cancer

Background

Postoperative venous thromboembolism (VTE) is a well-documented cause of morbidity and mortality in lung cancer patients. However, risk identification remains limited. In this study, we sought to analyze the risk factors for VTE and verify the predictive value of the modified Caprini risk assessment model (RAM).

Methods

This prospective single-center study included patients with resectable lung cancer who underwent resection between October 2019 and March 2021. The incidence of VTE was estimated. Logistic regression was used to analyze the risk factors for VTE. Receiver operating characteristic (ROC) curve analysis was performed to test the ability of the modified Caprini RAM to predict VTE.

Results

The VTE incidence was 10.5%. Several variables, including age, D-dimer, hemoglobin (Hb), bleeding, and patient confinement to bed were significantly associated with VTE after surgery. The difference between the VTE and non-VTE groups in the high-risk levels was statistically significant (P<0.001), while the low and moderate risk levels showed no significant difference. The combined use of the modified Caprini score and the Hb and D-dimer levels showed an area under the curve (AUC) was 0.822 [95% confidence interval (CI): 0.760-0.855. P<0.001].

Conclusions

The risk-stratification approach of the modified Caprini RAM is not particularly valid after lung resection in our population. The use of the modified Caprini RAM combined with Hb and D-dimer levels shows a good diagnostic performance for VTE prediction in patients with lung cancer undergoing resection.

Development and validation of a pulmonary complications prediction model based on the Yang's index

Background

Blunt chest trauma patients with pulmonary contusion are susceptible to pulmonary complications, and severe cases may develop respiratory failure. Some studies have suggested the extent of pulmonary contusion to be the main predictor of pulmonary complications. However, no simple and effective method to assess the severity of pulmonary contusion has been available yet. A reliable prognostic prediction model would facilitate the identification of high-risk patients, so that early intervention can be given to reduce pulmonary complications; however, no suitable model based on such an assumption has been available yet.

Methods

In this study, a new method for assessing lung contusion by the product of the three dimensions of the lung window on the computed tomography (CT) image was proposed. We conducted a retrospective study on patients with both thoracic trauma and pulmonary contusion admitted to 8 trauma centers in China from January 2014 to June 2020. Using patients from 2 centers with a large number of patients as the training set and patients from the other 6 centers as the validation set, a prediction model for pulmonary complications was established with Yang's index and rib fractures, etc., being the predictors. The pulmonary complications included pulmonary infection and respiratory failure.

Results

This study included 515 patients, among whom 188 developed pulmonary complications, including 92 with respiratory failure. Risk factors contributing to pulmonary complications were identified, and a scoring system and prediction model were constructed. Using the training set, models for adverse outcomes and severe adverse outcomes were developed, and area under the curve (AUC) of 0.852 and 0.788 were achieved in the validation set. In the model performance for predicting pulmonary complications, the positive predictive value of the model is 0.938, the sensitivity of the model is 0.563 and the specificity of the model is 0.958.

Conclusions

The generated indicator, called Yang's index, was proven to be an easy-to-use method for the evaluation of pulmonary contusion severity. The prediction model based on Yang's index could facilitate early identification of patients at risk of pulmonary complications, yet the effectiveness of the model remains to be validated and its performance remains to be improved in further studies with larger sample sizes.

A No-Chest-Drain Policy After Video-assisted Thoracoscopic Surgery Wedge Resection in Selected Patients: Our 12-Year Experience

BACKGROUND

Postoperative pleural drainage omission after video-assisted thoracoscopic surgery (VATS) for wedge resections may facilitate faster recovery. This retrospective cohort study presents our 12-year experience with omitting thoracic drainage in patients who underwent a VATS wedge resection, aiming to assess its safety and efficacy.

METHODS

Records from consecutive patients who underwent a VATS wedge resection at our hospital between February 2008 and October 2020 were retrospectively reviewed and assessed for eligibility. Patient and surgical characteristics as well as postoperative data were collected and compared between patients who received a chest drain (CD) or received no chest drain (NCD) after surgery. Univariable and multivariable analyses were performed to determine whether drain placement was associated with complications (primary outcome), and major complications requiring pleural drainage or length of hospital stay (secondary outcomes).

RESULTS

Data of 348 patients were analyzed. The drainless group (n = 98) and drain group (n = 237) were significantly different in the following baseline and surgical characteristics: sex, pulmonary function, interstitial lung disease, final pathology, number of wedges, and surgical approach. No significant differences were detected in postoperative complications (NCD 8.2%, CD 14.8%; P = .10), major complications (NCD 5.1%, CD 5.1%; P > .99), or complications requiring pleural drainage (NCD 5.1%, CD 3.8%; P = .56). The drainless group did show a significantly shorter hospitalization (NCD 2 ± 2, CD 3 ± 2 days; P < .001). Multivariable analyses revealed that drain placement was not significantly correlated with postoperative complications. In contrast, prolonged hospitalization was significantly influenced by drain placement.

CONCLUSIONS

Our findings suggest that a no-chest-drain policy after VATS wedge resections can safely fast-track rehabilitation for selected patients.

Development of Prediction Models for Cardiac Compression in Pectus Excavatum Based on Three-Dimensional Surface Images

In pectus excavatum, three-dimensional (3D) surface imaging provides an accurate and radiation-free alternative to computed tomography (CT) to determine severity. Yet, it does not allow for cardiac evaluation since 3D imaging solely captures the chest wall surface. The objective was to develop a 3D image-based prediction model for cardiac compression in patients evaluated for pectus excavatum. A prospective cohort study was conducted including consecutive patients referred for pectus excavatum who received a thoracic CT. Additionally, 3D images were acquired. The external pectus depth, its length, craniocaudal position, cranial slope, asymmetry, anteroposterior distance and chest width were calculated from 3D images. Together with baseline patient characteristics they were submitted to forward multivariable logistic regression to identify predictors for cardiac compression. Cardiac compression on CT was used as reference. The model's performance was depicted by the area under the receiver operating characteristic (AUROC) curve. Internal validation was performed using bootstrapping. Sixty-one patients were included of whom 41 had cardiac compression on CT. A combination of the 3D image derived external pectus depth and external anteroposterior distance was identified as predictive for cardiac compression, yielding an AUROC of 0.935 (95% confidence interval [CI]: 0.878-0.992) with an optimism of 0.006. In a second model for males alone, solely the external pectus depth was identified as predictor, yielding an AUROC of 0.947 (95% CI: 0.892-1.000) with an optimism of 0.0002. We have developed two 3D image-based prediction models for cardiac compression in patients evaluated for pectus excavatum which provide an outstanding discriminatory performance between the presence and absence of cardiac compression with negligible optimism.

First clinical results of 1-year follow-up of the femoral neck system for internal fixation of femoral neck fractures

BACKGROUND

Closed reduction and internal fixation (CRIF) is the preferred treatment to retain the native joint and maintain optimal functionality in femoral neck fractures. Sliding hip screw (SHS) and cannulated hip screws (CHS) are established CRIF options. SHS offer high biomechanical stability, whereas CHS are minimally invasive. These established systems have a 17-21% failure rate. The Femoral neck system (FNS) was recently developed to combine the advantages of both predecessors. The aim of this study was to describe the first clinical experience with this novel implant with special emphasis on the safety and efficacy.

METHODS

During a 1-year period all patients in our level-2 trauma centre with a FNF indicated for CRIF were treated using the FNS and evaluated at 2, 6, 12 weeks, 6 months and 1 year postoperatively using patient and fracture characteristics, surgical notes and radiographic imaging.

RESULTS

Thirty-four patients were included, mean age was 63 years (SD 8), 58.2% was female. Fractures were classified as Pauwels I (n = 10), Pauwels II (n = 15), Pauwels III (n = 9), Garden I (n = 1), Garden II (n = 17), Garden III (n = 12) and Garden IV (n = 4). Eight reoperations were reported after 1-year follow-up; osteosyntheses failed in 6 patients due to avascular necrosis (n = 4) and cut-out (n = 2). In two patients the implant was removed due to inexplicable pain. Age (< 65 years) was related to lower risk for failure. There was a trend for females having more failures.

CONCLUSION

This study indicates that the FNS is a potential safe and effective CRIF modality. Age (< 65 years) is an important factor to keep in mind when selecting patients for CRIF as it is related to lower risk for failure. Future long-term follow-up studies with larger populations should indicate if functional results and risk factors for failure are comparable to SHS or CHS.

Minimally invasive repair of pectus carinatum by the Abramson method: A systematic review

BACKGROUND

The aim of this review is to provide an overview of the outcomes after minimally invasive pectus cartinatum repair (MIRPC) by the Abramson method to determine its effectiveness.

METHODS

The PubMed and Embase databases were systematically searched. Data concerning subjective postoperative esthetic outcomes after initial surgery and bar removal were extracted. In addition, data on recurrence, complications, operative times, blood loss, post-operative pain, length of hospital stay, planned time to bar removal and reasons for early bar removal were extracted. The postoperative esthetic result, was selected as primary outcome since the primary indication for repair in pectus carinatum is of cosmetic nature.

RESULTS

Six cohort studies were included based on eligibility criteria, enrolling a total of 396 patients. Qualitative synthesis showed excellent to satisfactory esthetic results in nearly all patients after correctional bar placement (99.5%, n = 183/184). A high satisfaction rate of 91.0% (n = 190/209) was found in patients after bar removal. Recurrence rates were low with an incidence of 3.0% (n = 5/168). The cumulative postoperative complication rate was 26.5% (n = 105/396), of whom 25% required surgical re-intervention. There were no cases of mortality.

CONCLUSIONS

Minimally invasive repair of pectus carinatum through the Abramson method is effective and safe. Its efficacy is demonstrated by the excellent to satisfactory esthetic results in 99.5% and 91.0% of patients after respectively correctional bar placement and implant removal. Future studies should aim to compare different treatment options for pectus carinatum in order to elucidate the approach of choice for different patient groups.

Nuss bar removal without straightening is a safe technique: a single center experience

Background

A Nuss bar often placed to correct pectus excavatum is usually removed after a period of 2 to 3 years. Bar removal can result in potentially life-threatening complications. To minimize this risk, a recent systematic review recommends in-situ straightening of the bar before removal. Alternatively, the bar can be removed without straightening by extraction along the thoracic curvature. This study reports our single-center experience with this latter technique for bar removal, with focus on perioperative complications.

Methods

A single-center retrospective observational cohort study was conducted. Consecutive patients undergoing Nuss bar removal between 2011 and 2020 were eligible for inclusion. The primary outcome was the incidence of perioperative complications. Secondary outcomes included duration of operation, blood loss, and length of postoperative hospital stay.

Results

A total of 331 patients were included. Of these, 288 (87%) were male with a median age of 20 years [interquartile range (IQR), 19–26 years]. Perioperative complications occurred in a total of 4 patients (1%) following Nuss bar removal. Two patients (0.6%) experienced major complications (deep incisional surgical site infection and hemothorax respectively); there was no mortality. The median duration of surgery was 30 minutes (IQR, 20–40 minutes). Patients were discharged after a median postoperative stay of 1 day (IQR, 1–1 day).

Conclusions

Nuss bar removal without prior in-situ bar straightening appears to be a safe and effective technique. It is associated with a low complication rate of 1%.

Translation, cultural adaptation and linguistic validation of the pectus excavatum evaluation questionnaire

Background

Pectus excavatum often imposes significant burden on the patients’ quality of life. However, despite the known biopsychosocial effects, the deformity remains underappreciated. Patient reported outcome measures can be used to measure and appreciate results from a patient’s perspective. The pectus excavatum evaluation questionnaire (PEEQ) is the most employed disease specific instrument to measure patient-reported outcome measures (PROMs). A translation and linguistic validation of this questionnaire is presented for its use in the Dutch pediatric pectus excavatum population. By providing an insight in our translation process, we want to encourage other researchers to perform translations to other languages to make the questionnaire available to clinicians and researchers worldwide.

Methods

The 22-item PEEQ was translated and adapted according to the leading guidelines for the translation of patient reported outcome measures. Conceptual equivalence and cultural adaptation were emphasized.

Results

One forward translation was produced through reconciliation of two forward translations. Back translation resulted in 15 identical items, as well as 6 literal, and 1 conceptual discrepancy. The latter was expected as during the forward translation a more culturally appropriate translation was chosen. Ten patients were involved during the cognitive debriefing process, following which one item was revised and the final Dutch version was established.

Conclusions

We provide a culturally appropriate and linguistically validated Dutch version of the PEEQ.

Predicting Aesthetic Outcome of the Nuss Procedure in Patients with Pectus Excavatum

Patients suffering from pectus excavatum often experience psychosocial distress due to perceived anomalies in their physical appearance. The ability to visually inform patients about their expected aesthetic outcome after surgical correction is still lacking. This study aims to develop an automatic, patient-specific model to predict aesthetic outcome after the Nuss procedure. Patients prospectively received preoperative and postoperative 3-dimensional optical surface scanning of their chest during the Nuss procedure. A prediction model was composed based on nonlinear least squares data-fitting, regression methods and a 2-dimensional Gaussian function with adjustable amplitude, variance, rotation, skewness, and kurtosis components. Morphological features of pectus excavatum were extracted from preoperative images using a previously developed surface analysis tool to generate a patient-specific model. Prediction accuracy was evaluated through cross-validation, utilizing the mean root squared deviation and maximum positive and negative deviations as performance measures. The prediction model was evaluated on 30 (90% male) prospectively imaged patients. The model achieved an average root mean squared deviation of 6.3 ± 2.0 mm, with average maximum positive and negative deviations of 12.7 ± 6.1 and -10.2 ± 5.7 mm, respectively, between the predicted and actual postoperative aesthetic result. Our developed 2-dimensional Gaussian model based on 3-dimensional optical surface images is a clinically promising tool to predict postsurgical aesthetic outcome in patients with pectus excavatum. Prediction of the aesthetic outcome after the Nuss procedure potentially improves information provision and expectation management among patients. Further research should assess whether increasing the sample size may reduce deviations and improve performance.

VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases

OBJECTIVES

Early surgical stabilization of flail chest has been shown to improve chest wall stability and diminish respiratory complications. The addition of video‑assisted thoracoscopic surgery (VATS) can diagnose and manage intrathoracic injuries and evacuate hemothorax. This study analyzed the outcome of our 7-year experience with VATS-assisted surgical stabilization of rib fractures (SSRF) for flail chest.

METHODS

From January 2013 to December 2019, all trauma patients undergoing VATS-assisted SSRF for flail chest were included. Patient characteristics and complications during 1-year follow-up were reported.

RESULTS

VATS‑assisted SSRF for flail chest was performed in 105 patients. Median age was 65 years (range 21-92). Median injury severity score was 16 (range 9-49). Hemothorax was evacuated with VATS in 80 patients (median volume 200 ml, range 25-2500). In 3 patients entrapped lung was freed from the fracture site and in 2 patients a diaphragm rupture was repaired. Median postoperative ICU admission was 2 days (range 1-41). Thirty-two patients (30%) had a post‑operative complication during admission and six patients (6%) a complication within 1 year. In-hospital mortality rate was 1%. Six patients (6%) died after discharge, due to causes unrelated to the original injury.

CONCLUSIONS

Addition of VATS to SSRF for flail chest seems helpful to diagnose and manage intrathoracic injuries and adequately evacuate hemothorax. The majority of complications are low grade and occur during admission. Further prospective research needs to be conducted to identify potential risk factors for complications and better selection for addition of VATS to improve care in the future.

Partitioning the lung field based on the depth ratio in three-dimensional space

Background

To explore the feasibility of the depth ratio method partitioning the lung parenchyma and the depth distribution of lung nodules in pulmonary segmentectomy.

Methods

Based on the measurement units, patients were allocated to the chest group, the lobar group, and the symmetrical 3 sectors group. In each unit, the center of the respective bronchial cross-section was set as the starting point (O). Connecting the O point with the center of the lesion (A) and extending to the endpoint (B) on the pleural, the radial line (OB) was trisected to divide the outer, middle, and inner regions. The depth ratio and relevant regional distribution were simultaneously verified using 2-dimensional (2D) coronal, sagittal, and axial computed tomography images and 3-dimensional (3D) reconstruction images.

Results

Two hundred and nine patients were included in this study. The median age was 53 (IQR, 44.5–62) years and 64 were males. The intra-group consistency of the depth ratio region partition was 100%. The consistency of the inter-group region partition differed among the three groups (Kappa values 0.511, 0.517, and 0.923). The chest group, lobar group, and symmetrical 3 sectors group had 69.4%, 26.3%, and 4.8% mediastinum disturbance, respectively (P<0.001).

Conclusions

The depth ratio method in the symmetrical 3 sectors of the lung maximally eliminated the disturbance of the mediastinal structures and more accurately trisected the lung parenchymal in 3D space. Sublobar resection based on subsegments strategy is feasible for outer 2/3 pulmonary nodules when depth ratio is used as the measurement method.

Risk of Pneumothorax Requiring Pleural Drainage after Drainless VATS Pulmonary Wedge Resection: A Systematic Review and Meta-Analysis

OBJECTIVE

Omitting pleural drainage after video-assisted thoracic surgery (VATS) for pulmonary wedge resections has been shown to be a safe approach to enhance recovery. However, major concerns remain regarding the risk of postoperative pneumothoraces requiring surgical interventions. Therefore, our objective was to provide conclusive evidence whether chest tube omission after VATS wedge resection is safe and does not increase the risk of pneumothoraces requiring pleural drainage.

METHODS

Five scientific databases were searched. Studies comparing patients with (CT group) and without chest tube drainage (NCT group) after VATS wedge resection were evaluated. Outcomes included radiographically diagnosed pneumothoraces and pneumothoraces requiring pleural drainage, postoperative complications, hospitalization, and pain scores.

RESULTS

Overall, 9 studies (3 randomized controlled trials) were included (N = 928). Meta-analysis showed significantly more radiographically diagnosed pneumothoraces in the NCT group (risk ratio [RR] = 2.58, 95% confidence interval [CI]: 1.56 to 4.29, P < 0.001; I² = 0%). However, no significant differences were found in postoperative pneumothoraces requiring pleural drainage (RR = 1.72, 95% CI: 0.63 to 4.74, P = 0.29; I² = 0%) or complications (RR = 0.77, 95% CI: 0.39 to 1.52, P = 0.46; I² = 0%). Furthermore, the NCT group showed significantly shorter hospitalization (mean difference = -1.26, 95% CI: -1.56 to -0.95, P < 0.001) with high heterogeneity (I² = 58%, P = 0.02), and lower pain scores on postoperative day 1 (standard mean difference [SMD] = -0.98, 95% CI: -1.71 to -0.25, P = 0.009; I² = 92%) and postoperative day 2 (SMD = -1.28, 95% CI: -2.55 to -0.01, P = 0.05; I² = 96%) compared with the CT group.

CONCLUSIONS

VATS wedge resection without routine chest tube placement is suggested as a safe and less invasive approach in selected patients that does not increase the risk of a pneumothorax requiring pleural drainage.

Visual diagnosis of pectus excavatum: An inter-observer and intra-observer agreement analysis

BACKGROUND/PURPOSE

Among patients suspected of pectus excavatum, visual examination is a key aspect of diagnosis and, moreover, guides work-up and treatment strategy. This study evaluated the inter-observer and intra-observer agreement of visual examination and diagnosis of pectus excavatum among experts.

METHODS

Three-dimensional surface images of consecutive patients suspected of pectus excavatum were reviewed in a multi-center setting. Interactive three-dimensional images were evaluated for the presence of pectus excavatum, asymmetry, flaring, depth of deformity, cranial onset, overall severity and morphological subtype through a questionnaire. Observers were blinded to all clinical patient information, completing the questionnaire twice per subject. Agreement was analyzed by kappa statistics.

RESULTS

Fifty-eight subjects with a median age of 15.5 years (interquartile range: 14.1-18.2) were evaluated by 5 (cardio)thoracic surgeons. Pectus excavatum was visually diagnosed in 55% to 95% of cases by different surgeons, revealing considerable inter-observer differences (kappa: 0.50; 95%-confidence interval [CI]: 0.41-0.58). All other items demonstrated inter-observer kappa's of 0.25-0.37. Intra-observer analyses evaluating the presence of pectus excavatum demonstrated a kappa of 0.81 (95%-CI: 0.72-0.91), while all other items showed intra-observer kappa's of 0.36-0.68.

CONCLUSIONS

Visual examination and diagnosis of pectus excavatum yields considerable inter-observer and intra-observer disagreements. As this variation in judgement could impact work-up and treatment strategy, objective standardization is urged.

LEVELS OF EVIDENCE

III.

Outcomes after hybrid minimally invasive treatment of Boerhaave syndrome: a single-institution experience

BACKGROUND

Spontaneous esophageal perforation or Boerhaave syndrome is a life-threatening emergency, associated with significant morbidity and mortality. In this retrospective series we describe our single-center experience with a hybrid minimally invasive treatment approach for the treatment of Boerhaave syndrome.

METHODS

Clinical data of all patients who presented with spontaneous esophageal rupture between January 2009 and December 2019 were analyzed. All patients underwent esophageal endoscopic stenting to seal the perforation and debridement of the contaminated mediastinal and pleural cavity through video-assisted thoracoscopic surgery (VATS). Primary outcome measure was defined as in-hospital death and 30-day mortality.

RESULTS

Twelve patients were included with a median age of 63 years (interquartile range [IQR] 51-74 years) of whom 58% (n = 7) were male. The median Pittsburg perforation severity score was 6.5 (IQR 6-9). Endoscopic reintervention was required in 8 patients (67%), primarily due to stent dislocation. In addition, 5 patients (42%) required re-VATS due to empyema formation. Thirty-day mortality and in-hospital mortality were respectively 17% (n = 2) and 25% (n = 3).

CONCLUSION

Endoscopic stenting in combination with thoracoscopic debridement is an effective and safe minimally invasive hybrid approach for the treatment of Boerhaave syndrome. This is depicted by the relatively low mortality rates, even among patients with high perforation severity scores. The relatively low mortality rates may be attributed to the combined approach of rapidly sealing the defect and decontamination of the thorax. Future studies should aim to corroborate this evidence which is limited by its sample size and retrospective nature.

Expert consensus on resection of chest wall tumors and chest wall reconstruction

Chest wall tumors are a relatively uncommon disease in clinical practice. Most of the published studies about chest wall tumors are usually single-center retrospective studies, involving few patients. Therefore, evidences regarding clinical conclusions about chest wall tumors are lacking, and some controversial issues have still to be agreed upon. In January 2019, 73 experts in thoracic surgery, plastic surgery, science, and engineering jointly released the Chinese Expert Consensus on Chest Wall Tumor Resection and Chest Wall Reconstruction (2018 edition). After that, numerous experts put forward new perspectives on some academic issues in this version of the consensus, pointing out the necessity to further discuss the points of contention. Thus, we conducted a survey through the administration of a questionnaire among 85 experts in the world. Consensus has been reached on some major points as follows. (I) Wide excision should be performed for desmoid tumor (DT) of chest wall. After excluding the distant metastasis by multi-disciplinary team, solitary sternal plasmacytoma can be treated with extensive resection and adjuvant radiotherapy. (II) Wide excision with above 2 cm margin distance should be attempted to obtain R0 resection margin for chest wall tumor unless the tumor involves vital organs or structures, including the great vessels, heart, trachea, joints, and spine. (III) For patients with chest wall tumors undergoing unplanned excision (UE) for the first time, it is necessary to carry out wide excision as soon as possible within 1–3 months following the previous surgery. (IV) Current Tumor Node Metastasis staging criteria (American Joint Committee on Cancer) of bone tumor and soft tissue sarcoma are not suitable for chest wall sarcomas. (V) It is necessary to use rigid implants for chest wall reconstruction once the maximum diameter of the chest wall defect exceeds 5 cm in adults and adolescents. (VI) For non-small cell lung cancer (NSCLC) invading the chest wall, wide excision with neoadjuvant and/or adjuvant therapy are recommended for patients with stage T_3-4N_0-1M₀. As clear guidelines are lacking, these consensus statements on controversial issues on chest wall tumors and resection could possibly serve as further guidance in clinical practice during the upcoming years.

Thoracic surgery in the Netherlands

The purpose of this article, part of the Thoracic Surgery Worldwide series, is to provide a descriptive review of how thoracic surgery is organized in the Netherlands. General information is provided on the Dutch healthcare system, as well as on how Dutch thoracic surgeons are organized and trained. Additionally, this study provides information on our national quality surveillance system, an overview of the most common thoracic surgeries performed in our country, and details of academic research conducted by Dutch medical specialists. Furthermore, we discuss current challenges and future perspectives. In the Netherlands general thoracic surgical procedures are performed by approximately 110 general thoracic surgeons and 25 of the 135 cardiothoracic surgeons. Dutch thoracic surgeons provide minimally invasive lung surgery, chest wall surgery, thymic and mediastinal surgery, and surgical diagnosis and treatment of pleural disorders. Some recently published data on hospital mortality and postoperative adverse events of thoracic surgeries are reported. Furthermore, the structure of the thoracic surgical education and training program is discussed, highlighting the particular structure of two educational programs for thoracic surgery via a general thoracic and cardiothoracic surgery program. To assure high-quality surgical care, the Netherlands has a well-structured national quality surveillance system, involving frequent site visits and mandatory participation in the national lung cancer surgery registry for all hospitals. In terms of academic research, the Netherlands ranked 14th worldwide on number of clinical trials conducted across all medical disciplines in 2021. Furthermore, several thoracic-related (inter-)national multicenter randomized trials which are currently performed and initiated by Dutch hospital research groups are mentioned. Finally, future challenges and advances of Dutch thoracic surgery are addressed, including the implementation of lung cancer screening, imbalanced labor market, and centralization of care.

Negative pressure wound therapy for massive subcutaneous emphysema: a systematic review and case series

Background

Massive subcutaneous emphysema can cause considerable morbidity with respiratory distress. To resolve this emphysema in short-term, negative pressure wound therapy could be applied as added treatment modality. However, its use is sparsely reported, and a variety of techniques are being described. This study provides a systematic review of the available literature on the effectiveness of negative pressure wound therapy as treatment for massive subcutaneous emphysema. In addition, our institutional experience is reported through a case-series.

Methods

The PubMed, Embase and Cochrane Library were systematically searched for publications on the use of negative pressure wound therapy for subcutaneous emphysema following thoracic surgery, trauma or spontaneous pneumothorax. Moreover, patients treated at our institution between 2019 and 2021 were retrospectively identified and analyzed.

Results

The systematic review provided 10 articles presenting 23 cases. Studies demonstrated considerable heterogeneity regarding the location of incision, creation of prepectoral pocket, and surgical safety margin. Also closed incision negative pressure wound therapy and PICO^© device were discussed. Despite the apparent heterogeneity, all techniques provided favorable outcomes. No complications, reinterventions or recurrences were documented. Furthermore, retrospective data of 11 patients treated at our clinic demonstrated an immediate response to negative pressure wound therapy and a full remission of the subcutaneous emphysema at the end of negative pressure wound therapy. No recurrence requiring intervention or complications were observed.

Conclusions

The findings of this study suggest that negative pressure wound therapy, despite the varying techniques employed, is associated with an immediate regression of subcutaneous emphysema and full remission at the end of therapy. Given the relatively low sample size, no technique of choice could be identified. However, in general, negative pressure wound therapy appears to provide fast regression of subcutaneous emphysema and release of symptoms in all cases.

Video-Assisted Thoracoscopic Surgical Rib Fixation for Costochondral Separation Injury

Costochondral separation is a rare phenomenon following blunt thoracic trauma that can also be associated with secondary injuries. We present a case with complete costochondral separation of the right second rib with concomitant mediastinal compression. Definitive treatment was provided through video-assisted thoracoscopic surgical plate osteosynthesis.

Case report: ventricular fibrillation and cardiac arrest provoked by forward bending in adolescent with severe pectus excavatum

Background

Life-threatening arrhythmias have been reported in patients with severe pectus excavatum in absence of other cardiac abnormalities. Literature is scarce regarding diagnosis, cause and management of this problem, particularly regarding the question as to whether the placement of an implantable cardioverter-defibrillator (ICD) is necessary.

Case summary

A 19-year-old male patient with severe pectus excavatum was scheduled for elective surgical correction. During forward bending for epidural catheter placement, syncope and ventricular fibrillation (VF) occurred resulting in cardiac arrest. After successful cardiopulmonary resuscitation, extensive analysis was performed and showed no cause for VF other than cardiac compression (particularly of the left atrium, right atrium, and ventricle to a lesser degree) due to severe pectus excavatum. Postponed correction by modified Ravitch was performed without ICD placement, with an uneventful post-operative recovery. Eighteen months after surgery, the patient remains well. Upon specific request, he did remember dizzy spells when tying shoelaces. He always considered this unremarkable.

Discussion

In severe pectus excavatum with cardiac compression, forward bending can decrease central venous return and cardiac output, causing hypotension, arrhythmia, and cardiac arrest. In absence of structural or electric abnormalities, cardiac compression by severe pectus excavatum was considered a reversible cause of VF and ICD placement unnecessary. Patients with cardiac compression due to severe pectus excavatum may report pre-existing postural symptoms upon specific request. When these postural symptoms are present, extreme and prolonged forward bending postures should be avoided.

Sternal elevation by the crane technique during pectus excavatum repair: A quantitative analysis

Introduction

The crane technique is used to facilitate sternal elevation to provide safe mediastinal passage during the Nuss procedure. The aim was to objectively quantitate the elevation of the crane by 3-dimensional chest images acquired during the Nuss procedure.

Methods

A prospective cohort study was conducted. Patients undergoing the Nuss procedure were eligible. Sternal elevation was achieved by the crane technique providing a simultaneous lift of the anterior chest wall and reduction of the pectus excavatum depth. Both effects were evaluated. Three-dimensional surface images were acquired before incision, following sternal lift, and after bar implantation and quantitatively compared. Reduction of the external pectus excavatum depth was expressed as a percentage.

Results

Thirty patients were included. Ninety percent were male, with a median age of 15.5 years (interquartile range [IQR], 14.5-17.4), Haller index of 3.56 (IQR, 3.09-4.65), and external pectus depth of 18 mm (IQR, 11-23). Sternal elevation by the crane provided a median 78% (IQR, 63-100) reduction of the deformity, corresponding with a residual depth of 3 mm (IQR, 0-7). The percentual reduction diminished with increasing depth of the sternal depression (correlation, –0.86). Besides reducing the deformity, the crane caused an elevation of the anterior chest over a large surface area with a maximum lift of 26 mm (IQR, 19-32).

Conclusions

The crane is an effective sternal elevation technique, providing 78% reduction of the sternal depression, although its effect lessens with increasing depth. In addition, it produces an elevation of the anterior chest over a large surface area.

Surgical mediastinal lymph node staging for non-small-cell lung carcinoma

Background

The current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which lymph nodes are resected instead of biopsied is video-assisted mediastinoscopic lymphadenectomy (VAMLA) that is suggested to be superior in detecting N2 disease. Yet, evidence is conflicting and furthermore limited by sample size. The objective was to compare mediastinal staging through VAMLA and video-assisted mediastinoscopy.

Methods

A single-center cohort study was conducted. All consecutive patients that underwent surgical mediastinal staging of non-small-cell lung carcinoma by VAMLA (2011 to 2018) were compared to historic video-assisted mediastinoscopy controls (2007 to 2011). Patients with negative surgical mediastinal staging underwent subsequent anatomical resection with systematic regional lymphadenectomy. Primary outcome was the sensitivity and negative predictive value for detecting N2 disease.

Results

Two-hundred-sixty-nine video-assisted mediastinoscopic lymphadenectomies and 118 video-assisted mediastinoscopies were performed. The prevalence of N2 disease was 20% and 26% respectively in the VAMLA and video-assisted mediastinoscopy group, while the rate of unforeseen pN2 resulting from lymph node dissection during anatomical resection was 4% and 11%, respectively. Invasive staging using VAMLA demonstrated superior sensitivity of 0.82 and a negative predictive value of 0.96 when compared to video-assisted mediastinoscopy (0.62 and 0.89, respectively), offering a 64% decrease in risk of unforeseen pN2 following anatomical resection. However, VAMLA is also associated with a 75% risk increase on complications (P=0.36).

Conclusions

We conclude that performing invasive mediastinal lymph node assessment for staging of non-small-cell lung carcinoma, VAMLA should be the preferred technique with superior sensitivity and negative predictive value in detecting N2 disease. Though, VAMLA is also associated with an increased risk of complications.

Suture Anchor Repair of Pectoralis Major Muscle Dehiscence After Modified Ravitch

During repair of pectus excavatum by the modified Ravitch procedure, the major pectoral muscles are detached from their sternal insertion to obtain adequate surgical exposure. Following repair, the muscles are approximated in midline and reinserted through scarring. Dehiscence of the major pectoral muscles after the modified Ravitch procedure is a rare phenomenon, not previously reported in literature. We report on 2 cases and describe an effective treatment method using sternal suture anchors with good long-term results.

Three-dimensional Surface Imaging for Clinical Decision Making in Pectus Excavatum

To evaluate pectus excavatum, 3-dimensional surface imaging is a promising radiation-free alternative to computed tomography and plain radiographs. Given that 3-dimensional images concern the external surface, the conventional Haller index, and correction index are not applicable as these are based on internal diameters. Therefore, external equivalents have been introduced for 3-dimensional images. However, cut-off values to help determine surgical candidacy using external indices are lacking. A prospective cohort study was conducted. Consecutive patients referred for suspected pectus excavatum received a computed tomography (≥18 years) or plain radiographs (<18 years). The external Haller index and external correction index were calculated from additionally acquired 3-dimensional images. Cut-off values for the 3-dimensional image derived indices were obtained by receiver-operating characteristic curve analyses, using a conventional Haller index ≥3.25, and computed tomography derived correction index ≥28.0% as indicative for surgery. Sixty-one and 63 patients were included in the computed tomography and radiograph group, respectively. To determine potential surgical candidacy, receiver-operating characteristic analyses found an optimum cut-off of ≥1.83 for the external Haller index in both the computed tomography and radiograph group with a positive predictive value between 0.90 and 0.97 and a negative predictive value between 0.72 and 0.81. The optimal cut-off for the external correction index was ≥15.2% with a positive predictive value of 0.86 and negative predictive value of 0.93. The 3-dimensional image derived external Haller index and external correction index are accurate radiation-free alternatives to facilitate surgical decision-making among patients suspected of pectus excavatum with values of ≥1.83 and ≥15.2% indicative for surgery.

Right Anterolateral Thoracotomy Versus Sternotomy for Resection of Benign Atrial Masses: A Systematic Review and Meta-Analysis

OBJECTIVE

Primary benign cardiac tumors are rare disease entity that predominantly originate from the atria. Benign masses can induce heart failure, arrhythmia, or thromboembolic events. Therefore, surgical excision is often indicated. Current guidelines on the preferred approaches for resection (i.e., median sternotomy [MST] or right anterolateral thoracotomy [RAT]) are lacking. The aim of the current meta-analysis was to evaluate all studies comparing RAT to MST for excision of benign atrial masses in terms of safety, efficacy, and complications.

METHODS

The PubMed and EMBASE databases were searched through 9 June 2020. Data regarding mortality, complications, recurrence, ICU stay, and length of hospital stay were extracted and submitted to meta-analysis using random effects modelling. Heterogeneity was assessed by the I ² test.

RESULTS

Four retrospective observational studies were included, including 196 patients (RAT n = 97, MST n = 99). Mortality was 0% in both groups. Recurrence was <1% in the RAT group and 0% in the MST group. Complication rate tended to be lower in favor of the RAT group. Furthermore, RAT was associated with lower length of ICU stay (-17.7 hr, P = 0.01) and hospital stay (-4.0 days, P < 0.001). No significant differences in cardiopulmonary bypass (P = 0.09) and cross-clamp times (P = 0.15) were observed.

CONCLUSIONS

The RAT approach is as safe and effective as MST for the excision of benign atrial masses. Moreover, RAT is associated with a reduced complication rate and a reduced duration of hospitalization and could be considered as the preferred approach in anatomically suitable patients.

The Automatic Quantification of Morphological Features of Pectus Excavatum Based on Three-Dimensional Images

Visual examination and quantification of severity are essential for clinical decision making in patients with pectus excavatum. Yet, visual assessment is prone to inter- and intra-observer variability and current quantitative methods are inadequate. This study aims to develop and evaluate a novel, automatic and non-invasive method to objectively quantify pectus excavatum morphology based on three-dimensional images. Key steps of the automatic analysis are normalization of image orientation, slicing, and computation of the morphological features encompassing pectus depth, width, length, volume, position, steepness, flaring, asymmetry and mean cross-sectional area. A digital phantom mimicking a patient with pectus excavatum was used to verify the analysis method. Prospective three-dimensional imaging and subsequent surface analysis in patients with pectus excavatum was performed to assess clinical feasibility. Verification of the developed analysis tool demonstrated 100% reproducibility of all morphological feature values. Calculated parameters compared to the predetermined phantom dimensions were accurate for all but four features. The pectus width, length, volume and steepness showed an error of 4 mm (4%), 2 mm (2%), 12 mL (5%) and 1 degree (3%), respectively. Prospective imaging of 52 patients (88% males) demonstrated the feasibility of the developed tool to quantify morphological features of pectus excavatum in the clinical setting. Mean duration to calculate all features in one patient was 7.6 seconds. We have developed and presented a non-invasive pectus excavatum surface analysis tool, that is feasible to automatically quantify morphological features based on three-dimensional images with promising accuracy and reproducibility.

Safety and feasibility of rigid fixation by SternaLock Blu plates during the modified Ravitch procedure: a pilot study

Background

Patients with anterior chest wall deformities unsuitable for minimally invasive repair are commonly treated by the modified Ravitch procedure. Although rigid plate fixation of the sternal osteotomy has previously shown to facilitate adequate sternal union, its use is troubled by an implant removal rate of up to 23% due to local complaints or complications associated with bulky plates. In contrast, the use of thinner and therefore biomechanically weaker plates may result in a higher incidence of non- or mal-union. In this pilot study, we evaluate the feasibility, efficacy and safety of rigid sternal fixation by thin pre-shaped anatomical locking plates during the modified Ravitch procedure.

Methods

Between June 2018 and December 2019, all consecutive patients who underwent anterior chest wall deformity repair by the modified Ravitch procedure in our tertiary referral centre were included. Data was collected retrospectively. All pectus types were included. The sternal osteotomy was fixated using thin SternaLock Blu plates. Patients were followed for at least one year.

Results

Nine patients were included. The group consisted of six male and three female patients, with a median age of 20 years [interquartile range (IQR), 16–35 years]. Median duration of follow-up was 25 months (IQR, 16–28 months). No intraoperative complications occurred. No patients presented with symptomatic non- or mal-union. Plate removal was performed in one patient for atypical pain without relief. No other postoperative complications occurred.

Conclusions

Based on these pilot results, thin SternaLock Blu plates are deemed to be safe and effective in providing adequate rigid fixation of the sternal osteotomy during the modified Ravitch procedure. Compared to literature, the need for plate removal within 25 months after surgery was reduced.