-
The Annals of Thoracic Surgery Jul 2023Pectus excavatum is the most common congenital anterior chest wall deformity. Currently, a wide variety of diagnostic protocols and criteria for corrective surgery are... (Review)
Review
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.
Topics: Humans; Funnel Chest; Consensus; Lung; Spirometry; Postoperative Period
PubMed: 36997016
DOI: 10.1016/j.athoracsur.2023.02.059 -
The Annals of Thoracic Surgery May 2023Pectus excavatum frequently accompanies congenital heart disease and connective tissue diseases requiring cardiac surgery. Sometimes the indication is cardiac repair,... (Review)
Review
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.
Topics: Humans; Funnel Chest; Cardiac Surgical Procedures; Sternum; Thoracic Surgery; Heart Defects, Congenital; Treatment Outcome
PubMed: 36781097
DOI: 10.1016/j.athoracsur.2023.01.040 -
General Thoracic and Cardiovascular... Nov 2020Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine.... (Review)
Review
Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine. This review article aims to perform an updated overview of the literature about the effect of pectus excavatum correction at the spine and the management of patients with both pectus excavatum and scoliosis. Although acquired scoliosis has been rarely reported after a Nuss procedure, studies show that the Nuss procedure can have a beneficial effect in mild coexisting scoliosis especially when it is performed during the adolescence. The management of cases presented with both pectus excavatum and scoliosis depends on the severity of pre-operative scoliosis and demands detailed evaluation of the spine pre and postoperatively. In the rare condition of post-operative scoliosis following a Nuss procedure, the removal of the metallic bar and conservative measures may have satisfactory results on the spine.
Topics: Funnel Chest; Humans; Orthopedic Procedures; Scoliosis
PubMed: 32990868
DOI: 10.1007/s11748-020-01496-y -
Turk Gogus Kalp Damar Cerrahisi Dergisi Jan 2024Chest wall deformities are congenital disorders characterized by abnormal development and appearance of the thoracic wall. The most common form is the pectus excavatum... (Review)
Review
Chest wall deformities are congenital disorders characterized by abnormal development and appearance of the thoracic wall. The most common form is the pectus excavatum deformity, known as shoemaker's chest. Pectus carinatum, known as pigeon chest, is the second most common deformity. In general, most patients are asymptomatic, but cardiopulmonary problems may accompany the disease. The indication for treatment is mostly cosmetic. Treating patients before they reach adulthood increases the chance of success. Surgical treatment can be open or minimally invasive.
PubMed: 38584783
DOI: 10.5606/tgkdc.dergisi.2024.25899 -
Journal of Pediatric Surgery Mar 2022Among patients suspected of pectus excavatum, visual examination is a key aspect of diagnosis and, moreover, guides work-up and treatment strategy. This study evaluated...
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.
Topics: Adolescent; Funnel Chest; Humans; Imaging, Three-Dimensional; Observer Variation; Tomography, X-Ray Computed
PubMed: 34183157
DOI: 10.1016/j.jpedsurg.2021.06.003 -
Anesthesiology Clinics Sep 2020Over the past few decades, there have been many advances in pediatric surgery, some using new devices (eg, VEPTR, MAGEC rods) and others using less invasive approaches... (Review)
Review
Over the past few decades, there have been many advances in pediatric surgery, some using new devices (eg, VEPTR, MAGEC rods) and others using less invasive approaches (eg, Nuss procedure, endoscopic cranial suture release, minimally invasive tethered cord release). Although many of these procedures were initially met with caution or skepticism, continued experience over the past few decades has shown that these procedures are safe and effective. This article reviews the anesthetic considerations for these conditions and procedures.
Topics: Anesthesia; Child; Craniosynostoses; Funnel Chest; Humans; Minimally Invasive Surgical Procedures; Neural Tube Defects; Respiratory Insufficiency; Syndrome
PubMed: 32792179
DOI: 10.1016/j.anclin.2020.06.004 -
Interactive Cardiovascular and Thoracic... Jul 2021Pectus bar removal is the final step of minimally invasive repair of pectus excavatum. Complication rates related to bar removal have been reported in 2-15% of patients...
OBJECTIVES
Pectus bar removal is the final step of minimally invasive repair of pectus excavatum. Complication rates related to bar removal have been reported in 2-15% of patients and severe, near-fatal and fatal complications have been reported. No systematic assessment of complication severity or risk factors associated with bar removal has been reported in large study populations. The aim of this paper is to investigate the safety of the bar removal procedure with regard to complication rates and severities as well as assessment of risk factors.
METHODS
Between 2003 and 2019, 1574 patients underwent the bar removal procedure. Medical records were assessed retrospectively and complications registered. Complications were categorized in infections, bleedings and other complications. The severity of the surgical complications was systematically classified using the validated Clavien-Dindo classification. Furthermore, risk factors associated with complications were assessed.
RESULTS
The overall complication rate was 4.1% (Clavien-Dindo classification I-IV), mainly consisting of bleedings (1.3%) and infections (1.5%). Five cases of severe bleedings were registered (0.3%, Clavien-Dindo classification IV). Risk factors associated with complications during bar removal were greater age and removal of more than one bar.
CONCLUSIONS
The bar removal procedure is a safe and effective procedure. Both age and number of bars inserted should be considered prior to surgical correction of pectus excavatum as these factors predict complications related to bar removal.
Topics: Funnel Chest; Humans; Incidence; Minimally Invasive Surgical Procedures; Retrospective Studies; Risk Factors
PubMed: 34310684
DOI: 10.1093/icvts/ivab077 -
European Journal of Pediatric Surgery :... Aug 2022Pectus excavatum (PE) is a funnel-shaped indentation of the sternum and is the most common deformity of the chest wall. It is associated with syndromic diseases but... (Review)
Review
INTRODUCTION
Pectus excavatum (PE) is a funnel-shaped indentation of the sternum and is the most common deformity of the chest wall. It is associated with syndromic diseases but can occur as an isolated form. Familial occurrence is assumed in up to 40% of cases, but large-scale studies are lacking. Most of the data are obtained from case reports which postulate autosomal recessive, dominant with reduced penetrance, X-linked, and multifactorial patterns of inheritance. No monogenetic cause has been identified to date. This study was designed to provide basic information on the epidemiology, family history, and comorbidity for a large cohort of isolated PE and to show that there is an inheritance pattern for PE that indicates a genetic background.
MATERIALS AND METHODS
A retrospective study was done using a paper-based questionnaire for all PE patients attending two specialized centers for chest wall deformities. Patients with isolated PE were included and asked to provide information on family history and comorbidities.
RESULTS
Family history was available for 78 patients. A positive family history was found in 42 patients (54%) with a total of 53 affected family members.
CONCLUSION
The described family histories indicate an underlying genetic cause for PE. Identification of the genetic factors may contribute to characterize patients who are at risk of inheriting isolated PE.
Topics: Cohort Studies; Funnel Chest; Humans; Retrospective Studies; Sternum; Thoracic Wall
PubMed: 34126636
DOI: 10.1055/s-0041-1729898 -
Journal of Thoracic Disease Feb 2024A wide variety of congenital chest wall deformities that manifest in infants, children and adolescents exists, among which are pectus excavatum and pectus carinatum.... (Review)
Review
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.
PubMed: 38505013
DOI: 10.21037/jtd-23-957 -
Translational Pediatrics Aug 2023
PubMed: 37692546
DOI: 10.21037/tp-23-264