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Journal of Thoracic Disease Jul 2023The minimally invasive repair of pectus excavatum (MIRPE) is widely accepted as a method of pectus excavatum (PE) repair. Repair is rarely performed in patients with a... (Review)
Review
The minimally invasive repair of pectus excavatum (MIRPE) is widely accepted as a method of pectus excavatum (PE) repair. Repair is rarely performed in patients with a history of median sternotomy. A feared complication of this procedure is iatrogenic cardiac injury; the risk of injury in patients with prior sternotomy is especially high due to the development of post-surgical retrosternal adhesions, which obscures the "critical view" during MIRPE. A 14-center review reported the incidence to be as high as 7% after analyzing 75 patients with history of sternotomy who underwent MIRPE. Little literature exists on how to best prepare for MIRPE in patients with prior sternotomy. A review of the literature and a retrospective review of over 2,200 patients who underwent MIRPE at our institution was performed to analyze 9 patients who underwent MIRPE after prior sternotomy. Iatrogenic cardiac injury occurred in 2 patients. Given the infrequency in our experience and the low numbers reported in the literature, statistical conclusions cannot be drawn. However, prudent strategies based on this experience include thoracoscopy, routine sternal elevation, direct sub-xiphoid retrosternal dissection, coordination with cardio-thoracic surgeons, preparation for cardio-pulmonary bypass, and massive transfusion protocol availability to optimize surgical outcomes in patients undergoing MIRPE with a history of sternotomy.
PubMed: 37559617
DOI: 10.21037/jtd-22-1567 -
Radiology. Cardiothoracic Imaging Oct 2020To explore stress echocardiographic findings among patients with pectus excavatum (PEX) and their relationship with malformation severity.
PURPOSE
To explore stress echocardiographic findings among patients with pectus excavatum (PEX) and their relationship with malformation severity.
MATERIALS AND METHODS
A prospective registry involving consecutive patients with a diagnosis of isolated PEX referred to undergo chest CT and stress echocardiography to evaluate surgical candidacy and/or to define treatment strategies was developed. Malformation indexes were evaluated using chest CT.
RESULTS
This study included 269 patients with PEX (19.7 years ± 7.8 [standard deviation]; 245 men) and 35 healthy volunteers (20.7 years ± 6.1; 21 men). Patients with PEX achieved a lower maximal workload (PEX group, 8.2 metabolic equivalents ± 1.7; control group, 11.8 metabolic equivalents ± 5.5; < .0001). This study identified evidence of abnormal right ventricular diastolic function in 29% of patients with PEX and identified no evidence of this among those in the control group ( < .0001). Healthy controls showed a 37% increment in the tricuspid area during exercise, compared with 4% in patients with PEX ( = .002). Right ventricular systolic function was significantly lower in patients with PEX than in controls, both measured using tricuspid annulus plane systolic excursion (stress, 25.0 mm ± 5.5 vs 35.4 mm ± 3.7; < .0001), and the tricuspid systolic wave was also smaller (stress, 16.9 cm/sec ± 4.5 vs 20.5 cm/sec ± 3.9; < .0001). During stress, significant associations were detected between malformation indexes with right ventricular systolic and diastolic findings ( < .05 for all).
CONCLUSION
This study identified evidence of diverse adverse functional and morphologic cardiac manifestations in PEX, involving signs of abnormal diastolic and systolic right ventricular function and compression of the atrioventricular groove, which worsened during stress and were related to malformation severity.© RSNA, 2020
PubMed: 33778619
DOI: 10.1148/ryct.2020200011 -
American Journal of Transplantation :... Jan 2021Severe chest wall deformities are considered an absolute contraindication for lung transplantation. The significantly impaired chest compliance associated with pectus...
Severe chest wall deformities are considered an absolute contraindication for lung transplantation. The significantly impaired chest compliance associated with pectus excavatum is thought to result in a high risk of postoperative respiratory complications and significant morbidity and mortality. We herein report our pooled institutional experience consisting of 3 patients who underwent bilateral lung transplantation and simultaneous correction of a pectus excavatum. Two of the patients were children and 1 patient had severe asymmetric pectus. All patients received a size-reduced double lung transplant and the deformity was corrected by a Nuss or modified Ravitch procedure. The perioperative course was complicated by prolonged weaning requiring tracheostomy in 2 of the 3 patients. However, long-term results were good and all 3 patients are alive in excellent clinical condition 72, 60, and 12 months after the transplantation. This case series demonstrates that patients with severe chest wall deformities should not a priori be excluded from lung transplantation, and a combined approach is feasible for selected patients.
Topics: Child; Funnel Chest; Humans; Lung Transplantation; Postoperative Complications
PubMed: 32619074
DOI: 10.1111/ajt.16180 -
Frontiers in Surgery 2021Limited data exist for adults with recurrent pectus excavatum (PE) treated with minimally invasive surgical repair.
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, < 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, = 8.96, < 0.001).
CONCLUSIONS
The modified Nuss procedure with a new titanium alloy bar can achieve good results for adult patients with recurrent PE.
PubMed: 35155553
DOI: 10.3389/fsurg.2021.814837 -
Children (Basel, Switzerland) Apr 2022Pectus excavatum is the most common congenital anterior chest wall deformity, with an incidence of 1:400 to 1:1000. Surgical strategy has evolved with the revolutionary...
Pectus excavatum is the most common congenital anterior chest wall deformity, with an incidence of 1:400 to 1:1000. Surgical strategy has evolved with the revolutionary idea of Donald Nuss, who was a pioneer in the operative correction of this deformity using minimally invasive surgery. The aim of this paper is to compare the preliminary results of pectus excavatum repair in two University Centers with a moderate number of patients using the standard Nuss procedure and its modification, the extrapleural thoracoscopic approach. The statistical analysis showed no significant difference for the patient's age (14.52 ± 3.70 vs. 14.57 ± 1.86; = 0.95) and the CT Haller index (4.17 ± 1.58 vs. 3.78 ± 0.95; = 0.32). A statistically significant difference was noted for the duration of a pectus bar implant (2.16 ± 0.24 vs. 2.48 ± 0.68; = 0.03) between the Maribor and Novi Sad Center. We report 14 complications (28%), including dislocation of the pectus bar (10%), pleural effusion (8%), wound inflammation (6%), pericarditis (2%) and an allergic reaction to the pectus bar (2%). Standard and thoracoscopic extrapleural Nuss procedures are both safe and effective procedures used to correct a pectus excavatum deformity. The choice of surgical procedure should be made according to a surgeon's reliability in performing a particular procedure. Our study found no advantages of one procedure over the other.
PubMed: 35455601
DOI: 10.3390/children9040557 -
Frontiers in Surgery 2023The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay... (Review)
Review
INTRODUCTION
The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature.
METHODS
An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if -value was <0.05.
RESULTS
A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC.
CONCLUSION
The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE.
PubMed: 37693640
DOI: 10.3389/fsurg.2023.1235120 -
Interactive Cardiovascular and Thoracic... Jun 2021To compare a standard protocol using chest computed tomography (CT) to a non-irradiant protocol involving a low-cost portable 3D scanner and magnetic resonance imaging...
OBJECTIVES
To compare a standard protocol using chest computed tomography (CT) to a non-irradiant protocol involving a low-cost portable 3D scanner and magnetic resonance imaging (MRI) for all pectus deformities based on the Haller index (HI).
METHODS
From April 2019 to March 2020, all children treated for pectus excavatum or carinatum at our institution were evaluated by chest CT, 3D scanning (iPad with Structure Sensor and Captevia-Rodin4D) and MRI. The main objectives were to compare the HI determined by CT or MRI to a derived index evaluated with 3D scanning, the external Haller index (EHI). The secondary objectives were to assess the inter-rater variability and the concordance between CT and MRI for the HI and the correction index.
RESULTS
Eleven patients were evaluated. We identified a strong correlation between the HI with MRI and the EHI (Pearson correlation coefficient = 0.900; P < 0.001), with a strong concordance between a radiologist and a non-radiologist using intra-class correlation for the HI with MRI (intra-class correlation coefficient = 0.995; [0.983; 0.999]) and the EHI (intra-class correlation coefficient = 0.978; [0.823; 0.995]). We also identified a marked correlation between the HI with CT and the EHI (Pearson coefficient = 0.855; P = 0.002), with a strong inter-rater concordance (intra-class correlation coefficient = 0.975; [0.901; 0.993]), a reliable concordance between CT and MRI for the HI and the correction index (Pearson coefficient = 0.886; P = 0.033).
CONCLUSIONS
Non-irradiant pectus deformity assessment is possible in clinical practice, replacing CT with MRI and 3D scanning as a possible readily-accessible monitoring tool.
Topics: Child; Funnel Chest; Humans; Magnetic Resonance Imaging; Severity of Illness Index; Thorax; Tomography, X-Ray Computed
PubMed: 33657219
DOI: 10.1093/icvts/ivab036 -
PloS One 2021It is unclear if amianthoid transformation (AT) of costal cartilage extracellular matrix (ECM) has an impact on the development of pectus excavatum (PE) and pectus...
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.
Topics: Adolescent; Cartilage; Child; Extracellular Matrix; Female; Funnel Chest; Humans; Male; Pectus Carinatum
PubMed: 33493174
DOI: 10.1371/journal.pone.0245159 -
BMC Surgery Jul 2022Pectus excavatum is the most common congenital chest wall defect. Thoracolumbar spinal stenosis and kyphoscoliosis was seen in patients with pectus excavatum. It can be... (Review)
Review
BACKGROUND
Pectus excavatum is the most common congenital chest wall defect. Thoracolumbar spinal stenosis and kyphoscoliosis was seen in patients with pectus excavatum. It can be caused by ossification of the ligamentum flavum, which is rare in patients with pectus excavatum.
CASE PRESENTATION
We reported a 26-year-old woman presented bilateral lower extremities weakness and numbness for two months, progressive worsening. She was diagnosed as thoracolumbar spinal stenosis with ossification of the ligamentum flavum, thoracolumbar kyphoscoliosis associated with pectus excavatum. The posterior instrumentation, decompression with laminectomy, and de-kyposis procedure with multilevel ponte osteotomy were performed. Her postoperative course was uneventful and followed up regularly. Good neurologic symptoms improvement and spinal alignment were achieved.
CONCLUSIONS
Pectus excavatum, kyphoscoliosis associated with thoracolumbar spinal stenosis is rare, and thus her treatment options are very challengeable. Extensive laminectomy decompression and de-kyphosis procedures can achieve good improvement of neurologic impingement and spinal alignment.
Topics: Adult; Female; Funnel Chest; Humans; Kyphosis; Laminectomy; Scoliosis; Spinal Stenosis
PubMed: 35820858
DOI: 10.1186/s12893-022-01716-7 -
Cirugia Pediatrica : Organo Oficial de... Jul 2023To assess the efficacy of the vacuum bell during puberty, according to the daily hours of use and treatment duration.
OBJECTIVE
To assess the efficacy of the vacuum bell during puberty, according to the daily hours of use and treatment duration.
MATERIALS AND METHODS
A retrospective analysis of patients treated with vacuum bell during puberty in the 2010-2021 period was carried out. Several variables were collected, including baseline and final sinking, repaired sinking expressed in cm and as a percentage from baseline sinking, daily hours of use, treatment duration, and complications. Patients were categorized into groups according to the daily hours of use (≤ 3 hours; 4-5 hours; ≥ 6 hours) and treatment duration (6-12 months; 13-24 months; 25-36 months; > 36 months), and they were statistically analyzed.
RESULTS
A total of 50 patients -41 male and 9 female- were studied, with a mean age of 12.5 years (range: 10-14 years). No significant differences among groups were observed in terms of baseline sinking, thoracic index, and final sinking. Repaired sinking did increase with the daily hours of use, with significant differences. Complications were mild. 3 patients withdrew from follow-up, and 5 out of the 25 patients who completed treatment achieved a good repair.
CONCLUSIONS
To increase treatment efficacy, the vacuum bell should be used for 6 hours/day during puberty. This method is well-tolerated, causes mild complications, and may be an alternative to surgery in some cases.
Topics: Humans; Male; Female; Child; Funnel Chest; Vacuum; Retrospective Studies; Treatment Outcome; Puberty
PubMed: 37417215
DOI: 10.54847/cp.2023.03.11