Pectus Excavatum Patients Research Articles

Pectus patient information website has improved access to care and patient reported outcomes.

BackgroundPectus is the most common congenital disorder. Awareness amongst primary care physicians and the general public is poor. NHS commissioning bodies plan to withdraw funding for this surgery because they deem a lack of sufficient evidence of benefit. The purpose of this study is to assess the effects of introducing a patient information website on referral and activity patterns and on patients reported outcomes.MethodsWe produced an innovative information website, www.pectus.co.uk, accessible to the general public, providing information about pectus deformities; management options and advice about surgery. Referral patterns and number of cases where studied before and after the introduction of the website in 2010. Patients’ satisfaction post-op was assessed using the Brompton’s single step questionnaire (SSQ).ResultsThe website had considerable traffic with 2179 hits in 2012, 4983 in 2013 and 7416 in 2014. This has led to 1421 contacts and 372 email enquiries. These emails have resulted in an increased number of patients who have been assessed and go on to have surgery. We asked 59 pectus excavatum patients who were operated from 2008 to 2014 to complete the SSQ. We received 32 replies. Eighty-four percent (16/19) of patients who visited the website and then underwent surgery, found the website useful. All patients scored satisfactorily in SSQ. Even though those who visited the website tended to be more satisfied with the surgical outcomes this did not reach statistical significance. This group of patients said that would have the operation again given the option compared to 76.9 % of the group who did not visit the website before surgery (p=0.031). Despite the fact that patients who visited the website experienced more post-operative complications were equally or more satisfied with post-operative outcomes. The overall SSQ obtainable score was not different for the two subgroups, being more widespread in the group that did not visit the website.ConclusionsThe introduction of a pectus patient information website has significantly improved access to specialised services. Patients are overall highly satisfied with the surgical outcomes.

RECURRENT DYSPNEA IN A PATIENT WITH SEVERE PECTUS EXCAVATUM: THINK CONSTRICTIVE!

Dyspnea in Pectus Excavatum (PE) patients is mostly related to airflow compression with cardiac etiology being less likely. A 34 year-old male with severe persistent PE despite 2 repairs and broncho-pulmonary hypoplasia (BPH) presented with recurrent dyspnea and chest tightness limiting his

Assessment of potential confounders when imaging pectus excavatum with chest radiography alone

BackgroundChest radiography (CXR) has emerged as an attractive alternative imaging option for objective pre-operative assessment of pectus excavatum (PE) with comparable accuracy, reduced cost, and less radiation exposure when compared to computed tomography (CT). This study asked whether image quality, scoliosis, and asymmetry of the PE deformity would decrease the accuracy of CXR as compared to CT. MethodsA database of PE patients receiving preoperative CXR and CT was created, and Haller-indices (HI) and correction-indices (CI) were calculated using each imaging modality. Each potential confounding variable were analyzed using Spearman correlations the Fisher r-to-z transformation test. ResultsThe database was comprised of 77 patients. Image quality, scoliosis and the ‘eccentric type’ of asymmetry did not demonstrate any significant worsening of measurement accuracy. However, the correlation coefficients for CIs for those with and without the ‘unbalanced type’ of asymmetry were 0.593 and 0.890, respectively, with a Fisher r-to-z of 2.16 (p=.031). ConclusionsThe accuracy of CXR-derived pectus indices remains quite favorable despite the heterogeneity from radiographic quality, scoliosis and chest wall asymmetry. Nonetheless, the unbalanced type of chest wall asymmetry did emerge as a significant confounder. As such, use of CXR alone in cases of gross chest wall asymmetry should be cautioned.

Pectus Excavatum and Pectus Carinatum: Associated Conditions, Family History, and Postoperative Patient Satisfaction.

BackgroundPectus excavatum (PE) and pectus carinatum (PC) are the most common chest wall deformities. In this study, we aimed to characterize how patients obtained information about these deformities, as well as patients’ family history, associated medical problems, and postoperative satisfaction after the Nuss and Abramson procedures.MethodsThis cross-sectional retrospective study included patients who were operated by a single surgeon between 2006 and 2013. Follow-up calls were made after approval of our institution’s ethics committee. We reached 207 of the 336 PE patients (61.6%) and 73 of the 96 PC patients (76%).ResultsThe majority of the patients were male (85% of the PE patients and 91.8% of the PC patients). The age of diagnosis of PE was 14.52±0.51 years and the age at the time of operation was 17.89±0.42 years; for PC patients, the corresponding ages were 15.23±0.55 years and 16.77±0.55 years, respectively. A total of 70% of the PE patients and 63.8% of the PC patients obtained information about pectus deformities through the Internet. In 27.1% of the PE patients with an associated anomaly, 57.1% (n=13) had scoliosis, while 41.1% of the PC patients with an associated anomaly had kyphosis (n=5). Postoperative satisfaction, as evaluated on a scale from 0 to 10, was 8.17±0.15 for PE patients and 8.37±0.26 for PC patients. The postoperative pain duration was 51.93±5.18 days for PE patients and 38.5±6.88 days for PC patients.ConclusionIn this study, we found that most patients with pectus deformities were male. The Internet was an important resource for patients to learn about their deformities. Family history and associated anomalies were identified as important aspects for consideration in the clinical setting. The patients reported high levels of postoperative satisfaction, and pain management was found to be one of the most important elements of postoperative care.

Pectus excavatum repair using Prolene polypropylene mesh.

We aimed to assess the clinical outcomes of our surgical technique for repair of pectus excavatum using Prolene polypropylene mesh. Among 29 patients with pectus excavatum, the major complaint was cosmetic dissatisfaction, and the main symptom was exercise dyspnea in 15 patients. The Haller index used to assess pectus excavatum severity; it was significant in 22 patients. In all patients, a 2-layer sheet of Prolene polypropylene mesh was placed behind the sternum. No serious complication was observed postoperatively, and all patients were satisfied with the cosmetic result. Mitral valve prolapse improved in all cases after 3 months. Spirometry revealed improved pulmonary function after surgery. With due attention to the advantages of Prolene polypropylene mesh, such as remaining permanently in place, adapting to various stresses encountered in the body, resisting degradation by tissue enzymes, and trimming without unraveling, we concluded that this mesh is suitable for use as posterior sternal support in pectus excavatum patients.

Chest wall deformities and coincidence of additional anomalies, screening results of the 25.000 turkish children with the review of the literature

Background: The main subtypes of chest wall deformities are pectus excavatum (PE) and pectus carinatum (PC). Although these are not life threatening diseases, some functional or physico-social disabilities due to the abnormal chest wall structure require treatment. The main stem of the treatment is surgical correction. Since the beginning of the 20 th century various surgical techniques were introduced. In the last few decades some minimally invasive surgical techniques were also described. In the English literature many reports suggest that the vast majority of these abnormalities are PE. But in most of the reports patient groups consist of hospital admissions. The real frequency of this group of disease is controversial. Materials and Methods: In this report, a wide field study was designed to find the real frequency of the chest wall diseases. Total of 25117 children between 6-11 years of age were visited in the elementary schools of Kahramanmaras. The team members were a thoracic surgeon, a pulmonologist and a pediatrician. Results: A careful physical examination revealed that a total of 255 patients had different degrees of chest wall deformity. We found that PC (90.58%) was the most frequent type of deformity in contrast with the previous reports suggesting PE as the most frequent type. In our results only 5.49% of the patients had PE and 3.93% of the patients had mixed type PE+PC. The most frequent ECG abnormality seen in 49 cases (19% of cases with deformity) was a negative T wave on V1 derivation and a biphasic T wave configuration on V1-V2 derivations. 8 patients (3.13%) had concomitant scoliosis and 6 patients (%2.35) had different degrees of cardiomegaly. Conclusions: The real frequency of chest wall deformities is an enigma. When PE patients themselves or their family notice the abnormality, they may consider it as a big health problem and admit to a healthcare unit. But in contrast, PC patients mostly do not care about this disorder until adolescence, so admission rate is less then PE. We suggest that the real frequency of the chest wall deformities may be found only by widespread field studies. Moreover, we found more accompanying cardiac disorders in PC group, and this type of screening may allow early diagnosis of some cardiac diseases.

Patch Testing for Metal Allergy With Manufacturer-Supplied Materials Before Nuss Bar Insertion.

The increasing use of metal implantable devices has raised awareness of nickel allergy. Preoperative patch testing for patients with pectus excavatum (PE) with a known metal allergy or history of atopy is an accepted practice before the Nuss procedure. The Nuss bar manufacturer offers a metal disc for preoperative testing for metal sensitivities. However, the efficacy of this disc is not well understood. The purpose of this study was to determine the sensitivity of the metal disc in detecting nickel allergy compared with that of standard patch testing. Two PE patients were referred for preoperative patch testing with the metal disc to screen for metal allergy before the Nuss procedure. Based on our initial findings, 7 patients without PE scheduled for patch testing for the evaluation of chronic dermatitis were additionally tested with the metal disc if they were found to have risk factors for nickel allergy. All patch testing was performed according to set standards. The metal disc may not be adequately sensitive to determine nickel allergy before the Nuss procedure. Patch testing alone with standard formulations of nickel sulfate in petrolatum may be more sensitive in diagnosing nickel allergy.

How pulmonary function changes after pectus excavatum correction surgery.

We aimed to determine the effects of minimally invasive repair of pectus excavatum on pulmonary function and quality of life. Minimally invasive pectus excavatum repair was undertaken in 80 patients with a mean age of 16.91 ± 4.37 years (range 7-30 years) and a mean Haller index of 4.07 ± 1.39; 85% of the patients were male. They and their parents completed the Nuss Questionnaire Modified for Adults, and pulmonary function tests were performed on the patients before and 6 months after the operation. The mean Nuss score was 31.06 ± 6.78 before the operation and it increased to 37.1 ± 8.31 (p = 0.000) 6 months after the operation. Forced vital capacity decreased from 3.70 ± 1.23 to 3.48 ± 1.03 L (p = 0.05) postoperatively. The percentage of expected forced vital capacity decreased from 83.21% ± 16.97% to 76.52% ± 20.98% (p = 0.01). There was no significant change in forced expiratory volume in 1 s. The mean ratio of forced expiratory volume in 1 s to forced vital capacity was 86% preoperatively and it increased to 91% postoperatively (p = 0.000). Minimally invasive pectus excavatum repair has a positive impact on the quality of life of pectus excavatum patients, but a negative impact on forced vital capacity. Follow-up studies are needed to assess the long-term changes in pulmonary function after this operation.

Scoring of Deformed Costal Cartilages Reduces Postoperative Pain after Nuss Procedure for Pectus Excavatum.

The present study aims to elucidate whether or not scoring deformed cartilages reduces postoperative pain after the Nuss procedure for pectus excavatum patients. A total of 46 pectus excavatum patients for whom the Nuss procedure was conducted were included in the study. The patients were categorized into two groups, depending on whether or not the supplementary maneuver of scoring deformed cartilages was performed in addition to the Nuss procedure. Patients for whom deformed costal cartilages were scored were categorized as the Scoring Group (n = 24); those who received no such scoring were categorized as the Non-Scoring Group (n = 22). After evaluating the maximum stresses occurring on the thoraces by means of dynamic simulation using finite element analyses, intergroup comparison of the maximum von-Mises stress values was performed. Furthermore, after quantifying postoperative pain as the frequency with which patients injected anesthetics through an epidural pain-control system within 2 postoperative days, the degree of pain was compared between the two groups. The maximum stresses occurring on the thorax were significantly greater for the Non-Scoring Group than for the Scoring Group; injection frequency was also greater for the Non-Scoring Group (average 4.9 times for 2 days) than for the Scoring Group (average 2.5 times for 2 days). High stresses occur due to the performance of the Nuss procedure, causing postoperative pain. The stresses can be reduced by performing supplementary scoring on deformed cartilages. Accordingly, postoperative pain is reduced.

The case for using the correction index obtained from chest radiography for evaluation of pectus excavatum

BackgroundWe previously reported the use of a computed tomography (CT)-based Correction Index (CI) as a more accurate assessment of pectus excavatum (PE) severity than the historically used Haller Index (HI). This study examines the diagnostic capabilities of the CI as assessed by lateral chest radiography (CXR). MethodsA database of PE patients receiving preoperative CXR and CT was created. For each patient, a radiologist calculated a CT-based CI, while two pediatric surgeons independently calculated CXR CIs. ResultsThe database was composed of 69 patients. Significant correlations were found between CXR CI estimates of the two observers and between the CXR and CT CI for each observer. Per our previous work, CT CIs were used in this study for identifying patients meeting surgical criteria (CT CI≥28%). Observed CXR CIs demonstrated good interrater reliability. The sensitivity (0.83) and specificity (0.77) of CXR in diagnosing severe PE (CT CI≥28%) was high. However, sensitivity (0.89) markedly improved when only considering measured CXR CIs≤26%, and combined specificity rose to 0.86 when only considering measured CXR CIs≥30%. ConclusionsWe recommend the CI as measured by lateral CXR for the preoperative evaluation of PE, with CT used as a confirmatory test in patients measured to have a CXR CI between 26% and 30%.

Screening for pectus excavatum among primary students and establishment of a pectus excavatum screening program in Dongguan, China.

To carry out pectus excavatum (PEx) screening among primary school students in Dongguan, with an attempt to establish a PEx screening program and provide epidemiological evidences for developing guidelines on the diagnosis and treatment of PEx for young children. A total of 479,402 primary school students who were already in school in 2012 or newly enrolled in 2013 from 422 primary schools in 32 towns in Dongguan, Guangdong Province were screened for PEx. Meanwhile, about 420 medical staff from the infirmaries of 422 primary schools were provided with a serial of training, with an attempt to establish a PEx screening program and network. Valid screening results were obtained from 477,627 pupils (99.62%) from 406 primary schools in 31 towns. These students aged 4-15 years (mean: 8.78 years), among whom there were 244,545 males (N1; mean age: 8.22 years) and 233,082 females (N2; mean age: 8.89 years). Totally 257 PEx patients were identified, yielding a prevalence of 0.583%, among whom there were 176 males (N3; mean age: 8.79 years) and 81 females (N4; mean age: 8.77 years). With the PEx patients as the PEx group and the healthy children as the control group, chi square test with gender as the dependent variable showed that the incidence of PEx was significantly different between male and female students (P=0.00) (N3:N4 =2.172:1). In addition, 410 medical staff from the school infirmaries were trained, and a PEx screening program and network was established. The screening for PEx was successfully performed among pupils who were already in school in 2012 or newly enrolled in 2013 from 422 primary schools in Dongguan, Guangdong Province. Statistical analysis showed that the incidence of PEx differed between male and female pupils. A stable effective PEx screening program was established, which will provide personal and technical supports for the early diagnosis and treatment of this condition.

High rates of metal allergy amongst Nuss procedure patients dictate broader pre-operative testing

PurposeA previous study from our group estimated that as few as 2.2% of pectus excavatum patients suffered from allergy to the implanted metal bar. We sought to assess recent changes in incidence of metal allergy and identify the benefit of metal allergy testing prior to surgery. MethodsA retrospective review was performed of all consenting patients undergoing pectus repair during the six years between 9/2004 and 12/2010 at our institution. Incidence was based on clinical symptoms and/or T.R.U.E.® patch testing. Demographic data, history of atopy and history of metal allergy were collected. Type and number of bars used, suture site infection, skin rash and wound infection rates were reviewed. ResultsForty one of 639 patients (6.4%) had clinical or patch test evidence of metal allergy. Family history of metal allergy and pre-operative history of metal sensitivity were found to be statistically significant correlates. ConclusionsThe rate of metal allergy in the pectus excavatum population may be higher than previously reported. Patient or family history of metal allergy or metal sensitization may indicate increased risk. Metal allergy testing should be performed before Nuss procedure.

Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum.

This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric = 0–21; adult 17–99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.

Irregular location of major pectoral muscle can be a causative factor of pectus excavatum

Pectus excavatum—commonly known as funnel chest—is one of the most frequently observed congenital deformities, in which the patients’ thoraces present concavity. This paper presents our original hypothesis that the abnormal positioning of the major pectoral muscle can be a potential factor in the occurrence of pectus excavatum, and evaluates the validity of the hypothesis by performing an anatomical and a biomechanical study. An anatomical study on clinical cases revealed that the major pectoral muscle tends to be positioned more superiorly in pectus excavatum patients than in normal persons. The biomechanical study, using three-dimensional finite element dynamic simulation, revealed that the major pectoral muscle functions to elevate the sternum and that the elevating effect is reduced when the muscle is located at superior regions on the thoracic wall. These findings support our hypothesis that the abnormal position of the major pectoral muscle is a potential causative factor for pectus excavatum. This hypothesis suggests that, during surgical correction of pectus excavatum with an open approach, surgeons should reposition the major pectoral muscle to its correct anatomical position to avoid recurrence.

Modified Robicsek procedure for pectus excavatum in adult patients

The aim of this study was to clarify the short-term and mid-term outcomes of the modified Robicsek procedure using polypropylene mesh for adult pectus excavatum patients. Retrospective chart review was performed. Between 2001 and 2012, 46 consecutive adult patients underwent modified Ravitch repair using polypropylene mesh for pectus excavatum at our institution. There were 30 males and 16 females, with a median age of 25.5 (range: from 17 to 60). Potential risk factors for perioperative complications and early failure in pectus repair were analysed with χ(2) test or Fisher's exact test and Mann-Whitney test. Potential risk factors for postoperative mid-term recurrence were analysed using Cox proportional hazard regression model. The postoperative follow-up interval was 7.0 ± 15.1 months (mean ± standard deviation). No mortality and 11 patients (24.0%) of morbidity, including 2 patients with temporary mesh infection, were noted. A lower preoperative %FEV1.0 predicted was a significant factor (P = 0.0088) of morbidity in multivariate analysis. Regarding chest morphology, early failure in 1 patient (2.2%) and mid-term recurrence in 1 patient (2.2%) were seen. Previous pectus repair (P = 0.0324) and severe asymmetry (P = 0.04) were significant factors of early failure in multivariate analysis, while no significant factor for mid-term recurrence was found. Modified Robicsek procedure with a polypropylene mesh is associated with low incidences of early failure and mid-term recurrence. The procedure is recommended for adult pectus excavatum patients, including those with asymmetric or combined deformity as an initial or reoperative procedure.

Proper compression landmark and depth for cardiopulmonary resuscitation in patients with pectus excavatum: a study using CT

ObjectiveTo determine by chest CT the proper compression landmark and depth for cardiopulmonary resuscitation in patients with pectus excavatum (PE).MethodsThe chest CT of 22 patients with PE (mean age=27 years;...

Rib Cartilage Characterization in Patients Affected by Pectus Excavatum

Pectus excavatum (PE) is the most frequent anterior chest deformity which may be frequently associated with connective tissue disorders. We performed microscopic analyses to better understand cartilage behavior and obtain clues on its pathogenesis. In 37 PE patients, none with Marfan syndrome, we analyzed costal cartilage by light microscopy, immunohistochemistry and transmission electron microscopy. Control tissue specimens were harvested from four patients without any connective tissue disease. In both control and PE patients, chondrocytes were on the average <15 µm in diameter and occupied <10% of tissue volume; in most cases the extracellular matrix was stained by alcian blue, instead of safranin; no difference between PE and control samples was significant. All samples showed an uneven collagen type II immunolabeling both within the cells and pericellular matrix, and occasionally of the territorial matrix. In all cases numerous cells underwent apoptosis accompanied by matrix condensation as shown by electron microscopy. Our results suggest that matrix composition and the cell number and size of costal cartilage are dependent on the subject and not on the disease; the microscopic organization of cartilage is correlated with the stabilization of the defective shape rather than with the onset of the deformity.

Variations of the soft tissue thicknesses external to the ribs in Pectus Excavatum patients

BackgroundSurgical repair of pectus excavatum (PE) has become more popular due to improvements in the minimally invasive Nuss procedure. The pre-surgical assessment of PE patients requires Computerized Tomography (CT), as the malformation characteristics vary from patient to patient. ObjectiveThis work aims to characterize soft tissue thickness (STT) external to the ribs among PE patients. It also presents a comparative analysis between the anterior chest wall surface before and after surgical correction. MethodsThrough surrounding tissue segmentation in CT data, STT values were calculated at different lines along the thoracic wall, with a reference point in the intersection of coronal and median planes. The comparative analysis between the two 3D anterior chest surfaces sets a surgical correction influence area (SCIA) and a volume of interest (VOI) based on image processing algorithms, 3D surface algorithms, and registration methods. ResultsThere are always variations between left and right side STTs (2.54±2.05mm and 2.95±2.97mm for female and male patients, respectively). STTs are dependent on age, sex, and body mass index of each patient. On female patients, breast tissue induces additional errors in bar manual conception. The distances starting at the deformity's largest depression point at the SCIA are similar in all directions. Some diverging measures and outliers were found, being difficult to find similar characteristics between them, especially in asymmetric patients. ConclusionThe Nuss procedure metal bar must be modeled according to each patient's special characteristics. The studied relationships between STT and chest surface could represent a step forward to eliminate the CT scan from PE pre-surgical evaluation.

Comparison of the Nuss and sternal turnover procedures for primary repair of pectus excavatum

Pectus excavatum (PE) is a common chest wall deformity. There are several surgical alternatives for the repair of PE. In our practice, the sternal turnover (STO) procedure had been performed for decades. In 2008, we started treating PE patients with the Nuss procedure. Our objective of this study is to compare these two procedures. A retrospective chart review was conducted on 50 patients undergoing pectus excavatum repairs from March 2005 to January 2013, including 20 patients with the STO procedure and 30 patients with the Nuss procedure. Patients were evaluated for type of repair performed, operating time, drainage after operation, length of postoperative stay, complications, and cosmetic results. The mean age of the STO group was 11.0 years and that of the Nuss group was 15.0 years (p = 0.353). The Nuss procedure had a much shorter mean operating time, a less mean drainage after operation, and a shorter mean time to drainage tube removal than those of the STO procedure. The rate of complication was 40.0% (8/20) in the STO group and 33.3% (10/30) in the Nuss group. Follow-up data indicated that 90% (18/20) of patients in the STO group and 96.7% (29/30) of patients in the Nuss group regarded the results as good or excellent (p = 0.965). Our data suggests that both the STO and Nuss procedures are equally safe and effective correction methods. However, less trauma, faster recovery, and better cosmetic results are the benefits of the Nuss procedure.

Non-thoracoscopic and thoracoscopic modified Nuss procedure for correction of pectus excavatum

To summarize the curative effect, safety and experience of non-thoracoscopic modified Nuss procedure for correction of pectus excavatum (PE). From January 2007 to December 2011, 267 cases of PE patients were selected in our hospital. Among them 85 were treated by thoracoscopic minimally invasive modified Nuss Procedure and 182 by non-thoracoscopic procedure. The operation time, blood loss during operation, length of postoperative hospital stay and effect of treatment were compared retrospectively. All the 267 patients finished the repair procedure smoothly. The non-thoracoscopic group had advantage in terms of operative time (22.5 min vs 35.1 min, P<0.05). As for the blood loss during operation, length of postoperative hospital stay and effect of treatment, there was no significant difference among the 2 groups (P>0.05). There were no deaths. Non-thoracoscopic minimally invasive modified Nuss procedure is as safe and effective as thoracoscopic Nuss procedure. With advantages of simplified operation procedure and shorter operation time, it is easier in practice.