Surgical Correction Of Pectus Excavatum Research Articles

Multicenter Study of Pectus Excavatum, Final Report: Complications, Static/Exercise Pulmonary Function, and Anatomic Outcomes

A multicenter study of pectus excavatum was described previously. This report presents our final results. Patients treated surgically at 11 centers were followed prospectively. Each underwent a preoperative evaluation with CT scan, pulmonary function tests, and body image survey. Data were collected about associated conditions, complications, and perioperative pain. One year after treatment, patients underwent repeat chest CT scan, pulmonary function tests, and body image survey. A subset of 50 underwent exercise pulmonary function testing. Of 327 patients, 284 underwent Nuss procedure and 43 underwent open procedure without mortality. Of 182 patients with complete follow-up (56%), 18% had late complications, similarly distributed, including substernal bar displacement in 7% and wound infection in 2%. Mean initial CT scan index of 4.4 improved to 3.0 post operation (severe >3.2, normal = 2.5). Computed tomography index improved at the deepest point (xiphoid) and also upper and middle sternum. Pulmonary function tests improved (forced vital capacity from 88% to 93%, forced expiratory volume in 1 second from 87% to 90%, and total lung capacity from 94% to 100% of predicted (p < 0.001 for each). VO2 max during peak exercise increased by 10.1% (p = 0.015) and O2 pulse by 19% (p = 0.007) in 20 subjects who completed both pre- and postoperative exercise tests. There is significant improvement in lung function at rest and in VO2 max and O2 pulse after surgical correction of pectus excavatum, with CT index >3.2. Operative correction significantly reduces CT index and markedly improves the shape of the entire chest, and can be performed safely in a variety of centers.

Clinical experience of repair of pectus excavatum and carinatum deformities

We present the results of surgical correction of pectus excavatum (PE) and pectus carinatum (PC) deformities in adults, and also report a new method of sternal support used in surgery for PE deformities. We present the results of 77 patients between the ages of 10 and 29 years (mean 17) with PE (n = 46) or PC (n = 31) deformities undergoing corrective surgery from 2004 to 2011, using the Ravitch repair method. Symptoms of the patients included chest pain (15%) and tachycardia (8%). Three patients underwent repair of recurrent surgical conditions. All of the patients with dyspnoea with exercise experienced marked improvement at five months post operation. Complications included pneumothorax in 5.1% (n = 4), haemothorax in 2.6% (n = 2), chest discomfort in 57% (n = 44), pleural effusion in 2.6% (n = 2), and sternal hypertrophic scar in 27% (n = 21) of patients. Mean hospitalisation was eight days. Pain was mild and intravenous analgesics were used for a mean of four days. There were no deaths. Results after surgical correction were very good or excellent in 62 patients (80%) at a mean follow up of three years. Three patients had recurrent PE and were repaired with the Nuss procedure. In three patients who underwent the Ravitch procedure, a stainless steel bar was used for sternal support instead of Kirschner wire. Pectus deformities may be repaired with no mortality, low morbidity, very good cosmetic results and improvement in cardiological and respiratory symptoms.

Intra-cardiac erosion of a pectus bar

A 25-year-old man presented with acute pleuritic chest pain and dyspnoea with type I respiratory failure. Past medical history comprised of mild asthma and surgical correction of pectus excavatum 9 years prior by elevation of the sternum and stabilization over a Lorenz Pectus bar. Examination demonstrated tachypnoea, pan-systolic murmur at the left lower sternal edge and giant V-wave jugular venous …

Impairment of Tricuspid Annular Plane Systolic Excursion and Tricuspid Annular Peak Systolic Velocity in Patients with Pectus Excavatum

We read with interest the article “Echocardiographic assessment of right ventricular function before and after surgery in patients with pectus excavatum and right ventricular compression” by Gurkan et al.1 In our opinion, this is an interesting article describing an improvement of right ventricular (RV) function in adolescents and young adult patients with pectus excavatum (PE) after surgical correction. The authors found a reduced tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular peak systolic velocity (S′) in their PE patients compared with age-related normal values before surgical correction and found that RV systolic performance significantly increased after surgical correction. We completely agree with the findings of Gurkan et al1 that this increase of RV systolic performance after surgical correction of PE is due to the beneficial effects of surgery in PE patients, a fact that is known to be discussed contradictory in the literature. For the convenience of the audience of the journal The Thoracic and Cardiothoracic Surgeon, we would like to mention that in our opinion, a comparison of TAPSE and S′ data from their PE patients below 18 years of age to available TAPSE and S′ pediatric normal values and Z-scores2,3 would have improved the statistical power of their analysis although we have to state that the normal values for these age groups are very close to adult normal values. Gurkan et al1 nicely support the notion that the RV is highly susceptible to preoperative function impairment in patients with PE. We want to thank the authors for addressing the need for careful and systematic evaluation of the RV in patients with PE. We hope that with more interesting studies like this from Gurkan et al1 quantification of systolic RV function will become a routine measurement in preand postoperative PE patients.

Simultaneous Surgical Correction of Pectus Excavatum and Cardiac Disease in Two Adults

Thoracic reconstruction in patients with pectus excavatum with concomitant cardiac or aortic surgery poses a major clinical challenge. The report describes two cases of adult patients undergoing simultaneous surgical correction of cardiac disease and sternal deformity using one of two different techniques: a sterno-turnover method preserving the rectus muscle or a sternal elevation method with A-O plates.

Cardiac magnetic resonance imaging for perioperative evaluation of sternal eversion for pectus excavatum

Pectus excavatum is associated with varying degrees of exercise intolerance and symptomatology. Various forms of evaluation have been inconsistent in identifying objective data for correlation with symptoms. Cardiac magnetic resonance (CMR) imaging provides a promising method for delineating the anatomical and physiological components of pectus excavatum as well as measuring the results of surgical repair. Six patients with symptomatic pectus excavatum underwent preoperative evaluation with CMR. All patients had successful, uncomplicated repair of pectus excavatum using the sternal eversion technique. At the first postoperative visit, all patients underwent postoperative evaluation with CMR. Pre- and postoperative CMR measurements were compared for each patient. Preoperative CMR demonstrated evidence of anatomical and dynamical compression of the heart in all patients. After surgery, all patients showed improvement on postoperative CMR. Five of the 6 (83%) patients had complete relief of right ventricular compression, and 5 of the 6 (83%) patients had relief of left atrial compression. The degree of antero-posterior chest wall narrowing was also markedly improved, with an average postoperative vs preoperative Haller index of 3.2 (range, 2.7-3.8) vs 5.0 (range, 4.0-5.9). After surgical correction of pectus excavatum with the sternal eversion technique, CMR demonstrates improvement in both anatomical chest wall contour and cardiac performance. Sternal eversion provides the most complete anatomical correction and greatest relief of internal cardiac compression. We recommend CMR as the definitive modality for evaluation of patients with pectus excavatum, as this modality shows that the primary underlying physiological abnormality in pectus excavatum is cardiac compression.

Comparative pulmonary functional recovery after Nuss and Ravitch procedures for pectus excavatum repair: a meta-analysis

BackgroundPectus excavatum (PE) is a common chest wall malformation, with surgery being the only method known to correct the defect. Although the Nuss and Ravitch procedures are commonly used, there is no consensus as to whether surgical repair improves pulmonary function. We therefore investigated whether pulmonary function recovers after surgical repair, and if recovery is dependent on the type of procedure or time after surgery.MethodsLiterature searches were performed using PubMed, EMBASE, Health Periodicals Database, and CNKI (Chinese National Knowledge Index) from January 1990 to December 2007. The following keywords were used: pectus excavatum, chest wall deformity, funnel chest, pulmonary function, respiratory, lung function, and pectus severity index. The primary outcome of interest was possible changes in pulmonary function following surgical repair.ResultsMeta-analysis of 23 studies showed that, although there was evidence of statistically significant heterogeneity among studies (Chi-square, 17.11, p < 0.05), changes in pulmonary functional indices, including forced expiratory volume over 1 s (FEV1), forced vital capacity (FVC), vital capacity (VC), and total lung capacity (TLC), were similar 1 year after the Ravitch and Nuss procedures. Several years after surgery and bar removal, however, the changes in pulmonary functional indices significantly favored the Nuss procedure.ConclusionsPulmonary function tends to improve after the surgical correction of pectus excavatum. Although the Nuss procedure was not significantly better 1 year after surgery, long-term postoperative pulmonary function improvement was significantly better after bar removal.

The search for stability: bar displacement in three series of pectus excavatum patients treated with the Nuss technique

OBJECTIVES:To compare bar displacement and complication rates in three retrospective series of patients operated on by the same surgical team.METHOD:A retrospective medical chart analysis of the three patient series was performed. In the first series, the original, unmodified Nuss technique was performed. In the second, we used the “third point fixation” technique, and in the last series, the correction was performed with modifications to the stabilizer and stabilizer position.RESULTS:There were no deaths in any of the series. Minor complications occurred in six (4.9%) patients: pneumothorax with spontaneous resolution (2), suture site infection (2), and bar displacement without the reoperation need (2). Major complications were observed in eight (6.5%) patients: pleural effusion requiring drainage (1), foreign body reaction to the bar (1), pneumonia and shock septic (1), cardiac perforation (1), skin erosion/seroma (1), and displacement that necessitated a second operation to remove the bar within the 30 days of implantation (3). All major complications occurred in the first and second series.CONCLUSION:The elimination of fixation wires, the use of shorter bars and redesigned stabilizers placed in a more medial position results in a better outcome for pectus excavatum patients treated with the Nuss technique. With bar displacement and instability no longer significant postoperative risks, the Nuss technique should be considered among the available options for the surgical correction of pectus excavatum in pediatric patients.

Effects of Human Amniotic Fluid on Costal Cartilage Regeneration (an Experimental Study)

After surgical correction of thoracic wall deformities, promoting neochondrogenesis in the perichondrial bed is very important for obtaining a flexible chest wall. In this experimental study, we aimed to investigate the effects of human amniotic fluid on cartilage regeneration in the costal perichondrial bed in a rabbit model. Fifty-four adult New Zealand rabbits were divided into three groups, with 18 rabbits in each group. The third and fifth costal cartilages were excised totally on the right side and partially excised on the left side in all groups. Group 1 served as controls. All rabbits in group 1 underwent closure of the perichondrium of the third costal cartilage and closure of the perichondrium of the fifth costal cartilage with reimplantation of reshaped cartilage into the fifth costal perichondrial bed. Rabbits in group 2 underwent closure of the perichondrium of the third and fifth costal cartilages after the administration of human amniotic fluid into the perichondrial bed. Group 3 rabbits received both human amniotic fluid and underwent cartilage reimplantation. The third and fifth costal perichondriums in group 3 rabbits were closed after the administration of human amniotic fluid and the reimplantation of reshaped cartilages. Rabbits were sacrificed at two, eight and 12 weeks after operation. Numerical scores for the right perichondrial bed were significantly higher for group 2 compared to group 1 ( P < 0.05). But the difference was not significant for the left perichondrial bed ( P > 0.05). The diameter of chondrogenesis also did not differ significantly between left and right perichondrial bed for all groups. Our study shows that administration of human amniotic fluid into the perichondrial bed increases chondrogenesis in adult rabbits, an important finding which may contribute to improving chest wall flexibility after the surgical correction of pectus excavatum.

The factors determining the complications in the minimally invasive surgical correction of pectus excavatum

The factors determining the complications in the minimally invasive surgical correction of pectus excavatum

Hemodynamic impact of surgical correction of pectus excavatum - a cardiovascular magnetic resonance study

HELIOS Klinikum Berlin-Buch, Charite Campus-Buch, Humboldt University, Berlin, Germany Full list of author information is available at the end of the article Figure 1 Upper row: Axial SSFP-images before (left) and after (right) surgery Lower row: Short axis SSFP-images before (left) and after (right) surgery. Zagrosek et al. Journal of Cardiovascular Magnetic Resonance 2011, 13(Suppl 1):P190 http://jcmr-online.com/content/13/S1/P190

Surgical Correction of Pectus Excavatum. How Did We Get Here? Where Are We Going?

The currently applied techniques recommended for the repair of pectus excavatum anomalies are discussed, set against a historical review of early clinical studies and surgical interventions. The issues of the future direction pectus excavatum surgery may take are analyzed in detail, with the reviewer expressing reservations in connection with the recent trend to closed repair and concern over the potential for serious complications associated with the application of this technique.

Twenty-One Years of Experience With Minimally Invasive Repair of Pectus Excavatum by the Nuss Procedure in 1215 Patients

To review the technical improvements and changes in management that have occurred over 21 years, which have made the minimally invasive repair of pectus excavatum safer and more successful. In 1997, we reported our 10-year experience with a new minimally invasive technique for surgical correction of pectus excavatum in 42 children. Since then, we have treated an additional 1173 patients, and in this report, we summarize the technical modifications which have made the repair safer and more successful. From January 1987 to December 2008, we evaluated 2378 pectus excavatum patients. We established criteria for surgical intervention, and patients with a clinically and objectively severe deformity were offered surgical correction. The objective criteria used for surgical correction included computed tomography (CT) scans of the chest, resting pulmonary function studies (spirometry and/or plethysmography), and a cardiology evaluation which included echocardiogram and electrocardiogram. Surgery was indicated if the patients were symptomatic, had a severe pectus excavatum on a clinical basis and fulfilled two or more of the following: CT index greater than 3.25, evidence of cardiac or pulmonary compression on CT or echocardiogram, mitral valve prolapse, arrhythmia, or restrictive lung disease. Data regarding evaluation, treatment, and follow up have been prospectively recorded since 1994. Surgical repair was performed in 1215 (51%) of 2378 patients evaluated. Of these, 1123 were primary repairs, and 92 were redo operations. Bars have been removed from 854 patients; 790 after primary repair operations, and 64 after redo operations. The mean Haller CT index was 5.15 ± 2.32 (mean ± SD). Pulmonary function studies performed in 739 patients showed that FVC, FEV1, and FEF25-75 values were decreased by a mean of 15% below predicted value. Mitral valve prolapse was present in 18% (216) of 1215 patients and arrhythmias in 16% (194). Of patients who underwent surgery, 2.8% (35 patients) had genetically confirmed Marfan syndrome and an additional 17.8% (232 patients) had physical features suggestive of Marfan syndrome. Scoliosis was noted in 28% (340). At primary operation, 1 bar was placed in 69% (775 patients), 2 bars in 30% (338), and 3 bars in 0.4% (4). Complications decreased markedly over 21 years. In primary operation patients, the bar displacement rate requiring surgical repositioning decreased from 12% in the first decade to 1% in the second decade. Allergy to nickel was identified in 2.8% (35 patients) of whom 22 identified preoperatively received a titanium bar, 10 patients were treated successfully with prednisone and 3 required bar removal: 2 were switched to a titanium bar, and 1 required no further treatment. Wound infection occurred in 1.4% (17 patients), of whom 4 required surgical drainage (0.4% of the total). Hemothorax occurred in 0.6% (8 patients); 4 during the postoperative period and four occurred late. Postoperative pulmonary function testing has shown significant improvement. A good or excellent anatomic surgical outcome was achieved in 95.8% of patients at the time of bar removal. A fair result occurred in 1.4%, poor in 0.8%, and recurrence of sufficient severity to require reoperation occurred in 11 primary surgical patients (1.4%). Five patients (0.6%) had their bars removed elsewhere. In the 752 patients, more than 1 year post bar removal, the mean time from initial operation to last follow up was 1341 ± 28 days (SEM), and time from bar removal to last follow-up is 854 ± 51 days. Age at operation has shifted from a median age of 6 years (range 1-15) in the original report to 14 years (range 1-31). The minimally invasive procedure has been successfully performed in 253 adult patients aged 18 to 31 years of age. The minimally invasive repair of pectus excavatum has been performed safely and effectively in 1215 patients with a 95.8% good to excellent anatomic result in the primary repairs at our institution.

Review of the Technical Variants in the Repair of Pectus Excavatum

Many technical variations have been introduced for the surgical correction of pectus excavatum (PE). The authors reviewed the literature to provide a detailed overview of the general principles of pectus excavatum repair, bar insertion and removal techniques. A comprehensive review of the literature was undertaken. A summary of the different approaches and techniques of pectus excavatum repair, bar insertion and removal is presented. Various procedures, their advantages and disadvantages, the techniques employed and associated complications are discussed in depth. Pectus excavatum repair has undergone many changes since its first description. Despite previous descriptions of evolving procedures, comparative overviews of surgical variations, outcomes after pectus bar insertion and removal techniques are rare in the literature. The authors reviewed the literature to summarize the previous and current understanding of techniques and highlight the variations.

Comparison of Haller index values calculated with chest radiographs versus CT for pectus excavatum evaluation

Pectus excavatum is a common chest wall anomaly in children. Pre-operative imaging for pectus excavatum is performed with CT, which is used to calculate the Haller index to determine the severity of pectus excavatum. To determine the correlation between Haller index values calculated with two-view chest radiographs and those calculated with CT and to determine, with CT as the reference standard, the diagnostic performance of radiographic Haller index for identifying cases that meet imaging criteria for surgical correction of pectus excavatum. For the period 2001-2009, our radiology information system was searched to identify all children who had undergone CT for Haller index calculation. Children who had also undergone two-view chest radiography (CXR) within 6 months of the CT were included in this retrospective study. Two radiologists independently calculated CT Haller index and radiographic Haller index. Data distributions were tested for normality with the Shapiro-Wilk W test. The associations between CT Haller index and radiographic Haller index were determined with the Spearman coefficient of rank correlation. Differences between CT Haller index and radiographic Haller index were tested with the Wilcoxon signed rank test. Haller index values were dichotomized into positive (>3.2) and negative (≤3.2) cases. Using CT as the reference standard, the sensitivity, specificity, and accuracy of radiographic Haller index in identifying children who meet imaging criteria for surgery were calculated. CT and CXR for evaluation of pectus excavatum were available for 32 children (25 male; median age 14.5 years). With CT, the median Haller indices for observers 1 and 2 were 3.4 and 3.5 and with CXR 3.5 and 3.5. There were statistically significant correlations between the radiographic Haller index and CT Haller index estimated by the two observers [Spearman correlation coefficient (95% confidence interval) for observer 1 = 0.71 (0.48-0.85, P < 0.01) and for observer 2 = 0.77 (0.52-0.88, P < 0.01)]. A statistically significant correlation was found between the radiographic Haller index calculated by the two observers [Spearman correlation coefficient = 0.98 (0.95-0.99, P < 0.01)]. Using CT Haller index as the reference standard, radiographic Haller index had a sensitivity of 0.95 (0.75-0.99), specificity of 0.75 (0.43-0.94), and accuracy of 0.88 (0.72-0.95) for observer 1, and a sensitivity of 0.95 (0.75-0.99), specificity of 0.67 (0.35-0.90), and accuracy of 0.84 (0.68-0.93) for observer 2. Radiographic Haller index correlates strongly with CT Haller index, has good interobserver correlation, and has a high diagnostic accuracy for pre-operative evaluation of pectus excavatum. We suggest that a CT of the chest is not required for pre-operative evaluation of pectus excavatum, and a two-view chest radiograph is sufficient for preoperative imaging of pectus excavatum.

Cardiac Function Assessed by Transesophageal Echocardiography During Pectus Excavatum Repair

We assessed end-diastolic right ventricular (RV) dimensions and left ventricular (LV) ejection fraction by use of intraoperative transesophageal echocardiography before and after surgical correction of pectus excavatum in adults. A prospective study was conducted including 17 patients undergoing surgical correction of pectus excavatum according to the technique of Ravitch-Shamberger between 1999 and 2004. Intraoperative transesophageal echocardiography was performed under general anesthesia before and after surgery to assess end-diastolic RV dimensions and LV ejection fraction. The end-diastolic RV diameter and area were measured in four-chamber and RV inflow-outflow view, and the RV volume was calculated from these data. The LV was assessed by transgastric short-axis view, and its ejection fraction was calculated by use of the Teichholz formula. The end-diastolic RV diameter, area, and volume all significantly increased after surgery (mean values +/- SD, respectively: 2.4 +/- 0.8 cm versus 3.0 +/- 0.9 cm, p < 0.001; 12.5 +/- 5.2 cm(2) versus 18.4 +/- 7.5 cm(2), p < 0.001; and 21.7 +/- 11.7 mL versus 40.8 +/- 23 mL, p < 0.001). The LV ejection fraction also significantly increased after surgery (58.4% +/- 15% versus 66.2% +/- 6%, p < 0.001). Surgical correction of pectus excavatum according to Ravitch-Shamberger technique results in a significant increase in end-diastolic RV dimensions and a significantly increased LV ejection fraction.

Postoperative consumption of opioid analgesics following correction of pectus excavatum is influenced by pectus severity: a single-centre study of 236 patients undergoing minimally invasive correction of pectus excavatum☆

Surgical correction of pectus excavatum (PE) is primarily performed to achieve cosmetic and psychological benefits for the patient. Minimally invasive repair of PE is often associated with severe postoperative pain. This study estimates the effect of the severity of PE on the postoperative consumption of opioid analgesics following this procedure to optimise pain management. A retrospective study was conducted on 236 consecutive patients undergoing minimally invasive repair of PE from 2005 to 2008. The collected data included depth of preoperative pectus excavation, patient demographics, peri- and postoperative information, including data on pain management. The consumption of opioid analgesics was registered after discontinuation of epidural analgesia and other types of opioid analgesics used during the study period were converted to morphine equivalents. Multiple linear regression analysis was performed to estimate the effect of the severity of PE on the postoperative consumption of opioid analgesics and to adjust for potential confounding. The total morphine consumption following minimally invasive repair of PE ranged between 20 and 370 mg day(-1). Multiple linear regression analysis explained approximately 30% of the variation in daily morphine consumption (R-squared=0.2957). There was a significant positive linear relationship between pectus severity and the daily consumption of morphine. Thus, postoperative consumption of morphine increased by 6% (95% confidence interval (CI): 0.3-11%) when preoperative PE depth deteriorated with 1cm. This study confirms that pectus severity has a significant impact on the consumption of opioid analgesics following minimally invasive repair of PE. We conclude that knowledge of pectus severity might be useful in the prediction of the expected morphine consumption in future patients, especially during the critical transition period from epidural analgesia to oral analgesia.

Treating Heart Failure and Dyspnea in a 78-Year-Old Man With Surgical Correction of Pectus Excavatum

Reports documenting the cardiopulmonary significance of pectus excavatum are limited, and there remains a lack of consensus as to whether surgical repair can improve function. We present a case of pectus excavatum deformity and heart failure. Surgical repair was performed with significant improvement of performance and heart function.

Surgical correction of pectus excavatum

Pectus deformities arise from overgrowth of the cartilagenous portion of the ribs. Traditional resective/open procedures have been almost entirely replaced by video assisted retrosternal bar placement with excellent outcomes. This review considers the comprehensive evaluation and care of a pectus patinet as well as technical details regarding conduct of the surgery.

Can absorbable stabilizers be used routinely in the Nuss procedure?☆

During minimal invasive surgical correction of pectus excavatum the metal bar is rotated 180 degrees and fixed by one or two stabilisers. Previously, all stabilisers were made from metal, but they often caused chronic pain and had to be removed. Recently, a slowly absorbable stabiliser made from Lactosorb has been introduced. From 2001 to 2008 a total of 507 patients underwent minimally invasive repair of pectus excavatum at Aarhus University Hospital. Since February 2007 we routinely used absorbable stabilisers made by Lactosorb. We always used shorter pectus bars than originally suggested and always placed one stabiliser close to the entry in the thoracic cavity on the left side. All operations were performed by the same surgeon and all patients were seen 6 weeks after surgery. Patient records were reviewed for retrospective analysis. In 422 patients we used a metal stabiliser while 85 patients received a Lactosorb stabilizer. Seven patients received two stabilisers. During the follow-up period one metal stabiliser broke after 2(1/2) years (0.2%), but within 6 weeks after surgery three Lactosorb stabilizers broke (3.5%) and another three dislocated laterally (3.5%). Absorbable stabilisers may be used for minimal invasive surgery for pectus excavatum but they are more vulnerable and break easier than metal stabilisers. This is likely a consequence of high stress forces that may be more pronounced in patients who receive a shorter pectus bar, but further research is needed.