Symmetric Pectus Excavatum Research Articles

Computed tomographic evaluation of pectus excavatum in 14 cats.

Pectus excavatum (PE) is one of the most frequently reported chest deformities. However, limited studies are available with regard to its CT scan findings in cats. In the present research computed tomographic images of the thoraxes of 14 cats diagnosed with PE has been reviewed. This is one of the first studies exploring the use of CT to characterise PE in animals. The aim of this study was to present characteristic CT features of PE in cats. The introduction of new criteria for better assessing thoracic wall deformity–a correction index (CI) and an asymmetry index (AI)–was also proposed. The study revealed a high variety of morphological features of PE in cats. It was demonstrated that among the 14 cats: cranial PE (an atypical location) occurred in seven cats while seven cats had typical (caudal) PE, long PE occurred in five cats, while short PE had nine cats. Of the 14 cats included in the study eight showed symmetric PE, and asymmetric PE was found insix. Thoracic asymmetry was found in six cats. Six cats had sternal torsion. Based on the Vertebral Index moderate or severe PE was revealed in 11 animals. In the group of cats studied the CI ranged from 12.20 to 32.11. The magnitude of AI did not exceed 10% in any of the cats studied. The study confirmed statistically significant differences in the CI values between groups of cats with different degrees of PE severity (p = 0.02). CT examination showed many PE features that have not been discussed so far. The main benefit of CT examination is its ability to reveal asymmetric PE, thoracic asymmetry and sternal torsion. CI and AI provided a clinically useful tool to quantify thoracic wall deformity in order to obtain comparable results between cats with PE.

Noninvasive treatment of pectus excavatum with a vacuum bell combined with a three-dimensional scanner

Our aim was to evaluate the effect of a vacuum bell (VB) combined with a three-dimensional (3D) scanner for the noninvasive treatment of pectus excavatum (PE). A VB was used to create a vacuum at the anterior chest wall with a patient-activated hand pump, and it should be applied regularly for more than 2h each day at home. Eighty-two patients required to be followed up every three months were included in this retrospective study and distributed into four stages (stage 1: treated for 3months, stage 2: treated for 6months, stage 3: treated for 9months, and stage 4: treated for 12months). In addition, the deformity in the chest wall was scanned by a 3D scanner at the clinic, and the 3D depth (3D-DE) and 3D Haller index (3D-HI) of PE were calculated through Geomagic studio 2013 software. Eighty-two patients (12/2017-12/2019) met the criteria at the clinic, and 24 patients (29.3%) achieved excellent correction (3D-DE ≤ 3mm). When comparing the improvement in 3D-DE and 3D-HI of PE to the patient's treatment time, a statistically significant difference was observed between stages 2 and 1 (3D-DE p<0.01, 3D-HI p<0.01), stages 3 and 2 (3D-DE p<0.01, 3D-HI p<0.01) and stages 4 and 3 (3D-DE p<0.01, 3D-HI p<0.01). There was a statistically significant difference in sternum elevation between patients aged <10years and those aged ≥ 10years (3D-DE p = 0.006, 3D-HI p = 0.045) and patients with symmetrical and asymmetric PE (3D-DE p = 0.042, 3D-HI p = 0.032). However, there was no statistically significant difference in sternal elevation between males and females (3D-DE p = 0.27, 3D-HI p = 0.495). The main side effects were moderate subcutaneous hematoma, petechial bleeding, thoracalgia and chest tightness. With controllable side effects, noninvasive treatment for PE with a VB combined with a 3D scanner is safe, objective and radiation free, and the initial results to date are encouraging. Patients aged <10years, with symmetrical PE and treated for over 12months may achieve a better outcome.

The costochondral length in patients with pectus excavatum is longer than that of the normal thorax.

Recently, several investigators reported that costal cartilage does not overgrow in pectus excavatum (PE). We wished to clarify whether costochondral length is longer in PE than the normal thorax and we tried to clarify the change of the shape of precordial concavity according to the growth in PE. We evaluated 243 CT axial images of patients with PE and 246 CT axial images of patients without thoracic deformity. We divided the fifth costal cartilage into several lengths. We considered each part to be a straight line and calculated the length of the lines. We compared the approximate costochondral length between PE and normal thorax. We analyzed the distance between both anterior tips of fifth rib, and the ratio of the width and the depth of concavity to thoracic diameter in PE. The costochondral length in patients with PE is highly likely to be longer than that of the normal thorax. The length of costal cartilage may be longer in asymmetric PE than symmetric PE. It may start in infantile period in PE that the thoracic shape turns into asymmetry from symmetry. The precordial concavity of PE may be shaped by overgrowth of both costal cartilages and ribs.

Utility of radiation-free imaging for initial evaluation of pectus excavatum.

The OrtenBodyOne scanner is a radiation-free, 3-dimensional imaging system recently developed for evaluation of the severity of pectus excavatum (PE). The goal of this study was to evaluate the utility of this new imaging system compared with that of computed tomography (CT) for the evaluation of the severity of PE. Patients treated for PE from April 2015 to January 2017 with available CT and OrtenBodyOne data were included. Correlations between indexes calculated from CT and from OrtenBodyOne were determined by applying the non-parametric Spearman correlation procedure with a Bonferroni correction to adjust for multiple comparisons. Forty men (90.9%) and 4 women (9.1%), 20 with symmetrical (45.5%) and 24 with asymmetrical PE (54.5%), were included. The median age was 16.1 years (range 4.3-63.5 years). The following measures and indexes acquired using OrtenBodyOne and CT were significantly correlated: pectus depth (r = 0.84; P = 0.002), anthropometric index (r = 0.81; P = 0.002) and asymmetry index (r = 0.67; P = 0.002). The correlation between the CT Haller index and the external Haller index was only significant for symmetrical PE (r = 0.57; P = 0.008). The OrtenBodyOne imaging system can be used to evaluate the severity of symmetrical PE using the external Haller index. Asymmetry and anthropometric indexes are more reliable for the evaluation of asymmetrical PE. Measures can be repeated throughout treatment while avoiding unnecessary irradiation.

Rib overgrowth may be a contributing factor for pectus excavatum: Evaluation of prepubertal patients younger than 10 years old

Background/PurposeWe compared the costal cartilage and rib length between prepubertal patients with symmetric pectus excavatum and age- and sex-matched controls without anterior chest wall depression to evaluate if rib overgrowth is a contributing factor for pectus excavatum MethodsThe sample included 18 prepubertal patients <10years old with symmetric pectus excavatum and 18 age-and sex-matched controls without chest wall deformity. The full lengths of the fourth to sixth ribs and costal cartilage were measured using three-dimensional volume-rendered computed tomography and curved multiplanar reformatting techniques. The rib and costal cartilage lengths, total combined rib and costal cartilage length, and costal index ([length of cartilage/length of rib]×100 [%]) at the fourth to sixth levels were compared between the groups. ResultsThe rib lengths in the patient group were significantly longer than in the control group for the 6th right rib and 4th, 5th, and 6th left ribs. The costal cartilage lengths and costal indices were not different between two groups. ConclusionsIn patients with symmetric pectus excavatum aged <10years old, several of the ribs were longer than those of controls, suggesting that abnormal rib overgrowth may be a contributing factor responsible for pectus excavatum rather than cartilage overgrowth.

Radiological evaluation of the eighth thoracic vertebra rotation in the pectus excavatum

Material and methods An analysis of pre-operational 82 CT in children with the pectus excavatum deformity was made. Patients were divided into two groups depending on the chest deformation ; the first one consisted of patients with symmetric pectus excavatum, there were 48 patients (9 girls, 39 boys), the mean age was 12,8 years (4-16), the average Haller index was 3,6 (2,2-7,1); in the second group with dissymmetric pectus excavatum there were 35 patients (8 girls, 27 boys), the mean age was 11,8 years (7-17), the average Haller index was 2,9 (2,4-5,8).

Pectus Excavatum Surgery: Sternochondroplasty Versus Nuss Procedure

The repair of pectus excavatum (PE) by minimally invasive Nuss surgery is well established, but its complication rate is high and its indication is indiscriminate. Sternochondroplasty (SCP) provides good results with a low complication rate but requires a small transverse incision. To compare SCP and Nuss, we analyzed 40 patients with PE who underwent surgery (SCP, n = 20; Nuss, n = 20). Thirty subjects (75.0%) were male and 10 (25.0%) were female. In the SCP group, 9 (45.0%) had symmetric PE, and 11 (55.0%) had asymmetric PE. In the Nuss group, 17 (85%) had symmetric PE, and 3 (15%) had asymmetric PE (p = 0.020). The mean duration of SCP was 229.5 minutes, and the mean duration of Nuss was 54.3 minutes. The average length of hospital stay was 4 days with SCP and 6.3 days with Nuss (p = 0.172). The SCP results were favorable in 18 subjects (90%) and fair in 2 subjects (10%). In the Nuss group, we observed 17 patients (85.0%) with favorable results and 3 (15.0%) with poor results. Patients with asymmetric PE exhibited severe pectus carinatum. No complications were found in 17 patients (85%) in the SCP group. In the Nuss group, 9 patients (45.0%) had 13 complications (65.0%; p = 0.004). Sternochondroplasty surgery yielded better results than the Nuss procedure and more patients with asymmetric PE, less pain, and fewer complications. Nuss surgery had shorter operating times than SCP, younger patients, more symmetric PE, and 3 patients who experienced severe postoperative asymmetric pectus carinatum. In summary, for asymmetric PE the best indication is SCP.

Child pectus excavatum: Correction by minimally invasive surgery

Pectus excavatum (PE) is a congenital deformity essentially responsible for an unattractive aspect, much more rarely for compression problems. The classical treatments consist either in filling the excavation or in open thoracic reconstruction (the Ravitch technique). Alternatively, the treatment described by Nuss raises the sternum with a retrosternal metallic bar placed under thoracoscopic guidance. We present the preliminary results of a series of 25 children operated on using this technique. The minimally invasive procedure described by Nuss is a valid surgical strategy to treat PE. Twenty-five patients were operated on between February 2004 and April 2007 by the same surgeon. Nineteen of these patients presented a purely cosmetic indication. The six other patients were considered to have a more severe form of PE, with cardiorespiratory repercussions. In this group, there were two cases of Marfan syndrome and two patients presenting a history of previous cardiothoracic surgery. The technique has always consisted in placing a retrosternal bar through two lateral incisions. The surgery was always performed with right lung exclusion and was guided by thoracoscopy in 21 cases. In four particularly severe cases, a subxiphoid approach was required, making endoscopic guidance unnecessary. The severity of the lesion was evaluated by the Haller Index. All the patients had regular clinical follow-up (at three weeks, three months, and then every six months); assessment of pain, satisfaction with the cosmetic results, and perceived improvement in respiratory function were the criteria used for this follow-up. The cosmetic result was judged to be positive by 24 patients. One patient was dissatisfied (because of the asymmetrical shape resulting from the use of a single implant). Five patients presented minor complications with no repercussions on the cosmetic or functional result. One case of secondary bar displacement required revision on day 15. Following this revision evolution was uncomplicated (discharge on day 7 and activities resumed at three weeks). Finally, the hardware was removed at a delay after implantation ranging from one to two years. As of today, 13 patients have had their hardware removed with no complications or loss of the initial result. The original indication of the Nuss technique remains symmetrical PE in seven to 14-year-old children. The insubstantial scarring makes the technique valuable in the purely cosmetic forms of the condition. Based on this series, our technique has evolved toward certain adjustments depending on the severity and the etiology of the lesion. The most reported complication in the literature is secondary displacement of the bars. This problem is easily controlled by attaching the bar to a rib. Over the years, we have modified the implant design so as to improve its tolerance and stability. In asymmetrical forms of PE, implanting two bars has provided better efficacy. When a major form is present or when there is a history of cardiorespiratory problems, we recommend a short subxiphoid incision to release the pleural and pericardial adherences, precluding the need for thoracoscopic guidance. With these simple adjustments, this technique gains in reliability for cosmetic indications and its use can be extended to specific forms such as collagenosis or postoperative deformities. Level IV. Therapeutic Study.

Classification of the pectus excavatum and minimally invasive Nuss procedure

To investigate the improvement of the Nuss procedure with the classification of the pectus excavatum by symmetry and extend the indication of the operation for a better outcome. The clinic data of 403 patients who underwent repair of pectus excavatum by Nuss technique and its modifications from July 2002 to September 2007 were reviewed retrospectively. There were 299 male patients and 104 female patients. The age ranged from 2 years and seven months old to 32 years old, with a mean of (8.0 +/- 5.1) years old. The entire group of the CT index ranged from 3.25 to 51.20, with a mean of (5.0 +/- 3.0). According to the morphology of the pectus and practically the bar shaping, Park's classification was simplified to symmetric type, eccentric type, and unbalanced type. The patients of symmetric type were all received original Nuss procedure, and the other two types underwent the procedure using characteristic bar shaping and technical modification. Among the 403 patients, 257 patients (63.8%) were symmetric pectus excavatum, and 48 patients (11.9%) were eccentric, other 98 patients (24.3%) were unbalanced type. All the patients underwent the procedure successfully. The total time of the procedure ranged from 30 to 165 min, with a mean of (45.7 +/- 12.6) min. Volume of blood loss during the operation ranged from 1 to 80 ml, with a mean of (4.8 +/- 6.2) ml. The days of hospitalization ranged from 4 to 12 d, with a mean of (7.1 +/- 1.0) d. The duration of following up ranged from 1 month to 5 years, and the results of the repair were excellent in 391 patients (97.0%). Five patients received a further operation, including 1 patient of recurrent pectus excavatum caused by bar displacement, 4 patients of protruding side way. There were 23 patients of complications for an overall complication rate of 5.7%. And the other 18 patients of complications included 2 patients of pericardium perforation, 2 patients of bar displacements caused intercostal dilaceration, 2 patients of diaphragmatic muscle injuries, 1 patient of hemothorax, 8 patients of pneumothorax, 2 patients of intermittent pains for 2 months, 1 patient of scoliosis caused by persistent pain. To classify the pectus excavatum with symmetry and to choose different ways of procedure can extend the indication of Nuss procedure and receive a better outcome.

Mechanical Occlusion of the Inferior Vena Cava: An Unusual Complication After Repair of Pectus Excavatum Using the Nuss Procedure

We describe the case of a 13-year-old girl with a pectus excavatum in whom acute occlusion of the inferior vena cava developed after a nuss repair. In this hemodynamically unstable patient, we evaluated the possibility of a penetrating injury to the thoracic and abdominal structures before confirming the diagnosis of inferior vena cava obstruction with a venogram. Removal of the nuss bar relieved the unexpected problem.

Suture Repair of Pectus Excavatum at the Time of Cardiac Surgery on an Infant

An 11-month-old girl was diagnosed with pulmonary atresia with intact ventricular septum and symmetrical pectus excavatum that had developed after prior palliative operation. We performed a transannular patch repair and atrial septal defect closure. Simultaneously, to prevent postoperative right ventricular outflow tract compression, the sternum was elevated by two 1-0 braided polyester horizontal mattress sutures on the posterior side of the third and fourth costal cartilages. Postoperative respiratory distress did not occur and her hemodynamics was stable. Four months later, she is alive and well without recurrence of the thoracic deformity.

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The pectus excavatum treatment has two different approaches: non-surgical techniques (modified dynamic thoracic compressor, exercises and the vacuum bell) or surgical techniques (silastic or solid silicone implant, open surgical repair like sternochondroplasty and minimally invasive repair). The introduction of Nuss procedure improved the pectus excavatum treatment, but its low acceptance was due to the high complication rate (e.g. cardiac perfuration). The thoracoscopy use for bar mediastinal passage reduced the complication rate. In comparison with sternochondroplasty, the Nuss procedure has smaller incision, less blood loss and less operative time. However, it has more reoperations, complications, longer hospital stay and more readmission rates, more time of thoracic epidural catheter for postoperative analgesia and more need for analgesic after being discharged. Although Nuss procedure has been used in children, patients under ten years must be only observed. The Nuss procedure is applicable to moderate or light symmetrical pectus excavatum, without costal protrusion, in young and adolescents patients. Furthermore, the sternochondroplasty is applicable to severe or asymmetric pectus excavatum, with or without inferior costal protrusion. Therefore, Nuss procedure and sternocondroplasty are not antagonistic procedures, and they must be used in accordance with a treatment organogram and the technique choice must be by functional and aesthetic outcome.

Technical Innovations in the Minimally Invasive Approach for Treating Pectus Excavatum: A Paradigm Shift through Six Years’ Experience with 630 Patients

: The multiple-momentum (MM) based multitarget (MT) approach has been developed through a single surgeon's experience to overcome the limits of the conventional Nuss procedure, which is the single target-single momentum approach that corrects only symmetric pectus excavatum (PE). The new techniques that have been devised on a morphologic basis, according to the Terrain Contour Matching (TERCOM) system, have made this approach a comprehensive one that can cover all types of pectus deformity. The aim of this study was to elucidate the difference between the conventional technique and the new approach. : The data of 630 PE patients who received the modified Nuss procedure, based on the MM-MT-TERCOM approach, between 1999 and 2005, were retrospectively studied. The conceptual differences between the new approach and the conventional one were determined. The techniques according to a new paradigm, for treating asymmetry, adults, and complex morphology, as well as the bar fixation technique, were analyzed. The results of the repair were assessed with a new CT index, the Asymmetry Index (AI). : According to the morphologic classification, 269 patients were asymmetric (42.7%): 138 were eccentric (53 Grand Canyon type), 88 were unbalanced, and 36 were combined. On the basis of the MM-MT-TERCOM concept for repairing complex morphology, multiple targets were selected in 224 patients (35.6%). To correct targets simultaneously, positive momentum (630 patients, 100%) and negative momentum (124 patients, 19.7%) were applied as appropriate. The techniques used were an asymmetric bar (250 patients, 39.7%), a seagull bar (107 patients, 17%), a complex bar via TERCOM (126 patients, 20%), the crest compression technique (59 patients, 9.4%), and a compound bar (84 patients, 13.3%). The postoperative changes of the AI were from 1.03 ± 0.06 to 1.02 ± 0.13 (P = 0.117) in the symmetric group and they were from 1.1 ± 0.05 to 1.02 ± 0.02 (P < 0.001) in the asymmetric group. : Refinement of techniques in accordance with the morphology and cause-effect basis of the bar action provided reproducible results for achieving postrepair symmetry for treating complex PE. Therefore, the new approach with techniques that use multiple momentums (MM-MT-TERCOM) supports the new paradigm of the Nuss procedure is effective in repair of all morphologic types of PE.

Pectus Excavatum Repair: Review of 80 Cases in 32 Years

We examined the results for pectus excavatum (PE) repair using conventional methods?sternal elevation by modified Ravitch procedure (SEMR), sternal elevation elevation by metal struts (SEMS), sternal turnover (ST) and costoplasty (CP)?and minimally invasive repair of PE (MIRPE) in 80 patients (65 boys and 15 girls) operated between July 1972 and March 2005 at the First Department of Surgery, Nagasaki University Hospital. Of 80 patients, 23 (28.8%) had asymmetric PE, while 57 (71.2%) had symmetric PE. The medians of cosmetic appearance index, functional impairment index and CT index were 0.022, 0.160 and 5.0395, respectively. A significant (p<0.0001) difference was observed among the operative methods for operating time, blood loss and hospital stay; the median of operating time was 85, 252.5, 145, 170 and 170 min for MIRPE, ST, CP, SEMR and SEMS, respectively; the median of blood loss was 5, 299.5, 243, 105.5 and 547.5 mL for MIRPE, ST, CP, SEMR and SEMS, respectively; the median of hospital stay was 10, 18.5, 30.5, 9.0 and 23.5 days for MIRPE, ST, CP, SEMR and SEMS, respectively. Postoperative complications were noted in 23 patients (28.8%), and the most common complication was wound infections. Epidural analgesia was used for postoperative pain control in 12 (75.0%) of 16 patients receiving MIRPE and 4 (7.7%) of 52 patients receiving ST in 1991 or later. The present study suggests that SEMR and MIRPE will be most versatile methods for children among the 5 operation procedures because of minimum invasion and short hospital stay; MIRPE has advantages that it has no incision of anterior chest wall and that it does not require resection of rib cartilages.

The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients

Background The Nuss procedure is a minimally invasive technique using a retrosternal bar to repair pectus excavatum. Although its technical simplicity and cosmetic advantages are remarkable, early applications have been limited to children with symmetrical pectus excavatum. We report a large single-institution experience including technical modifications to correct asymmetric configurations and extend the procedure to adult patients. Methods We retrospectively reviewed 322 consecutive patients who underwent repair of pectus excavatum by the Nuss technique and its modifications between August 1999 and June 2002. Of the patients 251 (78%) were children and 71 (22%) were adults. Precise morphologic characterization of the pectus allowed appropriate shaping of the bar to achieve a symmetric repair. Results Of the 322, 185 (57%) had symmetric and 137 (43%) had asymmetric pectus excavatum. Within the asymmetric group 71 were eccentric, 47 were unbalanced, and 19 were combined. Modifications to the shape of the bar including asymmetric and seagull bars were developed to deal with these types of asymmetry. A double bar or compound bar technique was used in most of the adults. Multipoint wire fixations to ribs were utilized to prevent bar rotation. Postoperative complications included pneumothorax (n = 24, 7.5%) and bar displacement (n = 11, 3.4%). The bar was removed in 42 patients 2 years after the initial procedure. Conclusions Precise morphologic classification has led to modifications of the Nuss technique that facilitate correction of virtually all varieties of pectus excavatum including patients with asymmetric varieties and adults.

Pectus Excavatum / Pectus Carinatum: tratamento cirúrgico

OBJETIVO: Apresentar os resultados obtidos com técnica única para tratamento do Pectus Excavatum e Pectus Carinatum. MÉTODO: De 1976 a 2000 foram operados, 183 portadores de Deformidades da Parede Torácica Anterior sendo 98 Pectus Carinatum (70 P. Carinatum Simétrico, 18 P. Carinatum Lateral a Direita e 10 P. Carinatum Lateral a esquerda), 62 Pectus Excavatum (57 P. Excavatum Simétrico, 4 P. Excavatum Lateral a Direita e um P. Excavatum Lateral a Esquerda), 17 Pectus Carinatum Superior, um Pectus Combinado, quatro Protusões Costais Inferiores e uma Depressão Costal. A indicação foi exclusivamente estética em 182 (99,4%) dos pacientes. Foi utilizada técnica única para Pectus Carinatum e Pectus Excavatum: incisão transversal inframamária; ressecção subpericondral de todas as cartilagens envolvidas na deformidade; dissecção retroesternal mínima; osteotomia esternal anterior, fixação da osteotomia esternal com fios de aço;utilização da placa retroesternal em casos selecionados de Pectus Excavatum; pregueamento dos feixes pericondriais para dar maior rigidez a parede torácica e auxílio na manutenção do esterno na sua posição; drenagem do tecido celular subcutâneo e do plano submuscular, sutura intradérmica da pele. RESULTADOS: Bom ou excelente em 175 (95,6%) dos pacientes. Complicações ocorreram em 14 (7,6%) pacientes: oito casos (4,5%) de seroma; um (0,5%)hematoma de parede; dois (1,0%) caso de dor torácica intensa no pós-operatório; um(1,0%) caso de deiscência parcial da sutura da pele e dois casos (1,0%) de cicatriz hipertrófica que foram tratados com ressecção e betaterapia. CONCLUSÃO: Pelos resultados estéticos alcançados, a esternocondroplastia apresentada está indicada para correção de Pectus Excavatum/Carinatum.

Technical Considerations in the Surgical Management of Pectus Excavatum and Carinatum

During the past 25 years, 650 operations have been performed on 608 patients for anatomically significant pectus excavatum or carinatum deformities of the anterior chest wall. There were no deaths in this series, and serious complications were very rare. We conclude that repair of pectus excavatum and carinatum deformities should include the following operative steps: (1) adequate mobilization of the sternum and correction of its abnormal angulation by transverse osteotomy; (2) adequate bilateral removal of the involved costal cartilage; and (3) securing the corrected position of the sternum with the patient's own living tissue, retaining its blood supply and using it as an internal support. Using these principles, new surgical procedures were developed for the correction of: symmetrical pectus excavatum, asymmetrical pectus excavatum, pectus carinatum with xiphoid angulation, pectus carinatum without xiphoid angulation, asymmetrical pectus carinatum, chondromanubrial prominence with chondrogladiolar depression, and recurrent pectus excavatum. We recommend surgical correction for patients in whom the deformity is significant and no contraindication exists. The ill effects of this condition should not be underestimated.