Symptomatic Pectus Excavatum Research Articles

15 Years of Vacuum Bell Therapy for Pectus Excavatum: Long-term Outcomes and Influencing Factors

BackgroundLong-term results and factors affecting outcomes of vacuum bell therapy for pectus excavatum are relatively unknown. MethodsWe conducted a retrospective study on patients (<18y) treated with vacuum bell therapy between May 2008 and October 2021. Primary outcome was treatment success; secondary outcomes were analysis of daily time spent on treatment, treatment duration, complications, long-term follow-up, treatment for patients awaiting a Nuss procedure, treatment for female patients, and factors affecting outcomes. ResultsOf 259 patients treated with vacuum bell therapy, 18.9% (n = 49/259) were still being treated, 17.4% (n = 45/259) were lost to follow-up and 63.7% (n = 165/259) completed treatment, with a 52.1% (n = 86/165) success rate. Median follow-up was 64.0 months (interquartile range 48.0–87.0). More time spent daily on vacuum bell therapy, total treatment duration, and overnight use led to a higher success rate (P = 0.002, P < 0.001, P < 0.001 resp.). Complications (22.8%, n = 59/259) were minor, recurrence occurred in 2.3% (n = 2/86) of patients. Of the patients treated while awaiting a Nuss procedure, 26.7% (n = 4/15) no longer required the Nuss procedure. Breast growth made 39.3% (n = 11/28) of female patients quit treatment. Deeper deformities (P = 0.02, P = 0.009), flexible chest wall (P = 0.007) and symptomatic pectus excavatum (P = 0.02) resulted in lower success rates. ConclusionsVacuum bell therapy is successful in up to 52.1% of patients. Overnight vacuum bell use and treatment while awaiting a Nuss procedure should be encouraged. Older patients with a stiff chest wall can be successfully treated with prolonged treatment. For female patients watchful waiting or early treatment, to prevent challenges during breast growth, is preferred. Level of evidenceLevel II.

Management of Internal Mammary Artery Injuries Associated With the Nuss Procedure.

The minimally invasive repair of pectus excavatum (MIRPE), or Nuss procedure, is regarded as the gold standard technique for the treatment of symptomatic pectus excavatum. Minimally invasive repair of pectus excavatum is regarded as a low-risk operation with a reported life-threatening complication rate estimated at around 0.1%. Presented are three cases of right internal mammary artery injury (RIMA) after MIRPE resulting in massive hemorrhage in both the acute and chronic postoperative setting and subsequent management strategies. Exploratory thoracoscopy and angioembolization were utilized which achieved prompt hemostasis and allowed for complete patient recovery.

Nuss Procedure for pectus excavatum repair in a patient with osteogenesis imperfecta

A 17-year-old male with Osteogenesis Imperfecta (OI) type 1 and history of prior spinal instrumentation for kyphosis presented with severe symptomatic pectus excavatum (PEx). His Haller index was 6.7 with a Pectus Correction Index of 51%. He underwent uncomplicated Nuss procedure with insertion of 3 bars and complete repair of the PEx. A single sternal fracture was sustained during correction and healed without deformity. After two years, he developed left-sided pain and two of 3 bars were removed with maintained chest correction. This case report demonstrates the feasibility of Nuss procedure in adolescents with OI and outlines improvements to the technique in future patients with OI. • The Nuss procedure is feasible in teenagers with osteogenesis imperfecta. • Bone mass density should be optimized with bisphosphonates prior to procedure. • Multiple bars and vertical sternal elevation clamp placement may decrease fractures.

Can categorised values of maximal oxygen uptake discriminate patterns of exercise dysfunction in pectus excavatum: a prospective cohort study?

Cohort studies of patients with pectus excavatum have inadequately characterised exercise dysfunction experienced. Cardiopulmonary exercise test data were delineated by maximal oxygen uptake values >80%, which was tested to examine...

Surgical correction of recurrent pectus excavatum of an adult patient, case report, and review of literature.

The aim of this paper is to review the literature on recurrent pectus excavatum (PE) and present our surgical approach to a complex case of recurrent PE in an adult patient at a Mexican Hospital. We present the case of an adult patient with severe and symptomatic PE, with history of a failed Nuss procedure 1 year previous our intervention, which consisted of a combination of both classic techniques, by performing an osteochondrectomy of affected cartilages and placing a titanium bar substernal and stabilizing coastal arches with secondary osteosynthesis system (Stratos ™ system, medXpert, Germany). Adequate correction of thoracic silhouette and both cardiac and respiratory disorders in the 1-year follow-up was achieved as indicated by the improvement of the patient's Haller index. Successful surgical correction of pectus excavatum is achieved when the thoracic silhouette is restored, thus improving cardiopulmonary symptoms. As there are many different techniques available, the more minimally invasive ones are reserved for mild cases, but the treatment of complex cases as in our patient requires a combination of multiple techniques and reconstruction materials in order to achieve adequate correction of the thoracic deformity and reduce recurrence rate.

Long-term results of surgical correction of symptomatic pectus excavatum in seniors: improvements in cardiovascular function and quality of life

Long-term results of surgical correction of symptomatic pectus excavatum in seniors: improvements in cardiovascular function and quality of life

Pectus excavatum from a pediatric surgeon's perspective.

Historically, pectus excavatum (PE) was reported to be congenital, but in our experience only 22% are noticed in the first decade of life. Thus far, genetic studies support an autosomal recessive heritability, which coincides with only 40% of our patients having some positive family history, but is also contradictory given a constant sex ratio of 4:1 in favor of males. This inconsistency may be explained by the effect of more than one pectus disease-associated allele. Once the deformity is noticed, it tends to progress slowly until puberty, when rapid progression is often seen. We recommend surgical repair at around 12-14 years of age since the chest wall is still typically flexible and because this allows us to keep the bar in place as the patient progresses through puberty which may help decrease growth-related recurrences. Patients with mild to moderate PE are treated with therapeutic deep breathing, posturing, and aerobic exercises, and in appropriately selected patients, the vacuum bell may also be offered. Patients that have severe symptomatic PE are offered Minimally Invasive Repair of Pectus Excavatum (MIRPE). The surgical technique in children is similar to that of adults, except for the higher forces involved that often necessitate sternal elevation and more involved stabilization strategies. Postoperative management includes pain control, deep breathing, and early ambulation. Exercise restriction is mandatory for the first six weeks with slow resumption of normal activity after 12 weeks.

Symptomatic pectus excavatum in seniors: an exploratory study on clinical presentation and incidence in daily practice.

Objectives. Doctors all over the world consider a pectus excavatum usually as an incidental finding. There is some evidence suggesting that a pectus excavatum may cause symptoms in the elderly. It is not known how often a pectus excavatum occurs and how strong the relation is with symptoms. Methods. In hospitals and general practice data, we searched for evidence of a connection between cardiac symptoms and the presence of a pectus excavatum in a retrospective survey among patients in whom a pectus excavatum was found in a chest X-ray. In radiology reports, we searched for “pectus excavat∗ ” in almost 160000 chest X-rays. The identified X-rays were reviewed by 2 radiologists. Reported symptoms were combined to a severity sum score and the relation with pectus excavatum was assessed through logistic regression. Results. Pectus excavatum was found in 1 to 2 per 1000 chest X-rays. In 32% of patients (N = 117), we found symptoms that might reflect the presence of symptomatic pectus excavatum. We found a significant relation between the SPES sum score and the radiological level of pectus excavatum. Conclusions. A pectus excavatum found when examining the patient should not be neglected and should be considered as a possible explanation for symptoms like dyspnoea, fatigue, or palpitations.

Rapidly Progressive Scheuermannʼs Disease in an Adolescent After Pectus Bar Placement Treated With Posterior Vertebral-Column Resection

Case report and review of the literature. This case illustrates the importance of the costosternal complex in maintaining the stability and alignment of the thoracic spine. The patient was iatrogenically destabilized by placement of a pectus bar leading to rapid symptomatic progression of his Scheuermann's kyphosis, ultimately requiring surgical correction. Scheuermann's kyphosis is a disease process defined by strict radiographical and clinical criteria. Surgical treatment is generally recommended for curves greater than 75°. This case demonstrates the critical role of the costosternal complex in maintaining the stability of the thoracic spine. The patient described in this report underwent placement of a pectus bar for correction of symptomatic pectus excavatum. He subsequently developed a progressive symptomatic Scheuermann's kyphosis as a result of the destabilization of his costosternal complex. This patient ultimately required removal of the pectus bar and posterior instrumented kyphosis correction. Progressive symptomatic Scheuermann's kyphosis (105°) corrected by removal of the pectus bar, T11 posterior vertebral-column resection and T4-L3 instrumented posterior spinal fusion. The patient had an uneventful immediate postoperative course. He was discharged neurologically intact with dramatic kyphosis correction and significant symptomatic improvement. Radiographs obtained 3 years postoperatively reveal stable thoracolumbar correction. The costosternal complex plays a critically important role in the intrinsic stability of the thoracic spine. Iatrogenic disruption of the costosternal complex can result in rapid progression of thoracic/thoracolumbar kyphosis in the setting of Scheuermann's disease.

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.

Quantitative assessment of right ventricular function in pectus excavatum

Pectus excavatum is a common congenital chest wall deformity. Underlying cardiac chambers, in particular the right atrium and right ventricle (RV), may be compressed between the vertebral column and the depressed sternum in patients with this thoracic deformity. Citing improvement in indices of cardiovascular function after corrective surgery, some investigators have suggested that the deformed chest may contribute to cardiopulmonary impairment. Although cardiopulmonary impairment certainly may contribute to symptoms in patients with pectus excavatum and guide the need for and timing of corrective surgery, guidelines for the assessment of resting cardiovascular function remain undefined. Furthermore, the qualitative echocardiographic assessment of RV function and volumes among patients with pectus excavatum may be technically difficult and limited by subjectivity. Quantitative echocardiographic parameters, such as tricuspid annular plane systolic excursion (TAPSE) and RV fractional area change, may offer a more accurate assessment of RV function in this anatomically distinct population. Cardiac magnetic resonance (CMR) imaging has emerged as the criterion standard in RV functional assessment and, more recently, has been validated in patients with pectus excavatum. We compared qualitative assessment of RV systolic impairment by visual echocardiographic inspection with quantitative assessment of RV function with CMR and echocardiographically derived TAPSE and RV fractional area change in a series of patients referred to our institution with mild to severe symptomatic pectus excavatum. Patients were being considered for corrective surgery. Our hypothesis was that the patients would be found to have normal RV function when assessed quantitatively, either through CMR or quantitative echocardiographic examination, despite impairment seen qualitatively.

912 Open Pectus Excavatum Repairs: Changing Trends, Lessons Learned: One Surgeon’s Experience

Severe pectus excavatum (PE) is common, often causing physiologic impairment. Inconsistent results have been reported using a variety of open surgical techniques with extensive subperiosteal costal cartilage resection. Since 1969, 912 (80% men) symptomatic PE patients (mean severity index 4.9) underwent open surgical correction at UCLA Medical Center by one surgeon. Almost all patients had dyspnea, reduced endurance, tachypnea, and tachycardia with exertion. The mean age at operation was 19.8 years. Asymmetric depression was present in 465 (51%) patients; combined PE and pectus carinatum was present in 33 patients. Recurrent PE deformities were repaired on 73 patients. Progressively less deformed costal cartilage was resected during the 38-year period; almost all of the last 303 patients had only short segments excised from both ends with suture reattachment. Transverse wedge sternal osteotomy was used on all patients, and 883 (97%) had a sternal support strut for 6 to 9 months. Dyspnea, endurance, tachypnea, and tachycardia was improved in almost all patients within 5 months after repair. Repair for recurrent deformities and resection of mild localized cartilage protrusion was reduced more than threefold when minimal cartilage resection with wire reattachment was used. Postoperative complications in the last 537 patients were less frequent, pain was less severe, and results were better than when more extensive previous repairs were used (mean follow-up 7.6 years). Very good or excellent results were reported by 94.2% of all patients. In this largest series of open PE repair, progressively less extensive operative techniques have resulted in low morbidity, mild pain, short hospitalization, and very good physiologic and cosmetic results.

Management of pectus chest deformities in female patients

Background There is sparse published information regarding surgical management of females with pectus excavatum (PE) or carinatum (PC) deformities. Methods During the past 33 years 104 females with PE, and 21 with PC underwent surgical repair using extensive modifications of the Ravitch technique. Seven had previous right breast implants, 3 had prostheses placed in the PE deformity. Nine PE patients underwent successful pregnancy before repair, but had severe third trimester dyspnea. Results Very good to excellent results were reported by 96% (mean follow-up, 6 years). Increased endurance, decreased dyspnea, reduced chest discomfort, and less tachycardia occurred in all within 6 months. No patients had significant breast asymmetry after repair. Complications included mildly hypertrophic scar (8), transient pleural effusion (3), bar displacement (1), and mild recurrence (3). Conclusions Females with symptomatic PE or PC, can be repaired with low morbidity, mild pain, low cost, and improvement in body image and symptoms. Prostheses are not beneficial in the treatment of physiologic symptoms caused by pectus deformities.

Pectus excavatum: Tratamiento con técnica mínimamente invasiva

Introduction : pectus excavatum is a malformation of the anterior thoracic wall, characterized by a deep depression of the sternum and alteration of the inferior chrondosternal joints. In the majority of cases the malformation is congenital. Objective : to report our experience in the treatment of pectus excavatum using an minimally invasive surgical technique. Patient s: we analyze a serie of 8 patients aged between 4 and 15 years with symptomatic pectus excavatum and submitted to surgical correction using a videothoracoscopic method first described by Donald Nuss in 1997. The technique does not require rib resections or sternotomy. Results : A retrosternal metallic implant was introduced in all patients using videothoracoscopic support. No intraoperation complications occurred and with a satisfactory surgical correction of the deformity with a follow-up time of between 1 and 15 months. After 2 years the implant must be removed. Comments : After the publication of Nuss´s technique it has been used in various centers, who have published their results in the literature, valuing the good anatomical, physiological and esthetical results and the reduction of surgical operating time.

Repair of pectus excavatum and carinatum in adults

BACKGROUND: There is sparse published information regarding the repair of pectus chest deformities in adults. This report summarizes our clinical experience with the surgical repair of pectus excavatum and carinatum deformities in 25 adults. METHODS: During the past 11 years, 25 patients 20 years of age or older (mean 31) with symptomatic pectus excavatum (23) or carinatum (2) deformities underwent surgical repair using a temporary internal sternal support bar. RESULTS: Each of the patients with decreased stamina and endurance or dyspnea with exercise experienced marked clinical improvement within 4 months postoperation. Exercise-induced asthma was improved in 6 of 7 patients; chest pain was reduced in each of 9 patients. Postoperative complications included pneumothorax (1), keloid (2), and discomfort from sternal bar (2). The sternal bar was removed 7 to 10 months postoperation in 19 patients; there has been no return of preoperative symptoms or recurrent depression in any patient with a mean follow-up of 4.8 years. CONCLUSIONS: For adults who have symptoms and activity limitations related to uncorrected pectus chest deformities, surgical repair can be performed with low morbidity, low cost, minimal limitation in activity, and a high frequency of symptomatic improvement. The operation in adults is more difficult than in children, although the results are similar.