Underwent Pectus Excavatum Repair Research Articles

The implementation of a pectus bar insertion enhanced recovery after surgery pathway: A quality improvement initiative.

Pectus excavatum repair is associated with significant discomfort, and pain is a primary contributor to postoperative hospital length of stay. Recent advances in postoperative pain control include the use of intercostal cryoablation techniques that may now make it possible to discharge patients on the day of surgery. Unnecessary variation in patient care and noncompliance with care bundles may be a factor in extended length of stay. The global aim of this quality improvement initiative was to successfully implement an enhanced recovery after surgery (ERAS) pathway on patients undergoing pectus excavatum repair. The SMART aim was to have a greater than 70% compliance for the perioperative bundle elements within 1 year of the pathway implementation. Multiple Plan-Do-Study-Act (PDSA) cycles were designed to create and implement an ERAS pathway for patients undergoing a pectus bar insertion procedure. This multidisciplinary pathway was designed, managed, and implemented with key stakeholders from the Departments of Evidence Based Practice, Surgery, Anesthesiology, and Perioperative Nursing. Patient characteristics, outcomes, and compliance with elements of the pathway were measured for analysis for both the baseline and post-intervention groups with monthly automated reports. After implementation of the ERAS pathway, data on the first 50 patients showed a 90% compliance with the perioperative bundle elements. Mean length of stay was significantly decreased from 33 h (95% CI [28.76, 37.31]) to 18 h (95% CI [14.54, 21.70]). There were zero readmissions within 24 hours for patients who were discharged on the day of surgery. Employing a multidisciplinary approach in both planning and execution that standardized clinician practices and minimized unnecessary variation in patient care, an ERAS pathway for pectus bar insertion has been successfully established at our institution.

Analysis of Factors Affecting Postoperative Opioid Requirement in Pediatric Patients Undergoing Pectus Excavatum Repair with Multimodal Analgesic Management.

Children with pectus excavatum are treated with surgical repair in a procedure known as minimally invasive repair of pectus excavatum (MIRPE). MIRPE causes considerable postoperative pain, resulting in the administration of a substantial dose of opioids. This study aimed to identify perioperative factors that influence the requirement for opioids in children undergoing MIRPE. Retrospective data from children who underwent MIRPE were analyzed. A multimodal analgesic protocol was implemented with a continuous wound infiltration system and administration of non-opioid analgesics. Intravenous opioid analgesics were administered if the pain score was greater than 4. The cumulative opioid use was assessed by calculating the morphine equivalent dose at 6, 24, and 48 h after surgery. Perioperative factors affecting the postoperative opioid use were identified with multiple linear regression analyses. This study included 527 children aged 3-6 years, with a mean age of 3.9 years. Symmetrically depressed chest walls, a lower Haller index, and a lower revised depression index were found to be associated with decreased postoperative opioids. Boys required higher opioid doses than girls. Longer pectus bars (10 inches versus 9 inches) were associated with increased opioid use. Severity indices, gender, and the length of pectus bars influence postoperative opioid requirement in children undergoing MIRPE surgery with multimodal analgesia.

Long-Term Recurrence Rates and Patient Satisfaction after Repair of Pectus Excavatum.

Pectus excavatum deformities are usually repaired with a minimally invasive approach in which a metal bar is used to correct the chest wall abnormality. We aimed to evaluate long-term outcomes and patient satisfaction after surgical correction. Patients who underwent pectus excavatum repair and subsequent bar removal at a single tertiary care center from January 2000 to December 2020 were identified. A retrospective chart review was performed, and a telephone survey was conducted to evaluate perceived inward chest movement, need for surgeon reevaluation, surgical reintervention, and overall satisfaction. Data are presented as medians with interquartile ranges (IQRs) and frequencies with percentages. A total of 583 patients were included. The survey response rate was 26.2% (n = 153). The respondents were predominantly male (80.4%, n = 123) with a median age at surgical correction of 14.9 years (IQR 12.9, 16.1) and a median Haller index (HI) of 3.8 (IQR 3.4, 4.5). Median time to bar removal was 2.9 years (IQR 2.5, 3.0) with a median age at removal of 17.7 years (IQR 15.5, 19.0). Median time from surgery to survey follow-up was 9.6 years (IRQ 5.0, 11.4) with respondents having a median age at follow-up of 25 years (IQR 22.0, 28.4). The satisfaction rate was 96.7% (n = 148) with a reintervention rate of 2.0% (n = 3). The perceived inward chest movement was 30.7% (n = 47) with 12.8% (n = 6) of those requesting surgical reevaluation. There is a high level of satisfaction many years after correction of pectus excavatum and bar removal. With the advent of cryoablative therapy since 2017, patient satisfaction improved by experience of less postoperative pain. Reintervention rate is low despite some patients reporting a perceived chest wall inward movement.

Effects of oxycodone pharmacogenetics on postoperative analgesia and related clinical outcomes in children: a pilot prospective study.

Background: Variability in the pharmacokinetics and pharmacodynamics of oxycodone in children undergoing surgery could be due to genetic polymorphisms. Materials & methods: The authors studied the association between clinical outcomes and pharmacogenes in children undergoing major surgery. A total of 89 children (35 undergoing pectus excavatum repair and 54 undergoing spinal fusion) were recruited. Results: OPRM1 SNP rs6902403 showed an association with maximum pain score and total morphine equivalent dose (p<0.05). Other polymorphisms in OPRM1 SNP, PXR, COMT and ABCB1 were also shown to be associated with average morphine equivalent dose, length of hospital stay and maximum surgical pain (p<0.05). Conclusion: This study demonstrates novel associations between the above pharmacogenes and oxycodone's pharmacokinetics as well as postoperative outcomes in children. Clinical trial registration: NCT03495388 (ClinicalTrials.gov).

Intercostal Nerve Cryoablation is Associated with Reduced Opioid Use in Pediatric Oncology Patients

IntroductionIntercostal nerve cryoablation reduces postoperative pain in adults undergoing thoracotomy and children undergoing pectus excavatum repair. We hypothesize that cryoablation is associated with decreased post-thoracotomy pain and opioid use in pediatric oncology patients. MethodsA single-center retrospective cohort study was performed for oncology patients who underwent thoracotomy from January 1, 2017 to May 31, 2021. Outcomes included postoperative opioid use measured in morphine milligram equivalents per kilogram (MME/kg), pain scores (scale 0-10), and opioid prescription at discharge. Univariable analysis compared patients who received cryoablation to patients who did not receive cryoablation. Multivariable regression analysis controlling for age and prior thoracotomy evaluated associations between cryoablation and postoperative pain. ResultsOverall, 32 patients (19 males:13 females) underwent thoracotomy with 16 who underwent >1 thoracotomy resulting in 53 thoracotomies included for analysis. Cryoablation was used in 14 of 53 (26.4%) thoracotomies. Throughout the postoperative hospitalization, patients receiving cryoablation during thoracotomy consumed less opioids compared to patients who did not receive cryoablation (median 0.38 MME/kg, interquartile range [IQR] 0.20-1.15 versus median 1.47 MME/kg, IQR 0.71-4.02, P < 0.01). Maximum pain scores were lower in cryoablation patients (median 6, IQR 5-8) than noncryoablation patients (median 8, IQR 6-10), with a significant difference observed on postoperative day 4 (P = 0.01). Cryoablation patients were also less frequently prescribed opioids at discharge (21.4% versus 58.97%, P = 0.02). Multivariable regression demonstrated that cryoablation was associated with 2.59 MME/kg less opioid use (95% confidence interval −4.56 to −0.63) and decreased likelihood of opioid prescription at discharge (adjusted odds ratio 0.14, 95% confidence interval 0.03-0.67). ConclusionsCryoablation is significantly associated with decreased post-thoracotomy pain and opioid use in pediatric cancer patients and should be considered in postoperative pain regimens.

Evolution of technique and results after permanent open repair for pectus deformities.

ObjectiveOpen correction of pectus deformities has evolved since its origin. We performed a Ravitch type repair using a permanent titanium plate fixed with screws and describe the procedure with outcomes after our modifications.MethodsA retrospective review of 61 pectus excavatum and pectus carinatum cases from August 2013 to April 2021 was performed. Data were extracted from medical records and reported. In January 2016, we began administering satisfaction surveys at the 6-month postoperative visit; results are reported.ResultsThe mean age of our cohort was 24.5 years; 43 (70%) were male. Fifty-four underwent pectus excavatum repair, 6 pectus carinatum repair, and 1 mixed repair. Median Haller index was 3.8. Mean operative duration was 98 minutes; mean blood loss was 116.4 mL. Median chest tube duration was 5.0 days; median hospital stay was 4 days. Reexploration for bleeding was 30% in the first 10 patients. Protocol changes including postponing chemical deep vein thrombosis prophylaxis, using intraoperative hemostatic agents, and using shorter implantation screws decreased this to 0% for the remaining cases. The most frequent complication was urinary retention (21.3%). Postoperative surveys were completed for 37 of 50 patients. Seventy-five percent reported health improved, 65% reported exercise capacity improved, 75% reported breathing improved, and 59% reported chest pain improved. Self-esteem improved from 6.6 ± 2.5 (of 10) before surgery to 8.2 ± 2.1 after surgery. Ninety percent were satisfied and 86% would have the operation again.ConclusionsRavitch type repair with permanent titanium plate fixation is a safe and effective procedure for correction of pectus excavatum and carinatum. Most patients experience improvement in preoperative symptoms.

R15. Initiation of Clinical Care Guidelines for Pectus Excavatum Patients: A Retrospective Review

Adolescents undergoing pectus deformity repairs typically have significant postoperative pain. Management following repair consists of opioids, non-opioid adjuvants with either a thoracic epidural or paravertebral catheter.1,2 Enhanced Recovery After Surgery (ERAS) protocols have been established in the adult population and are now becoming more common in pediatrics and adolescents.2,3 A standardized Pectus Pain Management Clinical Pathway (PPMCP) was established in 2017 at our institution by the anesthesiology team. Later a multidisciplinary clinical care guideline (CCG) was established in May 2019 through collaboration with the surgery, anesthesia, physical therapy and nursing teams. The acute pain team at Lurie Children's Hospital of Chicago have observed improvement in the postoperative course of these patients since the establishment of both the PPMCP and then the CCG. Therefore, a retrospective study was done to evaluate the effects of standardization of care for patients undergoing pectus excavatum repair.

A New Device for Thoracoscopic Cryoanalgesia in Pectus Excavatum Repair: Preliminary Single Center Experience.

Introduction: Cryoanalgesia has been recently described as alternative technique for immediate and persistent pain treatment after pectus excavatum repair. Cryoanalgesia has the potentiality to reduce analgesic consumption and length of hospitalization. However, cryoanalgesia has not been standardized yet: the previous reports describe different techniques and systems and include only small series. In Europe, no reports on cryoanalgesia for pectus repair have been published so far.Materials and Methods: This is a prospective single center pilot study performed in adolescents undergoing minimally invasive pectus excavatum repair with a new cryoanalgesia system, using a probe designed specifically for thoracoscopy. This new double lumen probe has the theoretical advantage of freezing only in its tip, so reducing the risk of complications.Results: Seven patients undergoing pectus excavatum repair were treated with cryoanalgesia performed with the new probe. No complications of cryoanalgesia were reported. Total consumption of morphine during hospital stay was between 0.1 and 0.35 mg/kg, with no side effects reported. Mean time to discharge was 2.4 days. All patients reported a good pain control with a fair need of rescue medications for pain relief during the first week after discharge, and a very good pain control without need of rescue medications during following weeks.Conclusions: Our pilot study showed that the new cryoanalgesia device is efficacious in terms of pain control, hospital stay and resumption of post-operative activities. The cryoprobe designed allowed an easy and safe maneuver. A prospective trial is needed to better define the risks and benefits of this technique.

Cryoablation is associated with shorter length of stay and reduced opioid use in pectus excavatum repair.

The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE). A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications. LOS decreased to 2.5days in the INC group compared to 5days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group. INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.

Anesthetic management of a 12-year-old child with Kagami-Ogata syndrome for pectus excavatum: a case report

BackgroundKagami-Ogata syndrome (KOS) is due to abnormal gene expression in the 14q32.2 imprinted region. Laryngomalacia and bell-shaped thorax of children with KOS can affect airway management of general anesthesia.Case presentationA 12-year-old girl with KOS had a mechanical ventilation history and underwent pectus excavatum repair for cosmetic reasons. Although she had undergone invasive thoracic surgery under general and epidural anesthesia, her respiratory rate and tidal volume were stable with adequate pain control mainly through epidural analgesia at the end of the surgery. We examined her larynx by a bronchoscope. Then, we successfully extubated her after confirming the normal movement of her larynx.ConclusionsWhen patients with KOS undergo pectus excavatum repair, anesthesiologists should prevent postoperative respiratory failure by providing adequate postoperative analgesia. Evaluation of airway patency and respiratory pattern before extubation is critical.

Analyzing Outcomes of Nuss and Ravitch Repair for Primary and Recurrent Pectus Excavatum in Adults

Limited data exist for pectus excavatum repair in adults. We reviewed outcomes in adult patients undergoing Ravitch or Nuss pectus excavatum repairs to determine whether there was a statistical difference in postoperative complications and recurrence between primary and redo operations. Patients undergoing pectus excavatum repair between 2001 and 2018 were excluded if they were receiving a concurrent unrelated operation, aged younger than 18 years, or had less than 1 year of follow-up (for recurrence analysis). Postoperative complications were recorded based on procedure type (Ravitch/Nuss) and iteration of repair (primary/redo). Continuous patient data were compared using Student t tests for variables such as age, length of stay, estimated blood loss, body mass index, and number of bars inserted. Fisher exact or χ2 tests were performed for postoperative complications and recurrence rates between groups. Of 290 patients, there were no significant differences in postoperative complications or recurrence rates between all Nuss repairs (n= 237; P= .59) and all Ravitch repairs (n= 53; P= .48), redo Nuss repairs (n=53; P= .26) and Ravitch repairs (n=26; P= .99), and primary (P= .26) and redo Nuss (P= .10) repairs or primary (P= .99) and redo Ravitch (P= .99) repairs. There were significant differences in age, length of stay, follow-up, bars inserted, and estimated blood loss betweenall Nuss and Ravitch repairs (P < .05). Postoperative complication and recurrence rates were not statistically different between Nuss and Ravitch procedures of all types, suggesting either procedure may have utility in recurrent pectus excavatum. Further research may look to expand sample size and a prospective study investigating long-term outcomes.

Short-term Outcomes After Pectus Excavatum Repair in Adults and Children

BackgroundPectus excavatum is a common congenital chest wall deformity often repaired during adolescence, although a subset of patients undergo repair as adults. The goal of our study was to determine the effects of age at repair and repair technique on short-term surgical outcomes. Materials and methodsWe performed a cohort study of patients in the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project pediatric (age<18 y) and adult databases who underwent pectus excavatum repair. The primary outcome was the incidence of 30-d complications. Secondary outcomes included length of stay, reoperation, and readmission. Multivariable logistic regression was used to estimate the independent effects of patient age and type of repair on postoperative outcomes. ResultsOf the 2268 subjects included, 2089 (92.1%) were younger than 18 y. Overall, 3.4% of patients suffered a 30-d complication, and the risk was similar between age groups (risk ratio [RR], 0.69; 95% confidence interval [CI], 0.08-5.03; P = 0.731). Steroid therapy was an independent risk factor for complications (RR, 8.0; 95% CI, 1.9-19.7; P = 0.006). Median length of stay was 4 d (interquartile range, 3-5) and was similar between age groups. Risk for readmission and reoperation were 2.8% and 1.5%, respectively, and were similar for pediatric and adult patients. When comparing minimally invasive repair with and without thoracoscopy, risk for 30-d complications was lower among patients repaired with thoracoscopy (RR, 0.56; CI, 0.32-0.96; P = 0.034). ConclusionsPediatric and adult patients experience comparable rates of postoperative complications, readmission, and reoperation after pectus excavatum repair. Use of thoracoscopy during minimally invasive repair is associated with lower risk of complications. These findings suggest that thoracoscopy should be used routinely for minimally invasive repair of pectus excavatum.

Pain Management in Pectus Excavatum Surgery: A Comparison of Subcutaneous Catheters Versus Epidurals in a Pediatric Population

Pectus excavatum is a common chest wall anomaly. Achieving optimal pain control is a priority for adolescents undergoing surgical correction of this condition. Options for pain control include the use of subcutaneous catheters (On-Q® pumps) and epidurals. The objective of this study is to demonstrate the feasibility of using subcutaneous catheters for pain control and to compare them with the use of epidurals during surgical correction of pectus excavatum. We identified patients who underwent pectus excavatum repair at our institution between January 2010 and August 2016. Patients were divided into two cohorts (epidural or On-Q pump). Patient charts were reviewed for length of stay, pain scores, pain medications, and complications. A total of 124 patients were included. Forty percent of patients used an epidural (n = 50), and 60% had the On-Q pump (n = 74). The average patient age was 15.6 years. The average Haller index was 4.3. The On-Q pump population had a significant decrease in postoperative length of stay (mean [M] = 4.86, standard deviation [SD] = 0.85) compared with the epidural population (M = 5.60, SD = 0.97); P ≤ .001. There was a significant difference observed in pain scores for patients on the epidural (M = 2.91, SD = 1.13) and On-Q pump (M = 3.81, SD = 1.19; P ≤ .001). There was n = 1 wound infection in each group. The use of bilateral subcutaneous infusion catheters is a safe and effective method for pain control in patients undergoing surgical correction of pectus excavatum. Even though the degree of pain control is not necessarily superior to epidurals, in this study, the catheters were associated with a shorter postoperative length of stay in this patient population and did not increase the incidence of complications.

Complications after pectus excavatum repair using pectus bars in adolescents and adults: risk comparisons between age and technique groups.

To compare the complications associated with age and technique groups in patients undergoing pectus excavatum (PE) repair. The data of 994 patients who underwent PE repair from March 2011 to December 2015 were retrospectively reviewed. Mean age was 9.59 years (range 31 months-55 years), and 756 patients were men (76.1%). The age groups were defined as follows: Group 1, <5 years; Group 2, 5-9 years; Group 3, 10-14 years; Group 4, 15-17 years; Group 5, 18-19 years; Group 6, 20-24 years; and Group 7, >24 years. The technique groups were defined as follows: Group 1, patients who underwent repair with claw fixators and hinge plates; Group 2, patients who underwent repair with our 'bridge' technique. Complications were compared between age groups and technique groups. No cases of mortality occurred. Complication rates in the age groups 1-7 were 5.4%, 3.6%, 12.1%, 18.2%, 17.3%, 13.9% and 16.7%, respectively. The complication rate tripled after the age of 10. In multivariable analysis, odds ratio of Groups 4, 5 and 7 and asymmetric types were 3.04, 2.81, 2.97 and 1.70 (P < 0.01, P = 0.02, 0.03 and 0.03, respectively). The bar dislocation rate in technique Group 1 was 0.8% (6 of 780). No bar dislocations occurred in technique Group 2. Older patients have more asymmetric pectus deformity and they are also risk factors for complications following PE repair. The bridge technique provides a bar dislocation rate of 0%, even in adult patients. This procedure seems to reduce or prevent major complications following PE repair.

The Minimally Invasive Repair of Pectus Excavatum Using a Subxiphoid Incision.

Purpose Several surgeons have documented outcomes following the Nuss operation. Most reports have described the use of thoracoscopy to avoid cardiac injury. Since 1999, our group has utilized a subxiphoid incision, allowing insertion of the surgeon's finger into the substernal space to help guide the bar across the mediastinum. Our initial experience has been reported and we are now reporting our entire experience to date. Methods A retrospective review was conducted on all patients who underwent pectus excavatum repair using a subxiphoid incision from December, 1999 to September, 2015. Results During the study period, 554 repairs were performed. A total of 80% of the patients were male. The mean age was 14.3 years ± 3.1, the mean operating time was 52 minutes ± 17.4, the mean length of stay was 4.2 days ± 1.1, and the mean time to bar removal was 2.7 years ± 0.7. A total of 20 patients (3.6%) received two bars. No patients sustained cardiac injury or evidence of pericarditis. Postoperatively, 22 patients (4%) developed an infection, either cellulitis or a local abscess requiring incision and drainage and/or antibiotics. In four of these 22 patients, the wound infection developed after the bar had been removed. Only one patient required bar removal before 2 years due to an infection. A total of 12 patients required either repositioning of the bar due to rotation (4) or removal of a stabilizer due to chronic discomfort (8), 2 required early bar removal for chronic pain, and 1 patient developed a tension pneumothorax in the operating room. A recurrence has developed in two patients but neither patient has desired correction. Conclusion In this relatively large series of patients, the addition of a subxiphoid incision to the technique has allowed for safe passage of the bar across the mediastinum to avoid cardiac injury during the Nuss operation.

Patient Satisfaction After Minimally Invasive Repair of Pectus Excavatum in Adults: Long-Term Results of Nuss Procedure in Adults

Extensive literature has proved that the Nuss procedure leads to permanent remodeling of the chest wall in pediatric patients with pectus excavatum (PE). However, limited long-term follow-up data are available for adults. Herein, we report a single-institution experience in the management of adult PE with the Nuss procedure, evaluating long-term outcomes and overall patient satisfaction after bar removal. Adult patients who underwent PE repair with a modified Nuss procedure between January 1998 and June 2011 were retrospectively identified. Outcomes of interest were postoperative pain, recurrence, and patient satisfaction. A modified single-step Nuss questionnaire was administered to evaluate patient satisfaction and quality-of-life improvement after PE repair. Ninety-eight patients with a median age of 30.9 years (range, 21.8 to 55.1 years) at the time of repair were identified. One bar was placed in most patients (89.7%). Four patients (4.1%) required reoperation for bar displacement. Results after bar removal were overall satisfactory in 94.4% of patients; 2 patients required reoperation for recurrence. Thirty-nine patients participated in the survey. Satisfaction with chest appearance was reported by 89.7% of responders. Seven patients reported dissatisfaction with the overall results; the most common complaints were severe postoperative chest pain and dissatisfaction with surgical scars. Favorable long-term results can be achieved with the Nuss procedure in adults. However, postoperative pain may require a more aggressive analgesic regimen, and it may be the overriding factor in the patient's perception of the quality of the postoperative course.

Abstract 16138: Chest and Cardiac Compression on CT/MRI and on TEE Predicts Improvement in Right Heart Chamber Size and Right Ventricular Deformation Post Pectus Excavatum Repair Surgery

Background: Pectus excavatum (PE) deformity involves posterior depression of the sternum and adjacent costal cartilages. The relationship of CT/MRI chest cardiac compression indices used as indications for surgical repair of PE with echocardiographic findings and with improvement in cardiac chamber compression and function post PE repair is unknown. Methods: We evaluated right atrial (RA) size, tricuspid annulus (TA size, right ventricular (RV) outflow tract size as well as RV 2D strain on intra-operative trans-esophageal echocardiography (TEE) immediately pre and post surgical PE repair. Inspiratory and expiratory Haller Index (HI) and cardiac compression indices (CCI) were measured on pre op CT/MR scans (Figure). Offline measurement of chamber dimensions on TEE images was performed and Speckle tracking strain measurements were made using Syngo US Workplace software (Siemens). P&lt;0.05 was considered significant. Results: 60 patients, 73% male, 27% female, age 33.6±10.3 yrs underwent PE repair following CT/MRI from 2010-2014 (Figure). There was a strong correlation between expiratory CT/MRI chest AP diameter and pre-op RA size (panel A). Pre op RA and TA compression on TEE inversely correlated with pre op RV global longitudinal strain rate(RVGLSR) (panels B &amp; C). CCI predicted improvement in RA size post PE repair (panels D &amp; E). In addition pre op RA size on TEE correlated with improvement in RVGLSR post PE repair surgery (panel F). Conclusion: In patients with PE deformity, pre surgical CCI correlated with right-sided cardiac chamber compression on pre op TEE. Severity of chest and cardiac compression also predicted magnitude of improvement in right-sided chamber size and RV longitudinal deformation post PE repair. Our findings provide insight regarding the beneficial effects of PE surgery on right heart chamber compression and improvement in RV function and the important role of intraoperative TEE for patients undergoing PE repair surgery.

Pectus excavatum in adult women: repair and the impact of prior or concurrent breast augmentation.

Women present with pectus excavatum five times less frequently than men. Adult women may have additional, associated cosmetic factors, including hypoplastic or asymmetric breasts, or prior augmentation. The authors evaluated the impact of prior or concurrent cosmetic breast surgery in an adult female cohort undergoing repair of pectus excavatum deformity. A retrospective review was performed of women (≥18 years old) who underwent pectus excavatum repair at a single institution from January of 2010 to September of 2013. Pectus excavatum repair was performed on 47 women with a median age of 35 years (range, 18 to 63 years). Mean pectus severity index was 6.2 (range, 3.1 to 16). All patients had physiologic symptoms as the primary purpose for seeking repair. Twenty patients (43 percent) presented with existing implants or the desire for implants at the time of repair. Fifteen patients (32 percent) had a history of implant placement including prior breast augmentation (n = 14) and/or pectus implant (n = 4). Concurrent augmentation (n = 5), breast implant exchange (n = 8), and/or removal of chest wall implants (n = 4) was performed during repair. Morbidity included one implant-related hematoma. Complications and hospital stay were not significantly different for patients undergoing primary repair alone versus those with prior or concurrent augmentation. Breast cosmesis was a concern in nearly half of adult women presenting for pectus excavatum repair. The authors' experience suggests neither prior nor concurrent breast augmentation increases the risk of complications in repair. The authors recommend that cosmetic breast surgery be performed concurrently with pectus excavatum repair. Therapeutic, III.

Preoperative Patch Testing In Patients Undergoing Pectus Excavatum Repair

The Nuss procedure is a minimally invasive surgery to correct pectus deformities using a stainless-steel rod containing several metals including nickel. Occasionally, devastating complications occur in patients who develop delayed type hypersensitivity to the implanted rod. A retrospective study showed the incidence of metal hypersensitivity was 2.2% in patients having undergone the Nuss procedure. Yet, if metal contact dermatitis is determined a priori, a titanium bar is customized. This case series investigated preoperative incidence of metal allergy in patients scheduled to undergo the Nuss procedure.

EComment. Pectus excavatum: the surgical opinion

We read with great interest the state-of-the-art article by Brochhausen et al. regarding the pectus excavatum and we agree with the authors that its surgical treatment by various techniques can improve long term results in terms of cosmetics and potential cardiorespiratory function [1, 2]. Therefore, we would like to comment on the surgical approach. Criteria for the surgical treatment of pectus excavatum, according to Kelly and colleagues, are related to the severity of symptoms and anatomical deformity followed by two or more criteria such as computerized tomography-index (or Haller-index) greater than 3.25, signs of cardiac and or pulmonary compression on computerized tomography or echocardiography, mitral valve prolapse, arrhythmias and restrictive lung disease [2]. The minimally invasive Nuss procedure is safe [3]. In the relatively recent (study period 1987-2006) review of 18 series, reporting on 1949 children with a mean age of 10.6 years, there was no mortality and the incidence of morbidity was 15.4%. The average operative time was 68 minutes (from 28 to 200 min) and the average hospitalization was 5.5 days (from 2 to 27 days) [3]. The most common reported complications were bar related events (5.7%), pneumothorax (3.5%), wound infections (2.2%) and pleuropulmonary complications (2%) such as pleural effusions, atelectasis, and pneumonia [3]. In addition to common complications, Swanson and Colombani have reported on three cases within a period of 1 year with reactive pectus carinatum in patients who underwent pectus excavatum repair (two patients underwent minimally invasive Nuss procedure and one patient the Ravitch procedure). It should be noted that the pectus carinatum resolved in one patient who had an early bar removal. The other two patients required surgical correction at 3 and 6 years after the first surgical intervention .The need for close follow up for the early identification and successful treatment of this complication, particularly in the first six postoperative months, is of paramount importance [4]. In addition, Willekes et al. in their retrospective study of a 26-year experience with pectus deformities repair in 120 children with a mean age of 8.4 years (from 3 to 21 years) found that the long-term results of pectus deformities repair (excavatum and carinatum) through a vertical midline approach are excellent and the outcome with a temporary sternal bar is superior to that without a bar (p = 0.004). Nine patients had an associated congenital heart defect and underwent successfully simultaneous pectus excavatum and intracardiac repair with no additional morbidity [5]. In conclusion, surgical repair of pectus excavatum by various techniques has good long term results. However, a multidisciplinary approach and assessment of these patients on an individual basis is very important when considering the timing and type of procedure. A combined simultaneous approach in dealing with concomitant congenital or acquired heart conditions can be performed safely by an experienced team [2, 5].