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Pectus excavatum

Life-threatening complications and mortality of minimally invasive pectus surgery

Hebra A, Kelly RE, Ferro MM, Yüksel M, Campos JRM, Nuss D.

 2017 Jul 31. pii: S0022-3468(17)30461-X. doi: 10.1016/j.jpedsurg.2017.07.020. [Epub ahead of print

show abstract

Abstract


Pectus excavatum

Life-threatening complications and mortality of minimally invasive pectus surgery

Hebra A, Kelly RE, Ferro MM, Yüksel M, Campos JRM, Nuss D.

 2017 Jul 31. pii: S0022-3468(17)30461-X. doi: 10.1016/j.jpedsurg.2017.07.020. [Epub ahead of print

Abstract

The prevalence and type of life-threatening complications related to the minimally invasive repair of pectus excavatum (MIRPE) and bar removal are unknown and underreported. The purpose of this communication is to make surgeons aware of the risk of these life threatening complications as well as the modifications which have been developed to prevent them.

METHODS:

Data related to life-threatening complications of Pectus Excavatum (PE) patients was obtained from four sources: 1. A survey of Chest Wall International Group (CWIG) surgeons who specialize in repairing congenital chest wall malformations, 2. Papers and case reports presented at CWIG meetings, 3. Review of medico-legal cases from the USA and 4. A systematic review of the literature related to major complications post MIRPE.

RESULTS:

From 1998 to 2016, we identified 27 published cases and 32 unreported life-threatening complications including: cardiac perforation, hemothorax, major vessel injury, lung injury, liver injury, gastrointestinal problems, and diaphragm injury. There were seven cases of major complications with bar removal (reported and non-reported) with two lethal outcomes. Mortality data with bar placement surgery: Four published death cases and seven unpublished death cases. The overall incidence of minor & major complications post MIRPE has been reported in the literature to be 2-20%. The true incidence of life-threatening complications and mortality is not known as we do not know the overall number of procedures performed worldwide. However, based on data extrapolated from survey information, the pectus bar manufacturer in the USA, literature reports, and data presented at CWIG meetings as to the number of cases performed we estimated that approximately fifty thousand cases have been performed and that the incidence of life-threatening complications is less than 0.1% with many occurring during the learning curve. Analysis of the cases identified in our survey revealed that previous chest surgery, pectus severity and inexperience were noted to be significant risk factors for mortality.

CONCLUSIONS:

Published reports support the safety and efficacy of MIRPE; however major adverse outcomes are underreported. Although major complications with MIRPE and pectus bar removal surgery are very rare, awareness of the risk and mortality of life-threatening complications is essential to ensure optimal safety. Factors such as operative technique, patient age, pectus severity and asymmetry, previous chest surgery, and the surgeon's experience play a role in the overall incidence of such events. These preventable events can be avoided with proper training, mentoring, and the use of sternal elevation techniques.

 

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Miscellaneous

Chest wall stabilization in ventilator-dependent traumatic flail chest patients: who benefits?

Kocher GJ, Sharafi S, Azenha LF, Schmid RA

 2016 Dec 22

show abstract

Abstract


Miscellaneous

Chest wall stabilization in ventilator-dependent traumatic flail chest patients: who benefits?

Kocher GJ, Sharafi S, Azenha LF, Schmid RA

 2016 Dec 22

OBJECTIVES:

Traumatic flail chest is a potentially life threatening injury, often associated with prolonged invasive mechanical ventilation and intensive care unit stay. This study evaluates the usefulness and cost-effectiveness of surgical rib stabilization in patients with flail chest resulting in ventilator dependent respiratory insufficiency.

METHODS:

A retrospective study on a consecutive series of patients with flail chest with the need for mechanical ventilation was performed. Effectiveness of rib fixation was evaluated in terms of predictors for prolonged ventilation, cost-effectiveness and outcome.

RESULTS:

A total of 61 patients underwent flail chest stabilization using a locked titanium plate fixation system between July 2010 and December 2015 at our institution. 62% (n = 38) of patients could be weaned from the ventilator within the first 72 h after surgery. Multiple linear regression analysis revealed that closed head injury, bilateral flail chest, number of stabilized ribs and severity of lung contusion were the main independent predictors for prolonged mechanical ventilation (Odds ratio (OR) 6.88; 3.25; 1.52 and 1.42) and tracheostomy (OR 9.17; 2.2; 1.76 and 0.84), respectively. Furthermore cost analysis showed that already a two day reduction in ICU stay could outweigh the cost of surgical rib fixation.

CONCLUSIONS:

Operative rib fixation has the potential to reduce ventilator days and ICU stay and subsequently hospital costs in selected patients with severe traumatic flail chest requiring mechanical ventilation. Especially associated closed head injury can adversely affect mechanical ventilation time. Furthermore the subgroups of patients sustaining a fall from a height and those with flail chest after cardiopulmonary re-animation seem to profit only marginally from surgical rib fixation.

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Miscellaneous

Repair of sternoclavicular joint dislocations with FiberWire®

Adamcik S, Ahler M, Gioutsos K, Schmid RA, Kocher GJ.

 2017 Jan 21

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Abstract


Miscellaneous

Repair of sternoclavicular joint dislocations with FiberWire®

Adamcik S, Ahler M, Gioutsos K, Schmid RA, Kocher GJ.

 2017 Jan 21

PURPOSE:

Up to 50% of traumatic sternoclavicular joint (SCJ) dislocations need open reduction and fixation to prevent long-term complications and complaints. We present our preferred surgical approach for acute as well as chronic SCJ dislocations, including their outcome.

METHODS:

Five consecutive male patients with a median age of 27 (range 20-49) were treated for traumatic anterior (n = 2) or posterior (n = 3) SCJ dislocation. Open reduction and surgical fixation were achieved by a modified figure-of-eight sutures using Fiberwire®. In anterior dislocations, an additional reconstruction of the costoclavicular ligament was performed. Median follow-up was 11 months (range 9-48) and included clinical evaluation and the use of the DASH questionnaire.

RESULTS:

Open surgical reduction and SCJ repair were successfully achieved in all patients without complications. Repair resulted in very good functional outcomes in all five patients with DASH scores of 0, 8 (n = 3) and 5, 8 (n = 2), respectively.

CONCLUSIONS:

The presented technique allowed simple, effective, and durable repair of the SCJ joint in patients with SCJ dislocations with excellent functional outcomes.

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Pectus excavatum

Vacuum bell therapy

Haecker FM, Sesia S.

 2016 Sep;5(5):440-449.

show abstract

Abstract


Pectus excavatum

Vacuum bell therapy

Haecker FM, Sesia S.

 2016 Sep;5(5):440-449.

Abstract

BACKGROUND:

For specific therapy to correct pectus excavatum (PE), conservative treatment with the vacuum bell (VB) was introduced more than 10 years ago in addition to surgical repair. Preliminary results using the VB were encouraging. We report on our 13-year experience with the VB treatment including the intraoperative use during the Nuss procedure and present some technical innovations.

METHODS:

A VB with a patient-activated hand pump is used to create a vacuum at the anterior chest wall. Three different sizes of vacuum bells, as well as a model fitted for young women, exist. The appropriate size is selected according to the individual patient's age and ventral surface. The device should be used at home for a minimum of 30 minutes (twice a day), and may be used up to a maximum of several hours daily. The intensity of the applied negative pressure can be evaluated with an integrated pressure gauge during follow-up visits. A prototype of an electronic model enables us to measure the correlation between the applied negative pressure and the elevation of the anterior chest wall.

RESULTS:

Since 2003, approx. 450 patients between 2 to 61 years of age started the VB therapy. Age and gender specific differences, depth of PE, symmetry or asymmetry, and concomitant malformations such as scoliosis and/or kyphosis influence the clinical course and success of VB therapy. According to our experience, we see three different groups of patients. Immediate elevation of the sternum was confirmed thoracoscopically during the Nuss procedure in every patient.

CONCLUSIONS:

The VB therapy has been established as an alternative therapeutic option in selected patients suffering from PE. The initial results up to now are encouraging, but long-term results comprising more than 15 years are so far lacking, and further evaluation and follow-up studies are necessary.

 

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Pectus excavatum

Risk of serious perioperative complications with removal of double bars following the Nuss procedure.

Bilgi Z, Ermerak NO, Çetinkaya Ç, Laçin T, Yüksel M.

Interact Cardiovasc Thorac Surg. 2016 Oct 20

show abstract

Abstract


Pectus excavatum

Risk of serious perioperative complications with removal of double bars following the Nuss procedure.

Bilgi Z, Ermerak NO, Çetinkaya Ç, Laçin T, Yüksel M.

Interact Cardiovasc Thorac Surg. 2016 Oct 20

Abstract

OBJECTIVES:

The aim of this study is to present our experience with Nuss bar removal and evaluate potential risk factors. The Nuss procedure requires an operation to remove the bar 2-3 years after the initial correction. Although removal of the bar is generally believed to be safe, perioperative complications including major bleeding can occur.

METHODS:

All cases involving removal of the Nuss bar done since April 2007 were recorded in a prospective database. Data were collected on the amount of blood loss, the number of diagnostic interventions, operative management and postoperative course.

RESULTS:

Of a total of 246 (162 with single bars, 80 with double bars, 4 with triple bars) cases, 43 patients (17.5%) experienced perioperative complications. Five patients underwent secondary postoperative interventions; one patient required same-session emergency video-assisted thoracic surgery (VATS) due to major bleeding. Patients who had complications were significantly older than patients with no complications (20.5 ± 6.5 years vs 17.2 ± 5.9 years, P = 0.002). People having double bars removed were significantly more likely to have perioperative complications (12% vs 27%, P = 0.03) and complications requiring secondary interventions (n = 1 for a single bar, n = 5 for double bars, P = 0.01).

CONCLUSIONS:

Major complications after removal of the Nuss bar occur with some frequency. Although the double-bar removals in our cohort were associated with major complications, the reasons are poorly understood. Immediate management of the complications may require multidisciplinary care. Multicentric pooling of cases is needed for better risk stratification.

 

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Pectus carinatum

Success and duration of dynamic bracing for pectus carinatum: A four-year prospective study.

Emil S, Sévigny M, Montpetit K, Baird R, Laberge JM, Goyette J, Finlay I, Courchesne G.

J Pediatr Surg. 2016 Oct 27

show abstract

Abstract


Pectus carinatum

Success and duration of dynamic bracing for pectus carinatum: A four-year prospective study.

Emil S, Sévigny M, Montpetit K, Baird R, Laberge JM, Goyette J, Finlay I, Courchesne G.

J Pediatr Surg. 2016 Oct 27

Abstract

BACKGROUND:

This study sought to establish factors that can prognosticate outcomes of bracing for pectus carinatum (PC).

METHODS:

Prospective data were collected on all patients enrolled in a dynamic bracing protocol from July 2011 to July 2015. Pressure of correction (POC) was measured at initiation of treatment, and pressure of treatment (POT) was measured pre- and post-adjustment at every follow-up visit. Univariate and Cox regression analysis tested the following possible determinants of success and bracing duration: age, sex, symmetry, POC, and POT drop during the first two follow-up visits.

RESULTS:

Of 114 patients, 64 (56%) succeeded, 33 (29%) were still in active bracing, and 17 (15%) failed or were lost to follow-up. In successful patients, active and maintenance bracing was 5.66±3.81 and 8.80±3.94months, respectively. Asymmetry and older age were significantly associated with failure. Multivariable Cox proportional hazard analysis of time-to-maintenance showed that asymmetry (p=0.01) and smaller first drop in POT (p=0.02) were associated with longer time to reach maintenance.

CONCLUSIONS:

Pressure of correction does not predict failure of bracing, but older age, asymmetry, and smaller first drop in pressure of treatment are associated with failure and longer bracing duration.

LEVEL OF EVIDENCE:

Prospective Study/Level of Evidence IV.

 

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Pectus excavatum

Pectus bar removal: surgical technique and strategy to avoid complications

Hyung Joo Park, Kyung Soo Kim

J Vis Surg 2016;2:60

show abstract

Abstract


Pectus excavatum

Pectus bar removal: surgical technique and strategy to avoid complications

Hyung Joo Park, Kyung Soo Kim

J Vis Surg 2016;2:60

Background: Pectus bar removal is the final stage of the procedure for minimally invasive repair of pectus
excavatum. Based on our experience with one of the largest scale data, we would like to address the important
issues in pectus bar removal, such as appropriate duration of bar maintenance, techniques for bar removal,
and strategies to avoid complications.
Methods: Between September 1999 and August 2015, we operated on 2,553 patients with pectus excavatum
and carinatum using pectus bars for a minimally invasive approach. Among them, 1,821 patients (71.3%)
underwent pectus bar removal as a final stage of pectus deformity repair, and their data were analyzed
retrospectively to identify the outcomes and adverse effects of the pectus bar removal procedure. The mean
age of the patients was 9.13 years (range, 16 months to 44 years) and the male to female ratio was 3.55.
The study is approved by the Institutional Review Board (IRB), the ethical committee of Seoul St. Mary’s
Hospital. The IRB has exempted the informed consent from every patient in this study due to this is a
retrospective chart review without revealing any patients’ personal data.
Results: Our technique involved straightening of the bar in a supine position. The overall mean duration
of pectus bar maintenance was 2.57 years (range, 4 months to 14 years). The mean duration was 2.02 years
(range, 4 months to 7 years) for children under 12 years, 2.99 years (range, 7 months to 9 years) for teenagers
aged 12–20 years, and 3.53 years (range, 3 months to 14 years) for adults over 20 years. Forty-eight patients
(2.6%) underwent bar removal more than 5 years after bar insertion and 58 patients (3.2%) underwent bar
removal earlier than initially planned. The most common adverse reaction after bar removal was wound
seroma including infection (43 patients, 2.36%). Recurrence after bar removal occurred in nine patients
(0.49%), and seven of these required redo repair (0.38%).
Conclusions: Pectus bar removal is a safe and straightforward procedure with a low rate of complication.

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Pectus excavatum

Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults

Jaroszewski DE, Temkit M, Ewais MM, Luckritz TC, Stearns JD, Craner RC, Gaitan BD4, Ramakrishna H, Thunberg CA, Weis RA, Myers KM, Merritt MV, Rosenfeld DM.

 2016 Aug;8(8):2102-1

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Abstract


Pectus excavatum

Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults

Jaroszewski DE, Temkit M, Ewais MM, Luckritz TC, Stearns JD, Craner RC, Gaitan BD4, Ramakrishna H, Thunberg CA, Weis RA, Myers KM, Merritt MV, Rosenfeld DM.

 2016 Aug;8(8):2102-1

BACKGROUND:

Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q).

METHODS:

Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores.

RESULTS:

Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system.

CONCLUSIONS:

Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.

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Pectus carinatum

Complications Related to Pectus Carinatum Correction: Lessons Learned from 15 Years' Experience. Management and Literature Review

Del Frari B, Sigl S, Schwabegger AH

 2016 Aug;138(2):317e-29e

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Abstract


Pectus carinatum

Complications Related to Pectus Carinatum Correction: Lessons Learned from 15 Years' Experience. Management and Literature Review

Del Frari B, Sigl S, Schwabegger AH

 2016 Aug;138(2):317e-29e

BACKGROUND:

Various methods of corrective thoracoplasty for pectus carinatum deformity have been described, but to date no studies describe a review of complications and how to manage them. Complications are dependent not only on the technique used and the patient's age, but also on the experience of the treating surgeon. The authors present their 15 years' experience with surgical correction of pectus carinatum and the complications that have occurred. A literature review regarding complications with pectus carinatum surgery is performed.

METHODS:

A retrospective review of 95 patients (mean age, 19 years) was performed. One hundred four surgical procedures for repair of pectus carinatum were performed from July of 2000 to July of 2015 using a modified Ravitch technique, bioabsorbable material, postoperative bracing, and in some cases a diced rib cartilage graft technique. Intraoperative and postoperative complications were evaluated.

RESULTS:

The mean patient follow-up was 13.6 months (range, 4 months to 9.75 years). Intraoperative complications were pleura lesion and laceration of the internal mammary vein. Postoperative complications were recurrent mild protrusion, persistent protrusion of one or two costal cartilages, minor wound healing delay, skin ulcer, hypertrophic scar, transient intercostal dysesthesia, marginal pneumothorax, seroma, meningitis, and epidural hematoma.

CONCLUSIONS:

In our reported series of pectus carinatum repair, increasing experience and progressively less extensive techniques have resulted in fewer complications, low morbidity, and early return to activity. Complications were observed in the early period of application, predominantly because of a lack of experience, and usually subsided with increasing numbers of patients and frequency of surgery.

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Pectus excavatum

Nuss procedure for repair of pectus excavatum after failed Ravitch procedure in adults: indications and caveats

Kocher GJ, Gstrein N, Jaroszewski DE, Ewais MM, Schmid RA.

 2016 Aug;8(8):1981-5

 

show abstract

Abstract


Pectus excavatum

Nuss procedure for repair of pectus excavatum after failed Ravitch procedure in adults: indications and caveats

Kocher GJ, Gstrein N, Jaroszewski DE, Ewais MM, Schmid RA.

 2016 Aug;8(8):1981-5

 

BACKGROUND:

Recurrence of pectus excavatum (PE) is not an uncommon problem after open repair using the Ravitch technique. The optimal approach for redo surgery is still under debate, especially in adults with less chest wall pliability. Aim of this study was to investigate the usefulness and efficacy of the minimally invasive Nuss technique for repair of recurrent PE after conventional open repair.

METHODS:

We performed a retrospective multicentre review of 20 adult patients from University Hospital Bern (n=6) and the US Mayo Clinic (n=14) who underwent minimally invasive repair of recurrent PE after unsuccessful prior Ravitch procedure.

RESULTS:

Mean patient age at primary open correction was 21 years, with recurrence being evident after a mean duration of 10.5 years (range, 0.25-47 years). Mean age at redo surgery using the Nuss technique was 31 years, with a mean Haller index of 4.7 before and 2.5 after final correction. Main reason for redo surgery was recurrent or persistent deformity (100%), followed by chest pain (75%) and exercise intolerance (75%). No major intraoperative or postoperative complications occurred and successful correction was possible in all patients.

CONCLUSIONS:

Although the procedure itself is more challenging, the minimally invasive Nuss technique can be safely and successfully used for repair of recurrent PE after failed open surgery. In our series final results were good to excellent in the majority of patients without major complications or recurrence.

 

 

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Pectus excavatum

Cardiac function in adults following minimally invasive repair of pectus excavatum

Udholm S, Maagaard M, Pilegaard H, Hjortdal V

 2016 May;22(5):525-9

show abstract

Abstract


Pectus excavatum

Cardiac function in adults following minimally invasive repair of pectus excavatum

Udholm S, Maagaard M, Pilegaard H, Hjortdal V

 2016 May;22(5):525-9

OBJECTIVES:

To study if minimally invasive repair of pectus excavatum (PE) in adult patients would improve cardiopulmonary function at rest and during exercise as we have found previously in young and adolescent patients with PE.

METHODS:

Nineteen adult patients (>21 year of age) were studied at rest and during bicycle exercise before surgery and 1 year postoperatively. Lung spirometry was performed at rest. Cardiac output, heart rate and aerobic exercise capacity were measured using a photo-acoustic gas-rebreathing technique during rest and exercise. Data are shown as mean ± standard deviation.

RESULTS:

Fifteen patients completed the 1-year follow-up. No significant differences were found in neither cardiac output (14.0 ± 0.9 l min at baseline vs 14.8 ± 1.1 l min after surgery; P = 0.2029), nor maximum oxygen uptake (30.4 ± 1.9 and 33.3 ± 1.6 ml/kg/min; P = 0.0940 postoperatively). The lung spirometry was also unchanged, with no difference in forced expiratory capacity during the first second.

CONCLUSIONS:

Correction of PE in adult patients does not improve the cardiopulmonary function 1 year after surgery as seen in children and adolescents.

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Pectus carinatum

MyPectus: First-in-human pilot study of remote compliance monitoring of teens using dynamic compression bracing to correct pectus carinatum

Harrison B, Stern L, Chung P, Etemadi M, Kwiat D, Roy S, Harrison MR, Martinez-Ferro M

 2016 Apr;51(4):608-11

show abstract

Abstract


Pectus carinatum

MyPectus: First-in-human pilot study of remote compliance monitoring of teens using dynamic compression bracing to correct pectus carinatum

Harrison B, Stern L, Chung P, Etemadi M, Kwiat D, Roy S, Harrison MR, Martinez-Ferro M

 2016 Apr;51(4):608-11

BACKGROUND:

Patient compliance is a crucial determinant of outcomes in treatments involving medical braces, such as dynamic compression therapy for pectus carinatum (PC). We performed a pilot study to assess a novel, wireless, real-time monitoring system (MyPectus) to address noncompliance.

METHODS:

Eight patients (10-16years old) with moderately severe PC deformities underwent bracing. Each patient received a data logger device inserted in the compression brace to sense temperature and pressure. The data were transmitted via Bluetooth 4.0 to an iOS smartphone app, then synced to cloud-based storage, and presented to the clinician on a web-based dashboard. Patients received points for brace usage on the app throughout the 4-week study, and completed a survey to capture patient-reported usage patterns.

RESULTS:

In all 8 patients, the data logger sensed and recorded data, which connected through all MyPectus system components. There were occasional lapses in data collection because of technical difficulties, such as limited storage capacity. Patients reported positive feedback regarding points.

CONCLUSIONS:

The components of the MyPectus system recorded, stored, and provided data to patients and clinicians. The MyPectus system will inform clinicians about issues related to noncompliance: discrepancy between patient-reported and sensor-reported data regarding brace usage; real-time, actionable information; and patient motivation.

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Tumors

Chest Wall Resection and Reconstruction: Management of Complications

Hazel K, Weyant MJ

 2015 Nov;25(4):517-21

show abstract

Abstract


Tumors

Chest Wall Resection and Reconstruction: Management of Complications

Hazel K, Weyant MJ

 2015 Nov;25(4):517-21

The main indications for chest wall resection continue to be tumors, infection, and radiation injury. Complications surrounding chest wall resectionprocedures include respiratory failure, wound complications, and prosthetic complications. The main risk factors for complications are size ofdefect, age, and concomitant lung resection. Most complications related to either the wound or the prosthesis are late postoperative events. The identification of complications related to chest wall reconstruction requires clinical examination and the use of detailed imaging studies. The management of both prosthetic and wound complications often requires reoperation and removal of the prosthesis combined with soft tissue wound management.

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Pectus excavatum

The bridge technique for pectus bar fixation: a method to make the bar un-rotatable

Park HJ, Kim KS, Moon YK, Lee S

 2015 Aug;50(8):1320-2

show abstract

Abstract


Pectus excavatum

The bridge technique for pectus bar fixation: a method to make the bar un-rotatable

Park HJ, Kim KS, Moon YK, Lee S

 2015 Aug;50(8):1320-2

PURPOSE:

Pectus bar rotation is a major challenge in pectus repair. However, to date, no satisfactory technique to completely eliminate bar displacement has been introduced. Here, we propose a bar fixation technique using a bridge that makes the bar unmovable. The purpose of this study was to determine the efficacy of this bridge technique.

METHODS:

A total of 80 patients underwent pectus bar repair of pectus excavatum with the bridge technique from July 2013 to July 2014. The technique involved connecting 2 parallel bars using plate-screws at the ends of the bars. To determine bar position change, the angles between the sternum and pectus bars were measured on postoperative day 5 (POD5) and 4 months (POM4) and compared.

RESULTS:

The mean patient age was 17.5 years (range, 6-38 years). The mean difference between POD5 and POM4 were 0.23° (P=.602) and 0.35° (P=.338) for the upper and lower bars, respectively. Bar position was virtually unchanged during the follow-up, and there was no bar dislocation or reoperation.

CONCLUSIONS:

A "bridge technique" designed to connect 2 parallel bars using plates and screws was demonstrated as a method to avoidpectus bar displacement. This approach was easy to implement without using sutures or invasive devices.

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Pectus excavatum

Feasibility and Complications in Concomitant Lung Resection With Minimally Invasive Repair of Pectus Excavatum

Bilgi Z, Ermerak NO, Bostanc? K, Saçak B, Bat?rel HF, Yüksel M.

 2015 Aug;100(2):707-9

show abstract

Abstract


Pectus excavatum

Feasibility and Complications in Concomitant Lung Resection With Minimally Invasive Repair of Pectus Excavatum

Bilgi Z, Ermerak NO, Bostanc? K, Saçak B, Bat?rel HF, Yüksel M.

 2015 Aug;100(2):707-9

Minimally invasive repair of pectus excavatum (MIRPE) is the procedure of choice in experienced centers and can be offered in combination with other thoracic procedures. Between 2001 and 2013, 3 cases involving MIRPE and lung surgery were done in our clinic. While postoperative course of 2 procedures (MIRPE and video-assisted thoracoscopic surgery [VATS] segmentectomy and MIRPE and VATS bullectomy) were uncomplicated, the MIRPE and VATS lung biopsy patient developed major complications arising from prolonged air leak and was ultimately managed with an Eloesser flap. In carefully selected cases, simultaneous lung surgery and MIRPE can be done safely but problems of lung reexpansion, long-term drainage, and infection should be kept in mind.

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Pectus excavatum

Multicenter study of pectus excavatum, final report: complications, static/exercise pulmonary function, and anatomic outcomes

Kelly RE Jr, Mellins RB, Shamberger RC, Mitchell KK, Lawson ML, Oldham KT, Azizkhan RG, Hebra AV, Nuss D, Goretsky MJ, Sharp RJ, Holcomb GW 3rd, Shim WK, Megison SM, Moss RL, Fecteau AH, Colombani PM, Cooper D, Bagley T, Quinn A, Moskowitz AB, Paulson JF

 2013 Dec;217(6):1080-9

show abstract

Abstract


Pectus excavatum

Multicenter study of pectus excavatum, final report: complications, static/exercise pulmonary function, and anatomic outcomes

Kelly RE Jr, Mellins RB, Shamberger RC, Mitchell KK, Lawson ML, Oldham KT, Azizkhan RG, Hebra AV, Nuss D, Goretsky MJ, Sharp RJ, Holcomb GW 3rd, Shim WK, Megison SM, Moss RL, Fecteau AH, Colombani PM, Cooper D, Bagley T, Quinn A, Moskowitz AB, Paulson JF

 2013 Dec;217(6):1080-9

BACKGROUND:

A multicenter study of pectus excavatum was described previously. This report presents our final results.

STUDY DESIGN:

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.

RESULTS:

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.

CONCLUSIONS:

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.

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Pectus carinatum

Bracing is an effective therapy for pectus carinatum: interim results

Lee RT, Moorman S, Schneider M, Sigalet DL

 2013 Jan;48(1):184-90

show abstract

Abstract


Pectus carinatum

Bracing is an effective therapy for pectus carinatum: interim results

Lee RT, Moorman S, Schneider M, Sigalet DL

 2013 Jan;48(1):184-90

BACKGROUND:

Pectus Carinatum is a common congenital chest wall malformation. Until recently the mainstay of treatment was surgical remodeling of the deformed chest wall. Initial results suggest that non-operative bracing may be an effective therapy, but the optimal strategy for correction is not known. Herein we report the results of a self-adjustable low profile bracing system worn continuously until the defect is corrected (correction phase), then worn at night (8 h/day) until completion of axial growth (maintenance phase)-the Calgary Protocol.

METHODS:

Patients referred to a pediatric surgery chest wall clinic were prospectively asked to join an IRB approved outcomes monitoring study. 124 patients were evaluated from 2007 to 2011, and 98 were prescribed a brace and counseled to follow the protocol.

RESULTS:

98 patients consented to follow-up at starting bracing age: 14.4 ± 1.9 years, Tanner stage: 3.6 ± 0.5, protrusion: 2.1 ± 1.0 cm, self-rating of appearance: 2.9 ± 1.1, and exercise tolerance: 4.4 ± 1.1 (1-5 with 5 = normal). 10 patients are in correction phase, and 44 patients have completed correction after 7.0 ± 7.3 months: Tanner stage: 3.8 ± 0.1, protrusion: 0.5 ± 0.6 cm*, appearance: 4.3 ± 0.3* and exercise tolerance 4.6 ± 1.0. Correction occurred more quickly in patients prior to achieving Tanner stage IV (4.2 ± 0.9 months) vs. Tanner stage IV (8.0 ± 7.1 months) at the beginning of bracing. 21 patients completed maintenance bracing after 17.9 ± 19.0 months: Tanner stage: 3.9 ± 0.2, protrusion 0.5 ± 0.7 cm*, appearance: 4.3 ± 0.9*, and exercise tolerance: 4.8 ± 1.4. Average follow-up after bracing is 13.9 ± 16.0 months (mean ± S.D., *P < .05). There was one recurrence, likely due to early discontinuation of maintenance. This responded to an additional 6 months of bracing. 42 patients failed therapy secondary to non-compliance or were lost in follow up, while 2 patients did not respond to bracing and required open operation.

CONCLUSIONS:

If patients are compliant, a self- adjusting brace system can give rapid correction of the pectus carinatum protrusion with excellent patient satisfaction. These interim results suggest that continued bracing until skeletal maturity gives long term durability to the correction. Further studies will be required to further refine this promising therapy.

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Pectus carinatum

Dynamic compression system for the correction of pectus carinatum

Martinez-Ferro M, Fraire C, Bernard S

 2008 Aug;17(3):194-200

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Abstract


Pectus carinatum

Dynamic compression system for the correction of pectus carinatum

Martinez-Ferro M, Fraire C, Bernard S

 2008 Aug;17(3):194-200

Between April 2001 and 2007, we treated 208 patients with pectus carinatum by using a specially designed dynamic compression system (DCS) that uses a custom-made aluminum brace. Recently, an electronic pressure measuring device was added to the brace. Results were evaluated by using a double-blinded subjective scale (1 to 10). A total of 208 patients were treated over 6 years; 154 were males (74%) and the mean age was 12.5 years (range 3 to 18 years). Mean utilization time was 7.2 hours daily for 7 months (range 3 to 20 months). A total of 28 (13.4%) patients abandoned treatment and were not evaluated for final results. Of the 180 remaining patients, 112 completed treatment. A total of 99 of 112 (88.4%) had good to excellent results scoring between 7 and 10 points, and 13 (11.6%) patients scored 1 to 6 points and were judged as poor or failed results. The "Pressure for Initial Correction" (PIC) in pounds per square inch (PSI) proved that starting treatment with less than 2.5 PSI avoids skin lesions. Patients who require pressures higher than 7.5 PSI should not be treated with this method. We found a good correlation between PIC versus treatment duration and outcome. DCS is an effective treatment for pectus carinatum with minimal morbidity. We suggest that patients with pectus carinatum have a trial of compression therapy before recommending surgical resection. The use of pressure measurement avoids complications such as skin lesions, partial or poor results, and patient noncompliance.

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Miscellaneous

Repair of congenital sternal cleft in infants and adolescents

de Campos JR, Filomeno LT, Fernandez A, Ruiz RL, Minamoto H, Werebe Ede C, Jatene FB.

 1998 Oct;66(4):1151-4

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Abstract


Miscellaneous

Repair of congenital sternal cleft in infants and adolescents

de Campos JR, Filomeno LT, Fernandez A, Ruiz RL, Minamoto H, Werebe Ede C, Jatene FB.

 1998 Oct;66(4):1151-4

BACKGROUND:

Clinical and surgical aspects of sternal cleft repair are presented. Primary repair in the neonatal period is the best management for this rare condition, but none of the patients in this report were referred to us during that period. Autologous repair is suitable for older patients because it avoids problems related to the implant of prosthetic materials.

METHODS:

This article reviews 8 cases of sternal cleft not associated with ectopia cordis in patients presenting between October 1979 and November 1997. Surgical repair consisted of three sliding chondrotomies, three posterior sternal wall repairs, one combination with the Ravitch technique for pectus excavatum repair, and one posterior sternal wall repair associated with total repair of Cantrell's pentalogy.

RESULTS:

All patients who submitted to surgical correction had good aesthetic and structural results. The postoperative period was uneventful except that a subcutaneous fluid collection developed in 1 patient. The mean hospital stay was 5.8 days. The patients were followed up from 4 months to 18 years.

CONCLUSIONS:

Whether dealing with older children or young adults, the technique of reconstructing a new sternum with a posterior periosteal flap from sternal bars and chondral grafts is a simple, quick, inexpensive, and effective option.

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Pectus excavatum

A 10-year review of a minimally invasive technique for the correction of pectus excavatum

Nuss D, Kelly RE Jr, Croitoru DP, Katz ME.

 1998 Apr;33(4):545-52.

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Abstract


Pectus excavatum

A 10-year review of a minimally invasive technique for the correction of pectus excavatum

Nuss D, Kelly RE Jr, Croitoru DP, Katz ME.

 1998 Apr;33(4):545-52.

PURPOSE:

The aim of this study was to assess the results of a 10-year experience with a minimally invasive operation that requires neither cartilage incision nor resection for correction of pectus excavatum.

METHODS:

From 1987 to 1996, 148 patients were evaluated for chest wall deformity. Fifty of 127 patients suffering from pectus excavatum were selected for surgical correction. Eight older patients underwent the Ravitch procedure, and 42 patients under age 15 were treated by the minimally invasive technique. A convex steel bar is inserted under the sternum through small bilateral thoracic incisions. The steel bar is inserted with the convexity facing posteriorly, and when it is in position, the bar is turned over, thereby correcting the deformity. After 2 years, when permanent remolding has occurred, the bar is removed in an outpatient procedure.

RESULTS:

Of 42 patients who had the minimally invasive procedure, 30 have undergone bar removal. Initial excellent results were maintained in 22, good results in four, fair in two, and poor in two, with mean follow-up since surgery of 4.6 years (range, 1 to 9.2 years). Mean follow-up since bar removal is 2.8 years (range, 6 months to 7 years). Average blood loss was 15 mL. Average length of hospital stay was 4.3 days. Patients returned to full activity after 1 month. Complications were pneumothorax in four patients, requiring thoracostomy in one patient; superficial wound infection in one patient; and displacement of the steel bar requiring revision in two patients. The fair and poor results occurred early in the series because (1) the bar was too soft (three patients), (2) the sternum was too soft in one of the patients with Marfan's syndrome, and (3) in one patient with complex thoracic anomalies, the bar was removed too soon.

CONCLUSIONS:

This minimally invasive technique, which requires neither cartilage incision nor resection, is effective. Since increasing the strength of the steel bar and inserting two bars where necessary, we have had excellent long-term results. The upper limits of age for this procedure require further evaluation.

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Claus Petersen | Department of Pediatric Surgery | Hannover Medical School | Carl-Neuberg-Strasse 1 | 30625 Hannover, Germany
Tel.: +49-(0)511-532-9040 | Fax: +49-(0)511-532-8052 | www.chestwall.org | chestwall@mh-hannover.de