Abstract

Pectus excavatum

Recent Modifications of the Nuss Procedure: The Pursuit of Safety During the Minimally Invasive Repair of Pectus Excavatum

Robert E Kelly Jr , Robert J Obermeyer, Michael J Goretsky, M Ann Kuhn, Frazier W Frantz , Margaret M McGuire , Duane S Duke , Antarius Daniel , Donald Nuss

Objective: To review standardized Nuss correction of pectus excavatum and vacuum bell treatment over the last 10 years.

Summary of background data: In 2010, we reported 21 years of the Nuss procedure in 1215 patients.

Methods: Over the last 10 years, 2008-2018, we evaluated 1885 pectus excavatum patients. Surgery was indicated for well-defined objective criteria. A consistent operation was performed by 8 surgeons in 1034 patients, median 15 years, (range 6-46); 996 were primary, and 38 redo operations. Surgical patients' mean computed tomography index was 5.46. Mitral valve prolapse was present in 5.4%, Marfan syndrome in 1.1% and scoliosis in 29%. Vacuum bell treatment was introduced for 218 patients who did not meet surgical criteria or were averse to surgery.

Results: At primary operation, 1 bar was placed in 49.8%; 2 bars, 49.4%; and 3 bars, 0.7%. There were no deaths. Cardiac perforation occurred in 1 patient who had undergone previous cardiac surgery. Paraplegia after epidural catheter occurred once. Reoperation for bar displacement occurred in 1.8%, hemothorax in 0.3%, and wound infection in 2.9%; 1.4% required surgical drainage. Allergy to stainless steel was identified in 13.7%. A good anatomic outcome was always achieved at bar removal. Recurrence requiring reoperation occurred in 3 primary surgical patients. Two patients developed carinate overcorrection requiring reoperation. Vacuum bell treatment produced better results in younger and less severe cases.

Conclusions: A standardized Nuss procedure was performed by multiple surgeons in 1034 patients with good overall safety and results in primary repairs. Vacuum bell treatment is useful.

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.

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

Abstract

Abstract

Miscellaneous

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

Kocher GJ, Sharafi S, Azenha LF, Schmid RA

Eur J Cardiothorac Surg. 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.

Abstract

Miscellaneous

Repair of sternoclavicular joint dislocations with FiberWire®

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

Arch Orthop Trauma Surg. 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.

Abstract

Pectus excavatum

Vacuum bell therapy

Haecker FM, Sesia S.

Ann Cardiothorac Surg. 2016 Sep;5(5):440-449.

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

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

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

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.

J Thorac Dis. 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.

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

Plast Reconstr Surg. 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.

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.

Abstract

Pectus excavatum

Cardiac function in adults following minimally invasive repair of pectus excavatum

Udholm S, Maagaard M, Pilegaard H, Hjortdal V

Interact Cardiovasc Thorac Surg. 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.

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

J Pediatr Surg. 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.

Abstract

Tumors

Chest Wall Resection and Reconstruction: Management of Complications

Hazel K, Weyant MJ

Thorac Surg Clin. 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.

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

J Pediatr Surg. 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.

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.

Ann Thorac Surg. 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.

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

J Am Coll Surg. 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.

Abstract

Pectus carinatum

Bracing is an effective therapy for pectus carinatum: interim results

Lee RT, Moorman S, Schneider M, Sigalet DL

J Pediatr Surg. 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.

Abstract

Pectus carinatum

Dynamic compression system for the correction of pectus carinatum

Martinez-Ferro M, Fraire C, Bernard S

Semin Pediatr Surg. 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.

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.

Ann Thorac Surg. 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.