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PubMed1992

Obliteration of the descending aortic interface in pectus excavatum: correlation with clockwise rotation of the heart.

Obliteration of the descending aortic interface is a new radiographic finding in pectus excavatum. Seventy frontal and lateral chest radiographs and 33 computed tomographic (CT) scans of patients with pectus excavatum were retrospectively reviewed to evaluate the frequency, possible cause, and clinical significance of this finding, which was detected in 21 of 70 cases (30%) of pectus excavatum. No significant relationship was found between this finding and the extent of the thoracic deformity. In patients with this finding, the left inferior pulmonary vein (PV) entered the left atrium at an acute angle to the sagittal plane, as demonstrated at CT, and this angle was significantly smaller than that in patients without this finding. The PV angle also significantly correlated with the cardiac rotation angle. In pectus excavatum, partial obliteration of the descending aortic interface can be mistaken for adjacent disease.

Adult↗
PubMedDate not supplied

Chest wall implants: their use for pectus excavatum, pectoralis muscle tears, Poland's syndrome, and muscular insufficiency.

Solid customized and prefabricated silicone implants have been used by the author for 15 years in a wide range of chest wall deformities. Chest wall implants are often used in males seeking to augment a muscularly deficient or underdeveloped chest; however, their greatest use has come in a variety of deformities both congenital and acquired, such as pectus excavatum, Poland's Syndrome, and pectoralis muscle tears. The implants can be either customized using a moulage technique or are prefabricated, manufactured implants which can be modified on the operating table to repair the contour deformity. The immediate postoperative problem of seroma and subcutaneous implant "show" has been minimized by careful planning, gentle technique, deep insertion, improved patient positioning on the operating room table, and the use of oral anti-inflammatory medications. The long-term results of these implants seem very satisfactory. The patients are usually physically active, and the implants show no long-term sequelae such as seroma, infection, displacement, or rupture.

Adolescent↗
PubMed1994

Pectus excavatum: abnormal exercise scintigraphy with normal coronary arteries.

Pectus excavatum is the most common congenital abnormality of the chest wall, and is frequently associated with chest pain. The invasive, as well as the ECG and echocardiographic assessment of possible coronary artery disease (CAD) in adults with moderate to severe forms of this deformity, is often complicated by the associated displacement of the heart in the chest cavity in these patients. We present findings in a 67-yr-old male that demonstrate that the predictive accuracy of positive stress radionuclide ventriculogram (RVG) and SPECT scintigraphic studies may be significantly reduced in patients with moderate to severe forms of this abnormality. Our findings also suggest, however, that either lateral or even a shallow left posterior oblique detector positioning during RVG, a significantly revised SPECT acquisition orbit, or planar imaging may provide a more accurate means to assess possible CAD in these patients. Like-wise, physician input would appear to be invaluable in determining the optimal mode of imaging and the acquisition protocol for patients with pectus excavatum.

Adult↗
PubMed2002

Minimally invasive repair of pectus excavatum--the Nuss procedure. A European multicentre experience.

Since the first description in 1998, the minimally invasive repair of pectus excavatum has gained increasing acceptance. The aim of this survey is to report on the experiences of eight European centres with this technique. 172 patients with a mean age of 15.1 (+/- 4.6) years were treated and evaluated, 35.5 % were symptomatic. 45.3 % of the patients had an asymmetric configuration of the chest, 74.3 % had a CT index above 3.25. Mean duration of the operative procedure was 76 minutes. Major complications, including dislocation of the bar or stabiliser, pneumonia, atelectasis, local infection, pleural and pericardial effusion and liver injury occurred in 11.1 % of the patients. Minor complications, such as self-resolving pneumothorax, atelectasis and subcutaneous emphysema were reported in another 8.1 %. Early cosmetic results were excellent or good in 81.5 %. Although the surgical procedure is simple, blood-sparing and short, consideration of some important technical details, proper patient selection and knowledge of the limitations is of vital importance. Long-term results are still lacking.

Adolescent↗
PubMed1988

Surgical management of children and young adults with Marfan syndrome and pectus excavatum.

Significant chest wall deformities occur in two thirds of children with Marfan syndrome (MS). The symptoms, physical findings, and surgical outcome of 11 patients with MS and severe pectus excavatum who required operative repair were reviewed. The diagnosis of MS was made before the pectus repair in six patients, at the time of evaluation of pectus in two patients, and after the repair in three patients. Symptoms included dyspnea upon exertion, tachypnea, and chest pain. Physical findings included aortic root enlargement or valvular disease, mitral valve disease, ligamentous disease, congestive heart failure, and ocular disease. All patients had severe pectus deformities with a narrow anteroposterior diameter in the midline, as well as a broad chest defect that extended bilaterally to the midclavicular line. The heart was shifted into the left side of the chest in all patients. A Ravitch-type pectus repair with a stainless steel substernal strut was used in eight patients, with one patient suffering a late recurrence; in three patients no strut was used, and all three had recurrence. There were no postoperative complications. In the postoperative follow-up of seven patients, symptomatic improvement of cardiopulmonary performance was noted. Four of the patients required subsequent open heart surgery, including replacement of the aortic valve in one patient, and composite grafts of the ascending aorta in three patients. Postoperative cardiac arrest was the only major open heart complication. All four patients recovered and did well after surgery, showing significant cardiac and pulmonary functional improvement.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2005

The minimally invasive Nuss technique for recurrent or failed pectus excavatum repair in 50 patients.

PURPOSE: The aim of this study was to demonstrate the efficacy of the minimally invasive technique for recurrent pectus excavatum. METHODS: Fifty patients with recurrent pectus excavatum underwent a secondary repair using the minimally invasive technique. Data were reviewed for preoperative symptomatology, surgical data, and postoperative results. RESULTS: Prior repairs included 27 open Ravitch procedures, 23 minimally invasive (Nuss) procedures, and 2 Leonard procedures. The prior Leonard patients were also prior Ravitches and are therefore counted only once in the analyses. The median age was 16.0 years (range, 3-25 years). The median computed tomography index was 5.3 (range, 2.9-20). Presenting symptoms included shortness of breath (80%), chest pain (70%), asthma or asthma symptoms (26%), and frequent upper respiratory tract infections (14%). Both computed tomography scan and physical exam confirmed cardiac compression and cardiac displacement. Cardiology evaluations confirmed cardiac compression (62%), cardiac displacement (72%), mitral valve prolapse (22%), murmurs (24%), and other cardiac abnormalities (30%). Preoperative pulmonary function tests demonstrated values below 80% normal in more than 50% of patients. Pectus repair was done using a single pectus bar (66%), 2 bars (32%), or 3 bars (2%). Stabilizers were used in 88% of the patients. Median length of surgical time did not significantly differ from that of primary surgeries. Complications were slightly higher than those in primary repairs and included pneumothorax requiring chest tube (14%), hemothorax (8%), pleural effusion requiring drainage (8%), pericarditis (4%), pneumonia (4%), and wound infection (2%). There were no deaths or cardiac perforations. Initial postoperative results were excellent in 70%, good in 28%, and fair in 2%. Late complications of bar shift requiring revision occurred in 8%. Seventeen patients have had bar removals with 9 patients being more than 1 year postremoval. For the 17 patients who are postremoval, excellent results have been maintained in 8 (47%), good in 7 (41%), fair in 1 (6%), and failed in 1 (6%). There have been no recurrences postremoval. CONCLUSIONS: Although failed or recurrent pectus excavatum repairs are technically more challenging, reoperative correction by the Nuss procedure has met with excellent success.

Adolescent↗
PubMed1985

Rib cage mobility in pectus excavatum.

Pectus excavatum is generally regarded as a cosmetic deformity; however, some children with pectus excavatum complain of chest pain and exercise limitation. Physiologic studies sometimes show mild restrictive changes and suggest an increased oxygen cost of breathing. Limitation of rib cage mobility related to the deformity may explain these findings. If rib cage mobility is limited, the ability of the actively inspiring rib cage to lower abdominal pressure would be decreased. If this were so, increased swings in abdominal pressure would be seen during the respiratory cycle, especially at times of stress such as during exercise. To test the hypothesis that pectus excavatum is associated with decreased rib cage mobility, we studied 11 patients with pectus excavatum and 11 control subjects. Four control subjects were also studied with rib cage mobility restricted by chest wall strapping sufficient to decrease vital capacity by 5, 10, and 40%. Gastric pressure was measured using balloon catheters and was used as an index of abdominal pressure. Flow at the mouth was recorded and integrated to give volume. Measurements were made at rest, immediately after exercise, and during graded voluntary inspiration to total lung capacity. Gastric pressure was related to tidal volume, and pressure-volume loops were constructed. There were no differences in abdominal pressure swings during respiration between the patients with pectus excavatum and the control subjects. Both groups showed moderate increase in gastric pressure during inspiration at rest and smaller increases or even decreases in abdominal pressure at end inspiration after exercise and at total lung capacity.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1989

Preoperative and postoperative abnormalities in chest x-ray indices and in lung function in pectus deformities.

In 88 patients with pectus deformities radiologic chest indices and routine pulmonary function tests were measured before and 1 to 20 years after corrective surgery. A combination of anteroposterior indices at the upper and lower level of the chest were investigated to quantitate and to discriminate the different pectus deformities. The study comprised four groups: pectus excavatum, pectus carinatum, pectus deformatum and pectus excavatum with scoliosis. These indices were also assessed in 250 healthy males and females. Generally, several indices showed significant and discriminative changes in the different patient groups and improved again after surgery. Preoperative lung function was decreased in pectus excavatum only. In all groups lung function worsened after surgery. A stepwise discriminant analysis performed on the large group with pectus excavatum indicated that postoperative lung function was decreased if the preoperative value of FEV1 or VC was more than about 75 percent predicted and vice versa, but that it was not related to other factors such as radiologic indices, age at operation or time since operation.

Adolescent↗
PubMed1982

Symptomatic pectus deformities of the chest.

Aspects of pulmonary mechanics and exercise tolerance were investigated in 8 young male patients with pectus deformities, 5 of whom presented with the chief complaint of exercise limitation. Results of pulmonary mechanics studies did not adequately explain patient symptoms. Lung volumes were only mildly reduced. There was no evidence of airway obstruction. Measures of lung compliance were normal in 6 patients studied. Results of exercise studies did reveal significant abnormalities in symptomatic and asymptomatic patients; tidal volume at maximal effort expressed as a percentage of vital capacity was diminished, suggesting restriction of ventilation. Oxygen uptakes in the 4 symptomatic patients were normal at lesser work loads but progressively exceeded predicted values at greater work loads, suggesting an abnormally elevated work of breathing during vigorous exertion. Three asymptomatic patients demonstrated a normal linear pattern of increase in oxygen uptake with increasing work load. Respiratory symptoms in some patients with pectus deformities appear to have a physiologic basis. Our data suggest a dynamic restrictive pulmonary process as an explanation for these symptoms.

Adolescent↗
PubMed2002

Repair of recurrent pectus deformities.

A paucity of information is available regarding the surgical repair of recurrent pectus deformities (RPD). From 1993 through 2001 35 patients ranging in age from 6 to 51 years (mean, 23 years) underwent repair of RPD a mean of 11 years after the original repair: modified Ravitch repair (31), prosthetic implantation (three), and Nuss procedure (one). All patients had accompanying symptoms including decreased stamina (76%), chest discomfort (53%), asthma (33%). The repair performed was dependent on the findings at operation. A modified Ravitch procedure with Adkins strut was performed for 21 patients. Three had reattachment of mobile costal cartilages and/or xiphoid process to the sternum; three patients had autologous bone or cartilage grafts, three had muscular reconstruction, and two had resection of a localized cartilage protrusion. Three patients could not be reconstructed safely. Very good to excellent results were achieved for 32 patients (mean follow-up, 24.8 months). There were no deaths or major complications. Minor complications occurred in five patients. The mean blood loss was 105 mL. The mean hospital stay was 2.8 days. We conclude that although it is technically difficult RPD can be repaired with low morbidity, short hospital stay, and very good physiologic and cosmetic results.

Adolescent↗
PubMed2005

Tc-99m MAA SPECT in pectus excavatum: assessment of perfusion volume changes after correction by the Nuss procedure.

PURPOSE: The Nuss procedure is a minimally invasive technique for the repair of pectus excavatum. This investigation attempted to assess the impact of this corrective protocol on pulmonary functional volume through analysis of distribution volume data derived from Tc-99m MAA SPECT. MATERIAL AND METHODS: SPECT was performed in 3 patients before and 6 months after completion of the Nuss procedure. Before the clinical application of SPECT, phantom experiments were conducted to establish the threshold level based on the volume calculation program. Haller's index, a quantitative index of chest-wall deformity, was also obtained by x-ray CT. RESULTS: A threshold level of 30% was the most accurate determinant of pulmonary volume. Preoperative and postoperative Tc-99m MAA distribution volumes (MAA volume in mL) were 2812 and 3107 (an increase of 10%), 2212 and 2410 (9%), and 2341 and 2872 (23%), respectively. In all patients, MAA volume increased after corrective intervention. Changes were most striking in the left lung, which is affected to a greater extent by dislocation of the heart. Morphologic improvement in the lungs was also demonstrated by Haller's CT index in all patients, which decreased from 4.35, 3.52, and 10.67, preoperatively, to 3.45, 2.75, and 4.25, respectively, postoperatively. CONCLUSION: MAA volume assessment is an easy, suitable approach for detection of favorable changes produced by the Nuss procedure in pectus excavatum.

Adolescent↗
PubMed1992

Degree of severity of pectus excavatum and pulmonary function in preoperative and postoperative periods.

Pulmonary function was evaluated in 138 patients with pectus excavatum, paying particular attention to the degree of severity of chest deformity. We defined the severity of deformity quantitatively based upon a computed tomographic index obtained from a computed tomogram. We recognized a positive relationship between computed tomographic index (x) and percent vital capacity (y), as follows: y = 137x + 58 (n = 138, r = 0.61, p < 0.05). Pulmonary function tests were performed from 2 to 42 months postoperatively. Vital capacity decreased about 10% from the baseline value during the initial 2 months after surgical treatment and recovered to the preoperative level by 1 year after surgery. At 42 months after surgical correction, the pulmonary function was maintained at the baseline level and the severity of deformity was significantly improved. Surgical procedures for the treatment of pectus excavatum--sternocostal elevation and sternal turnover--resulted in an excellent cosmetic result but did not importantly affect respiratory function.

Adolescent↗
PubMed2003

Experience in 100 cases with the Nuss procedure using a technique for stabilization of the pectus bar.

The Nuss procedure is a new, minimally invasive technique for the repair of pectus excavatum. We describe our experience with this operation, in a relatively large series in a single institution, and introduce our technical modification for stabilizing the pectus bar. In 107 patients (75 male and 32 female) with pectus excavatum who underwent the Nuss procedure, age at operation ranged from 3 to 23 years old (mean: 7.5+/-4.1) and Haller's CT index ranged from 33 to 2.6 (mean: 6.1+/-3.5). To stabilize the pectus bars, we tied the rib and both edges of the bars with surgical steel wire, 0.8 mm in diameter, using a Duchenne needle to guide the wire behind the rib. Average operating time with this technique (n=100) was 48+/-20 min. The stability of pectus bars after the operation was assessed by lateral chest X-ray films. The position of the center of the pectus bars, facing the sternum at right angles, was classified as excellent. A minimal bar displacement of less than 45 degrees was classified as incomplete. The position of the bars that had rotated 90 degrees was classified as poor. The post-operative course was uneventful in all cases except for three patients who showed wound infection, hemothorax or pneumothorax, independently. Two patients required wire removal due to skin irritation as a late complication. Five patients underwent re-operations due to bar displacement. Among them, only two cases were included in the group of wire fixation. Only five teen-aged patients required a lateral stabilizing bar. Lateral chest X-ray films of 100 patients showed that the position of the pectus bar was excellent in 86 cases, incomplete in 12 cases and poor in two cases. In 70 patients aged less than 10 years, the position in 91% was excellent and in 9% was incomplete. In 30 patients aged 10 years and older, 14 required two pectus bars and the results were excellent in all cases. The other 16 patients with a single bar showed excellent results in eight (50%) cases, incomplete in six (37.5%) and poor in two (12.5%). The wire-fixation technique was safe, effective and time efficient to perform in young cases. Teen-aged patients, however, were at high risk of bar displacement. Therefore, the use of two bars and lateral stabilizing bars are recommended for these high-risk patients.

Adolescent↗
PubMed2004

Cardiorespiratory outcome after corrective surgery for pectus excavatum: a case study.

PURPOSE: The purpose of this case study was to examine the effect of pectus excavatum before and after surgical correction on ventilatory and cardiorespiratory responses to submaximal and maximal exercise. METHODS: The patient was a 30-yr-old longshoreman who had mild pectus excavatum since infancy that became worse during his adolescent growth years. The deformity persisted into adulthood with increasing symptoms. Although he had a history of habitual aerobic exercise, the patient experienced frequent episodes of pain in the lower anterior chest, breathlessness, and reduced stamina when performing activities of daily living. He performed pulmonary function tests, submaximal and maximal incremental exercise testing, before and 6 months after corrective surgery. RESULTS: Six months after corrective surgery, the patient demonstrated increases in FEV1 (13.0%), maximum voluntary ventilation (MVV, 32.3%), maximum power output (max, 15.5%), [OV0312]O2max (7.9%), metabolic threshold ([OV0312]O2theta, 30.8%), oxygen-pulse ([OV0312]O2/fc, 14.0%), and maximal tidal volume (VTmax, 11.7%). On submaximal testing, we found that the time constant for oxygen uptake kinetics was 46.8 s for the on-transit and 46.5 s for the off-transit before surgery and 33.6 s for the on-transit and 30.3 s for the off-transit six months after surgery. CONCLUSIONS: The information derived from this case study supports the opinion that corrective surgery for pectus excavatum may alleviate the impaired ventilatory and cardiorespiratory performance seen preoperatively.

Adult↗
PubMed1993

Sternal resection and reconstruction.

Twenty-one patients underwent sternal resection and reconstruction. Surgical indications included sternal infection in 9 patients, recurrent breast cancer in 6, metastatic carcinoma from an unknown primary in 2, pectus excavatum in 2, and osteogenic sarcoma and eosinophilic granuloma in 1 each. Management included partial sternectomy in 10 patients (group 1) and complete sternectomy in 11 (group 2). Chest wall reconstruction was by various flaps and mesh repairs. Blood transfusions averaged 2 units in group 1 versus 5.5 units in group 2 (p = 0.02). Average number of days until extubation was 2.6 in group 1 versus 7.3 in group 2 (p = 0.04). Average number of intensive care unit days was 4.4 for group 1 versus 9.4 for group 2 (p = 0.03). The number of days until discharge was 14 days for group 1 versus 20 days for group 2. Complications occurred in 40% of group 1 and 82% of group 2 patients. Overall mortality was 9.5%. Sternal resection and reconstruction, particularly complete sternal resections, are a major undertaking with substantial morbidity. Using a multidisciplinary approach (cardiothoracic, plastic and reconstructive, critical care medicine, and infectious disease) and aggressive pulmonary support, acceptable cosmetic and functional results are possible.

Adolescent↗
PubMed2002

Increasing social capital via local networks: analysis in the context of a surgical practice.

The relationship between social capital (support, trust, patient awareness, and increased practice revenue) and local networks (university hospital) in communities has received little attention. The development of computer-based communication networks (social networks) has added a new dimension to the argument, posing the question of whether local networks can (re-)create social capital in local communities. This relationship is examined through a review of the literature on local networks and social capital and a surgeon's practice management from 1990 to 2001 with respect to repair of pectus chest deformities. With respect to pectus repair there was a consistent but small number of new referrals (15-20 new patients/year), lack of patient awareness (eight to 12 self-referred patients/year), and modest practice revenue. Since the inception of an Internet website (social network) dedicated to pectus repair in 1996 there has been increased social participation (n = 630 hits/year to the website); facilitation of spread of information through E-mail messages (n = 430 messages/year); and a greater participation of groups such as women, minorities, adults, and those with disability (n = 120 patients/year). The dissemination of information via the local network has also allowed an "outward movement" with increased participation by interconnecting communities (n = 698,300 global Internet participants based on statistical ratios). We conclude that local networks have enhanced social networks providing new grounds for the development of relationships based on choice and shared interest.

Adult↗
PubMed1981

Pectus carinatum and pectus excavatum: are they the same disease?

Eighty cases of anterior chest wall deformities were reviewed. The group consisted of 47 patients with pectus carinatum and 33 patients with pectus excavatum. This 1.4:1 distribution has not been reported in the literature, where a 1:10 distribution is regularly cited. Important bronchopulmonary changes were found by chest x-rays in both groups. Formerly, alterations in pectus excavatum were attributed to the mechanical effect of the depressed sternum. The presence of the same symptoms and bronchopulmonary radiographic changes in patients with pectus carinatum suggests a primary pulmonary defect in both entities. However, bronchopulmonary changes were more prominent in patients with pectus excavatum than in patients with carinatum, which suggests that mechanical compression enhances the problem. Postoperative radiologic improvement was similar in both groups. The patients underwent a surgical procedure that included a sternal osteotomy and a complete removal of the costal cartilages. All patients survived. There were two recurrences. Considerable postoperative overgrowth of the unresected second costal cartilages was observed, hence our recommendation for routine removal of these structures. The habitus of prominent abdomen and stooped shoulders was not modified by the operation, but important symptomatic improvement and some radiologic improvement were observed in both groups.

Adolescent↗
PubMed2003

Evaluation of pectus bar position and osseous bone formation.

PURPOSE: Minimally invasive repair has become a popular approach for pectus excavatum (PE). The bar is secured to the thoracic wall and left for approximately 2 years. The authors have noticed an intense bone formation (BF) around some of these bars at removal. A review of children undergoing bar removal was performed to better understand this BF in relation to bar placement. METHODS: A retrospective review of children undergoing bar removal after PE repair since January 1998 was performed. Chart review included age at bar insertion and removal, bar insertion position (subcutaneous [SC] v submuscular [SM]), BF on Chest x-ray and at bar removal, operating time, and estimated blood loss (EBL). RESULTS: Thirty-six patients underwent bar removal during the study period (16 SC and 20 SM). Chest x-ray evaluation was possible in 27 patients (16 SM, 11 SC). No difference existed for length of time the bar was in place or age at insertion/removal between groups. EBL was higher in the SM (18.3 v 8.8 mL, not significant). BF was seen radiographically in 15 SM and 3 SC patients (P <.001). BF was encountered at removal in 19 SM patients and a single SC patient (P <.001). Operating time was statistically longer (P <.01) for the SM group (30.2 v 15.6 min). CONCLUSIONS: Bar position during repair of PE is important. SM positioning virtually always results in BF with increased EBL and statistically longer operating time at removal. Careful placement of the bar in the SC position without violating the fascia should be used to avoid these undesirable effects.

Blood Loss, Surgical↗