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PubMed2005

Midterm evaluation of cardiopulmonary effects of closed repair for pectus excavatum.

BACKGROUND/PURPOSE: Since the introduction of the closed technique for repair of pectus excavatum, increasing numbers of patients are presenting for surgery. However, controversy exists regarding the effects of repair on long-term cardiopulmonary outcome. This report details the effects over time of closed repair of pectus excavatum on pulmonary function, cardiac function, exercise tolerance, and the patient's perception of appearance and subjective ability to exercise. METHODS: All patients undergoing closed repair of pectus excavatum were evaluated prospectively. Preoperative computed tomography scan, static pulmonary function studies, exercise tolerance, and echocardiographic evaluation of cardiac function were done. Studies were repeated at 3 and 21 months post-bar placement, and then 3 months after bar removal. RESULTS: Pre- and postoperative data were available for an initial 48 patients, with 11 patients completing the full evaluation after bar removal. All measures of pulmonary function including forced expiratory volume in 1 second and forced vital capacity were reduced at 3 months postoperation, with a gradual increase during follow-up; however, pulmonary function remained below normative values for patients without pectus excavatum of similar age. Cardiac function as measured by cardiac output and index was increased at 3 months postoperation and maintained thereafter. Exercise tolerance declined initially and then increased by the 21-month evaluation point and after bar removal. Patients reported a subjective improvement in the ability to exercise immediately after bar insertion. CONCLUSIONS: These results corroborate previous studies which suggested that after closed repair of pectus excavatum there is an immediate subjective improvement in the ability to exercise which is paralleled by an improvement in cardiac output. However, there is an early postoperative decline in pulmonary function which does improve over time; however, this does not reach normal values for similar weight. Further studies are needed to determine whether these results are maintained, or whether after bar removal there is a further improvement in pulmonary status. These results do support the use of the closed repair of pectus excavatum for maintaining and possibly improving cardiopulmonary function in this patient population.

Adolescent↗
PubMed2005

Management of postoperative infections after the minimally invasive pectus excavatum repair.

PURPOSE: Pectus excavatum is frequently repaired using the minimally invasive placement of a substernal bar (Nuss procedure). Infectious complications after the Nuss procedure are potentially devastating. To date, the management of postoperative infectious complications has not been well described. METHODS: A retrospective review of all patients (N = 168) who underwent the Nuss procedure from January 1, 1997, to October 1, 2003, at our institution was performed. Six patients (4%) had postoperative infections, and their medical records were reviewed. RESULTS: Of the 6 patients, 5 underwent operative drainage for wound abscesses that developed 2 to 76 weeks postoperatively. The other patient developed cellulitis 12 months postoperatively and was treated effectively with antibiotics alone. Recurrent infections were treated in 3 of 6 patients, one of whom eventually required removal of the bar resulting in a mild, residual pectus excavatum defect. One of 6 patients has had the substernal bar removed electively. The remaining 4 continue to be without clinically apparent infection at this time and are over 1 year removed from their infection. CONCLUSIONS: Although uncommon, infectious complications after the Nuss procedure require complex management strategies. Despite recurrent infection in some cases, most infectious complications occurring after the minimally invasive repair can be effectively treated without having to remove the substernal bar.

Abscess↗
PubMed2005

Pectus excavatum in a 112-year autopsy series: anatomic findings and the effect on survival.

BACKGROUND/PURPOSE: The purpose of this study was to determine the frequency of pectus excavatum and associated conditions in a large autopsy series. It also sought to determine whether there were different survival patterns for pectus excavatum patients than for patients without pectus excavatum. METHODS: A computer-assisted search of autopsy files maintained by Johns Hopkins University was conducted, dating from 1889 to 2001. Each patient's Autopsy Pathology Information System report was reviewed for diagnosis and comorbid conditions. To determine whether there were differences in survival patterns, we tested whether pectus excavatum patients survived longer than controls, using a standard epidemiological method. Each patient in the autopsy series was compared with the 2 patients entered in the autopsy database chronologically immediately before and the 2 patients immediately after the case. A Kaplan-Meier survival analysis was conducted. RESULTS: Pectus excavatum was identified at autopsy in 62 of 50,496 cases. Of these 62 patients, 17 were 65 years or older and appeared to have died of causes unrelated to pectus excavatum, the oldest being 91 years. Twenty-one were between the ages of 14 and 65 years and were found to have coexisting conditions or syndromes. Six were between the ages of 1 and 4 years. One of the 6 died in 1947 because of complications from pectus repair. No autopsied patient with pectus excavatum died between the ages of 5 and 14 years. Eighteen were infants younger than 1 year, and all 18 died because of conditions unrelated to pectus excavatum. There were no reported cases of pectus excavatum before 1947, and the severity of deformity could not be determined from the autopsy data. Survival analysis indicated that pectus excavatum patients had a different survival than the controls. Pectus excavatum patients tended to die earlier (P = .0001). However, pectus excavatum patients who survived past the age of 56 years tended to survive longer than their matched controls (P = .0001). CONCLUSION: Although there were no histological abnormalities noted in the cartilage of the pectus excavatum patient's conditions, pectus excavatum was associated with several connective tissue abnormalities. Analysis is consistent with the theory that this condition can impact survival.

Adolescent↗
PubMed2005

Delayed near-fatal hemorrhage after Nuss bar displacement.

A novel case of Nuss bar displacement with near-fatal hemorrhage 3 months after insertion and 3 weeks after unreported bar movement is presented. Salient features of presentation, evaluation, and treatment are described including how to divide the bar from an intrathoracic approach.

Adolescent↗
PubMed2007

When it is not an infection: metal allergy after the Nuss procedure for repair of pectus excavatum.

PURPOSE: Increasing use of implantable bars for minimally invasive pectus excavatum repair has introduced metal allergy (nickel and chromium) to pediatric surgeons. Metal allergy is a well-recognized entity in neurologic, orthopedic, and craniofacial surgery. This study was performed to evaluate metal allergy and its effects on treatment with the Nuss procedure in 862 patients. METHODS: After institutional review board approval, we undertook a retrospective review of a prospectively gathered database of patients undergoing the Nuss procedure. Metal allergy was diagnosed either with the use of dermal patch or clinically, based on rash, fever, elevated erythrocyte sedimentation rate, cultures, and pathology specimens. Data collection included demographics, an allergy to jewelry, and history of atopy. Clinical outcomes including need for reoperation, removal of stainless steel bar, and replacement with titanium bar were evaluated. RESULTS: Over an 18-year period (1987-2005), 862 patients underwent the Nuss procedure. Nineteen (2.2%) were diagnosed with metal allergy, with an average age of 14.7 years (9-23 years). Eighteen (95%) were males. A history of atopy was present in 9 (56%) patients. Ten (63%) patients presented with rash and erythema, 1 (6%) with granuloma, 5 (32%) with pleural effusion, and 3 (15%) were diagnosed on preoperative screening. Stainless steel bars were removed because of allergic skin breakdown in 3 patients, with 2 patients requiring replacement titanium bars. In all 3 of these patients, symptoms resolved after removal of stainless steel bars. Titanium bars were placed in the 3 patients who were diagnosed preoperatively with metal allergy, without event. CONCLUSIONS: Allergy symptoms often are misdiagnosed as infection, but require different treatment. If a history of metal allergy or atopy is suggested preoperatively, the patient should be tested for metal allergy, and if positive, a titanium bar used. Because the consequences of metal allergy may include the need to replace the bar, pediatric surgeons should be aware of this occurrence.

Adolescent↗
PubMed2007

Infectious complications after the Nuss repair in a series of 863 patients.

PURPOSE: A nemesis of surgical implants is infection. We evaluated the various infectious complications after Nuss repair of pectus excavatum in 863 patients over 18 years. METHODS: After institutional review board approval, a retrospective review of a prospectively gathered database of patients was performed who underwent minimally invasive repair of pectus excavatum and developed an infection. All patients received intravenous antibiotics before surgery continuing until discharge. Patients with a persistent fever after operation were discharged with oral antibiotics. RESULTS: From January 1987 to September 2005, 863 patients underwent a minimally invasive pectus excavatum repair and 13 (1.5%) developed postoperative infections. These included 6 bar infections, 4 cases of cellulitis, and 3 stitch abscesses. Cellulitis was defined as erythema and warmth which responded to a single course of antibiotics. Bar infections were defined as an abscess in contact with the bar. Surgical drainage and long-term antibiotics resolved 3 of these abscesses, whereas 3 patients required early bar removal (1 after 3 months and 2 after 18 months). Cultures identified a single organism in each case and Staphylococcus aureus was the most common organism (83%) identified, and all being methicillin sensitive. All infections occurred on the side of the stabilizer if a stabilizer had been placed. CONCLUSIONS: Infectious complications after Nuss repair are uncommon and occurred in 1.5% of our patients. Published rates of postoperative infection range from 1.0% to 6.8%. Superficial infections responded to antibiotics alone. Bar infection occurred in only 0.7% and required surgical drainage and long-term antibiotics. Only 3 of these (50% of bar infections and 0.34% overall) required early bar removal at 3 and 18 months because of recurring infections. Early bar removal should be a rare morbidity with the Nuss repair.

Funnel Chest↗
PubMed2003

Quality of life of patients who have undergone the Nuss procedure for pectus excavatum: Preliminary findings.

BACKGROUND/PURPOSE: The current project is a preliminary qualitative exploration of changes in quality of life of patients who have undergone the Nuss Procedure. The current study explores quality of life after surgical repair from the perspectives of both the patients and the parent(s) of the younger participants. METHODS: This research constitutes the first segment in a mixed-method longitudinal design. The author conducted semistructured interviews based on the Keith and Schalock's quality of life model. Five youth who have undergone the Nuss Procedure and the parent(s) of the 4 younger participants were included in the study for a total of 10 participants. Textual analysis has been carried out using Atlas.ti, a qualitative data analysis program that facilitates such activities as selecting, coding, and comparing textual segments. RESULTS: Results based on these preliminary data indicate that the patients interviewed had significant improvement in overall quality of life, which they attributed to the surgery. Specific examples of patients' expressions of improved self-confidence and renewed interest in physical activity are given. CONCLUSIONS: The Nuss Procedure is a minimally invasive surgical option for correcting pectus excavatum deformities that may make important contributions to patients' self-perceptions and quality of life. The participants in the current study expressed satisfaction with both the physical results of the surgery and with how it improved their overall quality of life. The authors recommend further prospective longitudinal research that assesses pre- and postsurgery psychosocial status and the maintenance of perceived quality of life changes.

Adolescent↗
PubMed1980

Pulmonary scintigraphy in pediatrics.

Pulmonary radionuclide studies in children provide reliable information on regional lung perfusion and ventilation. They are easily and safely performed and they do not usually require full patient cooperation. Their clinical indications and applications are not as well defined as and frequently differ from those in pulmonary disorders of the adult patient. Radiation exposures resulting from radionuclide pulmonary examinations are well within acceptable limits set up for a variety of radiologic diagnostic procedures. Our lung scanning experience with a spectrum of congenital and acquired cardiopulmonary diseases is presented and the contribution of the radionuclide methods to the specific problems facing the pediatrician or the surgeon is discussed.

Adolescent↗
PubMed2004

Simultaneous repair of pectus excavatum and congenital heart defect in adults by using the convex bar.

Simultaneous repair of pectus excavatum and cardiac lesions remains technically difficult. In adults, most repairs of pectus deformity and heart lesions have been performed through long incisions, sternal splits, excision of deformed cartilages, and sternal turnover, which can result in poor cosmetic appearance because of sternal devascularization. We performed concomitant repair of pectus excavatum and an atrial septal defect through a short midline incision in an adult. The sternum was fixed by using absorbable plates and screws and was supported by a convex steel bar. The cosmetic appearance remained excellent after the operation. The technique and a review of the literature are included.

Bone Plates↗
PubMed2004

The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients.

BACKGROUND: The Nuss procedure is a minimally invasive technique using a retrosternal bar to repair pectus excavatum. Although its technical simplicity and cosmetic advantages are remarkable, early applications have been limited to children with symmetrical pectus excavatum. We report a large single-institution experience including technical modifications to correct asymmetric configurations and extend the procedure to adult patients. METHODS: We retrospectively reviewed 322 consecutive patients who underwent repair of pectus excavatum by the Nuss technique and its modifications between August 1999 and June 2002. Of the patients 251 (78%) were children and 71 (22%) were adults. Precise morphologic characterization of the pectus allowed appropriate shaping of the bar to achieve a symmetric repair. RESULTS: Of the 322, 185 (57%) had symmetric and 137 (43%) had asymmetric pectus excavatum. Within the asymmetric group 71 were eccentric, 47 were unbalanced, and 19 were combined. Modifications to the shape of the bar including asymmetric and seagull bars were developed to deal with these types of asymmetry. A double bar or compound bar technique was used in most of the adults. Multipoint wire fixations to ribs were utilized to prevent bar rotation. Postoperative complications included pneumothorax (n = 24, 7.5%) and bar displacement (n = 11, 3.4%). The bar was removed in 42 patients 2 years after the initial procedure. CONCLUSIONS: Precise morphologic classification has led to modifications of the Nuss technique that facilitate correction of virtually all varieties of pectus excavatum including patients with asymmetric varieties and adults.

Adolescent↗
PubMed2004

The use of a lateral stabilizer increases the incidence of wound trouble following the Nuss procedure.

BACKGROUND: A lateral stabilizer has been used to prevent bar displacement during the Nuss procedure for pectus excavatum repair in pediatric patients. We experienced wound troubles in patients who had a stabilizer placed within them. The aim of this study was to examine the effect of a lateral stabilizer and other clinical factors on wound troubles after the Nuss procedure. METHODS: 53 patients with pectus excavatum underwent repair by the Nuss procedure. Preoperative clinical data, operative data, and postoperative complications were examined in all patients. RESULTS: A lateral stabilizer was placed in 29 of the 53 patients. Short-term results were excellent in 42 patients (79.2%). Postoperative complications involved pneumothorax requiring drainage in two patients, atelectasis in one patient, pleural effusion in three patients, deterioration of scoliosis in one patient, erythema in one patient, persistent pain in two patients, bar displacement in four patients, and local wound complications (Seroma with dermatitis due to pressure damage) in five patients. All seromas with dermatitis due to pressure damage were initially aseptic around lateral stabilizers and became infected in four patients after resection of the seroma or spontaneous perforation. Removal of both the pectus bar and lateral stabilizer was performed in two of those four patients and the lateral stabilizer was removed in the other two patients to prevent catastrophic infection such as empyema or mediastinitis. The use of a lateral stabilizer increases the incidence of wound trouble (p = 0.041). CONCLUSIONS: Although the Nuss procedure has evolved into an effective method for pectus excavatum repair, the use of a lateral stabilizer increases the incidence of wound difficulties.

Adolescent↗
PubMed1982

A simplified approach to the repair of pediatric pectus deformities.

For the past 14 years, a simplified operation utilizing a metal strut for internal fixation has been used to repair pectus anomalies in 123 children. Subperichondrial cartilage resection is preformed through small incisions in the pectoral muscles. No sternal osteotomy required. A malleable strut is passed transsternally and removed in four to six months, frequently under local anesthesia. All children who underwent this procedure were discharged within five to six days, and no transfusions were necessary. The use of the technique has shortened operative time and decreased the necessity for extensive postoperative pulmonary physiotherapy. In 75 children followed for over 5 years, cosmetic results have been excellent, and self-image has improved substantially. In only 1 child was there a recurrence impressive enough to warrant reoperation.

Child↗
PubMed1978

Correction of pectus excavatum without prostheses or splints: objective measurement of severity and management of asymmetrical deformities.

From 1949 to 1977, 254 children underwent surgical reconstruction of pectus excavatum by means of a variety of operations at The Johns Hopkins Hospital. From 1970 to 1977, 68 children had a modified Ravitch repair, with the addition of a tripod internal fixation technique for support of the sternum. These children obtained excellent cosmetic reconstruction without prosthetic support or splints. During an 18-month period we used a new system of caliper measurement of the spatial anatomy of the thoracic cage in more than 50 children. During the same period, we originated an operative step to correct the not uncommon asymmetrical excavatum that is usually deeper on the right and associated with a troublesome rotation of the sternum, found in 9 of the last 27 children seen. Correction was accomplished with an oblique anterior sternal osteotomy. The groups were analyzed and compared with respect to age, postoperative complications, and end results in order to identify trends in the management of children with this condition. On the basis of this experience, we feel confident in recommending a standardized operation for all forms of pectus excavatum at an elective age between 4 and 6 years and without prosthetic splints.

Adolescent↗
PubMed1978

Marlex mesh support for the correction of very severe and recurrent pectus excavatum.

A method for the correction of very severe and recurrent pectus excavatum is presented. The technique consists of mobilization of the sternum, transverse osteotomy, parasternal resection of the costal cartilages (modified Ravitch procedure), followed by placement of Marlex mesh behind the sternum and suturing the edge of the Marlex mesh to the peripheral stump of the resected ribs. This method has been used with good results in 6 patients, 2 of them with recurrent deformities.

Adolescent↗
PubMed1977

Repair of pectus excavatum in children under 3 years of age: a twelve-year experience.

From 1964 to 1975, 50 children under 36 months of age had operative repair of severely deforming pectus excavatum. No child died or suffered a serious complication from the operation. Most young children needing early repair of progressive pectus excavatum can be identified by 18 months of age. Forty-five patients in this series (90%) have had a totally satisfactory cosmetic and anatomical result on one- to twelve-year follow-up. Early repair of marked pectus excavatum in young children is safe and is efficacious in providing a suitable body contour.

Age Factors↗