Measuring the impact of brace intervention on pediatric pectus carinatum using white light scanning

Background

Evaluation of Pectus Carinatum (PC) deformity in patients undergoing bracing is limited to subjective assessment of the chest through physical exam and photography. White Light Scanning (WLS) is a novel 3D imaging modality and offers an objective alternative that is quick, inexpensive, and safe. We previously demonstrated the feasibility of using a WLS-derived proxy for Haller index, called the Hebal–Malas Index (HMI), in measuring the surgical correction of Pectus Excavatum. The purpose of this study was to demonstrate the use of WLS to measure the severity of pre- and postbracing intervention of PC deformities and assess corrected difference between the two scans.

A novel technique to measure severity of pediatric pectus excavatum using white light scanning.

Background/purpose

Computed tomography (CT) derived Haller Index (HI) remains the standard for quantifying severity in patient with pectus excavatum (PE). Optical scanning described in literature reports optimistic results and new indices that correlate with HI. This study assessed the feasibility of a handheld White Light Scanner (WLS) to obtain 3D measurements and indices of PE deformity.

On the surgical treatment of pectus excavatum

80 cases of funnel chest were treated surgically, 9 by Gross procedure, 41 by turn-over technique and 30 by reverse "V" shape osteotomy of the sternum and ribs with internal fixation. There were 56 boys and 24 girls, with ages ranging from 2 to 14 years. The sternal depression varied in depth from 3 to 4 cm, and in volume from 20 to 120 ml. Roentgenographically, there were different extents of deviation of the heart to the left. Some patients had abnormal ECG. To study the results of operations, 48 cases were followed-up for 0.5 to 19 years. We found that the results of reverse "V" shape osteotomy of the sternum and ribs with internal fixation were superior to others. Its main advantage lies in the internal fixation which holds the sternum stable thus favoring wound healing and permanent correction. It is simple with less surgical trauma and postoperative complications. Some disappointing results in the other two techniques, such as uneven chest wall, flat chest and forward protruding of the sternum could also be avoided by this procedure. The internal fixation device was removed one year after operation. Follow-up for 3 to 4 years found the chest wall in satisfactory contour.     

Clinical classification and surgical correction of pectus excavatum

We described the experience in clinical classification and surgical correction of 320 cases of pectus excavatum (1984-1990). The patients age ranged from 2 to 14 years. According to the configuration, the deformity was divided into types: extensive type (7.5%); common type (74.3%); localized type (12.5%); mixed type or irregular (5.6%). We found such as four characteristic signs shoulder anteversion, kyphosis, chest excavation and abdominal bulge. Rotation of sternum, costal margin eversion, chest asymmetry and flat chest were also encountered. All these made the correction very difficult. A reverse "V" shape osteotomy of the sternum and ribs was with internal fixation. Small hand saw, special periosteum elevator and related internal fixation device were designed for the operation. In severe cases, satisfactory result was obtained by the technique combined with other surgical procedure.     

Anesthetic management for the correction of pectus excavatum using pectus bar under video-assistance

We report anesthetic management for a child undergoing Nuss operation, a minimally invasive operation which requires neither cartilage incision nor its resection for correction of pectus excavatum. The patient was a 7-year-old boy with the funnel index 5 and the mediastinal shift to the left. General anesthesia with endotracheal intubation was induced and maintained with nitrous oxide, sevoflurane and fentanyl. Thoracic epidural anesthesia was used with 0.125% bupivacaine to supplement analgesia. When the curved bar was passed under the sternum with the aid of an endoscope, sinus tachycardia occurred and continued for 5 minutes but subsided without medication. Otherwise operative course was uneventful with negligible blood loss. After surgery, the patient was kept at bed rest for 2 days, receiving epidural patient-controlled analgesia combined with sedation with midazolam with good results. He was allowed to sit 3 days, to walk 5 days and discharged 10 days postoperatively.     

Technical considerations in the surgical management of pectus excavatum and carinatum

During the past 25 years, 650 operations have been performed on 608 patients for anatomically significant pectus excavatum or carinatum deformities of the anterior chest wall. There were no deaths in this series, and serious complications were very rare.We conclude that repair of pectus excavatum and carinatum deformities should include the following operative steps: (1) adequate mobilization of the sternum and correction of its abnormal angulation by transverse osteotomy; (2) adequate bilateral removal of the involved costal cartilage; and (3) securing the corrected position of the sternum with the patient's own living tissue, retaining its blood supply and using it as an internal support.Using these principles, new surgical procedures were developed for the correction of: symmetrical pectus excavatum, asymmetrical pectus excavatum, pectus carinatum with xiphoid angulation, pectus carinatum without xiphoid angulation, asymmetrical pectus carinatum, chondromanubrial prominence with chondrogladiolar depression, and recurrent pectus excavatum.We recommend surgical correction for patients in whom the deformity is significant and no contraindication exists. The ill effects of this condition should not be underestimated.     

A pilot study of the impact of surgical repair on disease-specific quality of life among patients with pectus excavatum

Background

This study was conducted to determine the ability of 2 questionnaires (ie, child and parent versions) to measure physical and psychosocial quality-of-life changes after surgical repair of pectus excavatum.

Methods

The authors administered these questionnaires by telephone interviews with 22 parents and 19 children (ages 8 to 18) before surgery and 6 to 12 months after repair by the Nuss procedure.

Results

The instruments had high test-retest reliability (Rho > 0.6 for all retained questions). Children reported significant improvements in exercise intolerance, shortness of breath, and tiredness. Of 9 questions asking the children how they feel or act about their bodies, all but one question showed significant improvement after surgery. Parents also reported significant improvements in their child’s exercise tolerance, chest pain, shortness of breath, and tiredness and decreases in the frequency of the child being frustrated, sad, self-conscious, and isolated.

Conclusions

These questionnaires appear to be more than adequate to measure disease-specific quality-of-life changes after surgery. These data confirm for the first time that surgical repair of pectus excavatum has a positive impact on both the physical and psychosocial well-being of the child.     

Cardiovascular MRI assessment of pectus excavatum in pediatric patients and postoperative simulation using vacuum bell

BackgroundThe sternal lift by Vacuum Bell (VB) is effective, as largely demonstrated by its intraoperative use during surgical procedure to elevate the sternum during the Nuss procedure routinely. Indeed, the thoracic remodelling during VB application is comparable to post-surgical scenario, and suitable to compare cardiovascular parameters of the two different thoracic configurations immediately.ObjectiveWe would quantify and correlate preoperative parameters which determine the severity of the pectus excavatum (PE), and the cardiovascular effects at the baseline. Than we would assess the cardiovascular changes during VB positioning, mimicking the immediate, temporary effect of Pectus-correction.Materials and MethodsWe included 26 consecutive patients (mean age is 13,3 +/- 2,2 years) symptomatic and non, with a previous clinical diagnosis of PE. CMR was performed before and during application of VB, using the same imaging protocol. In both conditions, we measured thoracic indexes, and cardiac function as well as flow through main vessels.ResultsMean expiratory Haller Index (HI) was 5,4 (+/-1,4 SD; normal <3). During VB application, all patients showed improvement in the main morphologic parameters of the thorax (mean expiratory HI = 4,7 (+/-1,6 SD, delta -13%, P = 0,01). During VB application, a minimal but not significant increase of Right Ventricle End Diastolic Volume (RVEDVi) (delta +4,6%, P = 0,12), and Right Ventricle Ejection Fraction (RVEF) (delta +1,2%, P = 0,2) was observed.ConclusionIn adolescents affected by PE, cardiacMRI (CMR) demonstrates normal values of biventricular volume and systolic function. During VB application, beside significative improvements in chest wall anatomy, CMR shows a minimal positive variation in right ventricle volume and function. A minority of patients showed some degree of diastolic dysfunction at baseline, unchanged after VB application, with possible correlation between valve inflow and sternal impingement.     

The results of the Ravitch-Sutherland technic for surgical correction in pectus excavatum

The aim of our study was to assess the functional and cosmetic results after performing a modified Ravitch-Sutherland procedure in children presenting with excavatum. A series of 31 children with ages ranging between 5 and 16 years, presenting with pectus excavatum, were operated between 1986-1996 in our service. In 5 cases surgical treatment was required by the presence of respiratory and/or cardiac functional impairment due to the malformation. In the other 23 cases operation was performed mainly for cosmetic reasons. In all cases a modified Ravitch-Sutherland procedure was performed. Modification consisted in renouncing at the plicature of the perichondra and in associating a diaphragmatic elongation and Bedouelle laparoplasty in all cases. Longitudinal sternotomy was performed in 2 cases with severely impaired ventilatory capacity. Functional and cosmetic results were good in all cases. In 2 cases, in which recurrence of the condition was observed, a second identical procedure was performed, with a good result. The interval between the operation and the moment of long-term evaluation ranged between 3 months and 11 years. We conclude that the modified Ravitch-Sutherland procedure represents an effective method for the treatment of pectus excavatum cases, offering good functional and cosmetic long-term results.     

Incidence and severity of surgical complications after pectus excavatum bar removal

Open in a separate window OBJECTIVESPectus bar removal is the final step of minimally invasive repair of pectus excavatum. Complication rates related to bar removal have been reported in 2–15% of patients and severe, near-fatal and fatal complications have been reported. No systematic assessment of complication severity or risk factors associated with bar removal has been reported in large study populations. The aim of this paper is to investigate the safety of the bar removal procedure with regard to complication rates and severities as well as assessment of risk factors.METHODSBetween 2003 and 2019, 1574 patients underwent the bar removal procedure. Medical records were assessed retrospectively and complications registered. Complications were categorized in infections, bleedings and other complications. The severity of the surgical complications was systematically classified using the validated Clavien–Dindo classification. Furthermore, risk factors associated with complications were assessed.RESULTSThe overall complication rate was 4.1% (Clavien–Dindo classification I–IV), mainly consisting of bleedings (1.3%) and infections (1.5%). Five cases of severe bleedings were registered (0.3%, Clavien–Dindo classification IV). Risk factors associated with complications during bar removal were greater age and removal of more than one bar.CONCLUSIONSThe bar removal procedure is a safe and effective procedure. Both age and number of bars inserted should be considered prior to surgical correction of pectus excavatum as these factors predict complications related to bar removal.     

The seagull wing self retaining prosthesis in the surgical treatment of pectus excavatum

BACKGROUND: Between June 1958 and June 1996 we operated many patients affected by pectus excavatum with an original surgical technique. In this study we evaluated the durability of the results. METHODS: Experimental design: Retrospective study with a mean follow-up time of 15.8 years/pt, and 60% complete. SETTING: private and institutional practice. PATIENTS OR PARTICIPANTS: 357 patients (253 males and 104 females, mean age = 18.2+/-5.1 years) affected by pectus excavatum. The grade of PE (Chin classification) was I in 76 patients, II in 165 and III in the remaining 116. Most of the patients required operation for aesthetic reasons only (339 patients; 95%). INTERVENTION: the surgical technique consisted of a double transversal sternotomy at the level of the lowest and highest part of the depression associated with a longitudinal sternotomy. A wedge resection of the ribs was then performed and the sternum was fixed using an original stainless steel strut prosthesis moulded into a seagull wing. The strut was removed 12 months postimplantation. RESULTS: There were no operative deaths. Four patients (1.2%) had sternal wound infection, which was successfully treated. From the aesthetic point of view, the postoperative results were excellent in 262 patients (73.4%), good in 82 (22.9%) and poor in 13 (3.6%). All subjective symptoms, when present, disappeared after surgery. CONCLUSIONS: The seagull wing prosthesis appears to be safe, easy to implant and to remove, and comfortable for the patient. This technique has shown good long-term results independently of type of deformity and patient age.