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Current Development of Minimally Invasive Repair of Pectus Excavatum (MIRPE). CHILDREN 2022; 9:children9040478. [PMID: 35455522 PMCID: PMC9024707 DOI: 10.3390/children9040478] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022]
Abstract
For decades, open surgical repair was the only available method to treat congenital and acquired chest wall deformities (CWDs). In 1998, D. Nuss described a minimally invasive procedure for surgical repair of Pectus excavatum (PE). Today, the Nuss procedure is performed with increasing frequency worldwide and considered as the “gold standard”. After its introduction, the method experienced numerous modifications such as routine thoracoscopy and/or sternal elevation, increasing safety of the procedure. Placement of multiple bars and/or the so called cross-bar technique were introduced to correct complex CWDs. Standardized pain management, the introduction of cryo-analgesia and a standardized postoperative physiotherapy program including deep breathing exercises facilitate the establishment of an enhanced recovery after surgery (ERAS) process. However, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. Furthermore, several studies report near-fatal complications, not only during bar placement, but also during bar removal. This review focuses upon the most relevant modifications, including recent published surgical techniques of MIRPE, in order to describe current developments in the field.
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de Loos ER, Daemen JHT, Coorens NA, Maessen JG, Vissers YLJ, Hulsewé KWE. Sternal elevation by the crane technique during pectus excavatum repair: A quantitative analysis. JTCVS Tech 2021; 9:167-175. [PMID: 34647091 PMCID: PMC8501226 DOI: 10.1016/j.xjtc.2021.05.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/25/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction The crane technique is used to facilitate sternal elevation to provide safe mediastinal passage during the Nuss procedure. The aim was to objectively quantitate the elevation of the crane by 3-dimensional chest images acquired during the Nuss procedure. Methods A prospective cohort study was conducted. Patients undergoing the Nuss procedure were eligible. Sternal elevation was achieved by the crane technique providing a simultaneous lift of the anterior chest wall and reduction of the pectus excavatum depth. Both effects were evaluated. Three-dimensional surface images were acquired before incision, following sternal lift, and after bar implantation and quantitatively compared. Reduction of the external pectus excavatum depth was expressed as a percentage. Results Thirty patients were included. Ninety percent were male, with a median age of 15.5 years (interquartile range [IQR], 14.5-17.4), Haller index of 3.56 (IQR, 3.09-4.65), and external pectus depth of 18 mm (IQR, 11-23). Sternal elevation by the crane provided a median 78% (IQR, 63-100) reduction of the deformity, corresponding with a residual depth of 3 mm (IQR, 0-7). The percentual reduction diminished with increasing depth of the sternal depression (correlation, –0.86). Besides reducing the deformity, the crane caused an elevation of the anterior chest over a large surface area with a maximum lift of 26 mm (IQR, 19-32). Conclusions The crane is an effective sternal elevation technique, providing 78% reduction of the sternal depression, although its effect lessens with increasing depth. In addition, it produces an elevation of the anterior chest over a large surface area.
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Affiliation(s)
- Erik R de Loos
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jean H T Daemen
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.,Faculty of Health, Medicine and Life Sciences (FHML), School for Oncology and Developmental Biology (GROW), Maastricht, The Netherlands
| | - Nadine A Coorens
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Faculty of Health, Medicine and Life Sciences (FHML), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Yvonne L J Vissers
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Karel W E Hulsewé
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
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Nguyen TM, Le VT, Nguyen HU, Pham HL, Phung HSD, Vu NT, Nguyen VA, Do NK, Vu KD, Vo HL, Doan QH. An Initial 5-Year Single-Center Experience of 365 Patients Undergoing the Video-Assisted Thoracoscopic Surgery for Nuss Procedure for Pectus Excavatum in Resource-Scare Setting. Front Surg 2021; 8:693562. [PMID: 34195225 PMCID: PMC8236539 DOI: 10.3389/fsurg.2021.693562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/13/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Little is known about video-assisted thoracoscopic surgery in the Nuss procedure (VATS-NUSS) and its postoperative outcomes in the resource-scarce conditions in clinical practice such as Vietnam. Available evidence in the literature was mostly reported from large institutions in developed countries. Hence, this study was conducted to review our initial large single-center experience in the use of the VATS-NUSS for patients with pectus excavatum (PE) within 5 years. Methods: Data from 365 consecutive PE patients between January 2015 and December 2019 who were surgically treated with VATS-NUSS were retrospectively analyzed. Results: Of 365 patients, median age at operation was 15.61 ± 3.73 years (range = 5–27 years), most being child and adolescent. Three hundred nine patients (84.65%) were male. PE was commonly detected at puberty (n = 328, 89.9%). Postoperatively, early complications consisted of pneumothorax (n = 5, 1.37%), pleural bleeding/pleural fluid (n = 2, 0.55%), pleural hematoma (n = 1, 0.27%), pneumonia (n = 1, 0.27%), surgical wound infection (n = 1, 0.27%), incision fluid accumulation (n = 3, 0.82%), metal bar infection (n = 1, 0.27%), atelectasis (n = 3, 0.82%), and fever (n = 8, 2.19%). Late complications included surgical wound infection (n = 2, 0.55%), metal bar deviation (n = 5, 1.37%), metal bar allergy (n = 10, 2.74%), recurrent PE (n = 2, 0.55%), and persistent PE (n = 5, 1.37%). No deaths occurred. In 175 patients (47.95%) experiencing bar removal, mean operative time for bar removal was 34.09 ± 10.61 min, and the length of hospitalization following bar removal was 2.4 ± 1.34 days; the most frequent complication was pneumothorax (n = 19, 10.85%). One wound infection and one incision fluid accumulation happened following bar removal. Favorable midterm to long-term postoperative outcomes were achieved. Conclusions: From the beginning of the Vietnamese surgeons' experience, VATS-NUSS application obtained favorable outcomes with minimizing the occurrence of serious intraoperative and postoperative complications. Current rare evidence enables to give a real picture in the application, modification, and development of VATS-NUSS in the countries having similar resource-scarce conditions.
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Affiliation(s)
- The-May Nguyen
- Department of Cardiovascular and Thoracic Surgery, Viet-Tiep Friendship Hospital, Hai Phong, Vietnam
| | - Van-Thieu Le
- Department of Cardiovascular and Thoracic Surgery, Viet-Tiep Friendship Hospital, Hai Phong, Vietnam
| | - Huu-Uoc Nguyen
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam.,Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
| | - Huu-Lu Pham
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam
| | - Hong-Son Duy Phung
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam
| | - Ngoc-Tu Vu
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam.,Department of Cardiovascular and Thoracic Surgery, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Viet-Anh Nguyen
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam
| | - Nam-Khanh Do
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Kim-Duy Vu
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Hoang-Long Vo
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Quoc-Hung Doan
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam.,Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
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Bellia-Munzon G, Martinez J, Toselli L, Nazar Peirano M, Sanjurjo D, Vallee M, Martinez-Ferro M. From bench to bedside: 3D reconstruction and printing as a valuable tool for the chest wall surgeon. J Pediatr Surg 2020; 55:2703-2709. [PMID: 32811684 DOI: 10.1016/j.jpedsurg.2020.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/14/2020] [Accepted: 07/08/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE The development of computer-aided design/manufacturing and digital image technology shows promise to revolutionize several medical and surgical fields. In this context, we propose a different approach for minimally invasive repair of pectus excavatum (MIRPE) including preoperative planning, ambulatory template fitting, and implant customization. METHODS We prospectively collected data on 130 consecutive patients who underwent a novel process of implant customization for MIRPE between November 2015 and September 2019 at our institution. This process consisted of: 1) preoperative planning using 3D computed tomography scan reconstruction and 3D printing of the implant template, 2) an ambulatory fitting session with the template, and 3) manufacture of a custom made, prebent, metallic implant based on the 3D printed templates. We described the process in detail and analyzed the "implant-deformity" match, need for rebending, modification of the curvature or shape of the pectus implant intraoperatively, and accuracy of the number of bars planned preoperatively. RESULTS Preoperative planning including 3D reconstruction and printing resulted in a 92.3% optimal "implant-deformity" anatomic match. Minimal rebending without flipping of the implants was required in 5.4% of the patients. In two cases (1.5%), the implants were too short, and they tended to sink into the intercostal space, and in one case (0.8%), the patient's chest was extremely asymmetric, and the implant had to be removed and rebent intraoperatively. The number of implants planned preoperatively was precise in 100%. CONCLUSIONS In this study, we demonstrated that minimally invasive repair of pectus excavatum assisted by preoperative planning, ambulatory template fitting, and implant customization enables an excellent anatomic match, leading to minimal rebending, and avoiding implant flipping or removal after retrosternal passage as well as accuracy in the number of bars programmed preoperatively. TYPE OF STUDY Prospective registry. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Jorge Martinez
- Fundación Hospitalaria Mother and Child Medical Center, Buenos Aires, Argentina
| | - Luzia Toselli
- Fundación Hospitalaria Mother and Child Medical Center, Buenos Aires, Argentina.
| | | | - Daniela Sanjurjo
- Fundación Hospitalaria Mother and Child Medical Center, Buenos Aires, Argentina
| | - Maxroxia Vallee
- Fundación Hospitalaria Mother and Child Medical Center, Buenos Aires, Argentina; Fundación INICIAR, Buenos Aires, Argentina
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Takagi S, Hamatake D, Morinaga E, Morita A, Iwasaki A, Ohjimi H. Nuss procedure for pectus excavatum in a patient with cleidocranial dysplasia. Gen Thorac Cardiovasc Surg 2020; 69:538-541. [PMID: 32929692 DOI: 10.1007/s11748-020-01484-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 09/04/2020] [Indexed: 11/29/2022]
Abstract
Cleidocranial dysplasia is an autosomal skeletal disorder resulting from delayed or abnormal ossification of bony growth. Pectus excavatum independently presented in a 9-year-old boy with cleidocranial dysplasia and was corrected using the Nuss procedure. There were no perioperative complications, and the post-operative course was uneventful. Although there were concerns regarding extraordinary late consolidation or remodeling of the bony thorax, placement of a Nuss plate for 5 years and 6 months improved the patient's concave deformity without re-depression.
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Affiliation(s)
- Satoshi Takagi
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Daisuke Hamatake
- Department of General Thoracic, Breast and Pediatric Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Eri Morinaga
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Ai Morita
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Akinori Iwasaki
- Department of General Thoracic, Breast and Pediatric Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Hiroyuki Ohjimi
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
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Haecker FM, Krebs T, Kocher GJ, Schmid RA, Sesia SB. Sternal elevation techniques during the minimally invasive repair of pectus excavatum. Interact Cardiovasc Thorac Surg 2020; 29:497-502. [PMID: 31199434 DOI: 10.1093/icvts/ivz142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/06/2019] [Accepted: 05/13/2019] [Indexed: 11/13/2022] Open
Abstract
The aim of the review was to evaluate the routine use of sternal elevation techniques (SETs) during minimally invasive repair of pectus excavatum (MIRPE, the Nuss procedure). We performed a review of the literature between January 1998 and September 2018 with focus on different methods of SET during MIRPE. Reported effects and side effects were evaluated and compared with our own experience concerning the routine use of the vacuum bell for sternal elevation during MIRPE during the last 13 years. SET is more often used in adult patients than in adolescents. SET improves visualization and safety of MIRPE. Advancement of the pectus introducer, retrosternal dissection and placement of the pectus bar are easier. The risk of cardial and/or pericardial lesion is reduced significantly. Different types of retractors, a crane combined with a wire and/or customized hooks are reported to be used as SET. Furthermore, routine use of a subxiphoid incision is reported. However, more technical equipment, and in some SETs additional incisions are necessary. In contrast, no additional skin incision is necessary for the vacuum bell. The routine intraoperative use of the vacuum bell was safe and effective in 131 patients. It facilitates the retrosternal dissection and the insertion of the pectus bar like other SETs. Besides a temporary mild hematoma, no relevant side effect was observed. In conclusion, an increasing number of authors report on the routine use of SET during MIRPE to improve safety of the procedure. We recommend the routine intraoperative use of the vacuum bell during MIRPE.
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Affiliation(s)
- Frank-Martin Haecker
- Pediatric Surgery, Surgical Clinic, American Hospital Dubai, Dubai, United Arab Emirates.,Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Thomas Krebs
- Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Gregor J Kocher
- Division of General Thoracic Surgery, Bern University Hospital/Inselspital, Bern, Switzerland
| | - Ralph A Schmid
- Division of General Thoracic Surgery, Bern University Hospital/Inselspital, Bern, Switzerland
| | - Sergio B Sesia
- Division of General Thoracic Surgery, Bern University Hospital/Inselspital, Bern, Switzerland
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Abstract
Growing adoption of thoracoscopy by pediatric surgeons has resulted in increasingly complex operations being performed. Although common complications of these procedures have decreased with experience, surgeons are still at risk to fall into error traps where routine practice in uncommon situations results in unanticipated complications. A background culture of safety that rewards multidisciplinary communication, teamwork, openness and standardization of care can assist surgeons to recognize, address and report error traps when they arise. This article serves to encourage a culture of safety and raise awareness of error traps in pediatric thoracoscopy to minimize potential harm and improve quality of care.
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Affiliation(s)
- Sarah W Lai
- Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children, 2055 High Street, Suite 370, Denver, CO 80205, USA.
| | - Steven S Rothenberg
- Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children, 2055 High Street, Suite 370, Denver, CO 80205, USA.
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Tedde ML, Togoro SY, Eisinger RS, Okumura EM, Fernandes A, Pêgo-Fernandes PM, Campos JRMD. Back to the future: a case series of minimally invasive repair of pectus excavatum with regular instruments. ACTA ACUST UNITED AC 2019; 45:e20170373. [PMID: 30758428 PMCID: PMC6534412 DOI: 10.1590/1806-3713/e20170373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 04/10/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Minimally invasive repair of pectus excavatum (MIRPE) is a surgical treatment for PE. During the procedure, a specialized introducer is used to tunnel across the mediastinum for thoracoscopic insertion of a metal bar. There have been reported cases of cardiac perforation during this risky step. The large introducer can be a dangerous lever in unskilled hands. We set out to determine the safety and feasibility of using regular instruments (i.e., not relying on special devices or tools) to create the retrosternal tunnel during MIRPE. METHODS This was a preliminary study of MIRPE with regular instruments (MIRPERI), involving 28 patients with PE. We recorded basic patient demographics, chest measurements, and surgical details, as well as intraoperative and postoperative complications. RESULTS Patients undergoing MIRPERI had Haller index values ranging from 2.58 to 5.56. No intraoperative complications occurred. Postoperative complications included nausea/vomiting in 8 patients, pruritus in 2, and dizziness in 2, as well as atelectasis, pneumothorax with thoracic drainage, pleural effusion, and dyspnea in 1 patient each. CONCLUSIONS In this preliminary study, the rate of complications associated with MIRPERI was comparable to that reported in the literature for MIRPE. The MIRPERI approach has the potential to improve the safety of PE repair, particularly for surgeons that do not have access to certain special instruments or have not been trained in their use.
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Affiliation(s)
- Miguel Lia Tedde
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
| | - Silvia Yukari Togoro
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
| | | | - Erica Mie Okumura
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
| | - Angelo Fernandes
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
| | - Paulo Manuel Pêgo-Fernandes
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
| | - Jose Ribas Milanez de Campos
- . Departamento de Cirurgia Torácica, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - InCor/HC-FMUSP - São Paulo (SP) Brasil
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Takanari K, Toriyama K, Kambe M, Nakamura Y, Uchibori T, Ebisawa K, Shirota C, Tainaka T, Uchida H, Kamei Y. Nuss procedure for patients with pectus excavatum with a history of intrathoracic surgery. J Plast Reconstr Aesthet Surg 2018; 72:1025-1029. [PMID: 30638895 DOI: 10.1016/j.bjps.2018.12.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 11/07/2018] [Accepted: 12/02/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The aim of this study was to demonstrate the feasibility and safety of the Nuss procedure for patients with pectus excavatum (PE) with a history of intrathoracic surgery. PATIENTS From April 2010 to December 2013, we performed 6 cases of PE repair in patients with a history of intrathoracic surgery. The causes of previous operations were congenital cystic adenomatoid malformation in 4 patients and congenital diaphragmatic hernia in 2. The patients' median age was 5 years (range, 4-9 years) and median preoperative pectus severity index was 4.63 (range, 3.42-10.03). Their intraoperative and postoperative courses were reviewed retrospectively. RESULTS The mean overall operation time was 127.5 ± 17.0 minutes, and the mean operation time for endoscopic pneumolysis was 28.8 ± 12.3 minutes. Intraoperative exploration for pleural adhesion revealed that the endoscopic approach in the previous operation was associated with low pleural adhesion, and the open thoracotomy or laparotomy approach was associated with low to high pleural adhesion. One patient developed a pneumothorax on the first postoperative day. All the other patients had uneventful postoperative courses. All the patients received bar removal 2-3 years after bar insertion. One patient developed atelectasis after bar removal. All the other patients had an uneventful postoperative course. The mean postoperative follow-up time after bar removal was 20.1 ± 14.7 months. CONCLUSIONS History of intrathoracic surgery seems not a contraindication for the Nuss procedure. However, perioperative complications should be carefully monitored in both the bar insertion and removal operations.
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Affiliation(s)
- Keisuke Takanari
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya, Aichi 464-8560, Japan.
| | - Kazuhiro Toriyama
- Department of Plastic and Reconstructive Surgery, Nagoya City University Hospital, Japan
| | - Miki Kambe
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya, Aichi 464-8560, Japan
| | - Yutaka Nakamura
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya, Aichi 464-8560, Japan
| | - Takafumi Uchibori
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya, Aichi 464-8560, Japan
| | - Katsumi Ebisawa
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya, Aichi 464-8560, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Yuzuru Kamei
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya, Aichi 464-8560, Japan
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10
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Notrica DM. Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review. Semin Pediatr Surg 2018; 27:133-150. [PMID: 30078484 DOI: 10.1053/j.sempedsurg.2018.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- David M Notrica
- Department of Surgery, Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, United States; Mayo Clinic College of Medicine, United States; University of Arizona College of Medicine Phoenix, United States .
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11
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Velazco CS, Arsanjani R, Jaroszewski DE. Nuss procedure in the adult population for correction of pectus excavatum. Semin Pediatr Surg 2018; 27:161-169. [PMID: 30078487 DOI: 10.1053/j.sempedsurg.2018.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.
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Affiliation(s)
- Cristine S Velazco
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States.
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12
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The Vacuum Bell device as a sternal lifter: An immediate effect even with a short time use. J Pediatr Surg 2018; 53:406-410. [PMID: 28495420 DOI: 10.1016/j.jpedsurg.2017.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/23/2017] [Accepted: 04/26/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND To minimize cardiac perforation during the minimally invasive repair of pectus excavatum (MIRPE), several surgeons have suggested using a suction device to intraoperatively lift the sternum. Whether or not this technique is effective for all PE patients is not yet known. As such, our aim was to quantify the extent to which a suction device is capable of lifting the sternum with a short duration of use. METHODS 30 PE patients received a low-dose CT scan as part of standard PE evaluation. A Vacuum Bell suction was then applied for only two minutes, and a repeat CT scan was obtained only at the deepest point of the chest wall deformity. We compared chest dimensions before and after Vacuum Bell suction. RESULTS The Vacuum Bell lifted the sternum in all 29 patients included in the analysis. The absolute change in depth ranged from 0.29 to 23.67mm (M=11.02, SD=6.05). The average improvement in Haller index was 0.76. The suction was most effective for individuals with low BMI and smaller chest depths. Efficacy was not associated with gender, age, or chest morphology. CONCLUSIONS The Vacuum Bell device effectively lifted the sternum in PE patients with different demographics and chest morphologies. Future research is needed to address whether or not the device reduces risk of cardiac perforation during MIRPE. LEVELS OF EVIDENCE Prognosis Study Level IV.
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13
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Ewais MM, Chaparala S, Uhl R, Jaroszewski DE. Outcomes in adult pectus excavatum patients undergoing Nuss repair. PATIENT-RELATED OUTCOME MEASURES 2018; 9:65-90. [PMID: 29430201 PMCID: PMC5796466 DOI: 10.2147/prom.s117771] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.
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Affiliation(s)
- MennatAllah M Ewais
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Shivani Chaparala
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Rebecca Uhl
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
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Zou J, Luo C, Liu Z, Cheng C. Cardiac arrest without physical cardiac injury during Nuss repair of pectus excavatum. J Cardiothorac Surg 2017; 12:61. [PMID: 28738822 PMCID: PMC5525361 DOI: 10.1186/s13019-017-0624-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 07/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac arrest is a lethal complication of Nuss repair of pectus excavatum which is strongly related to heart or big vessels injury. A rare case developed cardiac arrest without direct cardiac injury during Nuss procedure is presented in this article. CASE PRESENTATION In July 2015, a previously healthy 18-year-old man undergoing Nuss repair for pectus excavatum developed cardiac arrest while the Nuss bar was being inserted into the chest. After successful resuscitation and exclusion of direct cardiac injury, the Nuss procedure was continued. The patient suffered a second cardiac arrest during rotation of the Nuss bar. This time, the patient had poor initial response to resuscitation and defibrillation until the retrosternal bar was removed. He ultimately recovered well from the episodes of cardiac arrest, but was unable to receive surgical correction of his pectus excavatum deformity. CONCLUSIONS The possible mechanisms of cardiac arrest and lessons we can learn from this complication are discussed.
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Affiliation(s)
- Jianyong Zou
- Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Canqiao Luo
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Zhenguo Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Chao Cheng
- Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China.
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Durry A, Gomes Ferreira C, Tricard T, Gicquel P, Becmeur F. Minimally invasive repair of pectus excavatum in children: Results of a modified Nuss procedure. ANN CHIR PLAST ESTH 2016; 62:8-14. [PMID: 27823841 DOI: 10.1016/j.anplas.2016.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 10/03/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Pectus excavatum (PE) is the most common deformity of the anterior thoracic wall. The Nuss technique allows the thorax to be reshaped with the aid of a retrosternal metallic bar. The aim of this study is to evaluate and compare the complication rate between the original Nuss technique and a lightly modified approach. MATERIAL AND METHOD We performed a retrospective single-center observational study based on the medical files of patients operated for PE in the Pediatric Surgery Unit between July 2004 and July 2015. We divided two patient groups according to the operating technique employed: the Nuss group (NG) and the modified Nuss group (MNG) with supplementary subxiphoid incision and bilateral thoracoscopy. RESULTS Twenty-seven patients were included: sixteen in the NG and eleven in the MNG. No significant differences were found between the two groups for all kinds of complications: total complication rate (50% for the NG versus 54% for the MNG, P>0.05), early (31% vs 46%, P>0.05), late (19% vs 9%, P>0.05), non-serious (37% vs 36%, P>0.05) or serious (13 vs 18%, P>0.05). There was no life threatening complication in the MNG, contrary to the NG. In the two groups, a significant difference was found (P=0.029) regarding the operating time: longer operating times (80±25min) were correlated with a higher complication rate. CONCLUSION The modified Nuss technique does not cause more complications than the original technique described by Nuss and it has the advantage to minimize the risk of heart damage.
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Affiliation(s)
- A Durry
- Unit of paediatric surgery, Strasbourg university hospital, Strasbourg, France.
| | | | - T Tricard
- Unit of paediatric surgery, Strasbourg university hospital, Strasbourg, France.
| | - P Gicquel
- Unit of paediatric surgery, Strasbourg university hospital, Strasbourg, France.
| | - F Becmeur
- Unit of paediatric surgery, Strasbourg university hospital, Strasbourg, France.
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Takahashi T, Okazaki T, Yamataka A, Uchida E. Usefulness of Kent retractor and lifting hook for Nuss procedure. Pediatr Surg Int 2015; 31:1103-5. [PMID: 26263876 DOI: 10.1007/s00383-015-3764-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 11/26/2022]
Abstract
Although the Nuss procedure for pectus excavatum has been widely employed, a variety of complications have been reported. The most dangerous complication is cardiac injury from the insertion of the introducer. To eliminate these complications, we present a sternum elevating technique using a Kent retractor and a lifting hook.
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Affiliation(s)
- Tsubasa Takahashi
- Department of Pediatric Surgery, Nippon Medical School Musashi Kosugi Hospital, 1-396 Kosugi-machi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan.
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Eiji Uchida
- Department of Surgery, Nippon Medical School, Tokyo, Japan
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Hybrid Technique for Repair of Recurrent Pectus Excavatum After Failed Open Repair. Ann Thorac Surg 2015; 99:1936-43. [DOI: 10.1016/j.athoracsur.2015.02.078] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 02/20/2015] [Accepted: 02/26/2015] [Indexed: 11/23/2022]
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Zhao J, Ma N, Yuan L, Li X, Han Y. Ultrasound-Guided Extrapleural Nuss Procedure for Pectus Excavatum Repair. Ann Thorac Surg 2014; 98:1863-4. [DOI: 10.1016/j.athoracsur.2014.04.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 03/04/2014] [Accepted: 04/04/2014] [Indexed: 11/29/2022]
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Minimally invasive repair of pectus excavatum in an adolescent with a history of a median sternotomy as an infant. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kim D, Idowu O, Palmer B, Kim S. Anterior Chest Wall Elevation Using a T-Fastener Suture Technique During a Nuss Procedure. Ann Thorac Surg 2014; 98:734-6. [DOI: 10.1016/j.athoracsur.2013.12.077] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 08/19/2013] [Accepted: 12/30/2013] [Indexed: 10/25/2022]
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Jeong JY, Lee J. Use of Needlescope and Crane Technique to Avoid Cardiac Injury in Nuss Procedure. Ann Thorac Surg 2014; 98:386-7. [DOI: 10.1016/j.athoracsur.2013.11.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 10/27/2013] [Accepted: 11/18/2013] [Indexed: 12/01/2022]
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Abstract
The aim of study was to introduce technical innovation of MIRPE which reduces the risk of cardiac injury. Modification of MIRPE method with semiflexible thoracoscope and sternum elevating technique has been used. Volkmann bone hook has been inserted percutaneously to the sternum. The hook elevates the sternum forward and enlarges the retrosternal space for safer passage of thoracoscopically guided introducer. Using semiflexible thoracoscope allows better view from various angles via one site of insertion. During the period 2005-2012, the MIRPE was performed on 29 girls and 151 boys; the mean age at the time of surgery was 15.9 years (range 13-18.7 years). The mean Haller index was 4.7 (range 2.7-20.5). The most common complication was pneumothorax (3.3 %) and the incidence of bar displacement was 2 %. The most serious complication was cardiac perforation when inserting Lorenz introducer. This occurred in a 16-year-old girl; she required urgent sternotomy with right atrial repair and recovered well. External elevation of sternum with the hook was used since this case. Subsequent 113 patients underwent surgery without any serious complications. Technical innovation using semiflexible thoracoscope and hook elevation of the sternum reduces the risk of cardiac injury. The hook opens the anterior mediastinum space effectively and makes the following dissection relatively safe and straightforward.
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Jaroszewski DE, Johnson K, McMahon L, Notrica D. Sternal elevation before passing bars: a technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients. J Thorac Cardiovasc Surg 2013; 147:1093-5. [PMID: 24237886 DOI: 10.1016/j.jtcvs.2013.09.049] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 07/10/2013] [Accepted: 09/25/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Dawn E Jaroszewski
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz; Department of Surgery, Phoenix Children's Hospital, Phoenix, Ariz.
| | - Kevin Johnson
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz
| | - Lisa McMahon
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz; Department of Surgery, Phoenix Children's Hospital, Phoenix, Ariz
| | - David Notrica
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz; Department of Surgery, Phoenix Children's Hospital, Phoenix, Ariz
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Jaroszewski DE. Forced Mechanical Sternal Elevation for Nuss Repair. Ann Thorac Surg 2013; 96:1914. [DOI: 10.1016/j.athoracsur.2013.05.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 04/10/2013] [Accepted: 05/14/2013] [Indexed: 10/26/2022]
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Johnson WR, Fedor D, Singhal S. A Novel Approach to Eliminate Cardiac Perforation in the Nuss Procedure. Ann Thorac Surg 2013; 95:1109-11. [DOI: 10.1016/j.athoracsur.2012.10.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/17/2012] [Accepted: 10/10/2012] [Indexed: 10/27/2022]
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