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

Vacuum bell therapy for pectus excavatum: a retrospective study

BACKGROUND

Pectus excavatum, the most common chest wall deformity, is frequently treated with Nuss procedure. Here we will describe non-invasive procedure and analyze the variables associated vacuum bell therapy for patients with pectus excavatum.

METHODS

Retrospective case-control study in a single center between July 2018 and February 2022, including patients with pectus excavatum treated with vacuum bell. Follow-up was continued to September 2022. The Haller index and Correction index was calculated before and after treatment to analysis the effectiveness of vacuum bell therapy.

RESULTS

There were 98 patients enrolled in the treatment group, with 72 available for analysis, and the follow-up period ranged from 1.1 to 4.4 years (mean 3.3 years). When analyzing with the Haller Index, 18 patients (25.0%) showed excellent correction, 13 patients (18.1%) achieved good correction, and 4 patients (5.6%) had fair correction. The remaining patients had a poor outcome. Characteristics predicting a non-poor prognosis included initial age ≤ 11 years (OR = 3.94, p = 0.013) and patients with use over 24 consecutive months (OR = 3.95, p = 0.013). A total of 9 patients (12.5%) achieved a CI reduction below 10. Patients who started vacuum bell therapy at age > 11 had significantly less change compared to those who started at age ≤ 11 (P < 0.05). Complications included chest pain (5.6%), swollen skin (6.9%), chest tightness (1.4%) and erythema (15.3%).

CONCLUSIONS

A certain percentage of patients with pectus excavatum can achieve excellent correction when treated with pectus excavatum therapy. Variables predicting better outcome including initial age ≤ 11 years both in HI and CI and vacuum bell use over 24 consecutive months in HI. In summary, pectus excavatum is an emerging non-invasive therapy for pectus excavatum and will be widely performed in a certain group of patients.

Is there a relationship between Haller Index and cardiopulmonary function in children with pectus excavatum?

Background

This study aims to systematically examine the cardiopulmonary functions in children with pectus excavatum and to compare the obtained findings with the Haller Index.

Methods

Between September 2017 and June 2018, medical records of a total of 31 patients (27 males, 4 females; mean age: 14.8±2.0 years; range, 9 to 18 years) with pectus excavatum were retrospectively analyzed. The patients were divided into Group 1 (<2.5), Group 2 (2.5 to 3.19), and Group 3 (>3.2) according to the Haller Index. All groups were systematically evaluated based on pulmonary function tests and echocardiography. Forced vital capacity, forced expiratory volume in 1 second, and the forced expiratory volume in 1 second/ forced vital capacity ratio were calculated. Left ventricular enddiastolic diameter, ejection fraction, mitral valve prolapses, and right ventricular cavity in the apical four-chamber position were evaluated with echocardiography.

Results

Of the patients, 19.4% were in Group 1, 38.7% in Group 2, and 41.9% in Group 3. The mean Haller Index value was 3.09±0.64. According to pulmonary function test results, 16.1% of the patients had restrictive disease and 6.5% had obstructive disease. There was a negative correlation between the index and forced expiratory volume in 1 second and forced vital capacity, and there was a statistically significant decrease in these values, as the Haller Index increased (p<0.017). There was a significant difference in the ejection fraction among the groups (p<0.001) and, as the Haller Index increased, ejection fraction statistically significantly decreased.

Conclusion

Our study results show a negative correlation between the severity of pectus excavatum and pulmonary dysfunction and, as the severity increases, left ventricular function may be affected by the deformity. As a result, there seems to be a significant relationship between the severity of the deformity and cardiopulmonary functions.

Academic performance in children with pectus excavatum: a real-world research with propensity score matching

BACKGROUND

The optimal timing of surgery for pectus excavatum (PE) is controversial. A large proportion of children will not undergo surgery before puberty. However, untimely surgery may lead to a decline in the children's social adaptation and competitiveness because the children have already developed psychological and physiological impairments due to PE at an early age. The study retrospectively compared the academic performance in PE children undergoing the Nuss procedure versus nonsurgical observation.

METHODS

This retrospective real-world research study included 480 PE patients with definite surgical indications, in whom it was first recommended that they undergo surgery between the ages of 6 and 12 years old. Academic performance was collected at baseline and 6 years later. A generalized linear regression was calculated to screen the factors affecting the performance. A propensity score matching (PSM) analysis was conducted to reduce the potential for confounding factors between surgical and nonsurgical PE patients.

RESULTS

Haller index (HI) and pulmonary function were recognized as factors affecting baseline performance according to the generalized linear regression. For PE children with surgical indications, their academic performance significantly declined after 6 years of nonsurgical observation (52.1% ± 17.1% versus 58.3% ± 16.7%, p = 0.042). The academic performance in the surgery group was better than that in the nonsurgery group 6 years after PSM (60.7% ± 17.7% versus 52.1% ± 17.1%, p = 0.008).

CONCLUSIONS

The severity of PE will affect the academic performance of children.For PE children with definite surgical indications between the ages of 6 and 12 years old, surgical intervention rather than nonsurgical observation is more conducive to the development of children's academic performance.

Incidence of chest wall deformity in 15,862 students in the province of Sivas, Türkiye

Background

This study aims to investigate the prevalence of chest deformity in middle- and high-school students in Sivas province of Turkey, to identify the risk factors associated with the psychological and physical disorders caused by the deformity, and to facilitate early diagnosis and treatment guidance by increasing awareness of this problem.

Methods

Between October 2011 and May 2012, a total of 15,862 students (8,508 males, 7,354 females; mean age: 15.9±1.3 years; range, 12 to 19 years) from public schools were included. A number of schools were randomly selected for study, and the students were screened by physical examination. A study protocol was developed in which patients with deformities were questioned about family history and symptoms.

Results

Chest wall deformity was detected in a total of 250 students (1.6%). The prevalence rates of pectus carinatum and pectus excavatum in the children were 0.7% and 0.6%, respectively. The overall prevalence of chest wall deformity was 1.6%.

Conclusion

Chest wall deformity is more common in boys and pectus carinatum is the most common deformity type. Chest wall deformity is more common in the 15-16 age group and female sex is a risk factor for psychological discomfort.

Translation and cultural adaptation of the pectus excavatum evaluation questionnaire to Spanish and Catalan

PURPOSE

Pectus excavatum (PE) is the most common congenital chest wall deformity. It can have a negative effect in exercise tolerance. However, cosmetic features are the most frequent concerns in these patients. The PE evaluation questionnaire (PEEQ) is a patient reported outcome (PRO) tool to measure the physical and psychosocial quality-of-life changes after surgical repair of PE. No specific tool has been developed in our languages to evaluate PRO in PE patients. Our aim is to translate and culturally adapt the PEEQ to Spanish and Catalan.

METHODS

Guidelines for translation of PRO were followed. The PEEQ, consisting of 34 items, was translated from English to Spanish and to Catalan. Three forward translations and one back translation were performed for each language. Cognitive debriefing interviews were developed.

RESULTS

The reconciliation of the forward translations revealed a 14.7% of inconsistencies for each language. The Spanish back translation showed a 64.7% of disagreement with the source, the Catalan 58.8%. Changes in each reconciled version were made to amend the diverting items. Cognitive debriefing: Catalan version: 15 participants, 10 males, 5 patients had been operated. 12 patients showed difficulties for understanding 4 of the items. Spanish version: 17 participants, 11 males, 5 had been operated. 13 patients showed difficulties for understanding 4 of the items. We made modifications of the problematic items, in order to make them easier to understand for our patients. We tested the last version in a new group of patients. Catalan: 7 patients, 5 males. One patient showed difficulties for understanding item 11, so we added a further clarification of this item. Spanish: 7 patients, all males. There were any difficulties for understanding.

CONCLUSION

After a thorough process of translation and cultural adaptation, we reached a Catalan and a Spanish version of PEEQ. This work constitutes the first step to reach a specific PE PRO tool in our languages. However, it needs to be validated, with a higher number of patients, before being widely used in a clinical setting.

Nuss Technique for Pectus Excavatum in Adult Patients: Cosmetic Satisfaction and Improvement of Quality of Life in a Single-Center Experience

Objectives

Since its introduction, the Nuss minimally invasive procedure for pectus excavatum (PE) repair (MIRPE) has become the method of choice. The current study describes our experience of PE correction in adults, with particular focus on postoperative outcomes, pain, quality of life, and patients’ satisfaction.

Methods

We enrolled for this observational study n = 93 adult patients from 2011 to 2018. The Haller index was used to quantify PE severity. Pulmonary function tests and cardiac examinations were performed preoperatively; we developed a standardized surgical technique and postoperative treatment, including follow-up at 3, 12, and 24 months after surgery and 6 months after bar removal. We also evaluated the quality of life and the satisfaction with the cosmetic result after the procedure with standardized questionnaires.

Results

No operative or perioperative deaths occurred nor life-treating complications. Thirteen complications occurred in 12 patients, with a total complication rate of 14% (n = 13/93). Pain intensity decreased in the follow-up [pain score visual analog scale at 3 months: median 1 (0–8); 12 months: median 1 (0–5); and 24 months: median 1 (0–4)]. Better or much better quality of life after the Nuss procedure was observed: n = 79 (84.1%) at 3 months, n = 80 (86%) at 12 months, and n = 85 (91.4%) at 24 months. After 2 years of observation, more than 90% of patients described improvement in their quality of life and satisfaction with the cosmetic results. Only a very small group of patients suffered from pain in the follow-up.

Conclusion

Our results demonstrate that the MIRPE procedure is safe and can be performed with excellent results in adults both for improvement of quality of life and for satisfaction with cosmetic results.

Pulmonary function, exercise capacity and dyspnea in patients 7 ​years after Nuss surgery

PURPOSE

Pectus excavatum is a frequent thoracic malformation increasingly treated with minimally invasive methods (MIRPE), which are performed for cardio-respiratory problems and in some centers also for esthetic considerations. Theoretically, MIRPE may increase thoracic elastic recoil, work of breathing and cause emphysema. The aim of the present study was to determine whether teenagers who underwent MIRPE may expect normal thoracic cage development, cardio-respiratory function, exercise capacity and asymptomatic functioning.

MATERIAL AND METHODS

Fifty five patients (21.1 ​± ​3.0 years) who underwent MIRPE between 2000 and 2010 were assessed 6.8 (±2.4) years after surgery. Controls were matched for sex, age and height to the intervention participants. Spirometry, body plethysmography, diffusion capacity and the 6 ​min walking test (6MWT) were performed. Anteroposterior (AP) and transverse chest diameters were measured.

RESULTS

Participants who underwent MIRPE had normal pulmonary function, and exercise capacity. After adjustment for potential confounders, the intervention group had lower mean BMI [-1.88 ​± ​0.56 (kg/m²); p ​= ​0.001] and chest AP diameter [-2.79 ​± ​0.57 (cm); p ​< ​0.001], but higher residual volume (RV%) [12.98 ​± ​5.31 (%); p ​= ​0.001], RV% total lung capacity (TLC) [5.56 ​± ​0.92 (%); p ​< ​0.001], forced expiratory volume in 1 ​s/forced vital capacity (FEV₁/FVC) [2.64 ​± ​1.28 (%); p ​= ​0.039] and 6MWT distance [29.10 ​± ​13.02 (m); p ​= ​0.025].

CONCLUSIONS

Young adults who undergo MIRPE may expect normal pulmonary function and exercise capacity. Observed differences in air trapping require further assessment in terms of emphysema development risk.

Next day discharge after the Nuss procedure using intercostal nerve cryoablation, intercostal nerve blocks, and a perioperative ERAS pain protocol

BACKGROUND

The Nuss procedure for pectus excavatum has historically been associated with significant postoperative pain, which has been the major factor contributing to hospital length of stay (LOS).

METHODS

A single-institution, prospective study of 40 consecutive patients undergoing Nuss bar placement for pectus excavatum between November 2019 and January 2021 was conducted to assess the effectiveness of a multimodality pain management protocol. All patients received T3-T8 intercostal nerve cryoablation (INC), T3-T8 bupivacaine intercostal nerve blocks, Exparel at the skin incisions, and management with a perioperative analgesia regimen that minimized narcotic usage. The primary outcome was LOS. Secondary outcomes included opioid use, pain scores, and time to sensory recovery.

RESULTS

37/40 patients (92.5%) were discharged home on postoperative day (POD) 1, and 3/40 (7.5%) were discharged on POD 2 (mean LOS = 1.1 days). The median average postoperative pain score was 2/10. After eliminating IVPCA from our protocol, total oral morphine equivalent (OME) decreased by 73% (55.5 mg to 15 mg) with no change in pain scores or discharge timing.

CONCLUSIONS

INC combined with bupivacaine intercostal nerve blocks and a pre- and post-hospital analgesia protocol facilitated discharge one day after the Nuss procedure, achieved excellent pain control, and eliminated the need for intravenous opioids.

[Correction of pectus excavatum and long-term outcome in adult]

Pectus excavatum is the most common congenital chest malformation characterized by symmetrical or asymmetric depression of the chest with deformation of the sternocostal complex. Pectus excavatum is often associated with other dysplastic diseases of connective tissue. Ravitch thoracoplasty and Nuss minimally invasive correction are the most common today. The authors report surgical correction of PE in a 50-years-old male who underwent Ravitch modified thoracoplasty with implantation of shape memory plate. Long-term treatment outcomes and technical properties of the plate after removing are analyzed.

Epidural analgesia and abnormal coagulation in patients undergoing minimal invasive repair of pectus excavatum

Background:

Epidural analgesia (EA) is effective in patients undergoing minimal invasive repair of pectus excavatum (MIRPE) but is associated with major complications such as epidural hematomas. It is recommended to assess coagulation status in patients receiving anticoagulant therapy prior to EA, although no consensus exists in patients without a history of bleeding tendency or anticoagulant therapy. Thus, the aim of this paper was to assess 1) the prevalence of abnormal routine coagulation parameters, i.e., international normalized ratio (INR) and platelet count, and 2) the safety of EA in patients undergoing MIRPE.

Methods:

In this retrospective study, we identified 1,973 patients undergoing MIRPE at our center between 2001 and 2019. Complications related to EA were registered for all patients. Information on coagulation parameters was present in 929 patients. Patients with spontaneously elevated INR ≥1.5 were referred for assessment of coagulation factor VII in order to assess the cause of the elevated INR.

Results:

Of 929 patients with coagulation information available, 18 patients had spontaneously elevated INR ≥1.5 (1.9%). In patients with INR ≥1.5, 12 patients underwent further assessment of factor VII, with all patients having a slightly reduced factor VII close to the lower reference range. The majority of the 1,973 patients undergoing MIRPE received EA (99.6%) with very low complication rates (0.2%) and no incidence of epidural hematomas.

Conclusion:

In patients undergoing MIRPE, coagulation screening prior to EA should not be mandatory as it revealed no clinically relevant consequences. EA is safe with very low complication rates.

[Chest Wall Deformities in Children and Adolescents]

Chest wall deformities as a whole are relatively common in children and adolescents, although they comprise a wide spectrum of entities, some of them rare. Pectus excavatum has the highest prevalence. While some patients are asymptomatic, others suffer from substantial limitations. All symptomatic patients should be offered treatment. Minimally invasive surgical correction is the more effective option of treatment, besides the alternative application of a suction bell. Pectus carinatum and combined manifestations of chest wall deformities can also lead to physiological and psychosocial impairment and require treatment tailored to the individual patient in such cases. Syndromal chest wall deformities, such as Jeune syndrome, comprise a separate group of rare diseases that are associated with considerable, occasionally life-threatening comorbidities. These patients should be cared for in centres with appropriate expertise in an interdisciplinary and multimodal manner. This review discusses the different chest wall deformities encountered in paediatric surgical practice, along with their significance and possible therapeutic approaches.

Surgical versus Vacuum Bell Therapy for the Correction of Pectus Excavatum: A Comparison of 1-Year Treatment Outcomes

Background

The purpose of this study was to compare 1-year clinical outcomes between patients who underwent a Nuss operation or vacuum bell therapy and to present vacuum bell therapy as a possible alternative treatment modality for patients who prefer non-surgical correction of pectus excavatum.

Methods

We conducted a retrospective review of pectus excavatum patients who had undergone vacuum bell therapy for more than 1 year and examined patients who had undergone Nuss bar removal more than 1 year previously. The treatment outcomes were evaluated by comparing changes in the Haller index before and after treatment in both patient groups.

Results

We included 57 patients in this study and divided them into 2 groups according to the type of treatment received. Both groups showed no significant difference in the post-treatment Haller index after 1 year of follow-up, although the Nuss operation group showed a greater change in the Haller index than the vacuum bell group.

Conclusion

Although the Nuss operation is a well-established and effective treatment of choice to correct pectus excavatum, vacuum bell therapy showed comparable outcomes and could become an alternative treatment modality for select patients who prefer non-invasive treatment.

The application of local rotating flap and latissimus dorsi flap in thoracic deformity correction

BACKGROUND

Wound healing problem is one of the main complications after correction of chest wall deformity. Orthopedic flap tissue repair technique has a clear significance in non-healing wound and defect wound and provides a new choice for poor wound healing after orthopedic surgery of chest wall deformity.

OBJECTIVE

To investigate, the application value of modified local rotary flap and latissimus dorsi myocutcutaneous flap in the treatment of poor wound healing after orthodontic treatment of chest wall deformity.

METHOD

A retrospective analysis was performed on patients who admitted to our department from August 2012 to November 2019 due to non-healing incision after surgery for thoracic deformity. Skin flap was selected according to the size of the wound surface, and the effect of skin flap repair was observed. The clinical data of the included patients were recorded, and the preoperative and postoperative wound conditions were evaluated.

RESULTS

This study included 13 patients with chest wall deformity who received plastic surgery tissue using flap technique for wound repair, 11 cases used modified local rotation skin flap, and 2 cases used modified latissimus dorsi myocutaneous flap. The mean age of the 13 patients was 18.54 ± 4.14 years old, the mean body mass index (BMI) was 17.02 ± 2.16 kg/m² , and the mean preoperative nonunion time of the incision was 64.77 ± 93.01 days. Five patients had positive bacteria culture on the wound surface, including 3 cases of Staphylococcus aureus, 1 case of Pseudomonas aeruginosa, and 1 case of Staphylococcus epidermidis. All the 13 patients achieved primary grade A healing.

CONCLUSION

The modified local rotary flap and latissimus dorsi musculocutaneous flap have a significant effect on the postoperative correction of chest wall deformity, which can ensure wound healing while retaining the orthopedic plate to the maximum extent to ensure the effect of the correction.

Ventilatory limitations are not associated with dyspnea on exertion or reduced aerobic fitness in pectus excavatum

Exercise intolerance and chest pain are common symptoms in patients with pectus excavatum. To assess if the anatomic extent of pectus deformities determined by the correction index (CI) is associated with a pulmonary impairment at rest and during exercise we performed a retrospective review on pectus patients in our center who completed a symptom questionnaire, cardiopulmonary exercise test (CPET), pulmonary function tests (PFT), and chest magnetic resonance imaging. Of 259 patients studied, dyspnea on exertion and chest pain was reported in 64% and 41%, respectively. Peak oxygen uptake (VO₂ ) was reduced in 30% and classified as mild in two-thirds. A pulmonary limitation during exercise was identified in less than 3%. Ventilatory limitations on PFT was found in 26% and classified as mild in 85%. Obstruction was the most common abnormal pattern (11%). There were no differences between patients with normal or abnormal PFT patterns for the CI, VO_2, or percentage reporting dyspnea or chest pain. Scatter plots demonstrated significant but weak inverse relationships between the CI and lung volumes at rest and during exercise. Multivariable linear regression modeling evaluating predictors of VO₂ demonstrated positive associations with the forced expiratory volume at one second and a negative association with the CI. We conclude that resting PFT patterns have poor correlation with the anatomic extent of the pectus defect, symptomatology or aerobic fitness. Pulmonary limitations on CPET are uncommon and lung volumes during exercise are only minimally associated with the CI.

The questionable benefit of pectus excavatum repair on cardiopulmonary function: a prospective study

 

OBJECTIVES

Since the introduction of the minimally invasive technique for repair of pectus excavatum (MIRPE), increasing numbers of patients are presenting for surgery. However, controversy remains regarding cardiopulmonary outcomes of surgical repair. Therefore, the aim of our prospective study was to investigate cardiopulmonary function, at rest and during exercise before surgery, first after MIRPE and then after pectus bar removal.

METHODS

Forty-seven patients were enrolled in a prospective, open-label, single-arm, single-centre clinical trial (Impact of Surgical Treatments of Thoracic Deformation on Cardiopulmonary Function) [NCT02163265] between July 2013 and November 2019. All patients underwent a modified MIRPE technique for surgical correction of pectus excavatum (PE), called Minor Open Videoendoscopically Assisted Repair of Pectus Excavatum. The patients underwent pre- and postoperative chest X-ray, three-dimensional volume-rendering computer tomography thorax imaging, cardiopulmonary function tests at rest and during stepwise cycle spiroergometry (sitting and supine position) and Doppler echocardiography. Daily physical activity questionnaires were also completed.

RESULTS

The study was completed by 19 patients (15 males, 4 females), aged 13.9–19.6 years at the time of surgery. The surgical patient follow-up was 5.7 ± 7.9 months after pectus bar removal. No significant differences in cardiopulmonary and exercise parameters were seen after placement of the intrathoracic bar, or after pectus bar removal, compared to presurgery.

CONCLUSIONS

Our findings indicate that surgical correction of PE does not impair cardiopulmonary function at rest or during exercise. Therefore, no adverse effects on exercise performance should be expected from surgical treatment of PE via the modified MIRPE technique.

Clinical trial registration number

clinicaltrials.gov [ClinicalTrials.gov number, NCT02163265].

Prevalence of comorbidities in a surgical pectus excavatum population

Background

Pectus excavatum is the most common chest wall deformity and is associated to various connective tissue, cardiopulmonary, and skeletal abnormalities. Several conditions and syndromes have been associated to pectus excavatum, although the overall health implications of the pectus excavatum phenotype are unclear. Therefore, in this study we aimed to examine the health implications of the pectus excavatum phenotype by assessing all comorbidities and previous medical conditions in a cohort of patients undergoing pectus excavatum surgery.

Methods

This single-centre retrospective prevalence study included 1,046 patients undergoing minimal invasive repair of pectus excavatum from 2001 to 2012. Hospital medical charts were assessed and comorbidities and previous medical conditions were registered systematically and categorized according to the affected organ system.

Results

In our study population of 1,046 patients, we registered 623 conditions. The median age was 17 years and the majority of patients (56%) had no previous or present conditions. Notable prevalence of asthma (8.8%), allergies (12.3%), previous hernia surgery (5.2%), and psychiatric conditions (4.9%) were found.

Conclusions

The majority of patients undergoing pectus excavatum surgery have no comorbidities or previous medical conditions. It seems that this patient category is comparable to the background population in this regard and our findings do not support screening this patient category for associated conditions.

Demographic characteristics of pectus deformities across Turkey

Background

This study aims to investigate the demographic characteristics and familial inheritance of pectus deformities across Turkey.

Methods

Demographic characteristics of a total of 5,098 patients (5,028 males, 70 females, mean age 23.6 years; range, 1 to 56 years) with pectus excavatum and pectus carinatum admitted to our outpatient clinic between January 1996 and December 2018 were retrospectively analyzed. The distribution of the patients across the country was made according to seven regions and 81 provinces. Familial inheritance was investigated using patients" data obtained from the clinical records and telephone calls.

Results

Of all patients, 3,330 (65.3%) had pectus excavatum and 1,768 (34.7%) had pectus carinatum deformity with a pectus excavatum-to-pectus carinatum ratio of 1/1.9. In the Southeast Anatolia region, the rate of pectus excavatum was lower than the overall average and higher in the Marmara region (p=0.009 and p=0.037, respectively). In the Southeast Anatolia region, the rate of pectus carinatum was higher than the general average and lower in the Marmara region (p=0.001 and p=0.003, respectively). Kastamonu, Çankırı, Karabük, and Sinop were the most common provinces for pectus deformity cases. Family history was positive in 39% of pectus excavatum and 43% of pectus carinatum patients. All regions showed a similar distribution in terms of the presence of family history.

Conclusion

This is the first study to report the distribution of pectus deformities in Turkey and the high frequency of pectus deformities in certain regions and provinces of Turkey indicates familial inheritance.

Clinical characterization of children and adolescents with NF1 microdeletions

PURPOSE

An estimated 5-11% of patients with neurofibromatosis type 1 (NF1) harbour NF1 microdeletions encompassing the NF1 gene and its flanking regions. The purpose of this study was to evaluate the clinical phenotype in children and adolescents with NF1 microdeletions.

METHODS

We retrospectively analysed 30 children and adolescents with NF1 microdeletions pertaining to externally visible neurofibromas. The internal tumour load was determined by volumetry of whole-body magnetic resonance imaging (MRI) in 20 children and adolescents with NF1 microdeletions. Furthermore, the prevalence of global developmental delay, autism spectrum disorder and attention deficit hyperactivity disorder (ADHD) were evaluated.

RESULTS

Children and adolescents with NF1 microdeletions had significantly more often cutaneous, subcutaneous and externally visible plexiform neurofibromas than age-matched patients with intragenic NF1 mutations. Internal neurofibromas were detected in all 20 children and adolescents with NF1 microdeletions analysed by whole-body MRI. By contrast, only 17 (61%) of 28 age-matched NF1 patients without microdeletions had internal tumours. The total internal tumour load was significantly higher in NF1 microdeletion patients than in NF1 patients without microdeletions. Global developmental delay was observed in 28 (93%) of 30 children with NF1 microdeletions investigated. The mean full-scale intelligence quotient in our patient group was 77.7 which is significantly lower than that of patients with intragenic NF1 mutations. ADHD was diagnosed in 15 (88%) of 17 children and adolescents with NF1 microdeletion. Furthermore, 17 (71%) of the 24 patients investigated had T-scores ≥ 60 up to 75, indicative of mild to moderate autistic symptoms, which are consequently significantly more frequent in patients with NF1 microdeletions than in the general NF1 population. Also, the mean total T-score was significantly higher in patients with NF1 microdeletions than in the general NF1 population.

CONCLUSION

Our findings indicate that already at a very young age, NF1 microdeletions patients frequently exhibit a severe disease manifestation which requires specialized long-term clinical care.

Application of diagnostic criteria for non-tuberculous mycobacterial disease to a case series of mycobacterial-positive isolates

The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have provided guidelines to assist in the accurate diagnosis of lung disease caused by nontuberculous mycobacteria (NTM). These microbiologic, radiographic, and clinical criteria are considered equally important and all must be met to make the diagnosis of NTM lung disease. To assess the significance of the three criteria, each was evaluated for its contribution to the diagnosis of NTM lung disease in a case series. Laboratory reports of any specimen positive for NTM isolation were collected between January 1, 2006 and December 31, 2010 at a university medical center. Medical records were reviewed in detail using a standardized form. The total number of patients with a culture from any site positive for NTM was 297 while the number from respiratory specimens during the same period was 232 (78%). Samples from two of these patients also yielded M. tuberculosis complex and were excluded. While 128 of the remaining 230 patients (55.7%) in the cohort met the microbiologic criterion for diagnosis of NTM lung disease, 151 (65.6%) and 189 (78.3%) met the radiologic and clinical criteria respectively. Only 78 patients (33.9%) met all three criteria provided by the ATS/IDSA for diagnosis of NTM lung disease. This evaluation reaffirms that defining NTM lung disease using either one or two of the criteria provided by the 2007 ATS/IDSA guidelines may significantly overestimate the number of cases of NTM lung disease. Based on the experience of defining NTM lung disease in this case series, recommendations for modification of the ATS/IDSA guidelines are provided which include expansion of both radiologic patterns and the list of symptoms associated with NTM lung disease.

Combining Correction of Pectus Excavatum and Open Heart Surgery in a Single-Stage Procedure

The presence of pectus excavatum in patients undergoing open heart surgery is rare, and no consensus has been reached regarding the surgical approach. Thus, this paper describes a single-stage procedure for correction of pectus excavatum with the modified Nuss procedure ad modum Pilegaard in 4 patients undergoing open heart surgery. Three of 4 patients successfully underwent the single-stage procedure. At follow-up after bar removal, all patients had no complications related to the Nuss bar, and all had excellent cosmetic results.

Behavioural disorders in children with pectus excavatum in China: a retrospective cohort study with propensity score matching and risk prediction model

OBJECTIVES

Surgical repair of pectus excavatum is typically carried out immediately prior to puberty. However, at the time of surgery, some psychosocial issues, such as behavioural disorders may already have developed and the likelihood of these psychosocial disorders resolving after surgery is unclear. For this reason, some surgeons choose to perform surgical repair at an earlier age in some children. The study retrospectively compares the rate of behavioural disorders in children undergoing the Nuss procedure at 4 vs. 10 years of age. We also attempted to develop a model to predict the risk of behavioural disorders in 10 year-old patients.

METHODS

The current study included children receiving Nuss procedure for pectus excavatum at either 4 or 10 years of age. The presence/absence of behavioural disorder was assessed preoperatively, and in the third year, after removal of the bar. A propensity score matching (PSM) analysis was conducted to reduce the potential for confounding by baseline factors. Multivariable logistic regression was conducted to establish a model to predict the risk of behavioural disorders in the third year after the removal of the bar. The model was accessed by discrimination and calibration. A formula and a nomogram were developed based on the results.

RESULTS

The number of patients in each group was 45 after PSM. The rate of behavioural disorders at the baseline was significantly higher in the children undergoing Nuss procedure at 10 years of age [36% vs 20%, odds ratio (OR) 2.21, 95% confidence interval (CI) 0.85-5.72; P = 0.157]. The rate of behavioural disorders in the third year after the removal of the bar was 36% and 18% in children undergoing surgery at 10 and 4 years of age, respectively (OR 2.55, 95% CI 0.96-6.79; P = 0.094). The rate of persistent behavioural disorders, defined as continuing to have behavioural disorders in the third year after the removal of the bar in those with behavioural disorders at the baseline, was 88% vs 56% (OR 3.47, 95% CI 0.56-21.36; P = 0.204). Two patients (4%) relapsed in each group. A risk prediction model by variables of gender, Haller index, pulmonary function and score of Child Behaviour Checklist at the baseline was provided.

CONCLUSIONS

The rate of behavioural disorders was considerably lower in children who underwent the Nuss procedure at 4 years of age than at 10 years of age. Behavioural disorders may not readily resolve after surgery. Performing surgery at an early age rather than just before puberty may be better for psychosocial development. Psychosocial aid is necessary in addition to surgery to address behavioural disorders.

Comparison of magnetic resonance imaging and computed tomography to measure preoperative parameters of children with pectus excavatum

IMPORTANCE

Pectus excavatum (PE) is the most common thoracic wall deformity in children, we need a method which could be used to evaluate pulmonary functions and effects on development.

OBJECTIVE

To evaluate the use of 3D T1-weighted (3DT1) and mDIXON magnetic resonance imaging (MRI) sequences for measuring the thoracic parameters and morphology of children with PE, comparing the measurements with those made on computed tomography (CT).

METHODS

This is a retrospective study of children with thoracic deformities who were hospitalized at the Department of Thoracic Surgery of the Heart Center, Beijing Children's Hospital, between June 2014 and June 2015. Chest CT was performed first, with the MRI scanning then being performed 0-3 days later. The mDIXON sequences were obtained in inspiratory and expiratory phases and the 3DT1 sequences were obtained during free breathing. Thoracic volume was measured using the acquired images.

RESULTS

The lung volumes measured on mDIXON MRI and CT were highly correlated, with the Haller index not being significantly different between the two methods. Bland-Altman analyses showed that lung, cardiac, and retrosternal parameters were similar between the two methods. Pulmonary parameters were higher with the end-inspiratory phase mDIXON images than with the end-expiratory phase images, as expected, while cardiac parameters were unaffected by the respiratory phase.

INTERPRETATION

Thoracic volumes measured on mDIXON MRI in combination with held respiration could reflect lung volume functions and help in observing the movement functions of the lungs and heart. The method could be used instead of CT, avoiding subjecting the patient to potentially harmful radiation.

An Open, Prospective Study to Evaluate the Effectiveness and Safety of Hyaluronic Acid for Pectus Excavatum Treatment

Background

Pectus excavatum (PE) is sometimes associated with psychological and physiological difficulties influencing a patient’s quality of life. Treatment with a hyaluronic acid (HA)-based gel may benefit patients and be an alternative to other more invasive treatments.

Objectives

The authors sought to evaluate the effectiveness in terms of satisfaction, duration, and safety of HA gel treatment for PE including impact on quality of life.

Methods

Males ≥18 years having PE without functional problems received HA gel injections (50 – 150 mL) at the site of deformity and in some cases at the medial pectoralis muscle borders to optimize the aesthetic result. Follow-up visits were performed after 1, 3, 6, 12, and 24 months with optional retreatment at the 24-month visit including a 1-month follow-up. Evaluations included Pectus Excavatum Evaluation Questionnaire, patient satisfaction, magnetic resonance imaging, and safety assessments.

Results

The treatment significantly improved patients’ self-esteem (P < 0.001) and psychosocial function (P ≤ 0.038) throughout the study, as assessed by Pectus Excavatum Evaluation Questionnaire. Patients were satisfied with the aesthetic outcome and considered the treatment mild in terms of level of pain during injection. Treatment effects were maintained up to 24 months and 58% of the HA gel remained at this visit, shown by Magnetic Resonance Imaging measurements. The treatment was well tolerated.

Conclusions

Treatment of PE with HA gel improved patient quality of life related to self-esteem and psychosocial functioning including aesthetically pleasing results. The treatment may also offer benefits in terms of safety and tolerability compared with other treatments.

Level of Evidence: 4

Changes in chest wall motion with removal of Nuss bar in repaired pectus excavatum - a cohort study

Background

The effects of the Nuss procedure on chest wall motion and spirometry have previously been described; we aimed to describe the effects of removal of the Nuss bar.

Methods

We studied 9 patients just prior to and 6 weeks after Nuss bar removal. Regional chest volume changes, synchrony of respiratory movement and spirometry were recorded using optoelectronic plethysmography (OEP) and compared. Recordings were performed at rest and exercise during cycle ergometry.

Results

There were small but statistically significant changes in tidal volumes of the diaphragmatic ribcage compartment during exercise (+ 48 ml, p = 0.038, Cohen’s d = 0.12) and percentage contribution of the diaphragmatic ribcage to total tidal volumes at rest (+ 2.7 percentage points, p = 0.038, Cohen’s d = 0.12). Synchrony of respiratory movements at rest and during exercise was unchanged following Nuss bar removal. There were no significant changes in spirometry and exercise capacity.

Conclusions

The effects of Nuss bar removal on diaphragmatic ribcage motion are detectable but small and unlikely to be of clinical significance. No change in exercise capacity should be expected after Nuss bar removal.

Trial registration

Registered at ClinicalTrials.gov, identifier NCT02958683, registered 5th August 2016, first patient enrolled July 2016, retrospectively registered.

[Costal cartilage structural and functional changes in children with a funnel or keeled chest]

Congenital chest wall deformities (CCWDs) in children are severe diseases leading to cosmetic defects and diseases of the respiratory and cardiovascular systems. The most common of these deformities are funnel-shaped (pectus excavatum, FD) and keeled (pectus carinatum, KD) ones. The pathogenesis of CCWDs and the role of costal cartilage structural and functional changes in their pathogenesis have now been not well studied, which makes it difficult to elaborate pathogenetic approaches to correcting these diseases. Analysis of the literature has shown that structural and functional changes occur in the matrix and chondrocytes from the costal cartilage in FD. Similar costal cartilage changes are observed in KD. It is still unknown exactly which pathological processes are present in the costal cartilage and how they result in the development of one or other type of CCWDs. The role of amianthoid transformation (AT) of costal cartilages in these processes is also unknown. It is not improbable that it is AT drastically changing the native cartilage matrix, which is one of the key mechanisms leading to changes in its properties and to the subsequent development of FD or KD.

Clinical Characteristics and Thoracic factors in patients with Idiopathic and Syndromic Scoliosis Associated with Pectus Excavatum

Introduction

The purpose of this study is to demonstrate the clinical characteristics and thoracic factors such as sternal tilt angle and Haller index in patients with idiopathic or syndromic scoliosis associated with pectus excavatum.

Methods

We performed a retrospective review on a cohort of 70 patients (37 males and 33 females) diagnosed with idiopathic and syndromic scoliosis associated with pectus excavatum between 1985 and 2014. We investigated age, location and Cobb angle of the main curve, and thoracic factors including sternal deviation and tilting angle and Haller index using radiographs and computed tomography of the chest.

Results

Patients' mean age at the first visit to our hospital was 10.3 years (1-18 years old). There were 41 patients with idiopathic scoliosis and 29 with syndromic scoliosis. Main curve locations were thoracic in 52 patients, thoracolumbar in 10, and lumbar in 8. The mean Cobb angle of the main curve was 45.0 degrees (11-109 degrees). The sternum was displaced on the left side in 72% of patients, central in 23%, and right in 5%. Mean sternal tilt angle was 12.4 degrees (2.3-34 degrees), and mean Haller index score was 4.9 (2.9-9.2). There was no significant correlation between Cobb angle and sternal tilt angle/Haller index. However, a significant difference was found between sternal tilt angle and Haller index.

Conclusion

Most patients with both scoliosis and pectus excavatum have left side deviated sternum and a higher Haller index score; therefore this can negatively impact cardiac function. Prone positioning and the corrective force applied during scoliosis surgery as well as thoracic compression during cast or brace treatment may have a negative effect on cardiac function in these patients.

[Contribution of computer-aided design for the conception of custom-made implants in Pectus Excavatum surgical treatment. Experience of the Nantes plastic surgery unit]

INTRODUCTION

Pectus excavatum is the most common congenital chest malformation and is a common reason for consultation in plastic surgery. Our attitude is most often a filling of the depression with a custom-made silicone prosthesis. The objective of this work was to evaluate the interest of computer-aided design (CAD) of implants compared to the conventional plaster molds method.

PATIENTS AND METHODS

We have collected all the cases of custom-made silicone implants to treat funnel chests in our plastic surgery department. The quality of the results was evaluated by the patient, and in a blind manner by the surgical team using photographs and standardized surveys. The pre-operative delays, the operating time and length of hospital stays, the number of surgical recoveries, and the post-operative surgical outcomes were recorded.

RESULTS

Between 1990 and 2016, we designed 29 silicone thoracic implants in our department. Before 2012, implants were made from plaster chest molds (n=13). After this date, implants were designed by CAD (n=16). Patients rated their results as "good" or "excellent" in 77% and 86% of cases respectively in the plaster and CAD groups. The surgical team's ratings for CAD implant reconstructions were better than in the plaster group: 8.17 versus 6.96 (P=0.001). CAD implants were significantly less detectable than the plaster group implants. The operating time was reduced in the CAO group: 60.2 compared to 74.7minutes in the plaster group (P=0.04), as was the length of hospitalization: 3.5 versus 5.3 days (P=0.01). There were no significant differences between the two groups in terms of post-operative complications.

CONCLUSION

The management of pectus excavatum by a custom-made silicone implant is a minimally invasive method that provides good cosmetic results. The design of these implants is facilitated and qualitatively improved by CAD.

Pectus updates and special considerations in Marfan syndrome

Congenital chest wall or pectus deformities including pectus excavatum (funnel chest) and pectus carinatum (pigeon chest) affect a significant proportion of the general population and up to 70% of patients with Marfan syndrome. Patients often experience significant morbidity and psychological distress, which can worsen with age. Here we discuss new techniques for both operative and non-operative treatment of pectus deformity, the importance of a welltimed intervention and special considerations in patients with Marfan syndrome.

Outcome of surgical repair of Pectus Excavatum in adults

Background

Pectus Excavatum (PEx) is the most common congenital chest wall deformity, accounting for over 90% of all chest wall deformities. Surgical correction is recommended because severe PEx can affect the physical and psychological development of patients. The aim of our study was to assess the impact of surgical repair of Pectus Excavatum in adults during hospital course and results after 1 year.

Methods

Prospective study was carried out on 86 adult patients aged ≥ 15 years, 52 males and 34 females (mean age was 26 ± 1.5 years). All cases were divided into two groups, group I: (15–25 years old) and group II: (> 25 years old). Preoperative, operative, and postoperative data were reviewed. Statistical analysis was performed.

Results

Statistical analyses revealed significant improvement postoperatively of cosmetic satisfaction (P-value < 0.0001), pain (P-value =0.0003), exertional dyspnea (p-value <0.05) and exercise tolerance. The degree of chest compression was significantly improved after surgical correction within 12 months and the estimated measurement postoperatively of Haller Index showed significant reduction (p-value <0.001). Patient satisfaction postoperatively was excellent in 77.9% of all cases.

Conclusion

Surgical correction of Pectus Excavatum using open technique in adults had excellent post-operative outcome in the short term follow up that encourage performing the procedure for all cases. Long term results need longer period for follow up. Etiology and predisposing factors still need further research.

Use of laryngeal mask airway for non-endotracheal intubated anesthesia for patients with pectus excavatum undergoing thoracoscopic Nuss procedure

BACKGROUND

The aim of the present study was to determine the safety and feasibility of the use of laryngeal mask airway (LMA) for non-endotracheal intubated anesthesia for patients with pectus excavatum (PE) undergoing thoracoscopic Nuss procedure.

METHODS

Between July 2015 and December 2015, 30 selected patients with PE were planned to undergo a thoracoscopic Nuss procedure using LMA for non-endotracheal intubated anesthesia in the Guangdong General Hospital. The clinical data were analyzed to evaluate the safety and feasibility of this technique.

RESULTS

Of the 30 selected patients, two were female, the mean age was 16.04±5.09 years and the average Haller index was 3.37±0.88. A total of 27 cases (90%) succeeded at the first attempt, one patient required conversion to an endotracheal tube (ETT) because of continuous air leak. The peripheral O2 saturation (SpO2), end-tidal carbon dioxide (EtCO2) values, heart rate (HR), and mean arterial blood pressure (MAP) remained stable throughout the procedure in all cases. All of the 30 patients were successfully corrected without requiring conversion to an open surgery. Two patients experienced postoperative nausea and one reported a sore throat. Neither gastro-esophageal reflux nor in-hospital mortality occurred.

CONCLUSIONS

The use of LMA for non-endotracheal intubated anesthesia for selected patients with PE undergoing thoracoscopic Nuss procedure is clinically safe and technically feasible.

Pectus excavatum in mummies from ancient Egypt

Pectus excavatum is one of the common congenital anomalies, yet there seems to be a suspicious absence of any cases or descriptions of this deformity from antiquity. This could represent a real change in disease prevalence but is more likely just due to an inadequate reporting in medico-historical literature. The current study reviews reports of computed tomography (CT) scans of 217 ancient Egyptian mummies, revealing 3 presumed cases of this deformity. Therefore, pectus excavatum was in fact present already in ancient times, with prevalence roughly similar to the modern one.

Correction of secondary deformity after Nuss procedure for pectus excavatum by means of cultured autologous cartilage cell injection

•

Different strategies are available for the re-correction after pectus excavatum surgery.

•

We cultured and propagated chondrocytes taken from a patient’s auricular cartilage.

•

The cultured chondrocytes are transplanted to the concave part of the chest.

•

The chest shape improved and the transplanted cells consolidated, forming part of the chest wall.

•

Transplantation of cultured chondrocytes is a useful treatment for pectus excavatum.

Introduction

For some cases of pectus excavatum, ideal chest shape cannot be achieved solely by performing the Nuss procedure. This manuscript presents a case where the residual deformity following Nuss was corrected using injection-transplantation of cultured autologous chondrocytes.

Presentation of case

The treatment was performed for an 18-year-old male, who sought improvement of his chest shape after previously undergoing the Nuss procedure. A 1 cm² auricular cartilage piece was harvested from his ear. Chondrocytes were isolated from the cartilage piece and were cultured. The cultured chondrocytes were processed into gel form and were injection-transplanted to the deformed region of the patient's chest. The grafted chondrocytes consolidated in one month, presenting elasticity equivalent to ordinary costal cartilage. The patient's chest remains in an optimal shape after a one-year postoperative follow up.

Discussion

Secondary correction of the chest deformity after previous operation for pectus excavatum is often tricky, because of the possible adhesion of the lungs or pericardium with the thoracic wall. Transplantation of cultured autologous chondrocytes does not require intra-thoracic maneuvers, and so is less invasive than other surgical interventions. Hence, priority can be placed, in some cases, on the chondrocyte transplantation rather than the re-correction of the thorax with the Nuss procedure or Ravitch procedure.

Conclusion

Transplantation of cultured autologous chondrocytes is recommended as a useful option for secondary correction of chest deformity after the Nuss procedure.

Pectus deformities and their impact on pulmonary physiology

Pectus excavatum (PE) and pectus carinatum (PC) are the most common anomalies of the thoracic cage and they have been recognized since ancient times [1-3]. The two conditions differ in their appearance, and their effect on lung function. There is no direct correlation between the appearance of the deformities and the clinical symptoms. Whether, and when these deformities should be corrected as well as with which method (surgical or conservative) remain controversial. The following article reviews the current concepts regarding the pathophysiology of both conditions as well as the advances in their evaluation and management.

Anesthesia and analgesia for pectus excavatum surgery

The technique of choice for surgical correction of pectus excavatum is the Nuss procedure, a minimally invasive technique in which rigid metal bars are placed transthoracically beneath the sternum and costal cartilages until permanent remodeling of the chest wall has occurred. Intraoperatively, anesthesia focuses on three areas: the potential for catastrophic blood loss caused by perforation of large capacitance vessels and the heart, the potential for malignant arrhythmias, and the consequences of bilateral iatrogenic pneumothoraces. Postoperatively, analgesia is institutionally dependent and controversial, based on usage and type of regional anesthesia. The necessity of multimodal analgesic techniques creates a common ground across different hospital systems.

Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum

This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric=0-21; adult 17-99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.

Thoracoscopic repair of pectus excavatum using different bar stabilizers versus open repair

Objectives

To identify the preoperative characteristics and compare operative variables and postoperative outcomes in adult patients with pectus excavatum undergoing thoracoscopic repair using different bar stabilizers or open surgical repair.

Methods

31 patients were randomly divided into 3 groups: group A was 9 patients who underwent a modified Ravitch repair, group B was 11 patients who underwent video-assisted thoracoscopic repair using metal stabilizers, and group C was 11 patients who underwent video-assisted thoracoscopic repair using absorbable stabilizers. Preoperative, intraoperative, and postoperative variables and mortality were compared among groups.

Results

In all groups, preoperative variables were well-matched for age, sex, and Haller index. Operative time was significantly longer in group A. The postoperative length of hospital stay was significantly shorter in group A. Postoperative complications occurred in 7 (22.6%) patients, mostly in groups B and C. All patients were satisfied with the cosmetic result.

Conclusions

Repair of pectus excavatum in adult patients can be performed effectively either through an open surgical technique or thoracoscopy, with no intraoperative complications and excellent immediate results, but video-assisted thoracoscopic repair using metallic or absorbable bar stabilizers gives a better cosmetic result; however, absorbable bar stabilizers are more vulnerable and break more easily than metal stabilizers.

Pectus excavatum in children with laryngomalacia

BACKGROUND

Laryngomalacia is the most common congenital laryngeal anomaly and is associated with several disorders including gastric reflux, sleep apnea, hypotonia and failure to thrive. Pectus excavatum (PE) is the most common chest wall deformity affecting 1-300/1000 individuals. Though many authors presume a relationship between PE and laryngomalacia, there is no published data to establish this association.

GOAL

To test the hypothesis that patients referred to our pediatric otolaryngology clinic for evaluation of laryngomalacia exhibit higher rates of PE than the general population.

METHODS

Retrospective review of prospectively enrolled children who presented with laryngomalacia (January 2008-June 2012) to a tertiary care, hospital based, pediatric otolaryngology practice. Each chart was examined for a concurrent diagnosis of pectus deformity.

RESULTS

Of the 137 laryngomalacia patients, 9 (6.6%) had documented PE. This represents a significantly increased rate of PE when compared to children without laryngomalacia (p = 0.001). Four of the 9 children with PE underwent supraglottoplasty for laryngomalacia, a significantly greater proportion than the 9/128 of the children with isolated laryngomalacia who underwent supraglottoplasty (p = 0.004).

CONCLUSIONS

This study suggests an association between laryngomalacia and PE. Pediatric otolaryngologists should be cognizant of this relationship, though further studies are needed to elucidate the nature of this association.

Pectus excavatum: a comparison of the Ravitch repair with the Nuss thoracoscopic technique with a standard metal bar or an absorbable bar

OBJECTIVE

Although pectus excavatum repair has evolved to a minimally invasive technique in prepubescent patients, the best approach in adults is less clearly understood. The aim of this study was to identify the preoperative characteristics, operative variables, and postoperative outcomes in adult patients with pectus excavatum undergoing thoracoscopic repair using different bar stabilizers compared with the open surgical repair.

METHODS

We conducted a prospective study between July 2009 and July 2012 in a single institution. Thirty-one patients (26 men and 5 women) aged 18 to 35 years were randomly assigned into three groups: group A, 9 patients underwent modified Ravitch repair; group B, 11 patients underwent video-assisted thoracoscopic repair using metal stabilizers; and group C, 11 patients underwent video-assisted thoracoscopic repair using absorbable stabilizers. Preoperative, intraoperative, and postoperative variables are compared between all groups.

RESULTS

In all groups, the preoperative variables were well matched for age, sex, and Haller index. Operative time was 2 hours longer in group A (P = 0.0001). There was no intraoperative complication. Length of hospital stay was 4 days shorter in group A. Morbidity was 23% and composed of pneumothorax (three), wound seroma (two), pleural effusion (one), and stabilizer break (one), occurring more frequently in groups B and C. There was no perioperative mortality. All patients were satisfied with the cosmetic results.

CONCLUSIONS

Repair of pectus excavatum in adult patients can be performed effectively through either open surgical technique or thoracoscopy, with no intraoperative complications and with excellent immediate results. Although the operative time for the Ravitch repair was longer, the hospital stay was significantly shorter than that for the video-assisted method.

Upper thoracic shape in children with pectus excavatum: impact on lung function

OBJECTIVE

Pectus excavatum (PE) can present with respiratory complaints in childhood. However severity of the PE, measured by the Pectus Severity Index (PSI), correlates only modestly with reduced vital capacity (VC). We hypothesized that another upper thoracic feature, a pectus gracilis (PG) or slender chest, co-exists with PE, and impacts lung function.

PATIENTS AND METHODS

We developed the Pectus Gracilis Index (PGI) based on the chest width to depth ratio at the gladiolar-manubrial sternal junction on computerized tomographic (CT) scans, and measured PGI among 316 control children 10-20 years old. PG was defined by PGI values >2 z-scores above the mean normal value. We determined the prevalence of PG in 97 children with PE and correlated PGI and PSI with VC among the 86 that performed spirometry.

RESULTS

The mean and upper limit of normal for PGI averaged 2.73 and 3.55, respectively for control children. The prevalences of a PG among controls and children with PEs were 3.2% and 59%, respectively (OR = 45, P < 0.00001). Among the children with PEs, the PGI, and PSI correlated with one another (r = 0.77, P < 0.001). Both PSI and PGI significantly correlated inversely with VC. (r = -0.34, P < 0.001 and r = -0.38, P < 0.001, respectively). Importantly, PGI correlated with VC after adjusting for PSI among children with PE. (r = 0.20, P < 0.03).

CONCLUSION

The upper thoracic feature of a PG is common among children with PE and contributes to reductions in VC. Assessment of the thorax, using the PGI, may improve the structure-function correlations previously described for children with PE.