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

Repair of pectus excavatum in a patient with an Eloesser thoracostomy window: sequential extrapleural Nuss procedure and modified Ravitch procedure

A 28-year-old man with a history of tuberculous empyema and pectus excavatum visited our hospital for progressive dyspnea and leg edema. The patient had undergone an Eloesser window operation for repetitive pleuro-cutaneous fistula due to chronic tuberculous empyema in the left thorax one year prior. Chest computed tomography demonstrated severe compression of the right ventricle and inferior vena cava and chronic empyema with the Eloesser window in the left thorax. Because conservative treatment had failed, the patient underwent a total extrapleural Nuss procedure, resulting in marked relief of compression and complete resolution of leg edema and congestive hepatopathy. However, he required ventilation support due to carbon dioxide retention. Therefore, the patient underwent a modified Ravitch procedure and was weaned off ventilation support. Herein, we represent the first report of a sequential extrapleural Nuss procedure and a modified Ravitch procedure in a patient with chronic tuberculous empyema with an Eloesser window.

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.

Factors influencing negative surgical outcomes in adult pectus excavatum patients undergoing Nuss procedure

BACKGROUND

This study aimed to examine the factors associated with the negative outcomes of Nuss procedure in adult pectus excavatum (PE) patients.

METHODS

Forty-seven adult PE patients were enrolled in this study. Mimics 21.0 software (Materialise) was used to reconstruct the preoperative and postoperative three-dimensional (3D) thoracic model. The preoperative and postoperative pulmonary volumes and function parameters were compared. The diaphragm positions were localized, and the anteroposterior diameter (APD) of the thoracic cavity was calculated using neoteric methods. Binary logistic regression was used to reveal the association between clinical factors and altered pulmonary parameters.

RESULTS

Postoperative lung volumes in adult PE patients decreased significantly (P<0.001). The mean preoperative lung volume was 4,592.82±946.54 cm³, which reduced to 3,976.26±867.35 cm³ postoperatively. The rate of postoperative lung volume reduction was approximately 12.1%. Physiologically, forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF) significantly decreased after Nuss procedure, and a near 10% reduction in FVC was observed. Diaphragm elevation was positively associated with decrease in lung volumes [odds ratio (OR) =40.51; P=0.011; 95% confidence interval (CI), 2.37-692.59]. The presence of reduced thoracic APDs was significantly associated with negative pulmonary function results (OR =1.21; P=0.008; 95% CI, 1.050-1.388).

CONCLUSIONS

This study reveals that thoracic APD reduction and diaphragm elevation are associated with decreased postoperative pulmonary volumes and function in adult PE patients. Nuss procedure for adult patients with PE must be considered cautiously by thoracic surgeons, especially in patients who expect to improve their cardiopulmonary function.

Outcomes of the Nuss procedure for pectus excavatum in adults

Limited data exist with regard to the outcome of the Nuss procedure for pectus excavatum repair in adults. Here, we analysed changes in lung capacity and thoracic morphology based on computed tomography (CT) imaging in adults with pectus excavatum before surgery, during bar insertion and after bar removal. Patients who underwent the Nuss procedure for pectus excavatum after the age of 20 were included in this study. Chest CT scans of the included participants were taken before the Nuss procedure, immediately before removal of the pectus bar and 6 months after removal of the pectus bar. Lung capacity and thoracic morphology measurements were made from the CT scans. Six patients aged 24-43 years were included in this study. After the Nuss procedure, lung capacity was decreased in all patients. Although the pectus bar was removed, lung capacity had not significantly increased and was almost the same volume as before the Nuss procedure. After the Nuss procedure, the funnel chest shape had improved in all cases, patients' thoracic spine had also moved forward as the thorax moved forward and patients' stoop had improved. Despite a lack of change in lung capacity, surgical modification should be considered to reduce stress on the thoracic spine and in turn, reduce pain in patients with pectus excavatum. However, further long-term observation seems necessary.