Does aggressive respiratory rehabilitation after primary nuss procedure improve pulmonary function?

OBJECTIVE

Here, we present the efficacy of an aggressive respiratory rehabilitation program that was initiated from early postoperative period, expecting to improve inspiratory volume at an early stage after primary Nuss procedure.

METHODS

The study was performed as a nonrandomized controlled study undergoing primary Nuss procedure at our institute from 2016 to 2018. We evaluated 34 patients and assigned them to two groups based on whether or not they received a respiratory rehabilitation. Group A (between June 2016 and March 2018) includes patients with inspiratory training postoperatively, and group B (between April 2018 and July 2018) includes patients without training. At the time of admission, a physiatrist provided each patient with a training instruction. From day five postoperatively, the patients in group A started training for inspiration with an incentive spirometer (Coach 2®PORTEX) four times a day. Patients were instructed to perform the same training at home after discharge. Using this device, we measured pre- and postoperative inspired volumes in each group. Data were analyzed with Wilcoxon-Mann-Whitney tests and a paired Student t-test. A p-value below 0.05 was considered statistically significant.

RESULTS

There were no statistically significant differences between the two groups concerning both operative age and the degree of the deformity calculated by Haller index. Preoperative inspiratory volume showed no significant differences. Although there were no statistical differences between two groups in the inspiratory volume at discharge, these two parameters were significantly higher in group A after three months postoperatively (A: 1404 ± 466 ml vs B: 900 ± 314 ml) and the values increased compared to the preoperative stage in group A.

CONCLUSIONS

These data indicate the aggressive respiratory rehabilitation is an effective regimen to increase inspiratory volume at an early stage after Nuss procedure.

LEVEL OF EVIDENCE

III.

Functional exercise capacity and lung function in patients undergoing an early rehabilitation program after the Nuss procedure: a randomized controlled trial

PURPOSE

The aim of this study was to compare the functional exercise capacity and the lung function among patients undergoing early rehabilitation with those submitted to the conventional care after pectus excavatum repair using the Nuss procedure.

METHOD

Patients were randomly allocated to the early rehabilitation group (ERG) who started rehabilitation after surgery and the group of the conventional care (CG) received routine care of the institution. They were evaluated before surgery (preoperative) and in hospital discharge day (postoperative).

RESULTS

Forty patients were evaluated, twenty in each group. All patients presented a significant reduction in FVC, FEV1, and PEF in the postoperative period, there was no statistically significant difference between groups. There was significant different in postoperative functional exercise capacity between the ERG and CG (506.26 ± 66.54 vs 431.11 ± 75.61, p = 0.02) and the difference between distance walked in the preoperative and postoperative period was lower in the ERC than in the CG (76.57 ± 49.41 vs 166.82 ± 70.13, p < 0.001).

CONCLUSION

Patients undergoing the early rehabilitation after the Nuss procedure presented a better postoperative functional exercise capacity in hospital discharge day compared with patients in the conventional group, with no difference in lung function between groups.

Minimally invasive treatment of pectus excavatum

Pectus excavatum (PE) is the most common congenital chest wall deformity. It consists of a concavity of the sternum, and the costal cartilages derived from an unbalanced growth of the costochondral regions of the anterior chest wall. The standard operative treatment for PE has been the Ravitch procedure. This technique requires a long incision in the anterior chest wall and bilateral resection of the affected costal cartilages, needing in most cases a posterior metal bar support. The belief that the treatment of PE is basically esthetic led Donald Nuss to develop in 1998 a minimally invasive surgical treatment based on the skeletal frame plasticity and reshape capacity applied to the thorax. Thereby he deviced a technique involving a retrosternal steel bar modifying the sternum´s concavity and supporting the shape of the amended thorax, all performed through two small incisions at each side of the thorax with the help of a thoracoscope. The bar is maintained from 2 to 3 years, and removed after this period. This procedure obtains >90% of positive results with significant esthetic improvement and patient satisfaction. This minimally surgical approach for PE is to be discussed in this review.

Cardiorespiratory Outcome after Corrective Surgery for Pectus Excavatum: A Case Study

PURPOSE

The purpose of this case study was to examine the effect of pectus excavatum before and after surgical correction on ventilatory and cardiorespiratory responses to submaximal and maximal exercise.

METHODS

The patient was a 30-yr-old longshoreman who had mild pectus excavatum since infancy that became worse during his adolescent growth years. The deformity persisted into adulthood with increasing symptoms. Although he had a history of habitual aerobic exercise, the patient experienced frequent episodes of pain in the lower anterior chest, breathlessness, and reduced stamina when performing activities of daily living. He performed pulmonary function tests, submaximal and maximal incremental exercise testing, before and 6 months after corrective surgery.

RESULTS

Six months after corrective surgery, the patient demonstrated increases in FEV1 (13.0%), maximum voluntary ventilation (MVV, 32.3%), maximum power output (max, 15.5%), [OV0312]O2max (7.9%), metabolic threshold ([OV0312]O2theta, 30.8%), oxygen-pulse ([OV0312]O2/fc, 14.0%), and maximal tidal volume (VTmax, 11.7%). On submaximal testing, we found that the time constant for oxygen uptake kinetics was 46.8 s for the on-transit and 46.5 s for the off-transit before surgery and 33.6 s for the on-transit and 30.3 s for the off-transit six months after surgery.

CONCLUSIONS

The information derived from this case study supports the opinion that corrective surgery for pectus excavatum may alleviate the impaired ventilatory and cardiorespiratory performance seen preoperatively.

A 10-year review of a minimally invasive technique for the correction of pectus excavatum

PURPOSE

The aim of this study was to assess the results of a 10-year experience with a minimally invasive operation that requires neither cartilage incision nor resection for correction of pectus excavatum.

METHODS

From 1987 to 1996, 148 patients were evaluated for chest wall deformity. Fifty of 127 patients suffering from pectus excavatum were selected for surgical correction. Eight older patients underwent the Ravitch procedure, and 42 patients under age 15 were treated by the minimally invasive technique. A convex steel bar is inserted under the sternum through small bilateral thoracic incisions. The steel bar is inserted with the convexity facing posteriorly, and when it is in position, the bar is turned over, thereby correcting the deformity. After 2 years, when permanent remolding has occurred, the bar is removed in an outpatient procedure.

RESULTS

Of 42 patients who had the minimally invasive procedure, 30 have undergone bar removal. Initial excellent results were maintained in 22, good results in four, fair in two, and poor in two, with mean follow-up since surgery of 4.6 years (range, 1 to 9.2 years). Mean follow-up since bar removal is 2.8 years (range, 6 months to 7 years). Average blood loss was 15 mL. Average length of hospital stay was 4.3 days. Patients returned to full activity after 1 month. Complications were pneumothorax in four patients, requiring thoracostomy in one patient; superficial wound infection in one patient; and displacement of the steel bar requiring revision in two patients. The fair and poor results occurred early in the series because (1) the bar was too soft (three patients), (2) the sternum was too soft in one of the patients with Marfan's syndrome, and (3) in one patient with complex thoracic anomalies, the bar was removed too soon.

CONCLUSIONS

This minimally invasive technique, which requires neither cartilage incision nor resection, is effective. Since increasing the strength of the steel bar and inserting two bars where necessary, we have had excellent long-term results. The upper limits of age for this procedure require further evaluation.

[Surgical treatment of funnel chest]

In 1976-1985, 39 patients were operated for the funnel chest. All patients were enrolled for the intensive rehabilitation program in the hospital, and correction exercises followed by swimming were recommended after release home. A favourable cosmetic effect was achieved in all patients in early postoperative period. However, a recurrence of the funnel chest has been noted in 10 patients (26%), later. Abnormality has been less advanced except 1 patient in whom subjective worsening has been noted.