eComment. Pectus excavatum: the surgical opinion.
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ABSTRACT: To review the literature and assess the cumulative data on the Nuss operation in children on its twenty years' anniversary: The Nuss procedure corrects the pectus excavatum by minimal access semi-permanent insertion of metal bars in order to reduce the deformity and refashion the contour of the growing thorax. The advantage over previous techniques is avoidance of osteochondrotomies and thence allowance for normal growth of the thorax. PubMed search was performed. Primary outcomes were mortality, morbidity and individual complications. Secondary outcomes were procedure time and hospital stay. We merged the data from 19 reports comprising 1949 children of mean age 10.6 years.No mortality was observed and the procedure was associated with morbidity of 15.4%. The commonest complications are bar-related adverse events (5.7%) and pneumothorax (3.5%). The average procedure time and the average hospital stay were 68 minutes and 5.5 days respectively. 20 years of initial evidence suggests that the Nuss group of procedures is a safe minimal access option for correction of pectus excavatum in childhood.Journal of Cardiothoracic Surgery 02/2008; 3:40. · 0.90 Impact Factor
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ABSTRACT: The Ravitch and minimally invasive Nuss procedures have brought widespread relief to children with pectus excavatum, chest wall deformities, over the last half century. Generally accepted long-term complications of pectus excavatum repair are typically limited to recurrence of the excavatum deformity or persistent pain. This study examines the authors' experience with patients who develop a subsequent carinatum deformity within 1 year of pectus excavatum repair. The authors retrospectively assessed the charts of all patients diagnosed as having a carinatum deformity subsequent to treatment for pectus excavatum at a tertiary urban hospital. We noted age at original correction of pectus excavatum, time from original correction to diagnosis of carinatum deformity, age at correction of carinatum deformity, complaints before correction, methods of repair, postoperative complications, and we reviewed relevant radiography. Three patients who underwent pectus excavatum repair between January 2000 and August 2007 developed a subsequent carinatum deformity. Two patients initially underwent minimally invasive Nuss correction of pectus excavatum; 1 patient underwent the Ravitch procedure. Within 1 year of original correction and despite intraoperative achievement of neutral sternal position, a protruding anterior chest deformity resembling de novo pectus carinatum emerged in each patient; we term this condition reactive pectus carinatum. The mean age of patients undergoing initial pectus excavatum repair was 13 years (range, 11-16 years). The pathophysiology of this reactive lesion is not well understood but is thought to originate from reactive fibroblastic stimulation as a result of sternal manipulation and bar placement. Patients who underwent Nuss correction initially were managed with early bar removal. Two of the patients eventually required surgical resection of the carinatum deformity at a time interval of 3 to 6 years after initial excavatum repair. In one patient, the carinatum deformity resolved spontaneously. Neutral chest position and absence of dyspenic symptoms were achieved in all patients. Reactive pectus carinatum is functionally encumbering and a poor cosmetic complication of either the Ravitch or minimally invasive Nuss procedures. Our experience with reactive pectus carinatum introduces the importance of postoperative vigilance even in patients without underlying fibroelastic disease. Examination of the chest with attention to the possibility of an emerging carinatum deformity, particularly in the first 6 postoperative months, is paramount. A telephone call to the patient at 3 months may be a useful adjunct to clinic visits. An optimal long-term result may be achieved through a combination of early Nuss bar removal or postpubertal pectus carinatum repair.Journal of Pediatric Surgery 09/2008; 43(8):1468-73. · 1.38 Impact Factor
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ABSTRACT: We reviewed our operative experience and long-term results with repair of pectus excavatum and carinatum deformities through a vertical midline approach, including those cases with simultaneous intracardiac repair. From 1972 through 1998, 120 children underwent pectus deformity repair. Operative technique used a vertical midline incision with subperichondrial resection of deformed cartilages and an anterior sternal osteotomy. Thirty-five patients had a temporary metal bar for retrosternal support for 6 months; 85 underwent repair without a bar. Patients and parents were asked to assess the outcome after pectus repair as poor, fair, good, or excellent. There were 94 male and 26 female patients (mean age, 8.4 years; range, 3 to 21 years). There were 111 cases of pectus excavatum and 9 of pectus carinatum. Fourteen children (11.5%) had an associated congenital heart defect; 9 patients had simultaneous pectus and intracardiac repair. One patient was referred for emergent open heart repair and pectus repair after attempted "Nuss" repair resulted in a perforated right atrium, perforated right ventricle, and partially disrupted tricuspid valve apparatus. There were no deaths and only one significant complication, which required a return to the operating room for bleeding. Morbidity was not higher in patients with simultaneous intracardiac repair. Long-term follow-up was established in 83% of patients. Results were classified as excellent in 64 patients (64%), good in 25 (25%), fair in 8 (8%), and poor in 3 (3%). Thirty (86%) of 35 patients with a sternal bar had excellent results versus 34 (52%) of 65 without a bar (p = 0.004); 97% of patients who underwent repair with a sternal bar classified the result as excellent or good. Long-term results of pectus excavatum and carinatum repair through a vertical midline approach are excellent. Outcome with a temporary sternal bar is superior to outcome without a bar. Concomitant repair of congenital heart defects and pectus deformity may be performed successfully without additional morbidity.The Annals of Thoracic Surgery 03/1999; 67(2):511-8. · 3.45 Impact Factor
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eComment. Pectus excavatum: the surgical opinion
Authors: Georgios Dimitrakakis and Ulrich O. von Oppell
Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
© The Author 2012. Published by Oxford University Press on behalf of the
European Association for Cardio-Thoracic Surgery. All rights reserved.
We read with great interest the state-of-the-art article by Brochhausen et al.
regarding the pectus excavatum and we agree with the authors that its surgical
treatment by various techniques can improve long term results in terms of cos-
metics and potential cardiorespiratory function [1, 2]. Therefore, we would like to
comment on the surgical approach.
Criteria for the surgical treatment of pectus excavatum, according to Kelly and
colleagues, are related to the severity of symptoms and anatomical deformity
followed by two or more criteria such as computerized tomography-index (or
Haller-index) greater than 3.25, signs of cardiac and or pulmonary compression on
computerized tomography or echocardiography, mitral valve prolapse, arrhythmias
and restrictive lung disease .
The minimally invasive Nuss procedure is safe . In the relatively recent (study
period 1987-2006) review of 18 series, reporting on 1949 children with a mean
age of 10.6 years, there was no mortality and the incidence of morbidity was
15.4%. The average operative time was 68 minutes (from 28 to 200 min) and the
average hospitalization was 5.5 days (from 2 to 27 days) . The most common
reported complications were bar related events (5.7%), pneumothorax (3.5%),
wound infections (2.2%) and pleuropulmonary complications (2%) such as pleural
effusions, atelectasis, and pneumonia .
In addition to common complications, Swanson and Colombani have reported
on three cases within a period of 1 year with reactive pectus carinatum in
patients who underwent pectus excavatum repair (two patients underwent min-
imally invasive Nuss procedure and one patient the Ravitch procedure). It
should be noted that the pectus carinatum resolved in one patient who had an
early bar removal. The other two patients required surgical correction at 3 and
6 years after the first surgical intervention .The need for close follow up for the
early identification and successful treatment of this complication, particularly in
the first six postoperative months, is of paramount importance . In addition,
Willekes et al. in their retrospective study of a 26-year experience with pectus
deformities repair in 120 children with a mean age of 8.4 years (from 3 to 21
years) found that the long-term results of pectus deformities repair (excavatum
and carinatum) through a vertical midline approach are excellent and the
outcome with a temporary sternal bar is superior to that without a bar (p =
0.004). Nine patients had an associated congenital heart defect and underwent
successfully simultaneous pectus excavatum and intracardiac repair with no add-
itional morbidity .
In conclusion, surgical repair of pectus excavatum by various techniques has
good long term results. However, a multidisciplinary approach and assessment of
these patients on an individual basis is very important when considering the timing
and type of procedure. A combined simultaneous approach in dealing with con-
comitant congenital or acquired heart conditions can be performed safely by an
experienced team [2, 5].
 Brochhausen C, Turial S, Müller FKP, Schmitt VH, Coerdt W, Wihlm JM,
Schier F, Kirkpatrick CJ. Pectus excavatum: history, hypotheses and treatment
options. Interact CardioVasc Thorac Surg 2012;14:801–806.
 Kelly RE, Goretsky MJ, Obermeyer R, Kuhn MA, Redlinger R, Haney TS,
Moskowitz A, Nuss D. Twenty-one years of experience with minimally inva-
sive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann
 Protopapas AD, Athanasiou T. Peri-operative data on the Nuss procedure in
children with pectus excavatum: independent survey of the first 20 years’
data. J Cardiothorac Surg 2008;3:40.
 Swanson JW, Colombani PM. Reactive pectus carinatum in patients treated
for pectus excavatum. J Pediatr Surg. 2008;43:1468–73.
 Willekes CL, Backer CL, Mavroudis C. A 26-year review of pectus deformity
repairs, including simultaneous intracardiac repair. Ann Thorac Surg
C. Brochhausen et al. / Interactive CardioVascular and Thoracic Surgery