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Abstract

Pectus excavatum (PE) is the most common chest wall malformation and one of the most frequent major congenital anomalies. The surgical repair of PE in childhood is a well-established procedure. Previously used operative techniques to correct PE were largely based on the Ravitch technique. Today, the minimally invasive repair (MIRPE) by Nuss is well established. Conservative treatment with the vacuum bell to elevate the funnel in patients with PE represents a potential alternative. A suction cup is used to create a vacuum at the anterior chest wall. A patient-activated hand pump is used to reduce the pressure up to 15% below atmospheric pressure. Three different sizes of vacuum bell exist which are selected according to the individual patients age. When creating the vacuum, the lift of the sternum is obvious and remains for a different time period. The device should be used for a minimum of 30 min (2 per day), and may be used up to a maximum of several hours daily. Presently, a 12-15-month course of treatment is recommended. In addition, the device was used intraoperatively during the MIRPE procedure to enlarge the retrosternal space to ensure safer passage of the introducer in a few patients. Thirty-four patients (31 males, 3 females), aged 6-52 years (median 17.8 years) used the vacuum bell for 1 to maximum 18 months (median 10.4 months). Follow-up included photography and clinical examination every 3 months. Computed tomographic scans showed that the device lifted the sternum and ribs immediately. In addition, this was confirmed thoracoscopically during the MIRPE procedure. After 3 months, an elevation of more than 1.5 cm was documented in 27 patients (79%). After 12 months, the sternum was lifted to a normal level in five patients (14.7%). Relevant side effects were not noted. The vacuum bell has proved to be an alternative therapeutic option in selected patients with PE. The initial results proved to be dramatic, but long-term results are so far lacking, and further evaluation and follow-up studies are necessary. In addition, the method may assist the surgeon during the MIRPE procedure.

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... In the meantime, materials have improved and the vacuum devices can now exert strong forces. Our initial results using this method proved to be promising (20). Today, we report our ongoing experience using the vacuum bell for conservative treatment of PE. ...
... Today, we report our ongoing experience using the vacuum bell for conservative treatment of PE. Note that a subset of these patients (the first 34 patients) was reported previously [20]. ...
... Long-term evidence of persistent effects of the treatment modality for more than 5 years are not yet available. However, initial results proved dramatic [20], and the acceptance and compliance of patients seem to be good. In many cases of PE, the degree of pectus deformity does not immediately warrant surgery, yet patients may benefit from some type of nonsurgical treatment. ...
... 19 Contrarywise, VB is contraindicated in patients suffering from skeletal disorders (e.g., osteogenesis imperfecta, osteoporosis, Glisson's disease), vasculopathies (e.g., Marfan's syndrome, aortic aneurysm or dilated aortic root), coagulopathies (e.g., hemophilia, thrombocytopenia), and cardiac disorders. 14,[16][17][18][20][21] These pathologies can be excluded with the use of a standardized evaluation protocol prior to VB application, according to Haecker et al. 14,16,17,20,21 ...
... 19 Contrarywise, VB is contraindicated in patients suffering from skeletal disorders (e.g., osteogenesis imperfecta, osteoporosis, Glisson's disease), vasculopathies (e.g., Marfan's syndrome, aortic aneurysm or dilated aortic root), coagulopathies (e.g., hemophilia, thrombocytopenia), and cardiac disorders. 14,[16][17][18][20][21] These pathologies can be excluded with the use of a standardized evaluation protocol prior to VB application, according to Haecker et al. 14,16,17,20,21 ...
... cm). Based on depth change, 37-90% of patients showed improvement, 14,17,20,[22][23][24] while in 10-40% of them, an excellent correction, defined as the elevation of the sternum to normal, was accomplished. [14][15][16][17][18]20,24 However, depth-improvement definitions vary between researchers, including elevation of more than 1-1.5 cm in 3 months 14,17,20 and reduction in depth over 67% of the initial. ...
Article
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Pectus Excavatum (PE) or “funnel chest,” the most common deformity of the anterior chest wall characterized by sternal depression, can be repaired via either operative or non-invasive techniques. Vacuum Bell (VB) device is the most widespread of the latter one which can be applied either intraoperatively or as monotherapy. The present narrative review examines the efficacy of that innovative method. A thorough search of the literature resulted in 13 English-written articles concerning VB therapy from its first description to February 2019. The studies included patients with mild to moderate PE, mainly evaluated via Haller-Index and/or sternum depth prior to and following treatment. Concerning depth-improvement, 37-90% showed amelioration while 10-40% of them an excellent correction to normal. In 42%, Haller-Index also improved with a median decrease of 0.3 after VB application. A correlation was attempted to be found between the efficacy of VB and factors such as the frequency and duration of VB application, patient age, gender, PE severity and type, and differential pressure of the suction cup. Complications may be frequent yet mild and temporary. Intraoperatively, VB widows Minimally Invasive Repair of Pectus Excavatum (MIRPE) operation a safer procedure with greater results. VB as conservative treatment is an effective and well-tolerated alternative therapeutic option for selected patients with PE who meet specific criteria. It also constitutes a device of significant efficacy, appropriate for intraoperative use during MIRPE procedure.
... We apologise for not having cited the article by Schier et al. [1] in our publication [2]. We regret this error which happened owing to the fact that Dr Haecker did the literature search for our article before publication of the above mentioned paper [1]. ...
... We offered the co-authorship of our article to Mr Klobe but he refused to be cited as a coauthor in any medical paper due to the fact that he is a technical engineer. However, we mentioned his name (p. 559) and his homepage in our article [2] 1 where interested readers can obtain further information regarding his construct. We stated in our article that Dr Bahr and Professor Schier did the initial tests to investigate the use of vacuum chest wall lifter children suffering from pectus excavatum (p. ...
... Thymectomy should be performed in hospitals that have extensive experience not only with the surgery but also with preoperative and postoperative management of myasthenia gravis. Recently, perioperative high-dose prednisone has been used and clinical benefits were provided [2,3]. The reason why we do not use preoperative steroid is because continuous use of steroid is not desirable for the fear of poor wound healing and the occurrence of postoperative infection. ...
... The vacuum bell (VB) has established its role in the treatment of pectus excavatum (PE) in the last 20 years [1][2][3][4][5][6] as an alternative to surgery it has been extensively reported by Haecker, et al. [1][2][3]. And then its usefulness has been confirmed by other authors [4]. ...
... The vacuum bell (VB) has established its role in the treatment of pectus excavatum (PE) in the last 20 years [1][2][3][4][5][6] as an alternative to surgery it has been extensively reported by Haecker, et al. [1][2][3]. And then its usefulness has been confirmed by other authors [4]. ...
... Using vacuum suction to lift the sternum was first described more than a century ago, and its usefulness has been confirmed in the treatment of PE over the last 20 years [1][2][3][4][5][6]. Obviously, one advantage brought by VB therapy compared to surgery is fewer associated risks and less discomfort. ...
Article
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Objective: Conservative treatment with a vacuum bell (VB) for pectus excavatum (PE) has now been gradually popularized as an alternative to surgery. We describe our initial experience with a novel three dimensional (3D) printed VB device. Methods: Prospectively collected data of all patients who started using a 3D printed VB in 2018 at our institution were analyzed. Linear and logistic regressions were used to identify factors associated with effectiveness of device usage. Results: In total, forty-two patients with a median age of 3.6 years were treated with the device. The median follow-up duration was 11.1 months and the mean initial Depth Ratio (DR) was 0.129. There were no permanent sequelae from side effects. Thirty patients with at least one follow-up body scan data showed varying improvement (z = - 4.569, p = 0.0000). Linear regression suggested that longer usage improved outcomes (R2 = 0.235, p = 0.014). By logistic regression there was a trend of younger ages and less initial DR for better improvement though neither was statistically significant (p = 0.086, 0.078, respectively). Conclusion: Our initial experience has shown the 3D printed VB may be as effective as other conventional VBs and could be used as an alternative to surgical treatment for selected patients with PE. More experience and studies with this type of VB are needed to demonstrate its superiority with regard to the 3D printing design and optimal timing and indication for use.
... Patients have shown interest in this alternative to surgery. The vacuum bell is recommended mostly for patients with prominent PE that is not severe enough to require surgery but does cause psychological complications [6][7][8][9]. In 1 study, Lopez et al. [6] noted that the vacuum bell can safely be used to treat children and adolescents with PE, although the long-term effects are not known. ...
... The thoracic kyphosis angle has been shown to have a significant negative correlation with inspiratory capacity, quality of life and lateral expansion of the thorax [12]. Additionally, the related literature recommends physiotherapy for patients who use the vacuum bell to enhance their physical activities and improve their postural distortion [6][7][8][9]. However, no randomized controlled study has considered the additional effects gained with the vacuum bell treatment. ...
... Obermeyer et al. [24] observed an average 0.5-mm elevation in 30 male patients. In a retrospective case series, Haecker and Mayr [9] observed an average 1.5 cm reduction in sternal depression in 3 months in 23 adolescent and paediatric patients. They recommended sports activities such as swimming and physiotherapy to their patients. ...
Article
Full-text available
Objectives: Vacuum bell and exercise therapy are non-invasive treatments for pectus excavatum (PE). The purpose of this study was to determine the effects of the physiotherapy programme applied in addition to vacuum bell treatment in patients with PE. Methods: The study included 26 male patients with PE aged 11-18 years. Patients were randomly divided into 2 groups: group 1 received only vacuum bell treatment; group 2 had vacuum bell therapy and physiotherapy. Patient demographic and disease-related characteristics, type of sternal depression, perception of their deformity, postural evaluations, treatment satisfaction and quality of life were evaluated before and 12 weeks after treatment. Results: From external chest circumference measurements related to PE, sternal depression and anthropometric index values showed improvement in both groups (P < 0.05), but better results were observed in group 2 than in group 1 (P < 0.05). Modified percent depth and scores from the T3 region (distance between the most prominent point of the sternum and the spinous process of the vertebra at the same level) showed improvement only in group 2 (P < 0.01), whereas severity of PE, the patient's perception of his deformity and parental physiological quality-of-life scores improved in both groups (P < 0.05). Posture, satisfaction with treatment and the patients' physiological quality-of-life scores were significantly better in group 2 (P < 0.05). Conclusions: Due to the additional improvements and greater satisfaction in the group receiving physiotherapy, we think that a proper rehabilitation programme should be applied simultaneously with the vacuum bell treatment in patients with PE. Clinical trial registration: clinicaltrials.gov: NCT04167865.
... These are presented in Table 1. [2]. Based on their pilot study [2], indications for VBT included mild PE in patients wanting to avoid surgery. ...
... [2]. Based on their pilot study [2], indications for VBT included mild PE in patients wanting to avoid surgery. In 105 patients (79%) after 3 months of treatment, an elevation of more than 1 cm was noted. ...
... A combination of subjective and objective measures was used to assess the success of therapy [2,5]. Perhaps the strictest definition of an 'excellent' result was by using a reference group of children with normal chest walls [6]. ...
Article
Full-text available
A best evidence topic in thoracic surgery was written in accordance to a structured protocol. The question addressed was: ‘In patients with a pectus excavatum deformity, is vacuum bell therapy (VBT) an effective treatment?’ Altogether, 19 papers were found using the reported search of which 7 represented the best evidence to answer the clinical questions. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Numerous groups have demonstrated the utility of VBT in pectus excavatum; the largest series has followed up patients over 13 years with sternal elevation of >1 cm being demonstrated in 105 patients. Initial age <11, initial chest wall depth <1.5 cm and chest wall flexibility have all been associated with better outcomes. The effects of VBT have been confirmed on computed tomography scanning and intraoperatively to lift the sternum to facilitate retrosternal soft tissue dissection during the Nuss procedure. There was significant heterogeneity in the studies reviewed, in terms of patient age, selection criteria, the VBT protocol, length of follow-up time following completion of VBT and the metrics used to assess success of therapy. VBT is a safe therapy for treating pectus excavatum in a non-surgical conservative manner with few complications reported. However, the success of VBT is largely dependent on patient compliance and motivation. Permanence of correction after completion of VBT needs to be properly assessed through rigorous follow-up, and currently the success of correction, i.e. permanence, remains in the hands of the patient.
... Abbildung 24: Anwendung einer Saugglocke (Haecker & Mayr, 2006) Es wird empfohlen, die Vakuumglocke für 12-15 Monate zweimal täglich für eine halbe Stunde zu verwenden. Die Saugglocke ist in drei verschiedenen Größen erhältlich und sollte entsprechend der Größe und dem Alter des Patienten angepasst werden (Haecker & Mayr, 2006). ...
... Abbildung 24: Anwendung einer Saugglocke (Haecker & Mayr, 2006) Es wird empfohlen, die Vakuumglocke für 12-15 Monate zweimal täglich für eine halbe Stunde zu verwenden. Die Saugglocke ist in drei verschiedenen Größen erhältlich und sollte entsprechend der Größe und dem Alter des Patienten angepasst werden (Haecker & Mayr, 2006). Nebenwirkungen der Vakuumglocke sind Hämatome, petechiale ...
... Einblutungen und Ödeme (Haecker & Mayr, 2006). ...
Thesis
Hintergrund und Ziele Als die mit Abstand häufigste angeborene Brustwanddeformität wird die sogenannte Trichterbrust beschrieben. In den vergangenen Jahren bemühten sich zahlreiche Chirurgen, eine optimale Operations-Methode zu entwickeln. In dieser Arbeit wird die postoperative Korrekturstabilität der Elastic Stable Chest Repair (ESCR)-Technik unter Verwendung einer reinen Plattenosteosynthese mit ihrer Sonderform, dem sog. Hybrid-Verfahren, verglichen und genau analysiert. Darüber hinaus wird die klinische Herausforderung der Behandlung iatrogener Folgezustände genau untersucht. Methode Im Rahmen einer retrospektiven Analyse wurden alle Patienten, die im Zeitraum von 2011 bis 2015 an einer Trichterbrust-Deformität in der Kinderchirurgie Erlangen operiert wurden, in Bezug auf den prä-, post- und intraoperativen Verlauf anhand aller verfügbaren Medien evaluiert. Die Patienten wurden abhängig von der Operationstechnik (ESCR vs. Hybrid) in zwei Hauptgruppen unterteilt und anhand der Anzahl der bereits erfolgten Voroperationen (Primär vs. Rezidiv) in je zwei Untergruppen eingeteilt. Eine weitere Subgruppenanalyse erfolgte für Patienten mit einem Floating Sternum nebst eines strukturierten Literaturreviews bisheriger Erkenntnisse. Die Follow up-Untersuchungen und Ergebnisse wurden statistisch ausgewertet und anhand der Subgruppen analysiert. Ergebnisse und Beobachtungen Im Beobachtungszeitraum erfüllten 86 Patienten die Einschlusskriterien, hierzu zählte das Alter sowie das offene Operationsverfahren der Trichterbrust. Patienten, die jünger als 12 Jahre alt waren oder an einer Kielbrust litten, wurden ausgeschlossen. Insgesamt wurden 38 Patienten mittels ESCR und 48 mittels Hybrid-Verfahren operiert. Eine weitere Unterteilung der Patienten erfolgte nach Vorliegen einer primären bzw. Rezidiv- Operation. Somit ergaben sich insgesamt vier Gruppen: A1 (ESCR, primär: 7 Patienten), A2 (ESCR, rezidiv: 31 Patienten), B1 (Hybrid, primär: 32 Patienten) und B2 (Hybrid, rezidiv: 16 Patienten). 1 Für alle Gruppen zeigte sich ein Korrekturergebnis im anatomischen Bereich mit Normalwerten des Haller-Index. Bezüglich der angebrachten Implantate wurde primär bei 77 % der Patienten ein Metallbügel verwendet, bei den Rezidiv-Patienten waren es 34 %. Bei allen Patienten waren Verplattungen nötig, davon kamen bei den primär Korrigierten (61,5 %) 36 längssternal angebrachte Platten zum Einsatz, bei den Rezidivkorrekturen (29,8 %) 16 Platten. Costosternale Verplattungen erhielten 25,6 % der Primär-Korrekturen und 74,5% der bereits Voroperierten. Bei 18 % der primär Operierten waren costo-sterno-costale Platten nötig (Rezidive: 55,3 %). Rippenbogenkorrekturen wurden bei 41 % bzw. 31,9 % der primär bzw. Rezidiv- Operierten Patienten vorgenommen. Zusätzliche Rippen wurden bei 35,9 % der primär und bei 8,5 % der Rezidiv-Patienten korrigiert. Aus den Rezidivpatienten zeigten 9 (19 %) eine bilateral serielle costosternale Instabilität, entsprechend einem Floating Sternum. Für dieses konnten verschiedene Ausprägungen identifiziert werden, stets mit Beteiligung der kaudalen Rippen 5-7 und fakultativ weiter kranial bis zur 4. Rippe reichend, was insgesamt 4 Rippenleveln entspricht. Die ersten Rippen waren nicht beteiligt. Bei keiner der Gruppen konnte ein Materialbruch beobachtet werden. Schlussfolgerung Sowohl das ESCR, als auch das Hybridverfahren präsentieren sich klinisch als erfolgversprechende Behandlungsmethode mit hoher Patientensicherheit. Beide Verfahren stellen somit eine gute Alternative zu den konventionellen und minimalchirurgischen Operationstechniken dar. Die klinische Überlegenheit der gezeigten Methoden begründet sich in der Möglichkeit, durch modulare Materialkombinationen selbst schwerste Deformitäten, Asymmetrien und Rezidivzustände behandeln zu können – inklusive der klinischen Herausforderung des Floating Sternums. Teilergebnisse der vorliegenden Arbeit wurden veröffentlicht in: „Elastic stable chest repair and its hybrid variants in 86 patients with pectus excavatum“, Journal of Thoracic Disease 2018;10(10):5736-5746 und „From pullout-techniques to modular elastic stable chest repair: the evolution of an open technique in the correction of pectus excavatum”, Journal of Thoracic Disease 2019; 11(7):2846-2860.
... Читайте нас на сайті: http://med-expert.com.ua Вступ Лійкоподібна деформація грудної клітки (ЛДГК) зустрічається приблизно в 0,1-0,8 випадку на 100 дітей і є проявом патології сполучної тканини [5,9,11,16,18]. ЛДГК -це вада розвитку, яка, крім косметичного дефекту у вигляді западіння грудини та ребер, супроводжується різного ступеня функціональними й органічними порушеннями в кардіореспіраторній системі, зокрема: рестриктивна вентиляційна недостатність, часті бронхіти та пневмонії, симптоми компресії серця, зменшення толерантності до фізичних навантажень, відставання в масі тіла тощо [5,[9][10][11]13,18,21]. Крім вказаних порушень, у таких хворих відзначаються часті психологічні проблеми, аж до суїцидальних нахилів, зниження самооцінки, порушення соціальної адаптації та відносин із протилежною статтю [9,18,21]. З огляду на це пацієнти з ЛДГК потребують лікування не тільки за медичними показаннями, але й за косметичними. ...
... Вступ Лійкоподібна деформація грудної клітки (ЛДГК) зустрічається приблизно в 0,1-0,8 випадку на 100 дітей і є проявом патології сполучної тканини [5,9,11,16,18]. ЛДГК -це вада розвитку, яка, крім косметичного дефекту у вигляді западіння грудини та ребер, супроводжується різного ступеня функціональними й органічними порушеннями в кардіореспіраторній системі, зокрема: рестриктивна вентиляційна недостатність, часті бронхіти та пневмонії, симптоми компресії серця, зменшення толерантності до фізичних навантажень, відставання в масі тіла тощо [5,[9][10][11]13,18,21]. Крім вказаних порушень, у таких хворих відзначаються часті психологічні проблеми, аж до суїцидальних нахилів, зниження самооцінки, порушення соціальної адаптації та відносин із протилежною статтю [9,18,21]. ...
... Після описання оригінальної методики Nuss продовжується її удосконалення різноманітними модифікаціями [2,7,8,11,17,19,21,23], які дають змогу уникати значної кількості ускладнень. На цей час у практику вже введені певні вдосконалення (використання двох пластин і мостових конструкцій під час операції [17], різноманітні способи фіксації пластини, елевація грудини різними підйомними пристроями та вакуумним дзвоном під час операції [4,5,14,20,22]; використання як стальних пластини, так і виготовлених зі сплавів титану; стабілізаторів -із матеріалів, що біодеградуються [19]; парціальна клиноподібна стернотомія тощо [11]. Кожна з описаних методик має певні переваги й недоліки. ...
Article
Лійкоподібна деформація грудної клітки (ЛДГК) – найчастіша вада розвитку передньої грудної стінки, що в багатьох випадках призводить до кардіореспіраторних порушень і психологічних проблем. Незаперечним прогресом в її лікуванні є операція Nuss, яка вважається «золотим стандартом». Водночас таке операційне втручання та його модифікації несуть потенційні ризики тяжких післяопераційних та інтраопераційних ускладнень. Мета – проаналізувати існуючі варіанти операції Nuss, розробити власну модифікацію такого хірургічного втручання для нівелювання інтраопераційних ризиків, зниження рівня післяопераційних ускладнень, мінімізації післяопераційного больового синдрому. Матеріали та методи. Авторами у 2018–2019 рр. прооперовано 34 пацієнтів із ЛДГК (виконано операцію Nuss у власній модифікації) із ІІ та ІІІ ступенями деформації. Проаналізовано післяопераційні ускладнення, рівень післяопераційного больового синдрому за шкалою NRSP до 3 місяців після операції; тривалість втручань, об’єм інтраопераційної кровотечі. Особливостями запропонованої модифікації операції є: 1) використання монолітної Т-подібної титанової пластини зі знімним стабілізатором; 2) формування тунелю суворо під м’язами; 3) жорстка підокісна фіксація стабілізаторів пластини до двох ребер із кожного боку; 4) використання пластин різної ширини для різних вікових категорій; 5) як пристрій для поетапного дозованого інтраопераційного підйому грудини застосовується талреп; 6) робочий порт вводиться через правий основний доступ і правий субпекторальний тунель; 7) корекція асиметричних форм деформації проводиться за рахунок асиметричної жорсткої фіксації стабілізаторів і тракції грудини кількома лігатурами. Результати. Запропонована модифікація операції Nuss зменшує інтра- та післяопераційні ризики: зареєстровано одне післяопераційне ускладнення (2,9%), спосіб фіксації пластини дає змогу уникнути ризиків прорізування, зміщення та розвороту пластини (не зареєстровано жодного випадку), значно зменшує післяопераційний больовий синдром і запобігає його хронізації. У всіх випадках корекції асиметричних форм деформації досягнуто позитивних естетичних результатів зі імплантацією однієї фіксуючої пластини. Висновки. Поетапна тракція грудини до положення помірної гіперкорекції нівелює ризик маніпуляцій у загрудинному просторі; субокісна фіксація пластини до двох ребер із кожного боку гарантує надійну фіксацію пластини без ризику її зміщення та розвороту. Менші товщина та ширина пластини; фіксація її як арочної конструкції зменшують травмування міжреберних судинно-нервових пучків та ребер і знижують ступінь післяопераційного болю. Ввведення робочого порту через точку виходу пластини з правої плевральної порожнини полегшує та убезпечує маніпуляції в межистінні за умови достатньої елевації грудини. За використання запропонованої модифікації в більшості випадків достатньо встановити одну коригувальну пластину. Дослідження виконано відповідно до принципів Гельсінської декларації. Протокол дослідження ухвалено Локальним етичним комітетом зазначеної в роботі установи. На проведення досліджень отримано інформовану згоду батьків дітей. Автори заявляють про відсутність конфлікту інтересів.
... Initial results using this method proved to be promising (19)(20)(21). Information on such new therapeutic modalities circulates not only among surgeons and paediatricians, but also rapidly among patients. In particular patients, who refused operative treatment by previously available procedures, now appear at the outpatient clinic and request to be considered for this method. ...
... According to the user instructions and our experience, the VB should be used for a minimum of 30 minutes, twice per day, and may be used up to a maximum of several hours daily (18,20,21). ...
... Additionally, patients' concerns about imperfect results after surgery have to be noticed. Contraindications of the method comprise skeletal disorders, vasculopathies, coagulopathies and cardiac disorders (18,20,21). To exclude these disorders, a standardised evaluation protocol was routinely performed before beginning the therapy. ...
Article
Background: Previously used procedures to correct pectus excavatum (PE) were largely based on surgical techniques like Ravitch procedure or the minimally invasive Nuss technique. Conservative treatment with the vacuum bell (VB) to elevate the funnel in patients with PE, represents a potential alternative to surgery in selected patients. Methods: A suction cup is used to create a vacuum at the anterior chest wall. Three different sizes as well as a model fitted for young women of VB exist which are selected according to the individual patients age. A patient-activated hand pump is used to create a vacuum at the anterior chest wall. When creating the vacuum, the lift of the sternum is obvious and remains for a different time period. The device should be used for a minimum of 30 minutes (2/day), and may be used up to a maximum of several hours daily. We have an IRB approval for it. Since this paper was conducted as a retrospective study, we did not have to have informed consent of every patient. Results: CT-scans showed that the device lifted the sternum and ribs immediately. In addition, this was confirmed thoracoscopically during the MIRPE procedure. Preliminary results published within the last 10 years proved to be successful. Conclusions: The VB has been established as an alternative therapeutic option in selected patients suffering from PE. The initial results proved to be dramatic, but long-term results comprising more than 15 years are so far lacking, and further evaluation and follow-up studies are necessary.
... While different treatment techniques have been described in the past, minimally invasive repair of pectus excavatum (MIRPE) developed by Dr. D. Nuss in 1987 and subsequently presented at the American Pediatric Surgery Association Congress in 1997, presently reflects the standard therapy for PE [9,10]. In mild to moderate cases and/or in patients reluctant to operative therapy, vacuum bell (VB) therapy reflects an alternative treatment option to surgery [8,[11][12][13][14]. VB therapy consists of a suction cup, attached to the anterior chest, covering the depression of the sternum. ...
... Suggested application time of vacuum bell ranges from 30 min twice per day up to several hours daily with a recommended 12-15-month treatment course. Contraindications to VB therapy consist of skeletal disorders such as osteogenesis imperfecta and Glisson's disease, vasculopathies, coagulopathies and some cardiac disorders [12]. Side effects of VB therapy comprise subcutaneous hematoma, petechial bleeding, dorsalgia, and momentary paresthesia of the arms during application [14]. ...
... While the effect of preoperative VB treatment was not quantified in the present study, all patients in the VB group discontinued VB therapy due to lack of treatment effect. Median duration of VB therapy was 17 months in the present study, exceeding the recommended 12-15-month course of treatment by Haecker and Mayr [12]. This might be explained due to the absent treatment effect and therefore prolonged therapy. ...
Article
Full-text available
Purpose It is unknown if failed preoperative vacuum bell (VB) treatment in patients undergoing minimally invasive repair of pectus excavatum (MIRPE), delays repair and/or affects postoperative outcomes. Methods A retrospective data analysis including all consecutive patients treated at one single institution undergoing MIRPE was performed between 2000 and 2016. Patients were stratified into preoperative VB therapy versus no previous VB therapy. Results In total, 127 patients were included. Twenty-seven (21.3%) patients had preoperative VB treatment for 17 months (median, IQR 8–34). All 27 patients stopped VB treatment due to the lack of treatment effect. Eight (47.1%) of 17 assessed VB patients showed signs of skin irritation or hematoma. VB treatment had no effect on length of hospital stay ( p = 0.385), postoperative complications ( p = 1.0), bar dislocations ( p = 1.0), and duration of bar treatment ( p = 0.174). Time spent in intensive care unit was shorter in patients with VB therapy ( p = 0.007). Long-term perception of treatment including rating of primary operation ( p = 0.113), pain during primary operation ( p = 0.838), own perspective of look of chest ( p = 0.545), satisfaction with the procedure ( p = 0.409), and intention of doing surgery again ( p = 1.0) were not different between groups. Conclusions Failed preoperative VB therapy had no or minimal effect on short-term outcomes and long-term perceptions following MIRPE.
... Previous studies have shown how the VB elevates the sternum [1,2], and demonstrated short-term efficacy of the VB [2-5]. As previously described, the patient creates a differential negative pressure inside the VB using a hand pump and thereby elevates the sternum [3][4][5]. So far, no tool has been available to measure the effect of the VB during its application in the patient, i.e. the degree of elevation of the sternum and the related pressure inside the VB. ...
... Details concerning the application of the VB by the patient himself are described previously [3][4][5]. ...
... The VB for elevating the depressed sternum is an old concept, and was first described by Lange in 1910 [8]. Since 2003, several studies have been conducted showing how the VB interact with the anterior chest wall [1][2][3][4][5], but none of them provided objective and measurable assessment regarding the effectiveness of the VB on the position of the sternum. To the best of our knowledge, this is the first report of objective assessment of the effect of VB. ...
Article
Background: The vacuum bell (VB) is a valid and the only non-invasive treatment for pectus excavatum (PE). To elevate the sternum the patient himself creates a differential negative pressure inside the VB using a hand pump. A distance and differential pressure measuring device (DPMD) enables us for the first time to assess objectively those parameters. Methods: After approval by the institutional review board, 53 patients recruited from our outpatient clinic were included in this retrospective study and distributed into three groups (group 1 aged 6 to 10years; group 2 aged 11 to 15years; group 3 aged 16 to 20years). Sternum elevation and differential negative pressure inside the VB compared to atmospheric pressure were assessed with the DPMD, a device developed by engineers at the University of Applied Sciences, Northwestern Switzerland. Pressure-elevation curves were recorded during VB therapy. For statistical comparison of the groups, analysis of variance was used. Post-hoc analysis was performed using the Tukey-Kramer test. A p-value of less than 0.05 was considered to be statistically significant. Results: The VB therapy was monitored in 53 children (39 males, 14 females) aged from 6 to 20years (average, 14years). Relationships were established between the differential negative pressure inside the vacuum bell, the elevation of the sternum, and the patient's age. The younger the patient, the lower is the differential negative pressure difference required to obtain a complete elevation of the sternum. Patient's age, weight, the pectus depth, the differential negative pressure inside the VB, and the elevation of the sternum were correlated. When comparing the depth 25 of the pectus excavatum to the patient's age, a statistically significant difference was verified between the groups 3 and 1 (p=0.0291) and 3 and 2 (p=0.0489). The older the patient, the deeper is the pectus excavatum. However, no statistically significant difference between the groups was found when comparing the sternum elevation to the patient's age (p=0.4574) and the elevation to pressure ratio to the patient's age (p=0.8048). The sternum elevation and the elevation to pressure ratio are independent of the patient's age. Conclusions: DPMD supplies objective data of the elevation of the sternum and the related pressure inside the VB during its application. Correlation between the patient's age, the elevation of the sternum and the pressure inside the VB were demonstrated, but additional data are needed to better understand their relationship and their impact in the treatment of PE by VB. Study type: Diagnostic Study. Level of evidence: IV.
... Initial results from pilot studies describing the use of VB therapy in PE patients were published 10 years ago and proved to be promising (17,18). CT-scans showed that the device was able to lift the sternum and ribs immediately (17). ...
... According to the instructions and our experience, the VB should be used at home for a minimum of 30 minutes, twice a day during 4-6 weeks. Afterwards, the application may be used up to a maximum of several hours daily (16,(18)(19)(20)(21)(22). The immediate elevation of sternum and ribs during application of the VB was demonstrated through a study by Schier and Bahr (17). ...
... We believe that VB therapy is indicated in patients who present with mild PE and/or wish to avoid surgical procedure. Contraindications to VB include musculoskeletal disorders, vasculopathies, coagulopathies and cardiac disorders (16,(18)(19)(20)(21)(22)24). To exclude these disorders, a standardized evaluation protocol is routinely performed before beginning the therapy. ...
Article
Background: For specific therapy to correct pectus excavatum (PE), conservative treatment with the vacuum bell (VB) was introduced more than 10 years ago in addition to surgical repair. Preliminary results using the VB were encouraging. We report on our 13-year experience with the VB treatment including the intraoperative use during the Nuss procedure and present some technical innovations. Methods: A VB with a patient-activated hand pump is used to create a vacuum at the anterior chest wall. Three different sizes of vacuum bells, as well as a model fitted for young women, exist. The appropriate size is selected according to the individual patient’s age and ventral surface. The device should be used at home for a minimum of 30 minutes (twice a day), and may be used up to a maximum of several hours daily. The intensity of the applied negative pressure can be evaluated with an integrated pressure gauge during follow-up visits. A prototype of an electronic model enables us to measure the correlation between the applied negative pressure and the elevation of the anterior chest wall. Results: Since 2003, approx. 450 patients between 2 to 61 years of age started the VB therapy. Age and gender specific differences, depth of PE, symmetry or asymmetry, and concomitant malformations such as scoliosis and/or kyphosis influence the clinical course and success of VB therapy. According to our experience, we see three different groups of patients. Immediate elevation of the sternum was confirmed thoracoscopically during the Nuss procedure in every patient. Conclusions: The VB therapy has been established as an alternative therapeutic option in selected patients suffering from PE. The initial results up to now are encouraging, but long-term results comprising more than 15 years are so far lacking, and further evaluation and follow-up studies are necessary.
... Inspired by Klobe's device, a number of alternatives have been proposed even tailored on the specific anatomy of a patient [6]. These devices achieve the elevation of the sternum by generating a negative pressure within them; the short-term effects of this type of treatment have already been proved as promising [7,8] especially when a precise medical guideline is followed by the patient. ...
... Klobe, in the vacuum bell manual user, recommends patients to operate the device twice a day for 30 min for the first 4-6 weeks; later, the period of daily application of the VB can be varied according to the patient's outcomes at the discretion of the physician. Haecker et al. in [7,8] carried out the measurement of the PE depth before and after the use of the VB by positioning the patient in a standardized supine position and by providing the depth using a designed scaled rod. Consequently, no real-time measurement during the treatment was encompassed. ...
Chapter
Full-text available
The introduction of the vacuum bell (VB) for the conservative treatment of Pectus Excavatum (PE) has led to a new non-invasive alternative to thoracic surgery. The VB works by elevating the chest as long as a negative differential pressure is internally assured. In recent years studies have been conducted to validate this type of treatment and to outline its correct use; results show a short-term PE improvement when the device is worn for a minimum of 30 min (twice a day) up to a maximum of several hours a day for 12–15 months. Although the worldwide diffusion of VB devices increases year after year, its ability to lift the chest during treatment with respect to the applied pressure has begun to be evaluated only recently. In this paper, a new instrument for measuring chest elevation during treatment is presented and validated. The proposed system consists of two measurement devices: a commercial instrument for the detection of the negative pressure inside the VB, and a specifically developed optical system for the detection of chest movement. The effectiveness of the proposed system, tested on five paediatric patients, paves the way to the objective definition of an optimised patient specific VB scheme of use.
... Il s'agit de la cloche à aspiration, une technique remise au goût du jour en 2002 par Eckart Klobe de Mannheim en Allemagne. La récente publication des premières expériences réalisées avec ce matériel [5,6] a suscité un gros enthousiasme de la part des patients concernés. Nous appliquons chez nous la méthode depuis environ onze ans. ...
... Le traitement conservateur par cloche à aspiration éveille ainsi un intérêt croissant notamment chez les patients à l'origine plutôt opposés à une intervention pour des raisons diverses ou chez ceux qui ne semblent pas de bons candidats à une correction chirurgicale en raison d'une malformation trop peu marquée. Même si on ne dispose pour l'heure encore d'aucune d onnée à long terme interprétable (≥10 ans de follow-up), les résultats de la présente étude sont encourageants et très prometteurs [6,7]. Nombre des patients qui se présentent à notre consultation pour une évaluation de PE n'ont pas forcément besoin d'une correction chirurgicale. ...
... The vacuum bell recently appeared as an alternative to surgical correction in selected patients with PE [9]. Patients undergoing this non-surgical treatment require close follow-up every 3-6 months to assess the proper usage of the device and to evaluate the decrease of the PE depth [3,10,11]. ...
... It could be used during the follow-up of young children with moderate deformities who do not need treatment, to evaluate the evolution of PE throughout the growing period. Moreover, it appears especially useful during the follow-up of patients treated with the vacuum bell, because it contributes to assessing the results of treatment and helps to provide personalized indications regarding the frequency of vacuum bell applications [9][10][11][25][26][27][28]. ...
Objectives: The OrtenBodyOne scanner is a radiation-free, 3-dimensional imaging system recently developed for evaluation of the severity of pectus excavatum (PE). The goal of this study was to evaluate the utility of this new imaging system compared with that of computed tomography (CT) for the evaluation of the severity of PE. Methods: Patients treated for PE from April 2015 to January 2017 with available CT and OrtenBodyOne data were included. Correlations between indexes calculated from CT and from OrtenBodyOne were determined by applying the non-parametric Spearman correlation procedure with a Bonferroni correction to adjust for multiple comparisons. Results: Forty men (90.9%) and 4 women (9.1%), 20 with symmetrical (45.5%) and 24 with asymmetrical PE (54.5%), were included. The median age was 16.1 years (range 4.3-63.5 years). The following measures and indexes acquired using OrtenBodyOne and CT were significantly correlated: pectus depth (r = 0.84; P = 0.002), anthropometric index (r = 0.81; P = 0.002) and asymmetry index (r = 0.67; P = 0.002). The correlation between the CT Haller index and the external Haller index was only significant for symmetrical PE (r = 0.57; P = 0.008). Conclusions: The OrtenBodyOne imaging system can be used to evaluate the severity of symmetrical PE using the external Haller index. Asymmetry and anthropometric indexes are more reliable for the evaluation of asymmetrical PE. Measures can be repeated throughout treatment while avoiding unnecessary irradiation.
... A strategy to assess the immediate effects of the PEcorrection on heart function in a non-invasive way is by applying the vacuum bell (VB), which is a CMR-safe, silicon device, designed to correct the deformity with immediate effect (19) (Figure 1). The VB was originally developed for the conservative treatment of PE; however, long term outcomes have suggested that it was not a reliable treatment option for all patients, particularly in the adult population (19)(20)(21)(22)(23). Nonetheless, the device can be successfully used during the minimally invasive repair of pectus excavatum (MIRPE) to elevate the sternum, facilitating bar introduction and reducing intraoperative risk of heart injury (24,25). ...
... Regional health system criteria for reimbursement of surgical correction of PE included: age <40 years; presence of psychological impairment; a Haller index (HI) ≥3.5 as verified on computed tomography (8,26). Patients were excluded if they suffered from claustrophobia or had other clinical contraindications to undergoing CMRI or VB application, including: osteogenesis imperfecta, Glisson's disease, Marfan syndrome, and coagulopathies (23). A healthy control group, matched for age and body surface area (BSA), was included. ...
Article
Full-text available
Background: Evidence of cardiac dysfunction in patients with pectus excavatum (PE) remains controversial. A growing number of studies report increased exercise tolerance following surgery. Nevertheless, many consider the correction of PE a cosmetic intervention, with post-operative changes ascribed to the concurrent growth of the young patient population. No studies have investigated non-invasively the immediate cardiac changes following relief of the deformity. The aim of this study was to assess cardiac function before and during temporary sternal elevation using the non-invasive vacuum bell (VB) device on young adults with PE. Methods: Adult patients scheduled for surgical correction of PE underwent cardiac magnetic resonance imaging (CMRI) before and during the application of the VB. Steady-state free precession sequences were used for the evaluation of biventricular volume and function. Phase contrast sequences measured the aortic and pulmonary flow to calculate stroke index (SI). Scans were analyzed post hoc by the same investigator. A control group of healthy individuals was assessed in the same way. Results: In total, 20 patients with PE (mean age 23±10 years) and 10 healthy individuals (mean age 25±6 years) underwent CMR before and during VB application. Before intervention, baseline cardiac volumes and function were similar between the groups, with patient-values in the low-to-normal range. Following VB application, PE patients revealed a 10% increase in biventricular SI. Furthermore, left ventricular end-diastolic volume index (LV EDVI) improved by 8% and right ventricular ejection fraction (RV EF) increased by 7%. These findings were not mirrored in the healthy individuals. No correlations were found between improved cardiac parameters and the baseline Haller index (HI) of PE patients. Conclusions: Non-invasive, momentary correction of PE is associated with an immediate improvement in SI, RV EF and LV EDVI, not observed in controls. The findings suggest that sternal depression in PE patients affects cardiac function.
... Aktuell wurde diese Behandlungsmethode wieder im Jahr 2002 von Herrn Eckart Klobe aus Mannheim, Deutschland, aufgegriffen. Die Publikation erster Erfahrungen in der jüngeren Vergangenheit [5,6] ist bei den betroffenen Patienten auf grosses Interesse gestossen. Die Methode wird bei uns seit circa elf Jahren angewandt. ...
... VB was developed by E. Klobe, an engineer who was himself suffering from PE, and consists of a bowl shaped device (to place upon deepest point of PE) and a hand pump capable of producing a negative pressure that lifts the sternum upwards, lessening the severity of the deformity [10]. The body is made of a silicone ring and a transparent polycarbonate window (for inspection). ...
Article
Full-text available
Pectus Excavatum, one of the most frequent chest wall deformities, is characterized by a depression of the sternum and costal cartilages. Patients with mild deformities are generally treated conservatively by using the so called Vacuum Bell (VB) i.e. a suction cup to be placed on the patient's sternal region. Three different sizes, as well as a model fitted for young women, of VB are available on the market. Unfortunately, the variability of the surface to be treated, the possible asymmetry of the caved-in area and the prolonged use, can make the device uncomfortable and, in some cases, ineffective for the patient. In order to cope with these issues, the present paper proposes a computer-aided method for customized vacuum bell design to be used by non-expert user, e.g. by medical staff. In particular, the present work entails the development of a system comprising: 1) a dedicated software capable of acquiring the 3D chest geometry - by using a low-cost range sensor, i.e. Kinect v2 - and of processing the point cloud so to generate NURBS surfaces of the chest; 2) a procedural CAD modeling of a personalized VB implemented within Siemens NX 11 CAD environment. Using the devised method, the medical staff is required only to use the 3D scanning system for acquiring the patient chest and to sketch, in a CAD-based interface, the boundary of the area to be treated. Once these tasks are performed, the system automatically builds the personalized VB model, ready to be manufactured.
... Neuere Untersuchungen zeigen allerdings, dass rund zwei Drittel der Erkrankungen bereits bei der Geburt und ein Drittel im ersten Lebensjahr entdeckt werden (vgl. Haecker & Mayr, 2006;Suita, Taguchi, Masumoto, Kubota & Kamimura, 2001). Die Deformität zeigt sich durch eine Hemmungsfehlbildung des Brustbeins, die durch die nach innen weisende Knickbildung des corpus sterni und angrenzender Rippenknorpel sowie die Einziehung der Brustoberfläche in Form eines Trichters entsteht (vgl. ...
Article
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In vorliegender Untersuchung sollten einerseits die von Wallisch (2004, Wallisch & Egger 2004) berichteten Ergebnisse zu Veränderungen von Körperbild, Selbstkonzept und psychischer Belastung bei Trichterbrustpatienten in Zusammenhang mit einer minimal invasiven Operationsmethode nach Nuss (MIRPE) überprüft und andererseits anhand einer Teilstich probe der längsschnittliche Verlauf betrachtet werden. Als Erweiterung sind auch die mittels strukturierter Interviews gewonnenen Fremdeinschätzungen erziehungsberechtigter Bezugspersonen zu werten. 17 Patienten (13 männliche, 4 weibliche) der Univ.-Klinik für Kinderchirurgie Graz, die 2003 vor der OP getestet wurden, füllten rund 4 Jahre nach der Operation erneut den Operations- Erwartungs-Fragebogen (OPE-FB, Wallisch), die Frankfurter Körperkonzeptskalen (FKKS, Deusinger) sowie die Symptom Checklist Revised (SCL-90-R, Derogatis) aus. Das Durchschnittsalter lag bei 19.6 Jahren (SD = 2.5). Die Patienten wurden in 2 Ausprägungsgraden der Trichterbrust unterteilt, wodurch 10 als „geringgradig“ (1) und 7 als „hochgradig“ (2) einzustufen waren. 17 strukturierte Interviews auf Basis des OPE-FB wurden mit Angehörigen durchgeführt. Mittels U-Test von Mann und Whitney sowie Wilcoxon-Test wurden Veränderungen über die Messzeitpunkte überprüft. Nahezu alle präoperativen Erwartungen stimmten mit den postoperativen Einschätzungen überein: Es konnte eine Verbesserung der Selbstsicherheit sowie eine Verschlechterung im allgemeinen Sportinteresse für Schweregradgruppe 1 ebenso nachgewiesen werden wie ein verbessertes körperliches Wohlbefinden, eine verbesserte Selbstakzeptanz und Akzeptanz des Körpers durch andere. Die Werte der SCL-90-R lagen für beide Gruppen im Normbereich, eine psycho-pathologische Auffälligkeit ist auf Gruppenebene nicht feststellbar. Die Einschätzung der Bezugspersonen zum benefit der Operation bestätigte die Patientenangaben. Obwohl die Pat. nur selten eine psychologische Unterstützung in der prä- wie postoperativen Phase wünschten, finden dies deren Eltern überwiegend sinnvoll. – Insgesamt kann die an der Kinderchirurgie Graz etablierte OP-Technik für Trichterbrust-Patienten sowohl aus chirurgischer als auch psycho-sozialer Sicht als sehr effizient interpretiert werden. Schlüsselwörter Pectus excavatum, Trichterbrust, minimal-invasive Operationsmethode nach Nuss, Selbstkonzept, Körperbild, psychische Belastung. Abstract The purpose of this study was to replicate the results of Wallisch (2004, Wallisch & Egger 2004) concerning changes of body-image, self-concept and mental exposure in patients with pectus excavatum (PE), who had undergone the minimal invasive repair by Nuss (MIRPE) at the Medical University Graz, Department of Pediatric Surgery. This time all aspects should be tested in a longitudinal design. Additionally a structured interview was assessed with a patient’s parent person. 17 patients (13 male, 4 female), who were preoperatively tested 2003, answered to (a) the survey OPE-FB (operation-expectations- questionnaire, Wallisch) for years later again, (b) FKKS (the Frankfurter Body-Concept Scales, Deusinger) and (c) SCL-90-R (Symptom Checklist Revised, Derogatis). The mean age of the pts was 19.6 years (SD = 2.5). All pts were classified in 2 groups based on the severity index of PE. There were 10 patients with a low severity index and 7 with a high one. Parents or a parent person were interviewed about the topics of OPE-FB by a structured interview. Data were analyzed using the Mann-Whitney-U-Test and Wilcoxon-Test. Nearly all expectations concerning the benefit of the surgical PE intervention could be confirmed postoperatively. Patients with severity index 1 showed a small loss in “general interest in sports” but improvements in self-assurance, health perception, self acceptance of one’s body and acceptance of one’s body by others. Data from SCL-90-R showed a normal range, on group level no psycho-pathological signs could be detected. Furthermore the interviews with the relatives affirm the overall good results concerning the pts benefit of MIRPE. Parents significantly more than the pts themselves wish psychological support pre and post intervention. Key words Pectus excavatum, minimal-invasive repair, Nuss-procedure, selfconcept, body image.
... Vacuum bell therapy for pectus excavatum (PE) has garnered increasing attention since it was initially introduced by Klobe et al. in 2005 [1]. Its early use was also extensively described by Haecker et al. [4] The treatment provides a conservative option for patients who do not meet surgical criteria or who choose not to undergo surgery. The vacuum bell has also been shown to play a perioperative role [5]. ...
Article
Purpose Conservative treatment of pectus excavatum with a vacuum bell device may be an attractive alternative to surgical repair. We describe an early North American experience with this device. Methods Prospectively maintained chest wall clinic registries from two institutions were reviewed to identify pectus excavatum patients ≤ 21 years treated with the vacuum bell from 2013 to 2017. Multivariate linear regression was used to compare mean improvements in deformity-depth and Haller Index between groups of patients based on age and usage metrics (hours/day and days/week). Results Thirty-one patients with a median age of 14 years received treatment with the device. Mean follow-up duration was 18 months. Median depth and Haller Index at treatment onset were 2.3 cm and 3.9, respectively. Improvements in deformity-depth were superior with device usage > 2 h/day (p < 0.01) and daily use (p < 0.01). After adjusting for compliance, younger age of treatment onset was associated with greater improvement in Haller Index but not deformity depth. Conclusion Our prospective early North American experience found the vacuum bell to be a potential alternative to surgical treatment for pectus excavatum. Longer usage periods in a daily frequency are associated with best results. Type of study Treatment study; case series with no comparison group. Level of evidence Level IV.
... Interestingly, Klobe developed the vacuum bell -a suction cup with a patient-activated hand pump used to create a vacuum at the anterior chest wall -and his company sells medical devices for the non-surgical correction of P.E. which often require parents to monitor that shadows use them systematically and efficaciously through time (Haecker, Mayr, 2006;Haecker, Sesia, 2016). Yet even among the conservative treatments, such as physical therapies and exercises to strengthen the chest muscles, what parents often aggrandise is White's (1997) third assumption of emancipation narratives, which rather than focusing on aspects of the youth's lives that contradict their most traumatic experiences, ends up universalising repressed human needs and seeks out solutions to assumed problems. ...
Thesis
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In his dissertation, Ticchi specifically focuses on the life stories of shadows - youths with a chest wall deformity (pectus excavatum, carinatum, etc.). Especially he focused on the congenital condition pectus excavatum, which is the most typical deformity of the upper body. The deformity causes shame and could evoke suffering, ridicule, and depression. ‘In fact, as a consequence of the societal and virtual preference for sexually objectified bodies with bare, muscular torsos, the social and self-stigma of living with a congenital anomaly of the chest wall plays an important role,’ Ticchi says. According to Ticchi, the youths and their families are often in a situation where they are unable to get professional help and where they lack knowledge about both the surgical and the psychosocial treatment options. Nowadays, most chest wall deformities can be surgically treated. However, Ticchi’s dissertation suggests that clinical social work practice with a narrative therapy approach could be used as a liberating and supportive method to surgical treatment. Telling stories would help youths with the deformity to better understand the problems associated with their body image and to learn to live with it. Ticchi says that the purpose of his dissertation is to find out how the narrative therapy approach in the treatment of physical anomalies could offer psychosocial support in a society that glorifies body perfection. ‘Trained clinical social workers could use accordingly their scientific knowledge and skills to support families to face the crises when a yes-or-no question about surgical repair significantly interferes with their optimal decision-making due to the family’s distress, in a continued emphasis on shadows being seen as diagnostic categories upon which a treatment plan is executed for the remediation of the problem,’ Ticchi finds. In addition, thanks to trained clinical social workers, the families would be more informed about the causes, nature, cost, treatment, and results of chest wall deformities. By using a narrative therapy approach, Ticchi’s dissertation opened a new focus for social work, which is more oriented to problems than disciplines, and which advocates the interdisciplinarity of thoracic surgery with clinical social work practice. In his dissertation, Ticchi uses data collected from both literature and different parties of the interviews (shadows themselves, their families, and so on). The public defence of 'Slender shadows of youths: A narrative therapy approach to explore life stories about social and self-stigma of chest wall deformities for clinical social work practice', the dissertation of Davide Ticchi, doctoral student of the School of Governance, Law, and Society of the Tallinn University, took place on Monday, 2 September. The supervisor of the doctoral dissertation is Merike Sisask, Professor of Social Health Care at Tallinn University. Opponents are Professor Diana DiNitto (University of Texas at Austin) and Meyer Children's Hospital Professor Antonio Messineo (University of Florence). The doctoral thesis is available in Tallinn University Digital Library: https://www.etera.ee/s/2QrzDhxdMo
... The most common chest wall malformation and one of the most frequent major congenital anomalies is pectum excavatum (PE) [1]. PE is characterised by variable depression of the sternum and lower costal cartilages. ...
... 19 In particular, the severity of the anomaly (in case of pectus excavatum evaluated with the Haller index and pectus correction index), 20,21 the presence of symptoms, and psychological discomfort were the indications for surgery. Younger patients, presenting without stiff thorax, were offered in the last 1 or 2 years a conservative treatment, based on a vacuum bell for pectus excavatum 22 and A dynamic compression system for pectus carinatum. 23 We have summarized the innovations and lessons learned in these years of experience. ...
Article
Background: Poland syndrome is a congenital deformity characterized by unilateral anomalies of pectoralis muscles, breast, nipple, axillary fold, subcutaneous tissue, ribs, and upper limb. The thoracic anomaly, which is the pathognomonic malformation of Poland syndrome, presents a wide phenotype variability and has been classified by different authors. However, these classifications do not include all the possible phenotypes of Poland syndrome. The aim of this study is to propose a simple classification of the whole spectrum of thoracic anomalies and a treatment algorithm that could have a practical value for determining the surgical approach. Methods: Since 2008, 100 patients have been evaluated by the same plastic surgical team at San Martino Hospital-IST and Istituto Gaslini of Genoa, Italy, using the thorax, breast, nipple-areola complex (TBN) classification. Thoracic anomalies were classified as follows: thorax (T), from T1 (muscle defect only) to T4 (complex deformity with rib and sternal involvement); breast (B), in B1 (hypoplasia) or B2 (amastia); and nipple-areola complex (N), from N1 (dislocation <2 cm) to N3 (athelia). Results: The most frequent thoracic anomalies were T1 (47 percent) and N2 (74 percent), whereas in female patients, B1 was more frequent than B2. The surgical approach to breast and pectoral reconstruction was based not only on the patient's age and sex, but also on the type of anomaly according to the TBN classification. In particular, a two-step approach with tissue expanders was required in N2 and N3 cases, whereas in N1 patients a single step was sufficient. Conclusion: The TBN classification can be a useful tool for surgical decision-making according to each specific thoracic anomaly. Clinical question/level of evidence: Diagnostic, IV.
... In prepubertal patients, an attractive option could be the noninvasive treatment with vacuum bell (VB). This device is used as an alternative to surgery for repairing pectus excavatum deformity in young patients, based on the elasticity of the rib cage [9]. VB has been demonstrated to have beneficial effects raising the anterior chest wall in pectus excavatum patients [10,11]. ...
Article
Background/Purpose Many studies on ex-preterm babies were conducted to evaluate their respiratory sequelae, but, to our knowledge, the condition described in this paper was never reported before and is not included in the classifications of thoracic anomalies proposed so far. Methods Clinical data and images of a novel thoracic deformity observed in the last 10 years are shown. This anomaly is characterized by an indentation of the ribs on both (less frequently one) anterolateral parts of the chest wall. All our patients with this condition were ex-preterm babies. We named this novel thoracic anomaly as “post prematurity thoracic dysplasia” (PPTD). Possible etiopathogenetic mechanisms and treatment options are discussed. Results We observed 8 patients with variable range of respiratory symptoms. In 2 cases the malformation caused a severe functional restriction of lung volumes and surgery was performed to improve respiratory symptoms; in other cases the symptoms were mild or absent and the malformation was a matter of concern only for cosmesis. Conclusions PPTD is a novel thoracic anomaly typical of ex-preterms. Clinical relevance is variable. In severe cases surgery can be considered. Level of evidence IV.
... Interestingly, an engineer who suffered from PE himself successfully treated his PE with a homemade modified vacuum device in 1992 [22]. Unfortunately, it was not until 2003 that a vacuum bell (VB) made of a silicone ring was widely used to treat PE patients by Haecker et al. [16]. The current effects have been inspiring. ...
Article
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Purpose: Our aim was to evaluate the effect of a vacuum bell (VB) combined with a three-dimensional (3D) scanner for the noninvasive treatment of pectus excavatum (PE). Methods: A VB was used to create a vacuum at the anterior chest wall with a patient-activated hand pump, and it should be applied regularly for more than 2 h each day at home. Eighty-two patients required to be followed up every three months were included in this retrospective study and distributed into four stages (stage 1: treated for 3 months, stage 2: treated for 6 months, stage 3: treated for 9 months, and stage 4: treated for 12 months). In addition, the deformity in the chest wall was scanned by a 3D scanner at the clinic, and the 3D depth (3D-DE) and 3D Haller index (3D-HI) of PE were calculated through Geomagic studio 2013 software. Results: Eighty-two patients (12/2017-12/2019) met the criteria at the clinic, and 24 patients (29.3%) achieved excellent correction (3D-DE ≤ 3 mm). When comparing the improvement in 3D-DE and 3D-HI of PE to the patient's treatment time, a statistically significant difference was observed between stages 2 and 1 (3D-DE p < 0.01, 3D-HI p < 0.01), stages 3 and 2 (3D-DE p < 0.01, 3D-HI p < 0.01) and stages 4 and 3 (3D-DE p < 0.01, 3D-HI p < 0.01). There was a statistically significant difference in sternum elevation between patients aged < 10 years and those aged ≥ 10 years (3D-DE p = 0.006, 3D-HI p = 0.045) and patients with symmetrical and asymmetric PE (3D-DE p = 0.042, 3D-HI p = 0.032). However, there was no statistically significant difference in sternal elevation between males and females (3D-DE p = 0.27, 3D-HI p = 0.495). The main side effects were moderate subcutaneous hematoma, petechial bleeding, thoracalgia and chest tightness. Conclusions: With controllable side effects, noninvasive treatment for PE with a VB combined with a 3D scanner is safe, objective and radiation free, and the initial results to date are encouraging. Patients aged < 10 years, with symmetrical PE and treated for over 12 months may achieve a better outcome.
... Pectus excavatum (PE) is one of the most common congenital abnormalities of the chest wall [1]. It occurs with an incidence of 1:800 with men being affected three times more often than women [2,3]. ...
Article
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Pectus excavatum (PE) is one of the most common congenital deformities of the thorax and is characterized by a depressed sternum with reduction of the antero-posterior thoracic diameter. Although the majority of patients with PE have no physiologic limitations, it is often associated with psychological problems influencing the patients’ quality of life. Surgical treatment options show particular variation with regard to invasiveness and morbidity of the respective procedures. Surgical treatment using a custom-made silicone implant represents a less invasive alternative for patients without further accompanying physical symptoms. This article describes the simultaneous correction of a PE combined with tubular breast deformity using this minimally invasive technique.
... Despite the high efficiency for PE, in some cases, it is possible to effectively use a vacuum bell, which is a noninvasive treatment method (19,20). Compressive external bracing is a high profile, non-invasive PC treatment method that could succeed in growing patients (21). ...
Article
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Background: Individuals affected by chest wall deformities may search for information on these conditions on the web. Google data may reflect the global interest in health-related information. Our aim was to investigate the global trends in searches associated with the topics “Pectus excavatum” and “Pectus carinatum” using Google Trends. Methods: We retrieved the global data from 1st January 2004 to 31st October 2019. We analyzed the relative search volume (RSV) for countries or areas with a no-low search volume. We compared differences in interest between seasons using the Kruskal-Wallis test with the post-hoc test. Results: The median RSV for the pectus excavatum was equal to 58.00 (54.00–65.00) while for pectus carinatum 28.00 (23.25–31.00). The interest in pectus excavatum decreases on average by 0.98 RSV each year, while interest in pectus carinatum increased each year by 0.87 RSV. We observed the highest interest in analyzed topics during summer and the lowest during winter. The relative difference in interest between summer and winter was equal to 21.4% for pectus excavatum and 19.2% for pectus carinatum. Pectus excavatum was the most popular topic in n=51 countries or areas, while pectus carinatum in n=7 countries or areas/regions. Conclusions: Globally, interest in pectus excavatum is higher than the interest in pectus carinatum that might reflect real-world prevalence. The interest in both topics shows seasonal variation. The Internet is an essential source of information on chest wall deformities. The medical professionals should provide quality content on pectus excavatum and pectus carinatum.
... 14 There are reports on the use of a device called a vacuum bell (Eckart Klobe, Germany) that applies negative pressure to the depressed area of the PE, resulting in complete improvement in 15 to 31% of patients. 15,16 The method does not reposition the ribs efficiently or correct asymmetrical pectus. When vacuum bell was combined with a braces, additional corrective improvements were observed. ...
Article
Full-text available
Objective: Pectus excavatum is a deformity that affects aesthetics and causes emotional disorders. Surgical correction is well established, but conservative treatment is less common. We investigated the long-term results of using a brace and performing specific physical exercises to treat localized pectus excavatum, a type of deformity in which the depressed area is restricted to the midline region along the nipple line. Methods: We selected 115 patients (mean age 12.8 years), with a minimum follow-up of 36 months, who were evaluated more than one year after the end of treatment and skeletal maturity. Results were correlated with deformity flexibility, severity, regular use of the device, and performance of specific exercises. The chi-square (χ2) and the Cochran-Mantel-Haenszel tests were used for statistical analysis. Results: Treatment was successful in 58% of patients, however, when exercises were performed and the brace was used regularly by patients with flexible deformities, the rate increased to 83% (p = 0.005). Severity and adherence to treatment greatly impacted successful treatment (p = 0.009 and < 0.001, respectively). Conclusion: The proposed treatment method was effective for correction or partial correction of the deformity in motivated patients followed up until skeletal maturity, especially when started early in milder and more flexible deformities. Level of Evidence V, Expert opinion.
... To minimize the risk of critical complications, the application of a vacuum device during the Nuss procedure to elevate the sternum while performing substernal tunneling was proposed by Schier et al. [7]. Shortly thereafter, the application of VBT as an alternative, non-invasive method for correcting PE was proposed and has been extensively performed by Haecker et al. [8][9][10]. ...
Article
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.
... Tedavi süresi de yaşa göre farklılık göstermektedir. Yine Haecker'in 2011 yılında yaptığı 133 olguyu içeren çalışmasında, 105 olguda 3 ay, 18 olguda ise 18 ayın üzerinde vakum bell uygulaması ile başarı sağlandığı bildirilmektedir (11) . Çalışmamızda, ilk 6 ayda olguların %23,3'ünde ve bir yıl sonra ek olarak %43,3'ünde daha başarılı sonuç alınmıştır. ...
Article
Twenty years have passed since Nuss performed the first minimally invasive pectus excavatum repair. From April 1999, when the procedure was first introduced in Japan, to March 2009, our institute has performed the Nuss procedure on 263 patients with pectus excavatum. In this paper, we discuss three topics related to the Nuss procedure : 1) the optimal timing of the operation ; 2) its long-term results on young patients in children (5-8 years old) ; and, 3) recent surgical innovations. According to Nuss, the best results are obtained in patients between the age of 6 and 12 years. However, we conclude that the optimal age is between 5 and 10 years. This is because, with age, the flexibility of the thorax gradually decreases, and the asymmetric deformity of the thorax increases. An advanced asymmetry in deformity makes reconstruction more difficult ; and, the reduced flexibility causes severe postoperative pain. The second topic we evaluated was the long-term consequences of the Nuss procedure on patients who underwent the operation within this optimal timing by comparing such patients with the patients who were treated with the Ravitch procedure within the same age ranges. Using CT images, three parameters - Haller's CT index ; the anteroposterior thoracic diameter at the level of 4th to 10th thoracic spine ; and, flattening ratio of the heart were calculated. Statistically significant differences of CT index (Ravitch vs Nuss; 3.93±1.54to2.99±0.42 (P<0. 0001)), anteroposterior thoracic diameter of all levels and flattering ratio of the heart (Ravitch vs Nuss ; 61.0± 5.4 % to 72.7±5.9 % (P<0.0001)) were observed. These results revealed that, over a long period, the Nuss procedure gains thicker anteroposterior thoracic diameter than the Ravitch ; and, it could release compression toward the internal organs such as the heart and the lungs. Therefore, the Nuss procedure operated during the optimal timing is effective for reconstructing the deformed thoracic cage in pectus excavatum even after a long period.
Article
Funnel chest (cobbler’s chest or pectus excavatum, PE) is one of the most commonly occurring congenital malformations. It is characterized by a concave sternum, the cause of which is postulated to be abnormal growth of the chondrocostal rib cartilage. In most cases this malformation may result in a pathological posture (e.g. kyphosis or scoliosis). When the malformation in childhood usually does not restrict patients, symptoms such as impairment of physical exercise, dyspnea and cardiac problems may worsen in adolescence and affect PE patients. In addition, for many patients PE is a severe psychological problem. Vacuum therapy is a commonly used conservative treatment method. The minimally invasive Nuss method or the open surgery method of Ravitch can be successfully used for corrective surgery of PE. The standard treatment for operative correction of PE is nowadays the minimally invasive repair of pectus excavatum (MIRPE) procedure. Children under 10 years old should first be treated using vacuum suction cup therapy. The MIRPE procedure is recommended for older children who already have a rigid thoracic wall. An accompanying physical therapy is recommended for all PE patients.
Article
Introduction: Surgical treatment of pectus excavatum was revolutionized in the 90s by the introduction of the Nuss technique. Methods: We present the experience of 12 Spanish Thoracic Surgery Departments with the Nuss technique. Results: Between 2001 and 2010 a total of 149 patients were operated on (mean age 21.2 years), 74% male. Initial aesthetic results were excellent or good in 93.2%, mild in 4.1% and bad in 2.7%. After initial surgery there were complications in 45 patients (30.6%). The most frequent were wound seroma, bar displacement, stabilizer break, pneumothorax, haemothorax, wound infection, pneumonia, pericarditis and cardiac tamponade that required urgent bar removal. Postoperative pain appeared in all patients. In 3 cases (2%) it was so intense that it required bar removal. After a mean follow-up of 39.2 months, bar removal had been performed in 72 patients (49%), being difficult in 5 cases (7%). After a 1.6 year follow-up period good results persisted in 145 patients (98.7%). Conclusion: Nuss technique in adults has had good results in Spanish Thoracic Surgery Departments, however its use has not been generalized. The risk of complications must be taken into account and its indication must be properly evaluated. The possibility of previous conservative treatment is being analyzed in several departments at present.
Article
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.
Chapter
Pectus excavatum (PE) and carinatum (PC) are characterized by an abnormal overgrowth of sternal and costal cartilages, which result in a depression or protrusion of the sternum and costal cartilages, respectively. Both chest wall malformations are cosmetic and functional pathologies. Whereas PE is commonly associated to cardiopulmonary dysfunction, PC causes deformation of the entire thoracic cage. PE is generally corrected operatively. In contrast, due to inherent risks of a major surgery, only severe cases of PC are operated. One of the authors (FMH) will describe his 12 years experience with vacuum bells to treat PE patients conservatively. The use of vacuum bells allow significant lift of the ribs and sternum, until definitive correction of cartilage growth takes place. When employed during minimally invasive repair of PE (MIRPE), vacuum bells can also be used as a tool to enhance retrosternal dissection, advancement of the pectus introducer and insertion and flipping of the pectus bar/s. The other author (MMF) will describe his 13 years experience with the FMF® Dynamic Compressor System to treat patients with PC conservatively. When considering results, there should be little doubt that no patient would be selected as a candidate for surgery before trying a non-operative approach. Further evaluation and follow-up studies are still necessary for both conservative approaches, though.
Article
Objective: This preliminary qualitative study evaluates the efficacy of cup suction in the correction of pectus excavatum (PE), and examines the place of this system as a strategic treatment and as an alternative to surgery. Materials and methods: Between October 2011 and June 2014, a total of 84 patients (children and adult) presenting with PE were treated by cup suction, in our chest wall deformities unit. On first consultation, the patients with typical PE and with at least partial correction during the first application of cup suction and a maximal suction pressure for correction of less than 300mbar (millibars) were included in this study. 11 patients were excluded from the present study as they presented with a complex carinatum/excavatum. The remaining 73 patients were divided into two groups: Group I, adult patients ≥18year old, 17 patients. The mean age was 22.8years old. Group II, pediatric patients <18years old, 56 patients. The mean age was 11.5years old. Medical photographic documentation was collected systematically. In addition, the depth of PE was measured. The management protocol involved: adjustment of cup suction, strengthening exercises, and clinical follow-up every two to three months. The evaluation criteria during, and on the completion of the trial were: depth of the PE, morbidity and treatment compliance. Partial and final results were evaluated by the patients, their parents, and doctor, using a qualitative scoring scale. Results: A total of 73 patients presenting typical PE (symmetric in 52 cases and asymmetric in 21 cases) were treated by cup suction. The mean depth of PE was 23mm (9-44). Of the 73 patients, one adult abandoned treatment and three children abandoned follow-up. The mean time of use of the device was 4h daily. At six months of treatment, the mean depth of PE was 9mm (0-30) across all patients. 23 patients completed the treatment and exhibited flattening of the sternum. These patients were considered to have an excellent aesthetic result. The mean treatment duration to normal reshape was achieved at 10months (4-21). The remaining patients are improving under continuing active treatment. The mean depth of PE in this group was 12mm (4-30), after a mean treatment duration of 9months (2-22). Conclusions: Treatment using cup suction is a promising useful alternative in selected cases of symmetric and asymmetric PE, providing that the thorax is flexible. Treatment duration is directly linked to age, severity and the frequency of use. It is becoming a well-recognized therapy, which improves the self-image of those patients whose anterior chest wall is still pliable. The cup suction can be used for pediatrics and young adults waiting for a treatment, possibly surgery, however, the long-term effect of this procedure remains unclear.
Chapter
With the triumphal march of the surgical method (MIRPE) in the correction of pectus excavatum deformities, according to Donald Nuss [6] the method originally described by Ravitch in 1949 and 1958 [9, 10] was partially dislodged into the background and minor scope was left for special applications only. However the Ravitch technique is still widely used as a standard procedure in the correction of pectus carinatum deformities (Chapter 7.1) Although a recent study consisting of a systematic review and meta-analysis methodology confirmed that the complication rate in the MIRPE technique is higher than in the Ravitch technique, and the period of requirement of postoperative analgesics seems to be lower than in the MIRPE collectives, a clear difference concerning the aesthetic outcome could not be elaborated. It seems that particularly the parameters of pain and aesthetic result, being of paramount importance for the patient self, could not be studied comparatively due to too many biasing factors and lack of long-term comparability [1, 5]. Despite that the MIRPE technique offers a method requiring far shorter surgery time and represents an overall elegant method with however pleasing results lasting for many years. The elegancy and straightforward technique in experienced hands with relatively hidden scars supported its triumphal march so far, convincing patients and surgeons as well. However, these findings are predominantly true for children and adolescents, but must be regarded differentiated in adults. For the latter collective of patients no comparative data are yet available.
Article
Background/Purpose We explored determinants of success in a large cohort of patients with pectus excavatum submitted to vacuum bell treatment and compared groups with satisfactory versus unsatisfactory outcomes. Methods Retrospective case-control study in a single center between May 2013 and January 2020, including patients with pectus excavatum treated with vacuum bell. We classified patients according to their status at closure of data registry (surveillance; withdrawal; complete correction; failure) and according to Obermeyer's classification of degrees of pectus excavatum correction. Determinants of success were calculated using receiver operating characteristic curves. Results Overall, 186 patients were included. Complete correction was achieved by 17% of the cases, while 45% remained under surveillance. Failure rates were low (n=9; 5%), whereas withdrawal rates were 34%. Based on Obermeyer's classification of degree of excavation correction, 35% had excellent/good, 25% fair, and 40% poor/worse results. When comparing patients with good/excellent results with those with unsatisfactory results, patients with good/excellent results had a longer treatment duration [19.0 (13.0; 28) months vs. 13.0 (6.5; 22.5) months, p<0.0001], and lower initial pectus depth [1.6 (1.2; 2.0) cm, vs. 2.0 (1.5; 2.6) cm, p=0.001]. Using ROC curves, the best determinants of success were an initial pectus depth ≤ 1.8 cm and a length of treatment > 12 months. Conclusion One-third of patients in treatment with a vacuum bell achieved excellent or good outcomes in our cohort. Determinants of success included an initial pectus depth of 1.8 cm or less and a minimum length of treatment of 12 months. Type of study retrospective comparative study Level of evidence III
Chapter
Pectus excavatum, “funnel chest,” is the most common congenital chest wall deformity and is characterized by a depression of the sternum and the lower costal cartilages resulting in a decrease in the anteroposterior diameter of the chest.
Article
The correction of deep pectus excavatum, with the Nuss procedure, frequently require a series of maneuvers that is inherently dangerous. Herein we describe 10 technical modifications to prevent potential complications. These modified techniques have certain advantages and according to the authors, with these maneuvers the risk of pericardial sac, cardiac injury, bar displacement and complications during the removal of the bar could be markedly reduced.
Chapter
Objective Previously used procedures to correct pectus excavatum (PE) were largely based on surgical techniques like Ravitch procedure or the minimally invasive Nuss technique. Conservative treatment with the vacuum bell to elevate the funnel in patients with PE, represents a potential alternative to surgery in selected patients. Methods A suction cup is used to create a vacuum at the anterior chest wall. Three different sizes as well as a model fitted for young girls and women of vacuum bell exist which are selected according to the individual patients age. A patient-activated hand pump is used to create a vacuum at the anterior chest wall. When creating the vacuum, the lift of the sternum is obvious and remains for a different time period. The device should be used for a minimum of 30 min (2/day), and may be used up to a maximum of several hours daily. Results Computed tomographic scans showed that the device lifted the sternum and ribs immediately. In addition, this was confirmed thoracoscopically during the MIRPE procedure. Preliminary results of a subset of our patients group including 133 patients (110 males, 23 females) were recently published. They proved to be successful. Conclusion The vacuum bell has been established as an alternative therapeutic option in selected patients suffering from PE. The initial results proved to be dramatic, but long-term results comprising more than 10 years are so far lacking, and further evaluation and follow-up studies are necessary.
Article
Purpose The purpose of this study was to determine variables predictive of an excellent correction using vacuum bell therapy for nonoperative treatment of pectus excavatum. Methods A single institution, retrospective evaluation (IRB 15-01-WC-0024) of variables associated with an excellent outcome in pectus excavatum patients treated with vacuum bell therapy was performed. An excellent correction was defined as a chest wall depth equal to the mean depth of a reference group of 30 male children without pectus excavatum. Results Over 4 years (11/2012–11/2016) there were 180 patients enrolled with 115 available for analysis in the treatment group. The reference group had a mean chest wall depth of 0.51 cm. An excellent correction (depth ≤ 0.51 cm) was achieved in 23 (20%) patients. Patient characteristics predictive of an excellent outcome included initial age ≤ 11 years (OR = 3.3,p = .013), initial chest wall depth ≤ 1.5 cm (OR = 4.6,p = .003), and chest wall flexibility (OR = 14.8,p < .001). Patients that used the vacuum bell over 12 consecutive months were more likely to achieve an excellent correction (OR = 3.1,p = .030). Follow-up was 4 months to 4 years (median 12 months). Conclusion Nonoperative management of pectus excavatum with vacuum bell therapy results in an excellent correction in a small percentage of patients. Variables predictive of an excellent outcome include age ≤ 11 years, chest wall depth ≤ 1.5 cm, chest wall flexibility, and vacuum bell use over 12 consecutive months. Type of study Retrospective chart review. Level of evidence Level III treatment study.
Article
Poland Syndrome (PS) is a rare condition, with an estimated incidence of approximately 1 per 30,000 births and encompasses a wide range of severities of chest and upper arm anomalies. The etiology remains unknown, but genetic involvement is suspected. Few radiological investigations have proven useful in the study PS phenotypes and we propose a reference algorithm for guiding pediatricians. Our experience with 245 PS patients in the last 10 years stimulated a phenotypical classification of PS. The management of the different PS types and a therapeutic algorithm according to the phenotypical features of each PS patient are also proposed.
Article
Full-text available
Objective: To study the methods and principles for simultaneous treatment in the children with pectus excavatum (PE) combined with congenital cardiothoracic diseases. Methods: The medical records of all children, who underwent simultaneous repair of PE combined with congenital cardiothoracic diseases, were retrospectively reviewed in Hunan Children's Hospital from January 2007 to September 2018. The patients were divided into a PE combined with congenital heart disease (CHD) group (n=17) and a PE combined with thoracic disease group (n=10). The repair with a custom-made sternal lifting device, a Nuss repair, were performed in the treatment of PE, and the correction of the CHD was performed by heart open surgery using cardiopulmonary bypass (through sternotomy or right infra-axillary thoracotomy) or by transcatheter closure under echocardiography or X-ray-guided percutaneous intervention in the PE combined with CHD group. The children in the PE combined with thoracic disease group underwent thoracic surgery plus Nuss procedure concurrently. Results: All 27 pediatric patients underwent simultaneous repair of the PE combined with congenital cardiothoracic diseases. In the PE combined with CHD group, the duration of hospital stay ranged from 8.0 to 25.0 (13.2±4.8) days. Two patients had delayed healing of the surgical wound and 1 patient developed a small left pleural effusion postoperatively. In the PE combined with thoracic disease group, the duration of hospital stay ranged from 10.0 to 34.0 (19.9±7.5) days. One patient was complicated with chylothorax and 2 patients were complicated with pleural effusionin. The treatment for the patients in the 2 groups was satisfactory. No severe complications like surgical death, severe bleeding, chest organ injuries, and implant rejections were observed. Conclusion: According to the characteristics of patients, individualized programs should be selected in order to correct children's PE combined with congenital cardiothoracic diseases in the same period, which are safe, effective and can avoid the risk of multiple operations and anesthesia, and can reduce the financial burden of family.
Preprint
Full-text available
Vacuum bell therapy has been acceptable substitute for pectus excavatum patients who want to improve their appearance but avoid surgical correction. The aim of this study was to assess the pre-treatment characteristics of patients with pectus excavatum and to establish characteristics that can potentially help identify ideal candidates for vacuum bell therapy. Expected improvements in thoracic indices were evaluated using pre-treatment chest computed tomography, which was performed before and after applying a vacuum bell device. Treatment results after 1-year of application were evaluated using changes in the Haller index before and after treatment. The patients were categorized into two groups: those with Haller index less than 0.5 (Group 1) and those with Haller index greater than or equal to 0.5 (Group 2). Pre-treatment Haller index was significantly lower in Group 1 than in Group 2 (3.1±0.46 vs. 4.2±1.14, respectively, p<0.001). The expected improvement in Haller index in Group 2 was significantly higher than that in Group 1 (3.3±0.60 vs. 2.8±0.54, respectively, p=0.001). The cut-off value of the expected improvement in Haller index was 0.46 with a sensitivity of 75.8% and a specificity of 83.3%. Patients who demonstrated pliability with a vacuum bell were identified as suitable candidates.
Chapter
Poland syndrome is a rare thoracic anomaly involving the thorax and in 60% of the upper arm. TBN classification is useful to describe the thoracic defect. Only in a minority of cases, thoracic surgery is required to improve respiratory dynamics due to rib cage defect or heart compression by sternal compression. Usually, the aim of surgical treatment in PS is cosmetical. TNB classification guides the surgeon in choosing the surgical path, individualized according to the single features. Evaluation for starting surgical path should be started at the beginning of puberty and not be postponed after complete growth. A combined approach (pediatric/thoracic and plastic surgery) is beneficial.
Chapter
Pectus excavatum (PE) is the commonest of chest wall anomalies, with a prevalence of 1/300–1000 people. PE represents a cosmetical concern for almost the patients affected, but in most cases, it is a cause of thoracic pain, discomfort, breathing difficulty, and physical exercise limitations. This is due mainly to heart compression by the sternum. Treatment includes conservative methods such as vacuum bell (especially in young patients with mild PE) or surgical approach (thoracoscopic placement of retrosternal bars, Nuss technique). The bar is maintained in situ for 3 years and then removed. This approach should be reserved for centers with large experience, as potential complications are severe.
Article
Full-text available
Vacuum bell therapy has been acceptable substitute for pectus excavatum patients who want to improve their appearance but avoid surgical correction. The aim of this study was to assess the pre-treatment characteristics of patients with pectus excavatum and to establish characteristics that can potentially help identify ideal candidates for vacuum bell therapy. Expected improvements in thoracic indices were evaluated using pre-treatment chest computed tomography, which was performed before and after applying a vacuum bell device. Treatment results after 1-year of application were evaluated using changes in the Haller index before and after treatment. The patients were categorized into two groups according the post- treatment changes in Haller index calculated using chest radiographs: those with changes in Haller index less than 0.5 (Group 1) and those with greater than or equal to 0.5 (Group 2). Pre-treatment Haller index was significantly lower in Group 1 than in Group 2 (3.1 ± 0.46 vs. 4.2 ± 1.14, respectively, p < 0.001). The expected improvement in Haller index in Group 2 was significantly higher than that in Group 1 (3.3 ± 0.60 vs. 2.8 ± 0.54, respectively, p = 0.001). The cut-off value of the expected improvement in Haller index was 0.46 with a sensitivity of 75.8% and a specificity of 83.3%. Patients who demonstrated pliability with a vacuum bell were identified as suitable candidates.
Article
Las deformaciones principales de la pared anterior del tórax son el pectus excavatum y el pectus carinatum. Las formas aisladas sin repercusión funcional grave son las más frecuentes. La causa sugerida en la mayoría de los casos es una displasia de los cartílagos costales asociada a un desequilibrio de su crecimiento. Se pueden plantear tres principios terapéuticos. El primero tiene un planteamiento radical. Se trata de la resección de los cartílagos costales anormales o esternocondroplastias. La técnica de condroplastia subpericóndrica por una vía de acceso horizontal mínimamente invasivo permite tratar las formas complejas en pacientes adultos, y en menos ocasiones en la infancia. A esta técnica se le asocia, en los casos de pectus excavatum, la colocación de una férula metálica retroesternal durante 6 meses. Las indicaciones de osteotomías esternales son actualmente infrecuentes. El segundo principio se basa en el modelado progresivo del tórax durante el período de crecimiento torácico. La corrección se realiza con una placa de osteosíntesis, que actúa como un auténtico tutor esternocostal temporal. Se puede introducir por una vía mínimamente invasiva con control toracoscópico. Esta técnica es exclusiva del pectus excavatum simétrico en adolescentes. En las formas particularmente graves, un acceso subxifoideo mínimo permite elevar el esternón y asegurar el paso de la placa. Se han descrito técnicas recientes, como las campanas de succión, con resultados considerados prometedores, pero que no se han demostrado por el momento. En el pectus carinatum, una compresión externa mediante una ortesis proporciona buenos resultados demostrados. El tercer principio terapéutico es un tratamiento paliativo dirigido al relleno de la excavación con una prótesis de silicona. Su interés es la sencillez inmediata. Presenta el inconveniente de los riesgos de complicación y de migración del implante de silicona que se mantiene colocado varias décadas. En resumen, las indicaciones terapéuticas pueden decantarse por técnicas quirúrgicas diferentes, pero complementarias.
Article
Background/purpose: The Nuss procedure is a minimally invasive pectus repair that helps avoid cartilage resection and osteotomy. This report compares outcomes in patients undergoing a standard pectus repair to patients with the Nuss procedure. Methods: One hundred three children (ages 5 to 20 years) with severe pectus excavatum underwent repair. Patients were evaluated for type of repair performed, associated anomalies, cardiopulmonary function, operating time, analgesia requirements, complications, length of hospital stay, hospital and operative charges, and cosmetic result. Statistical analysis was performed using the Mann-Whitney rank sum test. Results: There were 68 patients (average age, 12.6 years) in the standard group and 35, (average age, 9.5 years) in the Nuss group. Associated anomalies were found in 6 standard group and 2 Nuss group patients. Average operating time in Nuss was 3.3 hours and in open procedures, 4.7 hours. Postoperative complications occurred in 13 (20%) standard repair patients and 15 (43%) after the Nuss. In the standard group, 14 patients received intrathecal and 3 received epidural analgesia, while 35 (52%) required an intravenous patient-controlled anesthetic device (PCA; average, 1.8 days). In the Nuss group, 25 patients (71%) received epidural anesthesia (average, 3 days), and 31 (89%) utilized PCA (average 3.8 days). Four (6%) standard patients and 8 Nuss patients (29%) required reoperation. Length of stay averaged 4.0 days (range 2 to 30) in the standard group and 4.8 days (range, 2 to 11) in the Nuss group. Average operating room charge was $8,325 in the standard group and $9,480 in the Nuss group. Average hospital charge was $4,137 for the standard patient and $4,044 for the Nuss group. Analgesic requirements and length of hospital stay were increased (P <.05). The complication rate and operative and hospital charges were similar between groups. Conclusions: Although the Nuss repair is associated with shorter operating time, smaller incisions, and less dissection, early results indicate few other advantages. Drawbacks of the Nuss procedure include high complication and reoperation rates and lack of efficacy in older teenagers and those with connective tissue disorders. Long-term follow-up will be necessary to determine final cosmetic and functional outcomes and define the overall risks and benefits of this procedure as compared with the standard technique.
Article
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. 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. 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. 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.
Article
The aim of this study is to review the new technical modifications and results of 303 patients who have had pectus excavatum repair utilizing the minimally invasive technique. A retrospective chart review was conducted of 303 patients undergoing minimally invasive pectus repair from 1987 through August 2000. Since 1997, a standardized treatment pathway was implemented, and 261 of the 303 patients have been treated on this pathway. Preoperative evaluation included computed tomography (CT) scan, pulmonary function tests (PFT), and cardiac evaluations with electrocardiogram (EKG) and echocardiogram. Indications for operation included at least 2 of the following: progression of the deformity, exercise intolerance or restrictive disease on PFT, Haller CT index greater than 3.2, mitral valve prolapse (MVP), or cardiac compression. Technical and design modifications since 1998 have included routine thoracoscopy, the use of an introducer/dissector for creating the substernal tunnel and elevating the sternum, and routine use of a wired lateral stabilizer to prevent bar displacement. The bar is removed as an outpatient procedure in 2 to 4 years. In 303 patients undergoing minimally invasive pectus repairs, single bars were used in 87% and double in 13%. Lateral stabilizers were applied in 70% of patients and were wired for further stability in 65%. Bar shifts before the use of stabilizers were 15%, which decreased to 6% after stabilizers were placed and 5% with a wired stabilizer. Excellent results were noted in 85% with failure in only 1 patient. Complications included pneumothorax with spontaneous resolution in half of the patients and pericarditis in 7. The minimally invasive technique has evolved into an effective method of pectus excavatum repair. Modifications of the technique have reduced complications. Long-term results continue to be excellent.
Article
Minimally invasive repair of pectus excavatum (MIRPE) was first reported in 1998 by D. Nuss. This technique has gained wide acceptance during the last 4-5 years. In the meantime, some modifications of the technique have been introduced by different authors. Our retrospective study reports our own experience over the last 36 months and modifications introduced due to a number of complications. From 3/2000 to 3/2003, 22 patients underwent MIRPE. Patients median age was 15.5 years (10.7 to 20.3 years). Standardised preoperative evaluation included 3D computerised tomography (CT) scan, pulmonary function tests, cardiac evaluation with electrocardiogram and echocardiography, and photo documentation. Indications for operation included at least two of the following: Haller CT index > 3.2, restrictive lung disease, cardiac compression, progression of the deformity and severe psychological alterations. In 22 patients (2 girls, 20 boys) undergoing MIRPE procedure, a single bar was used in 21 patients and two bars in one boy. Lateral stabilisers were fixed with non resorbable sutures on both sides. Overall, postoperative complications occurred in six patients (27.3%). In two patients (9.1%) a redo-procedure was necessary due to bar displacement. An additional median skin incision was performed in two patients to elevate the sternum. Pneumothorax or hematothorax in two patients resulted in routine use of a chest tube on both sides. Long-term favourable results were noted in all patients. The MIRPE procedure is an effective method with elegant cosmetic results. Modifications of the original method help to decrease the complication rate and to accelerate acquirement of expertise.
Article
Minimally invasive repair of pectus excavatum (MIRPE) was first reported in 1998 and has gained wide acceptance since then. A 17-year-old girl who had undergone thoracotomy and cardiac surgery for transposition of great vessels at the age of 18 months presented with a deep, long pectus excavatum with asymmetry. After initial uneventful postoperative clinical course after MIRPE, the patient had bilateral pleural and pericardial effusion on the sixth postoperative day. Suspecting postpericardiotomy syndrome, systemic steroids were administered, and the symptoms resolved without affecting wound healing. Manifestation of a pericardial effusion combined with bilateral pleural effusion after MIRPE, especially in patients after cardiac surgery, may indicate a postpericardiotomy syndrome that can be treated successfully by intravenous steroids.
Article
The Nuss procedure is a minimally invasive procedure for correction of pectus excavatum. It involves insertion of a substernal metal bar. A feared complication of any implanted device is infection, which often necessitates removal. The purpose of this report is to describe the authors' experience with infectious complications after the Nuss procedure. From February 2000 to July 2002, 102 patients underwent the Nuss procedure in 2 pediatric surgical centers. In a retrospective way, the files of those patients in whom a postoperative infection developed were studied. Seven patients suffered postoperative infectious complications. Only one bar needed to be removed. The authors' experience indicates that there is no need for immediate removal of an infected Nuss bar. Most of these infections can be managed conservatively. However, early antibiotic treatment is warranted to ensure salvage of the bar.