Search

Background: Pectus excavatum, also known as sunken chest or funnel chest, is a structural deformity of the anterior chest wall, characterized by an inward sternum. This condition can lead to respiratory and cardiovascular issues, although it is often addressed for aesthetic reasons. This perspective article reviews the experiences of multiple centers in treating pectus excavatum, to explore whether a clear boundary exists between pathological and aesthetic needs. Methods: The research was conducted on PubMed, using the following targeted search queries to identify relevant studies: "pectus excavatum and surgery", and "pectus excavatum and conservative treatment." Additional searches were performed for articles related to the psychological and emotional state of patients with pectus excavatum. Results: Over 2000 articles related to the topic were identified in the literature. Only primary studies from the past 20 years were included, with a focus on centers reporting a minimum of 30 to 50 cases annually. Nearly 60% of these centers perform the Nuss procedure, exclusively. Major complications occurred in 1–2% of cases, particularly when the procedure was performed without videothoracoscopy. Post-surgery, improvements in lung function and exercise capacity were reported, along with significant reductions in depression and anxiety. Conclusions: The decision to pursue surgical correction of pectus excavatum requires a thorough evaluation of both therapeutic and aesthetic factors. A patient-centered approach, considering both the physical and emotional aspects of the condition, is essential for achieving the best possible outcome. [ABSTRACT FROM AUTHOR]

Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back towards the spine (excavatum), protrudes forwards (carinatum) or more rarely is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities (such as swimming, dancing) and from interactions that might 'expose' them (such as sleepovers, dating, going to the beach and wearing fashionable clothes). This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise (such as running) but can also limit moderate activity such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment usually also suffer from low self-esteem and depression. This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and non-surgical techniques including bracing and vacuum bell therapy. We also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants and other rare procedures such as Pectus Up. For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance and long-term support. All the interventions have risks and benefits that the patient, parents and clinicians need to carefully consider and discuss when deciding on the most appropriate course. We hope this evidence review of 'Best Practice for Pectus' will make a significant contribution to those considerations and help all involved, from patients to national policy makers, to deliver the best possible care. [ABSTRACT FROM AUTHOR]

The Nuss procedure for pectus excavatum (PE) is both less invasive and very simple compared to the Ravitch procedure. However, it may be difficult to perform the Nuss procedure in cases of severe PE. Therefore, we developed a Combined Ravitch and Nuss (CRN) procedure and examined its effectiveness in patients with severe PE. Nine patients with severe PE underwent the CRN procedure. Data on patient characteristics and perioperative results were collected retrospectively. The median Haller index (HI) was 15.4 (range, 6.3–29.3). No significant intraoperative adverse events were noted. Postoperatively, marked improvements in HI were seen in all cases (3.29, range, 2.72–4.96). Two surgical site infections on the shallow layer and one wound seroma occurred. No recurrences were observed during the observation period. Our novel CRN procedure is useful for achieving adequate and sustainable sternal elevation with less invasiveness for patients with severe PE. [ABSTRACT FROM AUTHOR]

Background and Aims: The management of post-operative pain after surgical repair of pectus excavatum with the Ravitch procedure is challenging. Although previous studies have compared various methods of pain control in these patients, few have compared different local anesthetics. This retrospective analysis compares the use of bupivacaine to its longer-acting form, liposomal bupivacaine, in patients who had undergone pectus excavatum repair with the Ravitch method. Material and Methods: Eleven patients who received local infiltration with liposomal bupivacaine were matched to 11 patients who received local infiltration utilizing bupivacaine with epinephrine. The primary outcome was total morphine milligram equivalents per kilogram body weight (MME/kg) over the complete length of hospital stay. Secondary outcomes included total cumulative diazepam, acetaminophen, ondansetron, and NSAID dose per kilogram body weight (mg/kg) over the course of the hospital stay, chest tube drainage (ml/kg body weight), number of post-operative hours until the first bowel movement, Haller Index, patient request for magnesium hydroxide, average pain scores from post-operative day 1 to post-operative day 5, and length of hospital stay. Continuous variables were reported as medians with inter-quartile ranges, and categorical values were reported as percentages and frequencies. Results: The total MME/kg [1.7 (1.2-2.4) vs 2.9 (2.0-3.9), P = 0.007] and hydromorphone (mg/kg) [0.1 (0.0-0.2) vs 0.3 (0.1-0.4), P = 0.006] use in the liposomal bupivacaine group versus bupivacaine with epinephrine was significantly reduced over total length of hospital stay. Similarly, there was a reduction in diazepam use in the liposomal bupivacaine group versus the bupivacaine group [0.4 (0.1-0.8) vs 0.6 (0.4-0.7), P = 0.249], but this did not reach statistical significance. The total dose of ondansetron (mg/kg) was not statistically different when comparing the liposomal bupivacaine group to the bupivacaine group [0.3 (0.0-0.5) vs 0.3 (0.2-0.6), P = 0.332]. Interestingly, the total dose of acetaminophen (mg/kg) was statistically increased in the liposomal bupivacaine group compared to the bupivacaine with epinephrine group [172 (138-183) vs 74 (55-111), P = 0.007]. Additionally, the total chest tube drainage (ml/kg) was significantly reduced in the liposomal bupivacaine group [9.3 (7.5-10.6) vs 12.8 (11.3-18.5), P = 0.027]. Finally, the percentage of patients without requests for magnesium hydroxide to promote laxation was significantly higher in the liposomal bupivacaine group than in the bupivacaine group (63.6% vs 18.2%, P = 0.027). Conclusion: The use of liposomal bupivacaine for local infiltration in patients who undergo the Ravitch procedure for pectus repair offers advantages over plain bupivacaine, including reduced opioid consumption and opioid-related side effects. However, more data are needed to understand the significance of these findings. [ABSTRACT FROM AUTHOR]

Pectus excavatum (PE) is often associated with scoliosis and can elicit cardiovascular disturbances under rare conditions. Here we report a patient who was treated with a combined Ravitch and Nuss procedure for PE with dyspnea following scoliosis repair to improve her symptoms. The patient was a 49-year-old woman with a history of PE and scoliosis. Right inferior pulmonary vein stenosis was caused by posterior spinal fusion for scoliosis prior to the PE repair. We could safely correct the chest wall deformity and treat dyspnea by performing a modified Ravitch repair in combination with the Nuss procedure. [ABSTRACT FROM AUTHOR]

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

The article is a response to a letter regarding a new international guideline for patients with pectus abnormalities, such as pectus excavatum and pectus carinatum. The guideline aims to provide a comprehensive approach to evaluating and treating these conditions, including non-surgical and surgical techniques. It emphasizes the cardiovascular and psychological benefits of surgery, while also highlighting the effectiveness of bracing and vacuum bell therapy for certain cases. The article discusses the preference for the Nuss procedure over the Ravitch procedure for pectus excavatum, but notes the lack of comparative studies between the two procedures. [Extracted from the article]

The aim of the study was to investigate whether the use of pre- and postoperative gabapentin can decrease postoperative pain, morphine consumption, anxiety and side effects, as well as improve patient satisfaction. A total of 56 patients, 9–17 years of age, undergoing a modified Ravitch procedure, were randomised (allocation ratio 1:1) to receive multiple perioperative doses of gabapentin (preoperatively 15 mg/kg, postoperatively 7.5 mg/kg, two times per day for three days) or a placebo. All the patients received intravenous infusion of morphine, paracetamol and non-steroidal anti-inflammatory drugs. Metamizole was given as a "rescue drug". The observation period included the day of surgery and three postoperative days. The primary outcomes were postoperative pain intensity (at rest, during deep breathing and coughing). Additional outcomes included the consumption of morphine, the total number of doses of metamizole, anxiety, postoperative side effects and patient satisfaction. Median average and maximal pain scores (on the day of surgery and on the second postoperative day) were significantly lower only in the gabapentin group at rest (p < 0.05). Compared to the placebo group, gabapentin treatment reduced the demand for morphine on the first postoperative day (median 0.016 vs. 0.019 mg/kg/h; p = 0.03) and the total number of metamizole doses (median 1 vs. 2 p = 0.04). Patient satisfaction was significantly greater in the gabapentin group (median 10 vs. 9; p = 0.018). Anxiety and postoperative side effects were similar in both groups (p > 0.05). Pre- and postoperative gabapentin administration as part of a multimodal analgesic regimen may decrease postoperative pain, opioid consumption and demand for a "rescue drug", as well as improve patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: We describe the successful heart transplantation of a brain‐dead male donor with a remote history of pectus excavatum repair. Method and Results: On computed tomography, the ascending aorta was in close proximity to metallic struts from the donor's sternal repair. Before harvesting the heart, visual and digital inspections revealed minimal space between the sternum and ascending aorta, complicated by severe adhesions in the lower sternum. After the pericardium was opened, the subsequent recovery of the heart was performed in a standard fashion. At one‐year post‐transplant, the recipient continues to have normal graft function. Conclusions: Careful evaluation, intraoperative consideration, and coordination with other transplant teams were essential in the successful recovery of the heart during a time of organ shortages. [ABSTRACT FROM AUTHOR]

Objective To determine whether the use of perioperative gabapentin reduces postoperative pain and anxiety, decreases ropivacaine consumption and side effects, and improves patient satisfaction. Design Randomized, placebo-controlled, phase 4 trial. Blinding Participants, care providers, investigators, data analysts. Setting Department of Thoracic Surgery of the Institute of Tuberculosis and Lung Disease, Rabka Zdrój Branch, Poland. Subjects Forty patients undergoing the Ravitch procedure. Methods Patients aged nine to 17 years were randomized into a gabapentin (preoperative 15 mg/kg, treatment) or placebo group. Postoperative analgesia included gabapentin (7.5 mg/kg) or placebo two times per day for three days, epidural ropivacaine + fentanyl, paracetamol, nonsteroidal anti-inflammatory drugs, and metamizol as a "rescue drug." Pain, anxiety, analgesic consumption, side effects, and patient satisfaction were recorded. Results There was no statistically significant difference in median pain scores (numerical rating scale < 1/10) or incidence of adverse side effects between the gabapentin group (N = 20) and the placebo group (N = 20). Postoperative anxiety scores were significantly lower than before surgery in the gabapentin group (6 [4–8] vs 7 [6–8.5], P < 0.01) and remained unchanged in the placebo group (6 [5–6.5] vs 6 [5–7], P = 0.07). Gabapentin-treated patients received a lower number of doses of ondansetron when compared with the placebo group (6 [5–6] vs 7 [6–9], P = 0.02). A significant negative association was found between patient satisfaction and postoperative state anxiety in the gabapentin group (R = –0.51, P = 0.02). Conclusions Perioperative administration of gabapentin resulted in a decrease of postoperative anxiety in pediatric patients undergoing the Ravitch procedure. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive repair of pectus excavatum (PE) (Nuss procedure) was a transmediastinal procedure. Intrathoracic adhesion might increase the risks of this procedure. Patients after previous thoracic surgery might have the problem of intrathoracic adhesion increasing the surgical risks of Nuss procedure. PE after surgical repair was not a rare problem, especially in adults. In this study, we were to investigate the efficacy and safety of a modified Nuss procedure, using bilateral thoracoscopic approach, to repair recurrent or residual PE in adult patients. Materials and Methods: We retrospectively included all adults with PE corrected by modified bilateral thoracoscopy-assisted Nuss repair from January 2015 to December 2016. The clinical and surgical data of patients repaired with primary or secondary Nuss procedure were recorded and analyzed. Results: One hundred and fifty-one adult patients (136 men and 15 women) with a mean age of 26.3 years were included. Eleven patients (9 men and 2 women) were secondarily repaired due to prior failed Ravitch (three patients) or Nuss procedure (eight patients). The pectus repair was done using a single pectus bar (8.6%), 2 bars (81.5%), or 3 bars (9.9%). The rate of postoperative complications (6 months after operation) was significantly higher (P < 0.01) in the secondary repair group (two patients, 18.2%) compared to the primary repair group (seven patients, 9.3%), but it was still lower than most of the previous reports in the world (around 40%). Conclusion: All patients with PE had excellent postoperative outcomes in both the groups, even if with a slightly higher postoperative complication rate in the secondary repair group. The number of bar insertions was higher than previous data but with a lower complication rate. The modified bilateral thoracoscopy-assisted Nuss repair for adult patients after failed Ravitch or Nuss procedure was a safe and effective method and could have good early results. [ABSTRACT FROM AUTHOR]

Purpose: Cryoanalgesia has shown to have safety and efficacy as an adjunct post-operative pain management for Nuss procedure. One retrospective study reported its efficacy for analgesia with the Ravitch procedure, with improved pain scores and decreased length of stay versus thoracic epidural. We describe our initial experience with the use of cryoanalgesia for an open repair of pectus carinatum.Methods: We retrospectively reviewed the medical records of all patients who received cryoanalgesia during an open repair of pectus carinatum from 2016 to 2019 at our institution. We recorded pain scores at immediate post-operative and at 1-week follow up after hospital discharge. Length of stay and mean follow up time were also recorded.Results: Five pediatric patients underwent open repair of pectus carinatum with cryoanalgesia. The median postoperative length of stay (LOS) was 1 (range 1-2) day. Only one patient reported a non-zero pain score during their hospitalization, and this was a 3 out of 10 in the post-analgesia care unit. At 1-week postoperative visit, all patients had a pain score of 0. Median follow up was 1 (0.5-2) year. No patients developed neuralgia.Conclusion: Cryoanalgesia is a safe and effective pain management strategy for pediatric patients undergoing open pectus carinatum repair. [ABSTRACT FROM AUTHOR]

Aim: In this study we analysed the early and late results of surgical treatment of asymmetrical pectus excavatum using complex surgery combining the Ravitch procedure and the Nuss procedure in the same general anaesthesia. Material and methods: Eighty out of 938 patients with pectus excavatum operated on between 2002 and 2013, 67 males and 13 females aged 11 to 49 years (mean: 19.2), underwent a complex surgical procedure. During surgery the Nuss procedure was usually performed first (one corrective bar was implanted in 35 patients and two bars were inserted in 45 patients). Because of the unsatisfactory cosmetic effect, additionally the Ravitch procedure was started. The bars were electively removed 3 years after the primary operation. Results: No mortality was observed in the early postoperative period. Non-life-threatening and transient postoperative complications occurred in 44 (55%) patients. The most common was pleural effusion (21%), which in 50% of patients required pleural drainage. A satisfactory and stable correction effect was achieved in 88% of cases. Six of those patients required repeat surgery due to recurrence of deformity. Conclusions: A complex corrective procedure is a successful method of surgical treatment in patients with asymmetrical pectus excavatum and is characterized by satisfactory postoperative results. The use of corrective bars enhances the cosmetic effect. The frequency of early, mostly non-life-threatening postoperative complications after a complex procedure is insignificantly higher than that after the Nuss procedure. [ABSTRACT FROM AUTHOR]

We would like to report a 14-year-old male patient with pectus excavatum that recurred 10 years later after Ravitch surgery who was successfully operated using Nuss procedure. The patient underwent pectus excavatum surgery using Nuss procedure. The patient was discharged from the hospital at post-operative 5.day. The bar is planned to be removed in post-operative 3.year. In conclusion, surgery of pectus excavatum that recurred after open surgery is risky. Nuss procedure, which is a minimally-invasive technique, is a safe procedure that can be successfully applied in recurring cases due to short time of surgery and minimal blood loss. [ABSTRACT FROM AUTHOR]

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

Purpose: Indications for surgical treatment for patients with pectus excavatum and carinatum are psychosocial issues, pulmonary or cardiac limitations or pain. When surgery is indicated in our institution, patients are treated with a modified thoracoplasty according to the Ravitch technique. In order to stabilize pectus excavatum, an allogenic bone strut is transplanted which does not require removal. Patient and methods: Seventy-one patients with a mean age of 17 years who were treated for pectus deformities between 1997 and 2007 were evaluated retrospectively. Results: The average period of follow-up was 5.3 years. Sixty-six percent of the patients suffered from pectus excavatum, 34% from pectus carinatum. One osseous revision had to be performed after overcorrection of pectus carinatum into pectus excavatum. Six minor complications occurred. At follow-up, the mean patient satisfaction score was 4.3 (scale 1-5). The Manchester Scar Scale resulted in 96% cosmetically well-healed scars. Clinically, 93% of the surgical results were rated good. Conclusions: This study retrospectively shows that this modification of the Ravitch approach is a safe and effective treatment option for pectus deformities with long-term satisfactory results for the patients without the need for bar removal. [ABSTRACT FROM AUTHOR]

The minimally invasive Nuss procedure has become the standard of care for surgical correction of pectus excavatum. Pectus excavatum is the most common congenital deformity of the chest wall. Historically, surgical correction was limited to the Ravitch procedure, an invasive procedure associated with significant drawbacks, where abnormal cartilage was removed and the sternum elevated and stabilized. Patients typically experienced a prolonged recovery period, from 6 to 9 months and significant postoperative pain. The Nuss procedure, invented in 1998, is much less invasive and has a success rate of 90% compared with the Ravitch procedure with a success rate of 70% to 80%. This more recent procedure normally has an exceedingly low complication rate, reported to be 8% to 11%. Postoperative analgesia ranges from patient controlled analgesia to a thoracic epidural depending on the surgeon's preference. This case report details an immediate postoperative complication that occurred with its subsequent anesthetic management. [ABSTRACT FROM AUTHOR]

OBJECTIVE. This study evaluated changes in both physical and psychological quality of life reported by the parent and child after surgical repair of pectus excavatum. METHODS. As part of a multicenter study of pectus excavatum, a previously validated tool called the Pectus Excavatum Evaluation Questionnaire was administered by the research coordinator, via telephone, to parents and patients (8-21 years of age) before and 1 year adter surgery. Eleven North American children's hospitals participated. From 2001 to 2006, 264 patients and 291 parents completed the initial questionnaire, and 247 parents completed the postoperative questionnaire. Responses used a Likert-type scale of 1 to 4, reflecting the extent or frequency of particular experience, with higher values conveying less-desirable experience. RESULTS. Preoperative psychological functioning was unrelated to objective pectus excavatum severity (computed tomographic index). Patients and their parents reported significant positive postoperative changes. Improvements occurred in both physical and psychological functioning, including less social self-consciousness and a more-favorable body image. For children, the body image component improved from 2.30 ± 0.62 (mean ± SD) to 1.40 ± 0.42 after surgery and the physical difficulties component improved from 2.11 ± 0.82 to 1.37 ± 0.44. For the parent questionnaire, the child's emotional difficulties improved from 1.81 ± 0.70 to 1.24 ± 0.36, social self-conciousness improved from 2.14 ± 0.75 to 1.32 ± 0.39. Ninety-seven percent of patients thought that surgery improved how their chest looked. CONCLUSIONS. Surgical repair of pectus excavatum can significantly improve the body image difficulties and limitations on physical activity experienced by patients. These result should prompt physicians to consider the physiologic and psychological implications of pectus excavatum just as they would any other physical deformity known to have such consequences. [ABSTRACT FROM AUTHOR]

• Pain following surgical repair of pectus excavatum is challenging. • The use of regional anesthesia is a viable option for the relief of postoperative pain. • Erector Spinae Plane block can be an effective and safe option as part of a multimodal approach. [ABSTRACT FROM AUTHOR]

• ESP block can be successfully done in patients with Harrington rods. • ESP block spread can be incomplete due to surgically altered back muscle anatomy. • ESP block is a useful adjunct for a multimodal postoperative analgesic plan. [ABSTRACT FROM AUTHOR]