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Chest wall malformations include excavated deformities or pectus excavatum (PEX) and carinated deformities or pectus carinatum (PC). These deformities can be mixed defects and they may also be a part of a congenital syndrome such as the Currarino Silverman syndrome. The development in the field of chest wall malformations has been steep in the three last decades and both adult and pediatric surgeons have become specialized in the subject pushing even forward the baggage of knowledge. We aim to introduce the reader in the different aspects related to pectus deformities.

ZUSAMMENFASSUNGDie Trichterbrust ist die häufigste Form der Brustwanddeformitäten. Die Therapieentscheidung erfolgt stets gemeinsam zwischen Patient, den Eltern und dem Chirurgen in wiederholten Gesprächen. Die nicht-invasive Saugglockentherapie stellt für Kinder, welche die Kriterien für eine operative Korrektur nicht erfüllen oder eine chirurgische Therapie ablehnen, eine gute Alternative dar und birgt keine Gefahren. Seit Einführung der minimalinvasiven Trichterbrustkorrektur (MIRPE) hat die Anzahl von Patienten, die eine operative Korrektur Ihrer PE wünschen, deutlich zugenommen. Die Ergebnisse der operativen Korrektur zeigen neben einer hohen Patientenzufriedenheit mit dem kosmetischen Ergebnis auch eine verbesserte Herzleistung und Sauerstoffaufnahmekapazität. Obwohl die MIRPE in erfahrenen Händen sicher und effektiv ist, sind ernsthafte lebensbedrohliche Komplikationen möglich.Zur Behandlung der Kielbrust ist die nicht-invasive Kompressionstherapie Therapie der Wahl. Dies gilt besonders für die dynamische Kompressionstherapie, welche eine objektive Messung und Einstellung der notwendigen Therapiedrücke, ein laterales Ausweichen der Thoraxwand und individuelle Anpassung ermöglicht. Der Therapieerfolg der Kompressionstherapie liegt „in der Hand des Patienten“. Eine operative Korrektur sollte nur nach nicht erfolgreicher Kompressionstherapie oder bei unbedingtem Patientenwunsch erfolgen.

Background Currarino-Silverman (CS) syndrome is an extremely rare congenital deformity of the anterior chest wall. The syndrome is often combined with congenital heart defects and spinal abnormalities. As of currently, there is a lack of definite description in the literature about this type of pectus deformity. Typically, patients do not require surgical intervention for medical reasons, and the correction is usually only for cosmetic purposes. The purpose of this study was to demonstrate surgical intervention for CS syndrome at a tertiary care facility, and to summarize the available literature. Methods Patients with CS syndrome were retrospectively reviewed from a period of June 2012 to August 2019. An extensive literature search for "Currarino-Silverman syndrome," "pouter pigeon chest," "chondromanubrial deformity," "type 2 pectus carinatum" and "pectus arcuatum" was performed. Results Four clinical cases of CS syndrome are presented, two of which were symptomatic and corrected. The procedure of choice was the modified Ravitch-type thoracoplasty with double osteotomy and implantation of support plates. Conclusions There is no clear definition of CS syndrome in the literature. Correct and uniform classification plays a crucial role in the surgical treatment of this pathology. Due to the extreme rarity of the disease, challenging deformity, and variable anatomy of the fused sternum, there are no clear guidelines in treatment approaches. The correction is mostly pursued only for cosmetic results, and the best surgical option for CS syndrome remains the relatively aggressive Ravitch-type procedure with multi-level wedge osteotomy.

Purpose. To analyze literature data and to find out optimal techniques for surgical correction of asymmetrical chest wall deformity in children.Material and methods. The researchers studied data on surgical treatment of children with asymmetrical chest wall deformity who had thoracoplasty performed with well-known techniques developed by Bairov, Timoshchenko, Paltia, Ravitch, Kondrashin which included the resection of crooked cartilage and internal metal fixation with consideration of deformity shape, location and severity. For comparison, the authors analyzed the data on the minimally invasive Nuss technique and its modifications.Results. The researchers found that thoracoplasty by the Bairov method is less effective which gives the largest number of postoperative complications (16.5%) in the form of hemothorax, pneumothorax and hydrothorax what significantly increased the length of hospital stay and the following rehabilitation process. On the contrary, minimally invasive interventions were the most effective, if to compare with all applied techniques for chest wall deformity correction, having a low percentage of complications; though their drawback is long-term postoperative analgesia.Conclusion. At present, there is no any consensus on the top-priority technique for surgical correction of chest wall deformity in children. It necessitates further research in this direction as well as improvement of the existing techniques and development of new ones.

Background/Aim. Pectus excavatum (PE) is the most common deformity of the frontal aspect of the chest wall in children. A particular dilemma arises about the degree of deformity that should be subjected to surgical treatment. The aim of this study was to compare several morphological methods of evaluating the degree of deformity and determine the matching among them, a s w ell a s t o determine the connection between the functional and morphological abnormalities of echocardiography. Methods. The study included 35 patients with PE, aged between 7 and 15 years. A noninvasive evaluation of chest deformity was carried out in all patients by photographic method (surrogate of clinical examination), native X-ray imaging, and computed tomography (CT), as well as by echocardiographic examination. Results. In our group of patients, males were more common (67.5%), as well as children with the Haller index (HI) > 3.5 [represented in most children (86.7%)]. A significant correlation of the index of the affected sternum segment (ASt) and the total length of the sternum (ASt/LSt) determined by the photographic method with that determined by the CT scan of the chest was established (p = 0.001). In addition, the correlation between HI, determined by the X-ray method and CT images was presented (p = 0.012). In contrast, despite the high frequency of echocardiographic abnormalities (69%), those were not mutually correlated with the degree of pronounced morphological deformities of the chest wall. Conclusion. A detailed clinical examination and photographic evaluation method, combined with the X-ray method, can determine the severity of deformity with a high degree of agreement with the CT chest findings. In this way, it is possible for children with PE, who are not candidates for surgical treatment, to be s pared f rom r epeated C T scans t hat a re c arried o ut i n order to monitor the development of chest deformities with growth. Echocardiographic evaluation remains an integral part of the assessment of children with PE.

Pectus excavatum is a common chest wall deformity with inward deviation of sternum and accompanying ribs. The depression can cause symptomatic cardiac compression, although the cardiopulmonary impact remains controversial. We present 2 cases of cardiac transplantation followed by modified minimally invasive pectus excavatum repair due to the hemodynamic consequences of the pectus deformity.

Most of the previous studies evaluating lung volume of pectus excavatum (PE) patients were based on spirometric measurements. We aimed to calculate lung volume of patients with PE and compare them with lung volume of patients without chest wall deformity using CT volumetry. After institutional review board approval, preoperative chest CT of PE patients who underwent minimal invasive procedure between January 2012 and February 2018, were evaluated retrospectively. As a control group, age and sex matched patients who underwent chest CT scan in the same period were enrolled. Total, right and left lung volumes were calculated using an automated software. Haller indexes were measured for both groups. Lung volumes and Haller indexes compared between the two groups. We also compared left and right lung volumes in both groups. We evaluated whether there is a correlation across the Haller index and total lung volume. Total, right and left lung volumes were not statistically different between the two groups. While left lung volumes were significantly smaller in PE group (p = 0.041), there was no significant difference between the left and right lung volume in the control group (p = 0.12). Haller index and total lung volume showed no significant correlation between patients with the same age and gender (p = 0.14, R = −0.3). PE deformity does not reduce lung volume when compared to age and sex matched control group. Quantitative CT volumetric evaluation of lung gives valuable data about lung volume.

Background The chest wall deformity is a well-known complication following costal cartilage harvest with the biomechanical factor considered to be a cause of this donor-site morbidity. Kawanabe-Nagata method is a widely-accepted approach to prevent the deformity. However, knowledge about the biomechanical properties of regenerated costal cartilage is limited, and the value of reimplantation of autologous costal cartilage blocks is not clear. Methods The fifth costal cartilage on both sides of six male, 8 weeks of age, New Zealand white rabbits were harvested with the perichondrium preserved intact in situ. The perichondrium was sutured to form a perichondrial pocket and part of the excised costal cartilage was cut into 0.5 mm cartilage blocks and returned to the perichondrial pocket of left side. The animals were sacrificed 16 weeks postoperatively and the regenerated and a piece native costal cartilage was harvested for morphological and three point bending test. Results There was no remarkable chest wall deformity in all animals, and there were no apparent differences in the appearance of the regenerated cartilage with and without reimplantation autologous cartilage blocks. The elastic modulus of native cartilage was significantly higher than the regenerated cartilage. The stiffness of regenerated cartilage without reimplantation was higher than that of with reimplantation, but this difference was not significant. Conclusions The stiffness of regenerated cartilage was significantly lower than the native cartilage. Reimplantation of autologous cartilage blocks was not superior to that without reimplantation in regard to restoring the volume defect and strengthening the regenerated cartilage.

Introduction Pectus excavatum (PE) is the most common chest wall deformity. Patients with PE may have cosmetic complaints, restricted physical capabilities, or both and may seek surgical correction. One method to assess satisfaction after surgery is the single step questionnaire (SSQ). Although the developers state that the SSQ produces a stabile score and only needs to be used once, we hypothesized that the score may depend on point in time after surgery. Materials and Methods One hundred and eight patients from a longitudinal cohort of patients undergoing a Nuss bar placement for PE were selected. Mean age was 16.0 years (range: 12–29). SSQ was completed at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Mean and median scores per question and total scores were calculated on each measurement moment. Overall scores were tested using the Friedman test. Results There were significant differences in overall SSQ scores (p Conclusion There were significant differences in total SSQ score depending on the time of application postoperatively. However, the most clinical relevant difference was between 6 weeks and 6 months. Assessment of the overall satisfaction postoperative with the SSQ questionnaire should not be done with a single measurement but rather at different postoperative time intervals before and after 6 months postoperatively.

Background Pectus excavatum is a chest wall deformity with no known cause and no standardized guidelines for evaluation or management. There is a pressing need to characterize the symptoms that these individuals experience and to evaluate a potential mismatch between their expected and observed experiences with health care. We hypothesized that these individuals would feel that their health-care needs are not adequately met. Methods A total of 331 participants with untreated pectus excavatum from 47 countries recruited from the Pectus Awareness and Support Group completed a questionnaire about living with pectus excavatum. We focused on characterizing physical and psychosocial symptom frequency and whether these problems were discussed with providers during encounters related to pectus excavatum. Results A total of 46% and 31% of participants experience daily physical and psychosocial symptoms, respectively, but providers disproportionally focus on physical symptoms. Seventy-seven percent and 61% of participants thought their providers could do more to address their physical and psychosocial symptoms, respectively. Only 8% of participants were very satisfied after their most recent health-care visit about pectus excavatum. The overwhelming majority of participants have encountered providers that lacked basic knowledge about pectus. Conclusions The results of this questionnaire expose a major discrepancy between expectations and delivery of care for people with pectus excavatum. These individuals should be routinely screened for both physical and psychosocial symptoms by general practitioners.

Purpose Scoliosis, chest wall deformities and pulmonary involvement are common features of Marfan syndrome (MFS). We aimed to assess the impact of spinal and chest wall deformities on pulmonary function in paediatric MFS patients with a surgically managed spinal deformity. Methods In this multicentre retrospective study, spirometry, lung volumes and radiographic imaging were performed on 26 MFS patients between the ages of seven and 18 years who were undergoing planned spinal fusion surgery for spinal deformity. A correlation analysis assessed the relationship between radiographic measurements of spinal and chest wall deformities and predicted total lung capacity (TLC), forced vital capacity (FVC) and the ratio between forced expiratory volume in one second and FVC (FEV1/FVC). Results In total, 18 patients (70%) had impaired pulmonary function. Thoracic kyphosis (mean 19.3°; -32° to 54°) had a strong positive correlation with FEV1/FVC (r = 0.65; p < 0.001). Significant decrease in FEV1/FVC below 80% occurred at kyphosis under 15° (p = 0.004). Kyphosis had a moderate negative correlation with FVC (r = -0.43; p = 0.03). Chest wall deformity had a strong negative correlation with FEV1/FVC (r = -0.61; p = 0.001). The magnitude of the thoracic curve (mean 55.2°; 28° to 92°) had a significant moderate negative correlation with TLC (r = -0.45; p = 0.04). Conclusion In MFS, three factors correlate with decreased pulmonary function measures: hypokyphosis, increasing chest wall deformity and increasing coronal curve magnitude. Hypokyphosis and increased chest wall deformity correlated with diminished FEV1/FVC; increasing thoracic spinal curvature with diminished TLC. Further analysis with a larger cohort will help better define the relationship between these deformities and pulmonary function in this unique population. Level of Evidence IV

Hypoventilation syndrome is defined as a decrease in alveolar ventilation leading to hypercapnia (PaCO2 > 35-45 mmHg) and hypoxemia. There are multiple causes of hypoventilation syndrome described in the literature, of which central and obesity-related causes are more prevalent. Other causes such as neuromuscular disorders and chest wall deformities are relatively less common. Multiple defects in the normal functioning of the respiratory function are implicated in the pathophysiological mechanism of hypoventilation syndrome, such as a hypoactive central ventilatory drive, decreased airway function, ventilation-perfusion mismatch, defective pulmonary mechanics, and respiratory muscle fatigue. Patients often present with dyspnea, headache, lethargy, repeated pulmonary infections, hypoxia that usually improves with low flow oxygen, and hypercapnia that may alter mental function. Nocturnal or diurnal assisted mechanical ventilation is proven to be an effective therapy for patients suffering hypoventilation syndromes. We describe a case of a 47-year-old woman with hypoventilation syndrome resulting from a rare chest wall deformity with inward protrusion of the costochondral junction of the ribs with ossification of the costal cartilage on CT who presented with dyspnea and hypercapnia.

Osteogenesis imperfecta is a genetic disorder caused by mutations in genes affecting type I collagen that is mostly found in bone, skin and tendons. In addition to bone fragility and increased risk of fractures, patients with osteogenesis imperfecta can have chest wall deformities including pectus excavatum and pectus carinatum. Cardiorespiratory problems caused by these deformities is the major cause of morbidity and mortality in these patients. Outcomes of surgical correction of pectus excavatum in patients with osteogenesis imperfecta have not been described in the literature. It is important to establish definitive treatment options for these patients to improve their respiratory capacity and reduce mortality. In this case series we present the case of two pre-pubertal pediatric patients with osteogenesis imperfecta type I who underwent surgical correction of pectus excavatum with the Nuss procedure after pamidronate therapy. Both patients had successful correction of the chest wall deformity with significant improvement in their quality of life.

A non-invasive and objective method of capturing upper body surface anatomy, such as 3D optical scanning, would be advantageous for evaluating chest wall deformity. By potentially eliminating the need for computed tomography scanning and superseding manual measurements subject to errors, a system that utilizes optical scanning presents great value to patients and practitioners. This work aimed to quantify the accuracy of two current generation 3D surface scanners, Azure Kinect & StructureIO Mark-II, in assessing the severity of chest wall deformities. 3D surface deviation analysis was conducted on the models created by each scanner, and the findings are reported.

Sternal clefts are infrequent congenital malformations, particularly in their complete presentation. There are less than 100 descriptions of these defects published in the literature worldwide. We report a clinical case of lower sternal cleft associated with congenital laparoschisis in a 2-year-old boy. Surgery was performed because of recurrent pneumopathy and the risk of cardiorespiratory decompensation in the midterm. A semi-resorbable prosthesis was used for sternal closure. We have not observed any complications with this sternal closure system in our patient. This approach is easy, safe, effective and not harmful to a child’s growth. Keywords. bifid sternum; chest wall deformity; congenital abnormality; laparoschisis; pentalogy of Cantrell syndrome; sternal cleft.

Scoliosis can cause various respiratory complications, even in the natural course, because of rearrangement of the intrathoracic anatomy owing to chest wall deformity. We experienced a patient with scoliosis who developed acute respiratory failure owing to bronchial obstruction induced by bronchial compression by the dorsal thoracic vertebra after right upper lobectomy for cancer. The symptom resolved after mobilization of the ipsilateral lower lobe, which was achieved by releasing the inferior pulmonary vein by U-shaped pericardial dissection with division of the pulmonary ligament. When planning lobectomy for patients with severe scoliosis, the anatomic changes caused by pulmonary resection must be considered.

Studies have been done extensively, about the difficulties of giving anaesthesia and endo-tracheal intubation, in patients with severe kyphoscoliosis, due to distortion of the airway anatomy. However, there is a little or no information about difficulties in doing thoracotomy, in such patients with distorted chest wall. We would like to report a case of severe kyphoscoliosis with deformed chest wall, who underwent thoracotomy for recurrent pneumothorax due to ruptured multiple bullae. The pitfalls and safety measures to be taken, have been explained.

Sternal cleft is a unique congenital chest wall malformation that results from failure of sternal fusion early in the embryological development. Surgical correction is advised both to protect mediastinal structures and to restore respiratory dynamics. Early surgical correction, preferably in the neonatal period, is recommended in order to benefit from the elasticity of the thoracic cage. In this article, we present a two-month-old female patient with a superior V-shaped sternal cleft, which was successfully corrected with posterior periosteal flap, sliding chondroplasty and cartilage graft interposition techniques.

Purpose Image acquisition protocols and reports in patients with pectus excavatum (PEX) differ significantly from routine examinations, and no imaging modality can enable a comprehensive assessment of PEX severity and cardiac impact within a single examination. We therefore attempt to establish recommendations about preoperative imaging in patients with PEX. Method Chest computed tomography (CT), stress echocardiography (Echo), and cardiac magnetic resonance (CMR) allow the evaluation of specific information regarding structural and functional characteristics of vital importance to assess surgical candidacy and define surgical strategies. We sought to provide a multidisciplinary state of the art document involving thoracic surgeons, radiologists, and cardiologists; to establish recommendations about the variables to be included in the reports of the imaging examinations performed in patients with PEX. Results We provide recommendations for preoperative image acquisition and analysis, aimed at the assessment of the severity of the chest wall deformity (CT); the site of maximum cardiac compression, extent of increased interventricular dependence, and presence of pericardial effusion (CMR); and the effect of PEX on the functional capacity and exercise-related systolic and/or diastolic function, and tricuspid annulus compression (Echo). Conclusions This multidisciplinary state of the art document involving thoracic surgeons, radiologists, and cardiologists provides recommendations about preoperative imaging for patients with PEX.

Chest wall deformity after tissue expansion for breast reconstruction is less recognized than complications such as infection, hematoma, skin necrosis and capsular contracture. However, the condition should not be discounted because pain, rib fracture and dyspnea may occur in severe cases. The aim of this study is to evaluate the extent of chest wall deformity quantitatively using computed tomography (CT) and to identify risk factors for this condition after tissue expansion. The subjects were 34 patients who underwent unilateral two-stage reconstruction and were examined by multidetector-row CT before expander surgery and during maximal tissue expansion. Chest wall deformity was assessed quantitatively using the Chest Wall Deformity Index (CWDI), which was measured before expander surgery (pre-CWDI) and during maximal tissue expansion (post-CWDI). Post minus pre (post−pre) CWDI was used as the index of chest wall deformity in the assessment of risk factors. Post-CWDI was significantly higher than pre-CWDI (3.66 ± 3.23% vs. 0.03 ± 2.74%, P

Background The nonsurgical treatment of chest wall deformity by a vacuum bell or external brace is gradual, with correction taking place over months. Monitoring the progress of nonsurgical treatment of chest wall deformity has relied on the ancient methods of measuring the depth of the excavatum and the protrusion of the carinatum. Patients, who are often adolescent, may become discouraged and abandon treatment. Methods Optical scanning was utilized before and after the intervention to assess the effectiveness of treatment. The device measured the change in chest shape at each visit. In this pilot study, patients were included if they were willing to undergo scanning before and after treatment. Both surgical and nonsurgical treatment results were assessed. Results Scanning was successful in 7 patients. Optical scanning allowed a visually clear, precise assessment of treatment, whether by operation, vacuum bell (for pectus excavatum), or external compression brace (for pectus carinatum). Millimeter-scale differences were identified and presented graphically to patients and families. Conclusion Optical scanning with the digital subtraction of images obtained months apart allows a comparison of chest shape before and after treatment. For nonsurgical, gradual methods, this allows the patient to more easily appreciate progress. We speculate that this will increase adherence to these methods in adolescent patients.

BACKGROUND: National data is limited on pectus excavatum, the most common chest wall deformity which is often repaired using the Ravitch and Nuss procedures. The purpose of the study was to describe demographics and outcomes of adult patients who underwent surgical repair of pectus excavatum via open and minimally invasive thoracoscopic methods. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2018 was performed, capturing patients 18 years or older with pectus excavatum as the postoperative diagnosis. Patients were placed into two groups of minimally invasive (Nuss) and open (Ravitch) repair procedure code. Baseline characteristics and postoperative outcomes were analyzed. RESULTS: A total of 168 adult patients were captured. Most of these patients were white (84.52%) male (69.64%) and 26 years old on average. Median operative time was longer in the open repair group [250 (IQR, 173–308) versus 122 (IQR, 94–160) minutes, P

As a result of the COVID-19 pandemic, most institutions have changed the way patients are assessed or investigated. Using novel non-contact technology, it is possible to continuously monitor the lung function of peri-operative patients undergoing cardiothoracic procedures. Primarily, this results in increased patient surveillance, and therefore, safety. Many centres, globally, are starting to use structured light plethysmography (SLP) technology, providing a non-aerosol generating procedure in place of traditional spirometry. While more evidence is needed, our clinical usage; previous and on-going studies; demonstrate definite potential that SLP is a valuable tool.

The Nuss procedure was introduced in 1998 as a less invasive surgical technique for correction of the chest wall deformity, pectus excavatum (PE). This chapter summarizes the clinical picture of PE, describes the Nuss procedure and explores the anesthetic requirements for a patient undergoing the procedure. The criteria for surgical correction and preoperative planning is outlined. Known and potential complications are discussed. Intra and postoperative pain management often presents a challenge to the anesthesiologist, therefore different methods of analgesia are examined. Multiple reviews of surgical outcomes describe success of the procedure as the surgical technique has been refined through the years.

The internal mammary vascular system has become the de facto preference for recipient vessels in microsurgical breast reconstruction. Harvest of the internal mammary vessels has historically required resection of a segment of the costal cartilage to facilitate exposure for the performance of microsurgical anastomosis. The “rib-sparing” approach to vessel harvest has evolved over the last two decades as a safe and reproducible model of vessel harvest, resulting in reduced patient morbidity and aesthetic chest wall deformity. This chapter will characterize the preoperative assessment, relevant anatomy, and surgical approach of the “rib-sparing” technique in the harvest of the internal mammary vessels.

Patients with severe chest wall deformity have a decreased capacity of the respiratory muscles due to rib cage deformity that can cause chronic respiratory failure. In recent years, NIMV treatment has become popular in patients with chronic respiratory failure due to chest-wall deformity. NIMV treatment can improve quality of sleep, physical activity, and quality of life.

Rationale: Custom-made implant is an accepted treatment option for treatment of chest deformity in Poland syndrome. Unlike the raised concerns and awareness for the long-term consequences of breast implants, the long-term complications of customized implants for special purposes like Poland syndrome has not been reported in the literature. Patient Concerns: A 44-year-old male with Poland syndrome presented to our institution complaining of a large bulge and fluctuation on the right chest wall. This occurred after 14 years from the initial implant surgery for correction of chest wall deformity. Upon failure of resolution by multiple aspirations, workup was carried out under suspicion of implant associated malignancy. Intervention: Total Capsulectomy and implant removal was done. Outcomes: Histology revealed chronic inflammation with fibrosis. Implant-associated malignancy was not found. He is being followed up with no signs of recurrence. Lessons: For rare cases of implant insertion such as Poland syndrome, awareness of delayed complications and workups based on suspicion of implant-associated malignancy is needed. Surgeon awareness and patient education is required.

Pectus excavatum is a chest wall deformity with an incidence of around 1 in 400 live births. The Nuss procedure is a surgical intervention that aims to restore functional integrity in these patients. We report the first case of bar migration into the stomach necessitating further surgical intervention for removal. Our case presents a rare complication of pectus excavatum repair and highlights the importance of vigilant follow-up in these patients. If bar migration does occur, imaging in the form of X-ray and CT scans may be of use in early detection in order to expedite management.

Background: pectus excavatum (PE) is the most common congenital deformity of the thoracic wall. Lately, significant achievements have been made in finding new, less invasive treatment methods for PE. However, most of the experimental work was carried out without the help of an animal model. In this report we describe a method to create an animal model for PE in Sprague-Dawley rats. Methods: We selected 15 Sprague-Dawley rat pups and divided them into two groups: 10 for the experimental group (EG) and 5 for the control group (CG). We surgically resected the last four pairs of costal cartilages in rats from the EG. The animals were assessed by CT-scan prior to surgery and weekly for four consecutive weeks. After four weeks, the animals were euthanized and the thoracic cage was dissected from the surrounding tissue. Results: On the first postoperative CT, seven days after surgery, we observed a marked depression of the lower sternum in all animals from the EG. This deformity was present at every CT-scan after surgery and at the post-euthanasia assessment. Conclusions: By decreasing the structural strength of the lower costal cartilages, we produced a PE animal model in Sprague-Dawley rats.

Breast asymmetry has been described as early as 1841 when Poland described the eponymous syndrome of chest wall deformity that can include musculoskeletal, breast and nipple malformations. While most patients have some asymmetry of the breast, there can be significant differences in size, shape and position in some patients requiring unique thought and approach to achieve satisfying aesthetic and symmetry goals for the patient and surgeon. Breast symmetry can have a significant psychological effects.

Pectus excavatum is the most common chest wall deformity, and some patients also have it combined with cardiac arrhythmias. It is a rare occurrence for there to be a severe conduction block that requires a temporary pacemaker implantation before the surgical correction. Here we reported a case of pectus excavatum with a second-degree atrial-ventricular (AV) block (Mobitz II) who had temporary pacemaker implantation before the Nuss procedure. The young patient had a chest wall deformity for 6 years and it got worse with age. The Haller index was 4.21, and we evaluated that he should receive the Nuss procedure. An AV block was found during the preoperative electrocardiogram examination; furthermore, Holter monitor proved that he had first-degree AV block and a second-degree AV block (Mobitz II). After consultation with the anesthesiologist and cardiologist, we suggested that a temporary pacemaker placement should be performed under local anesthesia before the minimally invasive operation and removed as soon as the patient revived from general anesthesia. A postoperative Holter monitor was implemented, and the conduction defect disappeared shortly after the operation. However, the Holter monitor showed that the conduction defect was still existed during the follow-up period, which indicated that severe conduction defects should be originated from the conduction system itself, rather than the compression to the heart. The temporary pacemaker was essential to ensure the conducting of the operation went smoothly.

Rib fractures are a serious problem in thoracic trauma resulting in high morbidity and mortality. Surgical stabilization in the management of rib fractures is gaining more popularity and recognition as outcomes continue to show positive results, however, there is still hesitancy among the trauma community to recommend this intervention. Although there still remains questions as to which patients to provide surgical stabilization to in the non-flail rib fracture patient population, surgical stabilization of rib fractures have been shown to be extremely beneficial in those patients with flail chest and should be strongly considered in this patient population, especially if they require ventilatory support. Here we present a 62-year-old female with severe chest wall deformity from 21 rib fractures after being trampled by a bull. This included a flail segment and a severely angulated 11th rib fracture piercing through the lung into the retroperitoneum. Furthermore, we also introduce a new technique for stabilization of rib fractures that are more posterior. Given the fact we surgically intervened early in our patient with severe chest wall trauma, she had a very favorable outcome, allowing her to be discharged from the hospital in a timely fashion with minimal overall morbidity. Keywords: Rib fractures, Flail chest, Surgical stabilization, Rib fixation, Chest wall deformity

Background To minimize cardiac perforation during the minimally invasive repair of pectus excavatum (MIRPE), several surgeons have suggested using a suction device to intraoperatively lift the sternum. Whether or not this technique is effective for all PE patients is not yet known. As such, our aim was to quantify the extent to which a suction device is capable of lifting the sternum with a short duration of use. Methods 30 PE patients received a low-dose CT scan as part of standard PE evaluation. A Vacuum Bell suction was then applied for only two minutes, and a repeat CT scan was obtained only at the deepest point of the chest wall deformity. We compared chest dimensions before and after Vacuum Bell suction. Results The Vacuum Bell lifted the sternum in all 29 patients included in the analysis. The absolute change in depth ranged from 0.29 to 23.67mm (M=11.02, SD=6.05). The average improvement in Haller index was 0.76. The suction was most effective for individuals with low BMI and smaller chest depths. Efficacy was not associated with gender, age, or chest morphology. Conclusions The Vacuum Bell device effectively lifted the sternum in PE patients with different demographics and chest morphologies. Future research is needed to address whether or not the device reduces risk of cardiac perforation during MIRPE. Levels of evidence Prognosis Study Level IV.

WOS: 000423449000012, PubMed ID: 27825548, Background: The minimally invasive pectus carinatum (PC) surgery described by Abramson has been performed in many centers. We have been using this technique since 2011. This article describes our experience with PC correction. Methods: Between 2011 and 2016, 32 patients at our institution underwent minimally invasive repair of a PC deformity. All patients presented with cosmetic complaints. The deformity involved the lower sternum (all had chondrogladiolar type PC), and three patients had asymmetrical deformities. All operations followed the principles defined by Abramson. Results: Satisfactory esthetic results were achieved in our patients. The hospital stay averaged 5.3 days (range 4-7 days). The most common early complication was pneumothorax, and the most common late complication was wire suture breakage. Conclusion: The Abramson technique is an effective, minimally invasive procedure for PC with shorter operating and hospitalization times and low morbidity rates. (C) 2016 Asian Surgical Association and Taiwan Robotic Surgical Association. Publishing services by Elsevier B.V.

Straight back syndrome is a rare condition usually associated with mitral valve prolapse and "pseudo-heart disease" caused by a very narrow anterior-posterior chest due to the loss of the normal dorsal curvature of the thoracic spine. More rarely, the narrowed upper chest may compress the trachea causing extrinsic tracheal obstruction. If severe enough, this requires operative repair by effectively opening up the upper chest by a variety of techniques to allow the trachea enough room to avoid compression.

Poland’s syndrome is a rare congenital condition classically characterized by partial or complete absence of chest muscles on one side of the body and usually webbing of the fingers of the hand on the same side. There may also be rib (aplasia or hypoplasia) and chest bone abnormalities, which may be noticeable due to less fat under the skin. Breast and nipple abnormalities may also occur, and underarm hair is sometimes sparse or abnormally placed. In most cases, the abnormalities in the chest area do not cause health problems or affect movement. Poland’s syndrome most often affects the right side of the body and occurs more frequently in males than in females. The etiology is unknown; however, interruption of the embryonic blood supply to the arteries that lie under the collarbone (subclavian arteries) is the prevailing theory. There are many methods of operative correction because of the polymorphic clinical features of this syndrome. We gathered data on the etiology, pathogenesis, and clinical presentation of Poland’s syndrome and reviewed the existing surgical treatment options.

Poland syndrome (PS) is a rare congenital condition with predominant unilateral chest wall deformity due to hypoplasia of the pectoralis muscles. However, its clinical features are highly variable as all the features may not be present in one individual or it may present with some rare associations or complications as being reported here. A 6-year-old boy was diagnosed, for the first time, as a case of PS but, detailed examination and work up revealed two rare associations and/or incidental findings of this disorder, namely, Dandy-Walker variant and partial anomalous pulmonary venous return. Hence, a detailed clinical examination and a through workup are mandatory to quantify the disease spectrum of this rare disorder.

Purpose: Pectus excavatum (PE) is the most common chest wall deformity in adolescents. The main complaint is cosmetic, but many patients also complain about exertional dyspnea. This may lead to the patient seeking surgery of the thoracic wall deformity (TWD). The assumption is that both, appearance and physical complaints will have a negative effect on being able or wanting to engage in sport activity. Methods: In December 2011 a prospective registration of sport activity in pectus excavatum patients started. Sport activity was assessed using questionnaires (CHQ SF-36 and PEEQ). Measurements were taken before corrective surgery (preoperatively) and 12 months postoperatively. Results: 127 patients have been included. The number of patients who were active in sports preoperatively and after 12 months remained steady. The type of sport activity, individual sport or team sport showed no significant change. The CHQ showed that physical activity caused fewer complaints (p

Monitoring the progress of therapeutic treatment is paramount to its success and to the patient's quality-of-life. An efficient, cost-effective, and accurate assessment of the treatment's progress that illustrates its tangible impact can motivate patients and guide the procedure. This work discusses such an assessment tool for both surgical and nonsurgical interventions to correct pectus excavatum – the most common chest wall deformity. The developed instrument utilizes optical scanning and registration techniques to provide an accurate evaluation of the improvement over the course of treatment. In this paper, a prospective study is conducted to report on and establish the validity of the instrument after deploying it for clinical use. Statistical tests are used to study the utility of the system in a clinical setting.

Pectus excavatum is the most common congenital chest wall deformity affecting 1 in 300–400 births. Patients typically describe a combination of physical and psychological symptoms relating to their deformity which can be debilitating for this young patient population. Surgical correction of the underlying chest wall deformity through internal bracing (MIRPE, minimally invasive repair of pectus excavatum or the Nuss procedure) or through a ‘break and re-set’ of the chest wall (modified Ravitch procedure) remains an important option in treating pectus excavatum particularly in the context of functional impairment.

This chapter describes the surgical procedure for “pectus carinatum repair” as performed by the open approach. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, needed equipment, and variations in technique for the procedure in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as that found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: incision and creation of myocutaneous flaps, exposure of the deformed chest wall, excision of the malformed costal cartilages with osteotomies and cartilaginous interposition, sternal plating, perichondrial plication, and rib reapproximation and closure.

INTRODUCTION Pectus excavatum (PE) is the most common paediatric chest wall deformity. The majority of patients are treated for cosmetic purposes, with the modified Ravitch and Nuss procedures the most commonly performed. We tested the preferences of healthy individuals over their choice of procedure. METHODS The study was conducted from February to August 2014. A five-item illustrated questionnaire was administered to teenagers and young adults aged 14–26 years over their willingness to seek medical advice if they had PE, provided its cosmetic appearance was the only complaint. They were asked about their preference over the modified Ravitch and Nuss procedures, with the surgical details for both procedures explained by medical professionals, alongside illustrated outcomes. RESULTS Two hundred and two healthy individuals were interviewed. The median age was 19.5 years (14–26 years) and 141 (69.8%) were male. Sixty seven (33.2%) participants refused any intervention, while 11 (5.4%) initially wanted an intervention but refused after understanding the surgical procedures available. Of the 135 respondents who chose surgical correction, 84 (62.2%) preferred the modified Ravitch operation, while 51 (37.8%) preferred the Nuss procedure. The main reason for choosing the modified Ravitch technique was not having something metal in the chest, while most participants who chose the Nuss procedure felt that it was “cosmetically better”. CONCLUSIONS Patients have preferences over the choice of procedure for PE repair that can affect the treatment decision. Paediatric and thoracic surgeons should therefore be experienced in performing both procedures.

Background/Aim: To determine the incidence of pectus excavatum (PE) and define anatomical chest wall metrics predictive of elevated mean heart dose (MHD) in patients with left-sided breast cancer receiving adjuvant radiotherapy. Patients and Methods: We reviewed 273 consecutively simulated patients from 1/2013-12/2014. Physical examination identified patients with clinically identifiable PE. Characteristics were compared between patients with and those without PE. Predictors of MHD were evaluated using linear regression. Results: The average MHD for the entire cohort was 172 cGy. Of 273 patients, 10 (3.7%) were found to have clinically significant PE. Increase in the Haller Index was correlated with higher MHD (p

Pectus arcuatum is a rare complex chest wall deformity. A 31-year-old female presented with a severely protruding upper sternum combined with a concave lower sternum. We planned a modified Ravitch-type operation. Through vertical mid-sternal incision, chondrectomies were performed from the second to fifth costal cartilages, saving the perichondrium. Horizontal osteotomy was performed in a wedge shape on the most protruding point, and followed by an additional partial osteotomy at the most concaved point. The harvested wedge-shape bone fragments were minced and re-implanted to the latter osteotomy site. The osteotomized sternum was fixed with multiple wirings. With chondrosternoplasty, a complex chest wall deformity can be corrected successfully.

Background: We used an Abramson technique for minimally invasive repair of pectus carinatum in patients who preferred surgery to brace therapy, had been unsuccessfully treated via brace therapy, or were unsuitable for brace therapy because of a rigid chest wall. Methods: Between July 2011 and May 2015, 16 patients with pectus carinatum underwent minimally invasive surgery. Results: The mean age of the patients was 24.35±13.20 years (range, 14–57 years), and all patients were male. The percentage of excellent aesthetic results, as rated by the patients, was 37.5%, and the percentage of good results was 56.25%. The preoperative and postoperative Haller Index values were 2.01±0.19 (range, 1.60–2.31), and 2.22±0.19 (range, 1.87–2.50), respectively (p-value=0.01), and the median hospital stay was 7.09±2.91 days (range, 5–15 days). Only one patient experienced postoperative complications. Conclusion: Minimally invasive repair is effective for the treatment of pectus carinatum, even in adult patients.

Poland’s syndrome (PS) is a congenital monolateral deformity that may involve breast, chest wall, and upper limb with different degrees of clinical expressions. In some cases, the problem is mainly cosmetic, and the reconstruction should be performed to achieve minimal scarring and donor site morbidity. The authors describe a case report of a male patient with PS who developed a severe capsular contraction after 25 years implant reconstruction, who was treated after explantation using free gracilis flap (FGF). In this patient, only the pectoralis major muscle was missing. An FGF was performed to reconstruct the anterior axillary fold and the soft tissue defect. There was no flap loss, the patient had a clearly improved appearance of the chest wall, and the pain syndrome was solved. In this case report, we demonstrate our experience with the use of an FGF for chest wall reconstruction in male patients with PS after prosthesis explantation.

Several measures were implemented among authors striving to tail off recurrence rates of thoracoscopic congenital diaphragmatic hernia repair. In the presented study, we extended the use of rib-anchoring stitches to reorient the diaphragmatic muscle leaflets in the types BC two ventilatory barotrauma and two mortalities. After a mean follow-up period of 29 months, five recurrences were reported (16%). Ipsilateral chest wall deformity was noticed in one case 3 years post repair. In the presented study, authors adopted thoracoscopic reorientation of diaphragmatic muscle leaflets in lateral congenital diaphragmatic hernia cases to achieve tension dispersal at primary repair. Short and mid-term results supported the efficacy and reproducibility of the described approach. However, long-term comparative studies seemed a necessity to validate this outcome.

BackgroundPectus excavatum, the most common chest wall deformity in children, accounts for nearly 90% of congenital malformations of chest wall. Initially, both parents and doctors paid more attention to the influence of this deformity on patient appearance and psychology. Following deeper studies of pectus excavatum, researchers found that it also affected cardiac functions. The purpose of this review aims to present recent research progress in the effects of pectus excavatum on cardiac functions.Data sourcesBased on aspects of CT, ultrasound cardiography (UCG) and MRI, all the recent literatures on the influence of pectus excavatum on cardiac function were searched and reviewed.ResultsModerate and severe pectus excavatum did have a negative effect on cardiac function. Cardiac rotation angle, cardiac compression index, right atrial and tricuspid annulus size, septal motion and myocardial strain are relatively effective indexes to evaluate cardiac function.ConclusionsPectus excavatum did have a negative effect on cardiac function; so surgeons should actively diagnose and treat such patients in clinical work. However, further research is needed on to explore the measures and indicators that can reflect the changes of cardiac function in patients objectively, accurately, effectively and timely.