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Background: Epidural analgesia (EA) is effective in patients undergoing minimal invasive repair of pectus excavatum (MIRPE) but is associated with major complications such as epidural hematomas. It is recommended to assess coagulation status in patients receiving anticoagulant therapy prior to EA, although no consensus exists in patients without a history of bleeding tendency or anticoagulant therapy. Thus, the aim of this paper was to assess 1) the prevalence of abnormal routine coagulation parameters, i.e., international normalized ratio (INR) and platelet count, and 2) the safety of EA in patients undergoing MIRPE.Methods: In this retrospective study, we identified 1,973 patients undergoing MIRPE at our center between 2001 and 2019. Complications related to EA were registered for all patients. Information on coagulation parameters was present in 929 patients. Patients with spontaneously elevated INR ≥1.5 were referred for assessment of coagulation factor VII in order to assess the cause of the elevated INR.Results: Of 929 patients with coagulation information available, 18 patients had spontaneously elevated INR ≥1.5 (1.9%). In patients with INR ≥1.5, 12 patients underwent further assessment of factor VII, with all patients having a slightly reduced factor VII close to the lower reference range. The majority of the 1,973 patients undergoing MIRPE received EA (99.6%) with very low complication rates (0.2%) and no incidence of epidural hematomas.Conclusion: In patients undergoing MIRPE, coagulation screening prior to EA should not be mandatory as it revealed no clinically relevant consequences. EA is safe with very low complication rates. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Patients with pectus excavatum (PE) after prior sternotomy for cardiac surgery present unique challenges for repair of PE. Open repairs have been recommended because of concerns about sternal adhesions and cardiac injury. We report a multi-institutional experience with repair utilizing substernal Nuss bars in this patient population. METHODS: Surgeons from the Chest Wall International Group were queried for experience and retrospective data on PE repair using substernal Nuss bars in patients with a history of median sternotomy for cardiac surgery (November 2000 to August 2015). A descriptive analysis was performed. RESULTS: Data for 75 patients were available from 14 centres. The median age at PE repair was 9.5 years (interquartile range 10.9), and the median Haller index was 3.9 (interquartile range 1.43); 56% of the patients were men. The median time to PE repair was 6.4 years (interquartile range 7.886) after prior cardiac surgery. Twelve patients (16%) required resternotomy before support bar placement: 7 preemptively and 5 emergently. Sternal elevation before bar placement was used in 34 patients (45%) and thoracoscopy in 67 patients (89%). Standby with cardiopulmonary bypass was available at 9 centres (64%). Inadvertent cardiac injury occurred in 5 cases (7%) without mortality. CONCLUSIONS: Over a broad range of institutions, substernal Nuss bars were used in PE repair for patients with a history of sternotomy for cardiac surgery. Several technique modifications were reported and may have facilitated repair. Cardiac injury occurred in 7% of cases, and appropriate resources should be available in the event of complications. Prophylactic resternotomy was reported at a minority of centres. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The Nuss procedure was originally thought to be the method to correct pectus excavatum in children and teenagers. It is now a well-established technique, and is also used in older patients. The aim of this study was to investigate the results in patients ≥30 years of age. Methods: Since 2001, we have routinely used the Nuss procedure for correction of pectus excavatum in more than 700 patients. The indication for surgery has been disabling cosmetic appearance. All operations have been performed by the same surgeon. Patient records were retrospectively analyzed. Results: The study included fifty-two patients, who were ≥30 years or older (range 30–53 years), with median age 37 years; and 85% were males. There was no operative mortality. Nearly three-quarters (70%) needed two bars or more to obtain a satisfactory perioperative result. The median operating time was 60min (range 18–104min). The median postoperative stay was 4 days (range 3–29 days). Postoperative complications were few; one patient developed deep infection after re-operation caused by lateral dislocation of the bars. Conclusion: The Nuss procedure can be used in older patients with excellent results. The operation time in their case is longer than in young patients because more patients need two bars; but the postoperative stay is equivalent to that in young patients. [Copyright &y& Elsevier]

Abstract: Objective: During minimal invasive surgical correction of pectus excavatum the metal bar is rotated 180° and fixed by one or two stabilisers. Previously, all stabilisers were made from metal, but they often caused chronic pain and had to be removed. Recently, a slowly absorbable stabiliser made from Lactosorb® has been introduced. Methods: From 2001 to 2008 a total of 507 patients underwent minimally invasive repair of pectus excavatum at Aarhus University Hospital. Since February 2007 we routinely used absorbable stabilisers made by Lactosorb®. We always used shorter pectus bars than originally suggested and always placed one stabiliser close to the entry in the thoracic cavity on the left side. All operations were performed by the same surgeon and all patients were seen 6 weeks after surgery. Patient records were reviewed for retrospective analysis. Results: In 422 patients we used a metal stabiliser while 85 patients received a Lactosorb® stabilizer. Seven patients received two stabilisers. During the follow-up period one metal stabiliser broke after 2(1/2) years (0.2%), but within 6 weeks after surgery three Lactosorb® stabilizers broke (3.5%) and another three dislocated laterally (3.5%). Conclusions: Absorbable stabilisers may be used for minimal invasive surgery for pectus excavatum but they are more vulnerable and break easier than metal stabilisers. This is likely a consequence of high stress forces that may be more pronounced in patients who receive a shorter pectus bar, but further research is needed. [Copyright &y& Elsevier]

The article comments on a study published within the issue which examined the possibility of detecting postoperative improvements in cardiac functions through magnetic resonance imaging (MRI) in patients with pectus excavatum at rest. The authors argued that the study failed to demonstrate clear objective measurements of the dynamic parameters of the physiology of patients hence its questionable conclusions.

The author discusses the Nuss procedure in which pectus excavatum (PE) represents an estimated 90% of the anomalies of the anterior chest wall and indicates an increase in corrections. Topics include the assumed growth retardation related to PE, the pathogenesis that causes PE represents an overgrowth of the cartilages and the study of Chang's group which focuses on the PE patient's chest length that shows no difference in height compared to PE patients with an age-matched group without PE.

Background Pectus excavatum (PE) can be associated with cardiac anomalies and some patients may have had prior sternotomy and cardiac procedures. Use of the Nuss procedure after sternotomy for PE repair is controversial. Methods and patients A survey of surgeons from the Chest Wall International Group was performed for data on patients for which they performed an attempted Nuss after prior sternotomy during November 2000-August 2015. Patient clinical records, demographics, operative course, outcomes and surgeon experience were summarized. Results Thirteen surgeons reported on 72 patients with prior sternotomy for cardiac surgery a mean of 7.7 years (median 5.7, range 0.8-27.2) before pectus repair. Mean age at PE repair was 11.5 years (median of 8.8, range 1.7-48.7); Haller index 5.1 (median of 3.96, range 2.8-20.5); 54.2% males; 98.6 % were successfully repaired with a modified Nuss. However, in 15.3% a redo sternotomy was performed prior to placement of support bars. Assisted sternal elevation (45.8%) and subxiphoid dissection (12.5%) was also described. Three cases of cardiac perforation occurred with no mortalities reported. Nine of 13 centers (69%) had cardiopulmonary bypass on standby should cardiotomy be experienced. Conclusions A modified Nuss procedure can be used to successfully repair PE in the majority of patients after prior sternotomy. The risk of cardiac injury is greater in this population and technique modifications including forced sternal elevation and directly visualized subxiphoid dissection should be considered if significant mediastinal adhesions are present. Re-sternotomy may be necessary and cardiopulmonary bypass should be available. [ABSTRACT FROM AUTHOR]

Complications following the Nuss procedure for the correction of pectus excavatum later than 30 days are rare. We report of a 40-year old man who developed dyspnoea and was diagnosed with a pulmonary stenosis more than 2 years after undergoing the Nuss procedure. This was discovered to be caused by a displaced pectus bar. Following removal of the pectus bars, the symptoms along with the right ventricular outflow tract obstruction disappeared. [ABSTRACT FROM PUBLISHER]

A response from the author of the article "Improved cardiopulmonary exercise function after modified operation for pectus excavatum," in the previous issue is presented.

Abstract: Objective: Surgical correction of pectus excavatum (PE) is primarily performed to achieve cosmetic and psychological benefits for the patient. Minimally invasive repair of PE is often associated with severe postoperative pain. This study estimates the effect of the severity of PE on the postoperative consumption of opioid analgesics following this procedure to optimise pain management. Methods: A retrospective study was conducted on 236 consecutive patients undergoing minimally invasive repair of PE from 2005 to 2008. The collected data included depth of preoperative pectus excavation, patient demographics, peri- and postoperative information, including data on pain management. The consumption of opioid analgesics was registered after discontinuation of epidural analgesia and other types of opioid analgesics used during the study period were converted to morphine equivalents. Multiple linear regression analysis was performed to estimate the effect of the severity of PE on the postoperative consumption of opioid analgesics and to adjust for potential confounding. Results: The total morphine consumption following minimally invasive repair of PE ranged between 20 and 370mgday−1. Multiple linear regression analysis explained approximately 30% of the variation in daily morphine consumption (R-squared=0.2957). There was a significant positive linear relationship between pectus severity and the daily consumption of morphine. Thus, postoperative consumption of morphine increased by 6% (95% confidence interval (CI): 0.3–11%) when preoperative PE depth deteriorated with 1cm. Conclusion: This study confirms that pectus severity has a significant impact on the consumption of opioid analgesics following minimally invasive repair of PE. We conclude that knowledge of pectus severity might be useful in the prediction of the expected morphine consumption in future patients, especially during the critical transition period from epidural analgesia to oral analgesia. [Copyright &y& Elsevier]

Abstract: Objective: Very few data are available on complications following elective bar removal after the Nuss procedure for pectus excavatum. The objective of this study was to investigate the data from 343 consecutive patients. Methods: From 2003 to 2009, 343 patients (85% males) had their pectus bar removed. Nine patients were excluded because of bar removal within the first year after implantation. Data were recorded from hospital records regarding: operation time, formation of callus around the bar, unilateral or bilateral incision, complications, postoperative hospital stay and if a senior resident or an intern performed the operation. Results: The median age at the time of bar removal was 19.1 years. The median time for removal after insertion of the bar was 1139 days (range 641–2575 days). The median operation time was 34min (range 5–183min). The operation time depended on the formation of callus around the bar (p <0.0001), numbers of bars to be removed (p <0.0002), the need for bilateral incision (p <0.0001) and the charge of the surgeon performing the operation (p <0.0008). Eight patients (2.4%) had complications after the surgery. Five patients had pneumothorax, of which three were treated with chest tubes, and two controlled with chest X-ray. Three patients had hemothorax. Two were treated with a chest tube and the third required open surgery. Most of the patients were discharged on the day of surgery (94%) or the day after surgery (4%). Only six (2%) required more than a single day of hospitalization. Conclusions: Bar removal following the Nuss procedure is a quick and safe operation with very few complications. Occurrence of complications is not dependent on the experience of the surgeon. [Copyright &y& Elsevier]

OBJECTIVES Patients with pectus excavatum have compromised cardiac function during exercise. We hypothesized that the Nuss technique would improve cardiopulmonary function during exercise. METHODS We investigated 75 teenagers (49 patients and 26 controls) at rest and during bicycle exercise prior to surgery and 1 year postoperative. RESULTS Prior to surgery, patients had a lower cardiac index 6.6 ± 1.1 l/min/m2 when compared with controls 8.1 ± 1.0 l/min/m2 during submaximal exercise, P = 0.0001. There was no difference in heart rate or increase in heart rate between the two groups. One year after surgery, cardiac index had significantly increased in the pectus group, P = 0.0054 although cardiac index was still significantly lower 7.2 ± 1.0 l/min/m2 when compared with the control subjects (8.5 ± 1.6 l/min/m2, P = 0.0008). Both the patients and the controls increased their VO2 max during the one-year study period although the controls increased most. Right ventricular diastolic dimension increased in both groups over the one-year study period and left ventricular dimensions increased in the patients. Before operation, the patients had lower forced expiratory capacity FEV1 86 ± 13% when compared with controls 94 ± 10%, P = 0.009. Patients increased FEV1/forced vital capacity over the one-year long study course although there were no differences between groups. CONCLUSION Patients with pectus excavatum have lower cardiac index at submaximal exercise when compared with healthy age-matched controls. Their cardiac index and FEV1 are increased one year after the modified Nuss operation. [ABSTRACT FROM AUTHOR]