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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]

Pectus excavatum (Pectus) repair may be offered for those with significant cardiopulmonary compromise or severe cosmetic defects. The influence of hospital center volume on postoperative outcomes in children is unknown. This study aimed to investigate the outcomes of children undergoing Pectus repair, stratified by hospital surgical volume. The Nationwide Readmission Database was queried (2016–2020) for patients with Pectus (Q67.6). Patients were stratified into those who received repair at high-volume centers (HVCs; ≥20 repairs annually) versus low-volume centers (LVCs; <20 repairs annually). Demographics and outcomes were analyzed using standard statistical tests. A total of 9414 patients with Pectus underwent repair during the study period, with 69% treated at HVCs and 31% at LVCs. Patients at LVCs experienced higher rates of complications during index admission, including pneumothorax (23% vs. 15%), chest tube placement (5% vs. 2%), and overall perioperative complications (28% vs. 24%) compared to those treated at HVCs, all p < 0.001. Patients treated at LVCs had higher readmission rates within 30 days (3.8% vs. 2.8% HVCs) and overall readmission (6.8% vs. 4.7% HVCs), both p < 0.010. Among readmitted patients (n = 547), the most frequent complications during readmission for those initially treated at LVCs included pneumothorax/hemothorax (21% vs. 8%), bar dislodgment (21% vs. 12%), and electrolyte disorders (15% vs. 9%) compared to those treated at HVCs. Pediatric Pectus repair performed at high-volume centers was associated with fewer index complications and readmissions compared to lower-volume centers. Patients and surgeons should consider this hospital volume-outcome relationship. Retrospective Comparative. III. • Previous studies on outcomes in HVCs compared to LVCs have been limited in the volume of patients and centers enrolled, as well as the quality and homogeneity of the data. Most of them have yet to examine this relationship, specifically with surgical repair of pectus. • This is the first study to examine the influence of hospital center volume on postoperative outcomes and cost in children undergoing pectus repair. [ABSTRACT FROM AUTHOR]

Anterior chest wall depression known as Pectus excavatum (PE) , is currently the most common congenital chest wall deformation, with incidence estimated at 1/400 births, five times more frequently in boys than girls (5:1 ratio in occurrence). 1 Etiology of this deformity is formed by several hypothesis, including overgrowth of the ribs, developmental failure of the bony thorax or weakness and abnormal flexibility of the sternum. While theoretical concepts of its origin may differ, the common ground is the characteristics of said deformation: a posterior depression of the sternum and the lower costal cartilages. 2 Surgical treatment options were described since 1949 with Ravitch procedure and since then a number of new ones has been developed. For many years Ravitch and Nuss procedures were the main way to treat pectus excavatum, with a growing bias towards latter one. Since the Nuss procedure characterizes with less invasive approach and fever overall complications 3 its popularity outgrew Ravitch procedure and currently is described as MIRPE – Minimally Invasive Pectus Excavatum Repair. 4 However afterward then many new techniques were developed, focusing on reducing overall procedure risks, improving patient safety and quality of life and including new technical possibilities. The aim of this study was to gather and evaluate current literature to highlight new treatment options.

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.

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]

Abstract 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.

Surgical correction of pouter pigeon chest deformity traditionally requires invasive procedures including total removal of the affected costal cartilages and major dissection of the sternum. We present a novel minimally invasive two-stage technique that was applied to an 8-year-old girl. First, the depressed lower chest was elevated using a plate with the Nuss procedure. Then, after 30 months, simultaneously with plate removal, correction of the remaining projection of the upper chest was also performed. This involved excision of only two pairs of deformed costal cartilage and a local osteotomy at the manubriosternal joint. Intraoperative blood loss was 20 mL, and the patient was discharged 7 days postoperatively. Because both the primary and secondary stages involve manual bending of the costal cartilages, our procedure may be suitably indicated only for patients in their early teenage years.

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]

Objective: Pectus excavatum (PE) repair is burdened by severe postoperative pain. This retrospective study aimed to determine whether the analgesic effect of ultrasound-guided erector spinae plane block (ESPB) plus standard intravenous analgesia (SIVA) might be superior to SIVA alone in pain control after PE surgical repair via Ravitch or Nuss technique. Design: A retrospective cohort study. Setting: At a university hospital. Participants: All participants were scheduled for surgical repair of PE. Interventions: From January 2017 to December 2019, all patients who received ESPB plus SIVA or SIVA alone were investigated retrospectively. A 2:1 propensity-score matching analysis considering preoperative variables was used to compare analgesia efficacy in 2 groups. All patients received a 24-hour continuous infusion of tramadol, 0.1 mg/kg/h, and ketorolac, 0.05 mg/kg/h, via elastomeric pump, and morphine, 2 mg, intravenously as a rescue drug. The ESPB group received preoperative bilateral ESPB block. Postoperative pain, reported using a numerical rating scale at 1, 12, 24, and 48 hours after surgery; the number of required rescue doses; total postoperative morphine milligram equivalents consumption; and the incidence of postoperative nausea and vomit were analyzed. Measurement and Main Results: A total of 105 patients were identified for analysis. Propensity-score matching resulted in 38 patients in the SIVA group and 19 patients in the ESPB group. Postoperative pain, the number of rescue doses, and postoperative nausea and vomit incidences were lower in the ESPB group (p < 0.005). Conclusions: Erector spinae plane block may be an effective option for pain management after surgical repair of PE as part of a multimodal approach. This study showed good perioperative analgesia, opioid sparing, and reduced opioid-related adverse effects. [ABSTRACT FROM AUTHOR]

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.

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 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]

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.

Aims: (1) To compare the efficacy of bupivacaine/fentanyl and ropivacaine/fentanyl for postoperative pain control (2). To identify the predictors of acute post-operative pain at rest, during deep breathing and coughing. Methods: The study was performed in patients aged 6-18 years after thoracic surgery. The subjects were randomized to the bupivacaine 0.125%/fentanyl 5.0 μg/mL (n=46) or ropivacaine 0.2%/fentanyl 5.0 μg/mL (n=48) group; analgesic mixtures were administered through epidural catheter. All the patients received paracetamol and non-steroidal anti-inflammatory drugs. The observation period after surgery lasted 72 h. Pain intensity was assessed at rest, during deep breathing and coughing and was based on the Numerical Rating Scale and the FLACC scale (range 0-10). If the pain was above 2/10, the analgesia was modified. Results: Median pain scores at rest (0.4 vs. 0.5), during deep breathing (0.3 vs. 0.3) and coughing (0.6 vs. 0.6) were comparable in BF and RF group. The intensity of pain at rest was associated with the number of drains inserted into the thorax (β=0.39), the number of pain intensity measurements (β=0.36) and the number of nursing interventions undertaken to relieve pain (β=0.16). Pain intensity at rest determined the intensity of pain during deep breathing (β=0.60), which in turn decided on the severity of pain during coughing (β=0.80). The intensity of pain was increased by age. Conclusions: Thoracic epidural bupivacaine/fentanyl provided adequate pain relief and similar analgesia to ropivacaine/fentanyl. The effectiveness of analgesia depended on the number of pain measurements and interventions by nurses to relieve the pain. Trial Registration: ClinicalTrials.gov; Multimodal Analgesia in Children and Adolescents After the Ravitch Procedure and Thoracotomy; NCT03444636; https://clinicaltrials.gov/ct2/show/NCT03444636

Aims/Background. The proportion of patients who experience anxiety prior to planned surgery, even a minimally invasive one, is estimated at 50-70%. Thoracic surgery, causes significant preoperative anxiety, especially in children. The aim of this study was to determine the effect of an important component of psychological preparation for a surgery as information support on levels of anxiety, pain and satisfaction with postoperative analgesia. Methods: The randomized double blind study including patients aged 9-18 years qualified for lateral thoracotomy or Ravitch procedure. The subjects were randomized to the control group (n=56) provided with a routine preoperative information by a nurse, and the experimental group (n=56) offered additional psychological consultation. Data were collected via the State-Trait Anxiety Inventory. Results: In the experimental group, the level of state anxiety at 48 h post-surgery was significantly lower than prior to the procedure, but only in subjects with preoperative trait anxiety Conclusion: Information support from a psychologist offered prior to a thoracic surgery decrease the level of postoperative state anxiety solely in children with lower levels of trait anxiety. Higher level of postoperative state anxiety negatively affect patients' satisfaction with post-surgical analgesia. Trial Registration: ClinicalTrials.gov; Influence of Preoperative Support on Anxiety, Pain and Satisfaction With Postoperative Analgesia; NCT03488459, https://clinicaltrials.gov/ct2/show/record/NCT03488459?cntry=PL&city=Rabka-Zdr%C3%B3j&rank=1

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Background: A number of techniques are described for correction of pectus excavatum (PE). This article describes the experience with an innovative procedure which combines features from the Ravitch and Nuss procedures without using prosthetic material. Methods: This cross-sectional study included 12 cases of PE from January 2000 to March 2017 managed by excision of deformed costal cartilages and support to the thoracic cage using an autologous free rib graft as a strut. Indication for surgery was Haller's Index above 3.2 with or without respiratory distress. Noncontrast computed tomography scans were done at 6 months after surgery to document the position of the strut and to see the final correction and new Haller's Index, respectively. Results: The male-to-female ratio was 2:1. Preoperative Haller's Index in all cases was >3.2 (range 3.25–14). The average age at surgery was 5 years and 8 months (range: 7 months–15 years). Mean duration of hospital stay was 11 days (range 5–16 days).The 11th rib was used commonly although in two cases, the 10th rib was used as the 11th rib was considered relatively short. Pericardial effusion requiring strut removal was seen in one case; in another case, removal of the rib was needed because of nonhealing of a delayed dehisced surgical wound. Others had an uneventful postoperative period. The mean postoperative Haller's Index was 2.75 (range 2.0–7). Conclusion: This modified procedure using an autologous rib strut is technically feasible and reproducible even with limited facilities and gives excellent results.

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]

Pectus excavatum (PEXT) consists of an overgrowth of the chondral region with posterior displacement of the inferior part of the sternum, resulting in a concave chest deformity. Characteristic clinical and imaging findings may occur, depending on the compression that right cardiac chambers suffer, when squeezed between the sternum and the column vertebrae.

Aims. (1) To compare the efficacy of bupivacaine/fentanyl and ropivacaine/fentanyl for postoperative pain control (2). To identify the predictors of acute post-operative pain at rest, during deep breathing and coughing. Methods. The study was performed in patients aged 6-18 years after thoracic surgery. The subjects were randomized to the bupivacaine 0.125%/fentanyl 5.0 μg/mL (n=46) or ropivacaine 0.2%/fentanyl 5.0 μg/mL (n=48) group; analgesic mixtures were administered through epidural catheter. All the patients received paracetamol and non-steroidal antiinflammatory drugs. The observation period after surgery lasted 72 h. Pain intensity was assessed at rest, during deep breathing and coughing and was based on the Numerical Rating Scale and the FLACC scale (range 0-10). If the pain was above 2/10, the analgesia was modified. Results. Median pain scores at rest (0.4 vs. 0.5), during deep breathing (0.3 vs. 0.3) and coughing (0.6 vs. 0.6) were comparable in BF and RF group. The intensity of pain at rest was associated with the number of drains inserted into the thorax (β=0.39), the number of pain intensity measurements (β=0.36) and the number of nursing interventions undertaken to relieve pain (β=0.16). Pain intensity at rest determined the intensity of pain during deep breathing (β=0.60), which in turn decided on the severity of pain during coughing (β=0.80). The intensity of pain was increased by age. Conclusions. Thoracic epidural bupivacaine/fentanyl provided adequate pain relief and similar analgesia to ropivacaine/ fentanyl. The effectiveness of analgesia depended on the number of pain measurements and interventions by nurses to relieve the pain. Trial Registration: ClinicalTrials.gov; Multimodal Analgesia in Children and Adolescents After the Ravitch Procedure and Thoracotomy; NCT03444636; https://clinicaltrials.gov/ct2/show/NCT03444636 [ABSTRACT FROM AUTHOR]

Aims/Background. The proportion of patients who experience anxiety prior to planned surgery, even a minimally invasive one, is estimated at 50-70%. Thoracic surgery, causes significant preoperative anxiety, especially in children. The aim of this study was to determine the effect of an important component of psychological preparation for a surgery as information support on levels of anxiety, pain and satisfaction with postoperative analgesia. Methods. The randomized double blind study including patients aged 9-18 years qualified for lateral thoracotomy or Ravitch procedure. The subjects were randomized to the control group (n=56) provided with a routine preoperative information by a nurse, and the experimental group (n=56) offered additional psychological consultation. Data were collected via the State-Trait Anxiety Inventory. Results. In the experimental group, the level of state anxiety at 48 h post-surgery was significantly lower than prior to the procedure, but only in subjects with preoperative trait anxiety <7/10 sten. In the control group, the level of postoperative anxiety was significantly higher than prior to the surgery; this effect was observed irrespectively of preoperative trait anxiety level. Lack of preoperative psychological consultation (β=-0.23), trait anxiety ≥7 sten (β=0.25), and higher level of preoperative state anxiety (β=0.65) were independent predictors of greater state anxiety at 48 h post-surgery. Patients from the experimental group did not differ significantly from the controls in terms of their median pain scores and satisfaction with postoperative analgesia. Greater state anxiety was associated with 22% lesser likelihood of complete satisfaction with the analgesia. Conclusion. Information support from a psychologist offered prior to a thoracic surgery decrease the level of postoperative state anxiety solely in children with lower levels of trait anxiety. Higher level of postoperative state anxiety negatively affect patients' satisfaction with post-surgical analgesia. [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]

Pectus excavatum (PEXT) consists of an overgrowth of the chondral region with posterior displacement of the inferior part of the sternum, resulting in a concave chest deformity. Characteristic clinical and imaging findings may occur, depending on the compression that right cardiac chambers suffer, when squeezed between the sternum and the column vertebrae. [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]

Skeletal deformities in the form of pectus excavatum or scoliosis are unavoidable sequalae of large diaphragmmatic defects irrespective of the technique of repair used at the time of primary procedure. These sequelae lead to cosmetic and functional issues in the rapidly growing skeleton of a young child. The crux of management is adequate correction of these deformities with minimal residual functional impairment. A customized case-based approach using the modified Ravitch procedure is an excellent technique to repair these pectus defects. We describe such a procedure in a 3-year-old girl. [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]

Abstract: Background/Purpose: Anticipated postoperative pain may affect procedure choice in patients with pectus excavatum. This study aims to compare postoperative pain in patients undergoing Nuss and Ravitch procedures. Methods: A 5year retrospective review was performed. Data on age, gender, Haller index, procedure, pain scores, pain medications, and length of hospital stay were collected. Total inpatient opioid administration was converted to morphine equivalent daily dose per kilogram (MEDD/kg) and compared between procedures. Results: One hundred eighty-one patients underwent 125 (69%) Nuss and 56 (31%) Ravitch procedures. Ravitch patients were older (15.7 yo vs 14.6 yo, p=0.004) and had a higher Haller index (5.21 vs 4.10, p=<0.001). Nuss patients had higher average daily pain scores, received 25% more opioids (MEDD/kg 0.66 vs. 0.49, p=<0.001), and received twice as much IV diazepam/kg. In the multivariate analysis, higher MEDD/kg correlated with both the Nuss procedure and older age in the Nuss group. Opioid administration did not correlate with Haller index or Nuss bar fixation technique. Increased NSAID administration did not correlate with lower use of opioids. Conclusion: The Nuss procedure is associated with greater postoperative pain compared to the Ravitch procedure. Opioid use is higher in older patients undergoing the Nuss procedure, but is not associated with severity of deformity. [Copyright &y& Elsevier]

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]

Objective: To assess the factors related to perioperative state anxiety in paediatric patients and their parents., Methods: A cohort study was conducted on paediatric patients 9-17 years of age, who underwent the modified Ravitch procedure ( n = 96), and their parents ( n = 96). The level of anxiety was measured using the State-Trait Anxiety Inventory questionnaire. Multivariable linear regression models were calculated to find the relationships between the pre- and postoperative state anxiety of the patients/parents and the independent variables, both demographic (age, gender) and clinical (e.g., postoperative pain, trait anxiety)., Results: Preoperative anxiety in the paediatric patients was positively correlated with their trait anxiety (β = 0.47; 95% CI: 0.29 to 0.64) and preoperative parental anxiety (β = 0.24; 95% CI: 0.07 to 0.42). The high level of preoperative anxiety (vs. low and moderate) (β = 0.40; 95% CI: 0.22 to 0.58), trait anxiety (β = 0.22; 95% CI: 0.04 to 0.40) and average postoperative pain at rest (β = 0.18; 95% CI: 0.01 to 0.34) had a positive impact on the postoperative anxiety in patients. However, the patients' age was negatively correlated with postoperative anxiety (β = -0.19; 95% CI: -0.35 to -0.02). Three variables were found to predict preoperative parental anxiety: their trait anxiety (β = 0.41; 95% CI: 0.23 to 0.59), female gender (β = 0.18; 95% CI: 0.002 to 0.36) and the intravenous route for the postoperative pain management in the patients (β = -0.18; 95% CI: -0.36 to -0.001). The parental postoperative anxiety was influenced by their trait anxiety (β = 0.24; 95% CI: 0.04 to 0.43), preoperative anxiety in patients (β = 0.21; 95% CI: 0.02 to 0.40) and female gender of children (β = 0.19; 95% CI: 0.001 to 0.39)., Conclusions: Trait anxiety was a strong factor positively affecting the perioperative state anxiety. In addition, paediatric patient anxiety before surgery was related to their parents' anxiety, and, after surgery, this was associated with high preoperative anxiety, pain and age. The parents' anxiety before surgery was influenced by gender and the type of postoperative analgesia in the patients, while, after surgery, this was influenced by the patients' preoperative anxiety/gender.

Objective: To compare the efficacy of analgesia with intravenous infusion of morphine and thoracic epidural infusion of ropivacaine with fentanyl in pediatric patients after the Ravitch procedure., Methods: Postoperative analgesia was achieved by intravenous morphine infusion with a dose of 0.02-0.06 mg/kg per hour (intravenous group, n = 56) or thoracic epidural infusion of 0.2% ropivacaine and fentanyl 5 µg/mL with a flow rate of 0.1 mL/kg per hour (epidural group, n = 40). Furthermore, the multimodal pain management protocol included paracetamol, non-steroidal anti-inflammatory drugs, and metamizole as a rescue drug. The primary outcomes included pain scores (according to the Numerical Rating Scale, range 0-10), while the secondary outcomes included consumption of the rescue drug, anxiety, postoperative side effects, and patient satisfaction. The observation period lasted from postoperative day 0 to postoperative day 3., Results: Median average and maximal pain scores at rest, during deep breathing, and coughing were significantly lower in the intravenous group compared to the epidural group ( p < 0.05). The effect size was medium (Cohen's d ranged from 0.5 to 0.7). Patients receiving morphine required significantly lower numbers of metamizole doses than in the epidural group (median 1 vs. 3; p = 0.003; Cohen's d = 0.6). Anxiety, postoperative side effects, and patient satisfaction were similar in both groups ( p > 0.05)., Conclusions: An intravenous infusion of morphine may offer better postoperative analgesia than a thoracic epidural infusion of ropivacaine with fentanyl.

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]

Abstract: Background/Purpose: Despite success of several techniques described for pectus excavatum repair, a minority of patients require multiple reoperations for recurrence or other complications. We aimed to review our experience in reoperative pectus excavatum repairs and to identify features correlating with need for additional reoperations. Methods: Charts were reviewed of all patients undergoing reoperative pectus excavatum repair for 3 years at a university-based children''s hospital. Number and type of previous repairs, time between operations, lengths of stay, analgesia, and complications were recorded. Results: From February 2004 to December 2007, 170 pectus excavatum repairs were performed. Among these, 27 were reoperative. Overall, 18.2% of reoperative patients required subsequent additional reoperations. 21.1% of patients undergoing repeat open repairs and 33.3% of patients undergoing repeat minimally invasive repairs required further operative interventions. There was no need for additional repairs among patients who had open repairs after minimally invasive repairs, nor for any patients who had minimally invasive repairs after open repairs. Conclusions: We conclude that patients with failed open repairs will have better success with minimally invasive reoperations, whereas patients with failed minimally invasive repairs will have better success with open reoperations. When faced with reoperative pectus excavatum, we recommend consideration of an alternative operative approach from the initial procedure. [Copyright &y& Elsevier]

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]

Abstract: Purpose: The purpose of this study was to compare clinical and health-related quality-of-life (HRQL) outcomes within a group of patients treated for pectus excavatum (PE). Methods: A retrospective 3-year review of patients undergoing Nuss or Ravitch correction of PE was performed. Health-related quality-of-life assessment was performed using the Child Health Questionnaire (CHQ-CF87) and the 17-item Pectus Excavatum Evaluation Questionnaire, and results were compared between groups and with age-matched CHQ-CF87 normative data. Results: Forty-three patients (39 males; 91%) underwent surgery; 19 (44%) by Nuss procedure. Duration of postoperative opioid analgesia and length of hospital stay (LOS) were significantly longer in Nuss patients. The overall survey response rate was 53%. The groups differed significantly in the CHQ on one item (Change in Health). On the Pectus Excavatum Evaluation Questionnaire, Nuss patients reported being “less bothered” by the appearance of their chest. Compared to Australian age-matched norms, the aggregate PE sample showed better scores for family activity domain and worse scores in mental health, general health perceptions, change in health, bodily pain, and self-esteem. Conclusions: Patients undergoing surgery for PE by either Nuss or Ravitch procedure have similar clinical and HRQL outcomes, but as a group have poorer HRQL scores than age-matched population norms. [Copyright &y& Elsevier]

One of the more common chest wall anomalies seen in children is pectus excavatum. Although some studies suggest a physiologic impact of this anomaly on cardiac function during exercise, this remains somewhat controversial. Regardless, a number of children are symptomatic from either the appearance of the deformity or from the standpoint of tolerance to exercise. Most are relieved of these symptoms with surgical repair. Several different operations have been utilized for repair of this anomaly, but two techniques now are the predominant methods in use today. These are the modified Ravitch procedure and the Nuss procedure. Both have been shown to provide satisfactory results. [Copyright &y& Elsevier]