Pectus excavatum (PE) is a common congenital chest malformation in children, manifested by inward depression of the anteriorthorax wall, which can compress the normal tissues and organs in the chest and cause adverse effects on the physiology and psychology of patients. Surgery is the most important means of treating PE, and with the invention of Nuss surgery, the surgical treatment of PE has entered the minimally invasive era. At present, there are many indexes to evaluate the severity of thoracic malformations in PE patients, and selecting appropriate evaluation indexes is of great significance for the formulation of surgical protocols. As a physical and mental disease, PE's deformed thoracic appearance not only affects the function of thoracic organs, but also affects the psychological state of patients. Therefore, there is still controversy over whether the role of orthopedic surgery is to improve function or cosmetic plastic surgery. At the same time, the orthopedic efficacy and postoperative complications of the existing modified and novel surgical methods need to be further observed and evaluated. In addition, the design of surgical plan and the selection of surgical timing for PE combined with other diseases are also critical and controversial issues in clinical practice. Therefore, this article explores and reviews the controversial points in the current surgical treatment of PE.
ObjectiveTo investigate the effect of anterior chest wall depression on the cardiac function and the effectiveness of minimally invasive surgery for pectus excavatum by comparing cardiac function and morphology between pre- and post-operation. MethodsBetween August 2009 and December 2010, 102 adult patients with pectus excavatum were treated with minimally invasive surgery, including the primary operation in 95 cases and the reoperation in 7 cases. There were 84 males and 18 females, aged 18-57 years (mean, 23.4 years). The haller index (HI) was 4.59 ± 1.51. Of 102 patients, 59 were classified as pectus excavatum type I and 43 as type II; 42 had clinical symptoms and 19 had the physical sign of heart. The preoperative chest CT examination showed cardiac compression in all patients and heart displacement in 74 patients. The left ventricular ejection fraction (LVEF) was 68.9% ± 6.2%. ResultsThe procedure was successful in all patients, and no death or serious complication occurred. The patients were followed up 12-28 months (mean, 21 months). The clinical symptoms and cardiac physical sign of the patients disappeared after operation. HI was 2.70 ± 0.33 at 12 months after operation, showing significant difference when compared with preoperative HI (t=5.83, P=0.00). According to Nuss’s evaluation method, the results were excellent in 99 patients and good in 3 patients. CT examination showed complete relief of cardiac compression in 101 patients and mild cardiac compression in 1 patient; the heart position was normal at 12 months after operation. Electrocardiogram returned to normal in 4 patients having abnormal electrocardiogram. LVEF was 70.5% ± 4.8% after operation, showing no significant difference when compared with preoperative LVEF (t=1.08, P=0.30). ConclusionThe main effects of pectus excavatum in adults on heart are compression and displacement. Cardiac compression may be relieved efficiently and the patient’s clinical symptoms can be abated by minimally invasive surgery.
OBJECTIVE: To provide experimental basis for improving the curative effect of pectus excavatum. METHODS: Twelve rabbits were adopted in this experiment. After the bilateral second and third costal cartilages of the rabbits were resected subperichondrially, their right second and third costal perichondriums were damaged intentionally. Then, the bilateral third costal perichondriums were stitched into a tube-like structure and the second ones were left opened. After 2, 4, 6 of operation, the bilateral second and third neocartilages were measured for their width, and histological character were observed under microscope. RESULTS: 1. After 2, 4, 6 months of operation, the average width of the bilateral second neocartilages were significantly greater than the preoperative ones. 2. 4 and 6 months after operations, there was no significant difference in the average width of the bilateral third neocartilages and the preoperative ones. 3. The amount, distribution of costal neocartilage cells and the arrangement of costal neocartilage matrix within the left second and third costal cartilages were better than the right under the light microscope. 4. The left third costal neocartilage was regenerated and remodeled better than all the others. CONCLUSION: The integrality of costal perichondrium is in favor of the regeneration of costal cartilage, and the sleeve stitch of costal perichondrium facilitates the remodeling of costal neocartilage.
ObjectiveTo explore the clinical efficacy of thoracoscopy-assisted modified Nuss procedure for pectus excavatum (PE) in children.MethodsThe clinical data of patients with PE who underwent thoracoscopy-assisted modified Nuss procedure from October 2013 to October 2020 in Daping Hospital were retrospectively analyzed.ResultsA total of 86 patients were collected, including 79 males and 7 females with a mean age of 14.03±3.36 years. The operations were performed successfully in all patients without intraoperative cardiac vascular injury or perioperative death. The mean operation time was 87.30±33.45 min, bleeding volume was 19.94±14.60 mL, and the postoperative hospitalization stay time was 6.89±2.59 d. Early postoperative complications included 2 patients of pneumothorax, 2 patients of wound fat liquefaction and infection, 2 patients of bar flipping and displacement. One patient had bar displacement 1 year after the surgery. The total complication rate was 8.14%. All patients were followed up for 3-42 months. The bars were taken out about 36 months after the surgery. According to the evaluation criteria of orthopedic effect, 68 (79.07%) patients were excellent, 10 (11.63%) patients were good, 5 (5.81%) patients were moderate and 3 (3.49%) patients were poor.ConclusionMinimally invasive and individualized shaping via the Nuss procedure for PE children is safe and convenient, with satisfied effect. It is worthy of popularization in the clinic.
The surgical treatment of pectus excavatum has a history of more than 100 years, which has gone through from traditional open surgery to the current popular minimally invasive surgery. Nuss procedure, as the most classic minimally invasive operation, has been improved in accordance with the clinical needs since its inception to achieve fewer complications and better results, but there are still limitations that are difficult to break through, attracting a large number of scholars to make continuous innovation and develop updated devices and operation methods. This article reviews the history of funnel chest surgery, application and improvement of Nuss operation, double compression and complete fixation bar system and Wang procedure.
ObjectiveTo develop a symptom and function assessment scale for patients after Nuss procedure for pectus excavatum and to test its reliability and validity. MethodsFollowing the principles and procedures of patient-reported outcome (PRO) scale development stipulated by the U.S. Food and Drug Administration, an initial draft was formed through literature analysis, qualitative interviews, and Delphi expert consultation. The preliminary draft was used to conduct a pre-survey on patients who underwent Nuss procedure for pectus excavatum at Guangdong Provincial People's Hospital, and the reliability and validity of the scale were tested. ResultsA preliminary PRO-based symptom and function scale was constructed, covering two domains: symptoms and impact on daily functions. The symptom dimension includes six items: chest tightness, palpitations, pain, shortness of breath, foreign body sensation of the steel plate, and distress; while the impact on daily functions includes four items: difficulty in getting out of bed or lying down, raising arms, bending over, and standing or sitting for a long time. A total of 73 patients who underwent Nuss procedure for pectus excavatum were included in the questionnaire survey, with 70 valid questionnaires collected, including 64 males and 6 females, with 56 patients aged 12-17 years and 14 patients≥18 years. Through exploratory factor analysis, two common factors were extracted, with a cumulative variance contribution rate of 70%. The Cronbach's α coefficient of the scale is 0.917. ConclusionThe scale developed in this study has good reliability and validity, high reliability and stability, and can be used as an evaluation tool for the recovery status of patients after Nuss procedure for pectus excavatum.
Abstract： Objective To study thoracic bone remodeling and clinical effects after minimally invasive correctionfor pectus excavatum （PE） in children. Methods A retrospective review was conducted of a prospectively gathereddatabase of 74 child patients who underwent minimally invasive repair of PE at General Hospital of Beijing MilitaryDistrict between Apr. 2009 and Sept. 2010. Of the patients, 63 were males and 11 females; the age was（ 11.90±8.50）years, 11 patients ＜ 10-year-old among them. Under general anesthesia, two incisions were made at the side midaxillaryline, and the introducer created a tunnel at the trans-substernum and shaped the thoracic cavity. The bar was then insertedinto the retrosternum by video-assistant thoracoscopic monitoring. All patients were checked by chest computerizedtomography（CT） scan preoperatively and one week after operation, with three-dimensional reconstruction. The sagittalview was by means of the center line of the body of thoracic vertebrae. The distance between the sternum and the frontaledge of the body of thoracic vertebrae was measured and the return of displacement of the heart was observed. ResultsAll 74 operations were successful; there were no deaths. One bar was used for 66 patients （89.19%）, while two barswere used for the other 8 patients （10.81%）. Comparing the results of pre- with post-correction, for patients youngerthan 10 years（n=11） who had one bar placed, the inferior extremity of the manubrium and midsternum displacedforward to 3.76-22.92 mm. For 11-17 year-old patients（n=55） , anterior displacement of only the middle and lowerpart of the midsternum was 2.08-10.42 mm. There was a significant difference between the two groups in the inferiorextremity of the midsternum displaced（t=14.24, P ＜ 0.05）. For those patients with two bars, the inferior extremity ofthe manubrium and the midsternum were each displaced forward 4.19-15.03 mm at 7 d after operation. At 7 d after operation,the cardiac position in 65 patients（ 87.84%） of the all putted back by CT image. The chest shape of patients who received twobars was better than that of patients who received one bar. After 6-23 months of follow-up, it was pre-operative symptomsdisappeared in the patients, chest shape was satiation. Cardiac position in all patients was completely recovered. ConclusionThe thoracic bones of children with PE after minimally invasive repair have favorable remodeling. Older children requiregreater strength of support of the sternum during correction, but still realize a satisfactory therapeutic effect.
ObjectiveTo explore the indication, surgical technique, and clinical efficacy of the cross bar based on the Nuss procedure in pectus excavatum. MethodsThe clinical data of patients who underwent cross bar based on the Nuss procedure from August 2023 to August 2024 in Guangdong Provincial People's Hospital were retrospectively analyzed. ResultsA total of 88 patients including 85 males and 3 females with a mean age of (17.56±5.20) years were enrolled. All operations were performed successfully without intraoperative cardiac injury, pericardial injury or diaphragmatic injury. The mean operation time was (147.65±47.75) min. The mean blood loss was (13.30±9.06) mL. The mean postoperative hospitalization stay was (4.81±1.55) days, without perioperative death. Six (6.82%) patients developed early postoperative complications, including 3 patients of pleural effusion, 1 patient of subcutaneous hematoma, 1 patient of suffocation and 1 patient of bar rotation. The postoperative outcomes were excellent in 71 (80.68%) patients, good in 16 (18.18%) patients and moderate in 1 (1.13%) patient. The excellent and good rate was 98.86%. ConclusionThe cross bar technique is safe and convenient, with satisfactory results. It is worth promoting in clinical application.
Objective To summarize the early experience of modified Nuss procedure with thoracoscope for repairing pectus excavatum in children. Methods Fiftythree pediatric pectus excavatum were treated by modified Nuss procedure with thoracoscope from June 2004 to July 2006, theage ranged from 2.4 to 16.0 years, the average age was 8.1 years. Thirtysix patients were symmetric pectus excavatum and 17 patients were asymmetric pectus excavatum. Results The operation in all patients were successful, the average blood loss was less than 10ml. Pericardium perforation occurred in 2 earlier patients during the operation, pneumothorax occurred in 6 patients postoperatively,pleural effusion occurred in 3 patients, and all resolved by corresponding treatments. The average hospital length of stay was 5.5 days. All patients had a satisfied deformity correction and no needs of transfusion. The depression was thoroughly corrected in 48 patients, residual depression was less than 20% of preoperative degrees in 5 patients. Therapeutic results evaluation showed excellent in 46 patients and good in 7 patients. All patients were followed up in 1-25 months without any complaints, the activity ability was same as normal children; there were no bar displacement and injury event occurred. The bar had been removed in 1 patient 24 months after surgery who still kept in excellent results. Conclusion Modified Nuss procedure is easy to be performed with minimal invasion and good shortterm results. Thoracoscopic visualization facilitates the safety of this technique. It is recommendable to be tried and extended applied.
ObjectiveTo investigate the changes and clinical significance of cardiac structure and function evaluation by cardiac magnetic resonance imaging (CMR) for patients with pectus excavatum deformity at preoperation. MethodsWe retrospectively analyzed 54 patients (24 children and 30 adults) who underwent pectus excavatum surgery from June 2012 to June 2014. There were 48 males and 6 females at age of 7-33 (19.08±5.17) years. All the patients underwent CMR using 1.5 Tesla scanner for evaluation of compressing and displacement of the heart. The major and minor dimensions of right ventricle were measured. The right ventricle end-diastole volume (RVEDV), right ventricle end-systolic volume (RVESV), and right ventricle ejection fraction (RVEF) were also recorded and analyzed. ResultsThe heart compression and displacement occurred in 83.3% of the children group and 90.0% of the adults group. The extent of heart displacement in the adults was more serious than that in the children (76.86%±13.30% vs. 67.99%±8.15%, P<0.05). The structure of right ventricle were striking distorted because right atrum or right ventricule below valve ring was compressed locally, with the major dimension of right ventricle obviously increased, and the minor dimension of right ventricle obviously decreased. The indices of right ventricle major dimension and right ventricle minor dimension were 61.14±0.44 mm/m2 and 14.82±2.52 mm/m2 in the children, 49.54±15.40 mm/m2 and 18.90 ±3.14 mm/m2 in the adults. The RVEDV and RVESV were significantly higher in the adults than those in the children (139.09±29.08 ml vs. 121.50±31.27 ml; 73.61±16.05 ml vs. 64.92±19.28 ml; P<0.05). RVEF was similar between the children and the adults (45.29%±4.14% vs. 46.30±6.09%). The patients' symptoms disappeared after correction of pectus excavatum. ConclusionCMR is an useful method for evaluating right ventricular structure and functions in patients with cardiac compression and distortion by pectus excavatum before operation, which can bring strong indications for pectus excavatum repair surgery.