Finding suitable candidates for vacuum bell therapy in pectus excavatum patients

Vacuum bell therapy has been acceptable substitute for pectus excavatum patients who want to improve their appearance but avoid surgical correction. The aim of this study was to assess the pre-treatment characteristics of patients with pectus excavatum and to establish characteristics that can potentially help identify ideal candidates for vacuum bell therapy. Expected improvements in thoracic indices were evaluated using pre-treatment chest computed tomography, which was performed before and after applying a vacuum bell device. Treatment results after 1-year of application were evaluated using changes in the Haller index before and after treatment. The patients were categorized into two groups according the post- treatment changes in Haller index calculated using chest radiographs: those with changes in Haller index less than 0.5 (Group 1) and those with greater than or equal to 0.5 (Group 2). Pre-treatment Haller index was significantly lower in Group 1 than in Group 2 (3.1 ± 0.46 vs. 4.2 ± 1.14, respectively, p < 0.001). The expected improvement in Haller index in Group 2 was significantly higher than that in Group 1 (3.3 ± 0.60 vs. 2.8 ± 0.54, respectively, p = 0.001). The cut-off value of the expected improvement in Haller index was 0.46 with a sensitivity of 75.8% and a specificity of 83.3%. Patients who demonstrated pliability with a vacuum bell were identified as suitable candidates.

Minimally Invasive Modified Nuss Procedure for Repair of Pectus Excavatum in Pediatric Patients: Single-Centre Retrospective Observational Study

Background: The treatment of pectus excavatum can be conservative or surgical. The aim of this study was to determine the factors influencing the outcomes of treatment after a minimally invasive Nuss corrective surgery procedure in pediatric patients. Methods: A total of 30 patient who underwent a minimally invasive Nuss corrective procedure for pectus excavatum from 1 January 2014 to 31 December 2020 were included in thisretrospective study. The collected data included thepatient’s demographic characteristics (age, sex, height, weight, body mass index—BMI, Haller index), treatment outcomes (duration of surgery, length of hospital stay, intraoperative complications, early and late complications, postoperative analgesia), and overall patient and legal guardian satisfaction two years after the procedure. Results: A total of 22 male and 8 female patients were included in the study. The median age was 15 years (interquartile range—IQR 14, 16), and the median BMI was 18.5 kg/m2 (IQR 17.7, 20.4) and 18.2 kg/m2 (IQR 16.9, 18.6) for males and females, respectively. The median CT Haller index was 3.67 (IQR 3.48, 4.09) for male and 3.69 (IQR 3.45, 3.9) for female patients. The median surgery duration was 120 min (IQR 100, 130), and the median hospital stay length was 8.5 days (IQR 8, 9.75). Indications for surgery were psychological (47%), followed by respiratory (30%) and combined respiratory-cardiac (20%) and respiratory-psychological disorders (3%). Early complications were observed in 18 patients (60%), and late complications were observed in 7 patients (23.3%). Intraoperative complications were not recorded. The most common early complications were pneumothorax and subcutaneous emphysema (30%), while late complications included bar displacement (10%) and deformity recurrence (6.6%). Overall,the procedure was successful in 93.1% of patients. Upon arrival home, 22 patients (81.5%) used analgesics for at least one day, up to a maximum of six months. A total of 23 (76.7%) operated patients determined that the surgical procedure had excellent results (grade 5) , 4 (13.3%) patients report a good result (grade 4), 1(3.3%) patient reported a mediocre result, and one patient (3.3%) reported a bad result (grades 3 and 2, respectively). Conclusion: The Nuss procedure is a safe and effective method for treating funnel chest in children and adolescents. It also providesexcellent cosmetic and aesthetic results as well as subjective satisfaction with the outcome of surgical treatment.

Variations in Nuss Procedure Operative Techniques and Complications: A Retrospective Review

Introduction The Nuss procedure is the most common and preferred operative correction of pectus excavatum. Surgeon preference and patient factors can result in variations in Nuss procedure technique. We hypothesize that certain techniques are associated with increased risk of complications. Materials and Methods We performed a single-center retrospective review of Nuss operations from 2016 to 2020. Variations in intraoperative techniques included sternal elevator (SE) use, number of bars placed, and usage of bilateral stabilizing sutures. Patient demographics, intraoperative data, and postoperative outcomes were reported as median with interquartile ranges or percentages. Statistical significance (p < 0.05) was determined with Wilcoxon's rank-sum and chi-square tests. Multivariate analysis was performed to control for introduction of intercostal nerve cryoablation and surgeon volume, and reported as odds ratio with 95% confidence interval. Results Two hundred and sixty-five patients were identified. Patients repaired with two bars were older with a larger Haller index (HI). Patient demographics were not significantly different for SE or stabilizing suture use. Placement of two bars was associated with significantly increased risk of readmission. Similarly, SE use was associated with increased risk of pleural effusion and readmission. Finally, the use of bilateral stabilizing sutures resulted in less frequent slipped bars without statistical significance. Conclusion Older patients with a larger HI were more likely to need two bars placed to repair pectus excavatum. Placement of multiple bars and SE use are associated with significantly higher odds of certain complications.

Trichterbrust-Korrektur-OP unter Zuhilfenahme einer 3-D-Rekonstruktion des Thorax zur präoperativen Anpassung des Korrekturstabes

Zusammenfassung Hintergrund Die Trichterbrust ist eine angeborene Deformität des Thoraxskeletts, bei der das Sternum und die angrenzenden Rippen trichterförmig in Richtung Wirbelsäule einsinken. Die Pathogenese ist bisher nicht eindeutig geklärt. Es gibt verschiedene Therapieansätze, von konservativen Maßnahmen über minimalinvasive Eingriffe bis hin zur offenen Korrektur-OP. Die betroffenen Patienten leiden unter der ästhetischen Beeinträchtigung sowie kardiopulmonalen Einschränkungen durch die Einengung des Mediastinalraumes. Die Indikationsstellung zur Trichterbrust-Korrektur-OP unterliegt funktionellen und ästhetischen Gründen. Patienten Wir berichten über einen 23-jährigen männlichen Patienten mit einer subjektiv beeinträchtigenden und objektiv mäßiggradigen Trichterbrust. Präoperativ wurde ein CT des Thorax angefertigt. Der sternovertebrale Abstand betrug 8 cm, der Thoraxquerdurchmesser 28,9 cm (Haller-Index 3,6). Im präoperativen Lungenfunktionstest zeigte sich eine leichte Restriktion. Anamnestisch beschrieb der sonst gesunde Patient Kurzatmigkeit bei stärkerer Anstrengung. Die Indikation zur Trichterbrust-Korrektur-OP wurde gestellt. Diese erfolgte in kombinierter Operationstechnik: untere Sternotomie und Knorpelkeilresektion nach Brunner/Grob sowie Implantation eines Metallbügels ohne seitliche Antirotationsplatte. Ein zeitaufwendiger Schritt der OP besteht in der intraoperativen Anpassung des Metallbügels. Daher fertigten wir im Vorfeld der OP anhand des Thorax-CTs eine 3-D-Rekonstruktion des knöchernen Thorax mittels 3-D-Drucker an. Der Metallbügel wurde daran angepasst und im OP eingesetzt. Dies verkürzte die Operationsdauer um mindestens 15 min. Ergebnisse In den postoperativen Nachuntersuchungen zeigten sich ein aufgerichteter Trichter und ein zufriedenstellendes ästhetisches Ergebnis. Sieben Monate nach Implantation erfolgte die planmäßige Stabexplantation. Die postoperative CT-Kontrolle ergab nun einen Haller-Index von 3,25, der Lungenfunktionstest eine funktionelle Verbesserung. Subjektiv war der Patient allzeit beschwerdefrei. Schlussfolgerung Die Implantatanfertigung am 3-D-Modell hilft, OP-Zeit zu sparen. Die Praktikabilität ist noch nicht etabliert, da durch die Erstellung eines 3-D-Modells des knöchernen Thorax ein anderweitig höherer Aufwand entsteht. Mit zunehmender Digitalisierung der medizinischen Welt ist es jedoch vorstellbar, dass zukünftig die Erstellung von digitalen und realen 3-D-Modellen einfacher und kostengünstiger wird.

How to Identify Suitable Candidates With Pectus Excavatum for Vacuum Bell Therapy?

Vacuum bell therapy has been acceptable substitute for pectus excavatum patients who want to improve their appearance but avoid surgical correction. The aim of this study was to assess the pre-treatment characteristics of patients with pectus excavatum and to establish characteristics that can potentially help identify ideal candidates for vacuum bell therapy. Expected improvements in thoracic indices were evaluated using pre-treatment chest computed tomography, which was performed before and after applying a vacuum bell device. Treatment results after 1-year of application were evaluated using changes in the Haller index before and after treatment. The patients were categorized into two groups: those with Haller index less than 0.5 (Group 1) and those with Haller index greater than or equal to 0.5 (Group 2). Pre-treatment Haller index was significantly lower in Group 1 than in Group 2 (3.1±0.46 vs. 4.2±1.14, respectively, p<0.001). The expected improvement in Haller index in Group 2 was significantly higher than that in Group 1 (3.3±0.60 vs. 2.8±0.54, respectively, p=0.001). The cut-off value of the expected improvement in Haller index was 0.46 with a sensitivity of 75.8% and a specificity of 83.3%. Patients who demonstrated pliability with a vacuum bell were identified as suitable candidates.

Thoracoscopic esophagectomy in the prone position for esophageal cancer patients with pectus excavatum: a report of two cases

Background Pectus excavatum is a common thoracic deformity that can be encountered during thoracoscopic esophagectomy. Here, we report two cases of esophageal cancer complicated by pectus excavatum that were treated with thoracoscopic esophagectomy with the patients in the prone position. Case presentation The first patient was a 64-year-old male diagnosed with esophageal cancer (cT3N0M0, Haller index 8.5) and underwent radical thoracoscopic esophagectomy in the prone position following neoadjuvant chemotherapy. The second patient was a 67-year-old male diagnosed with esophageal cancer (cT1bN0M0, Haller index 4.3), and the same procedure was performed in this patient. In cases of patients with a high Haller index, where securing the surgical field is difficult, preoperative computed tomography in the prone position can help surgeons to understand the mediastinal field of view and is safe. Conclusions Radical thoracoscopic esophagectomy in the prone position may be a surgical option in patients with pectus excavatum.

Abstract 13730: Electrical Axes of P and T but Not QRS Waves on ECG Are New Indicators of Successfulness of the Nuss Operation for Pectus Excavatum Considering Anatomical Severity as Indicated by the Haller Index Acquired by CT

Introduction: Pectus excavatum (PEX) is a depression of the sternum which can physically constrict the heart and cause abnormal ECGs. The Nuss operation is a minimally invasive technique for PEX repair. Hypothesis: As right (RA) and left atria (LA) are compressed in PEX, axes of P, QRS, and T waves are abnormal and the Nuss operation normalizes them. We also took the Haller index (HI) into to account. Methods: 17 PEX patients (14 male, 12±6 years) underwent CT and ECG before and after the Nuss operation. Results: All Nuss operations were successful, and HI was significantly improved from 5.62±2.29 to 3.29±0.65 (P=0.0002). There were no significant differences before and after surgery for electrical axes of P waves (46±20 vs 65±55, P=0.20), and QRS waves (75±33 vs 76±23, P=0.72), but T waves were greater thereafter (22±27 vs 40±19, P=0.001). Correlation coefficients (CC) between the degree of axes of P, QRS and T waves, and HI before operation were -0.23, -0.06, and 0.11, respectively. These values after operation were -0.25, -0.06, and 0.19, respectively. As HI is an indirect indicator of heart compression, we evaluated the degree of RA and LA compression qualitatively as none, mild, and moderate/more. Of 17 patients, 5 had moderate/more compression of RA and/or LA by PEX (group 1); the remaining 12 did not show compression (group 2). Only P wave values were significantly smaller in group 1 than 2 before surgery, but these differences disappeared after surgery. In both groups, degree of axes of T waves was significantly greater after the operation. Conclusion: In patients with PEX, axes of T waves after the Nuss operation became significant greater than before the operation in patients with moderate or more compression of RA and/or LA by PEX. For P waves, this was smaller before the operation in those with compression but this was improved by the Nuss operation. P and T wave axes but not QRS could be therefore non-invasive indicators of Nuss operation success in addition to gross PEX appearance.

Influence of Nuss surgical operation for pectus excavatum on electrocardiogram abnormality considering anatomical severity as indicated by Haller index acquired by computed tomography and age

Background Pectus excavatum (PEX) is a depression of the sternum relative to costal cartilages and sometimes depress heart anatomically which cause abnormal ECG change. Nuss operation is minimal invasive technique for PEX repair. Purpose We speculated this Nuss operation would improve these ECG abnormalities. We also considered the Haller index (HI) and age to these influences. HI is an anatomical severity indicator of PEX calculated from CT. Methods A total of 17 patients (14 male, 12±6 years), who underwent Nuss operation for PEX, underwent unenhanced CT and ECG before and after the Nuss operation. Results All Nuss operation was successfully performed. On CT, HI was significantly improved from 5.62±2.29 to 3.29±0.65 (P=0.0002). A P wave with a negative portion &gt;1 mm deep and &gt;40 ms duration in V1 lead, incomplete right bundle branch block (RBBB), sinus arrhythmia, and right-axis deviation of a QRS wave were diagnosed in 15, 6, 12, and 5 patients, respectively. Comparing before with after Nuss operation, there were no significant differences of the degree of electrical axis of QRS waves, the degree of electrical axis of P waves, or the PQ interval, respectively (All P=NS). Absolute values of voltage of a negative portion of the P wave in V1 lead was significantly improved after the operation (1.55±1.25 vs 0.76±0.91mm, P&lt;0.001). Among 12 patients with sinus arrhythmia, only one patient improved to that without. Among 6 patients with incomplete RBBB, only one patient improved to that without. The correlation coefficient (CC) between “values of the improvement of negative portion of the P wave in V1 lead after the operation” and “HI before operation” was 0.305 (P&lt;0.05). The CC between “absolute values of the improvement of negative portion of the P wave in V1 lead after the operation” and “age at the operation” was −0.216 (P&lt;0.05). Conclusion In patients with PEX, successful Nuss operation could achieve improvement of negative portion of the P wave in V1 lead positively correlated with “HI before operation” and negatively correlated with “age”. Nuss procedure would be more effective to abnormal ECG change, when anatomical severity is severer or age is younger. Improvement of negative P wave Funding Acknowledgement Type of funding source: None