Evaluating the web as a source of information for patients with chest wall deformities: insights into engagement and disparities.

BACKGROUND: Recent data highlight the internet's pivotal role as the primary information source for patients. In this study, we emulate a patient's/caregiver's quest for online information concerning chest deformities and assess the quality of available information. METHODS: We conducted an internet search using combination of the terms "pectus excavatum," "pectus excavatum surgery," "funnel chest," "pectus excavatum repair" and identified the first 100 relevant websites from the three most popular search engines: Google, Yahoo, and Bing. These websites were evaluated using the modified Ensuring Quality Information for Patients (EQIP) instrument. RESULTS: Of the 300 websites generated, 140 (46.7%) were included in our evaluation after elimination of duplicates, non-English websites, and those targeting medical professionals. The EQIP scores in the final sample ranged from 8 to 32/36, with a median score of 22. Most of the evaluated websites (32.8%) originated from hospitals, yet none met all 36 EQIP criteria. DISCUSSION: None of the evaluated websites pertaining to pectus excavatum achieved a flawless "content quality" score. The diverse array of websites potentially complicates patients' efforts to navigate toward high-quality resources. Barriers in accessing high-quality online patient information may contribute to disparities in referral, patient engagement, treatment satisfaction, and overall quality of life. LEVEL OF EVIDENCE: IV.

Pectus excavatum in motion: dynamic evaluation using real-time MRI.

OBJECTIVES: The breathing phase for the determination of thoracic indices in patients with pectus excavatum is not standardized. The aim of this study was to identify the best period for reliable assessments of morphologic indices by dynamic observations of the chest wall using real-time MRI. METHODS: In this prospective study, patients with pectus excavatum underwent morphologic evaluation by real-time MRI at 3 T between January 2020 and June 2021. The Haller index (HI), correction index (CI), modified asymmetry index (AI), and modified eccentricity index (EI) were determined during free, quiet, and forced breathing respectively. Breathing-related differences in the thoracic indices were analyzed with the Wilcoxon signed-rank test. Motion of the anterior chest wall was analyzed as well. RESULTS: A total of 56 patients (11 females and 45 males, median age 15.4 years, interquartile range 14.3-16.9) were included. In quiet expiration, the median HI in the cohort equaled 5.7 (4.5-7.2). The median absolute differences (Δ) in the thoracic indices between peak inspiration and peak expiration were ΔHI = 1.1 (0.7-1.6, p < .001), ΔCI = 4.8% (1.3-7.5%, p < .001), ΔAI = 3.0% (1.0-5.0%, p < .001), and ΔEI = 8.0% (3.0-14.0%, p < .05). The indices varied significantly during different inspiratory phases, but not during expiration (p > .05 each). Furthermore, the dynamic evaluation revealed three distinctive movement patterns of the funnel chest. CONCLUSIONS: Real-time MRI reveals patterns of chest wall motion and indicate that thoracic indices of pectus excavatum should be assessed in the end-expiratory phase of quiet expiration. KEY POINTS: • The thoracic indices in patients with pectus excavatum depend on the breathing phase. • Quiet expiration represents the best breathing phase for determining thoracic indices. • Real-time MRI can identify different chest wall motion patterns in pectus excavatum.

Modified bar bending method of thoracoscopic nuss procedure on pectus excavatum: a retrospective single-center study.

BACKGROUND: Pectus excavatum (PE) is the most common disease of chest wall deformity, with an incidence of 1 in 300-400 births. Nuss procedure has proved to be the best surgical treatment method and has been widely used after clinical use for 30 years. We aimed to review the clinical data of pectus excavatum (PE) of thoracoscopic Nuss procedure adopted the Modified bar bending method of the six-point seven-section type, and compare it with the traditional curved bar bending method to explore the clinical application effect. METHODS: Forty-six cases of clinical data were summarized of children with PE who adopted the treatment of the Modified bar bending method of the six-point seven-section type from January 2019 to December 2021, and 51 cases were compared of PE children who adopted the treatment of traditional curved bar bending method from January 2016 to December 2018, including the data of age, gender, preoperative symptoms, symmetry, Haller index, operation time, bar bending time, intraoperative bleeding, postoperative complications, bar migration, postoperative effect evaluation, etc. RESULTS: The Procedure duration (P = 0.008), bar bending time (P < 0.001), and duration of postoperative pain (P < 0.001) were reduced significantly, and the incidence of bar migration after surgery was reduced as well by the modified bar bending method. There was no difference compared with traditional Nuss produce, like the incidence of evaluation of postoperative effects (Excellent, P = 0.93; Good, P = 0.80; Medium, P = 1.00; Poor, P = 1.00), bar migration (P = 1.00), postoperative complications (P = 1.00), Clavien- Dindo classification of surgical complications (I = 0.165; II = 1.00; IIIa = 1.00; IIIb = 1.00; VI = 1.00; V = 1.00), operative safety, and operative validity. CONCLUSION: Modified bar bending method of the six-point seven-section type, which is a kind of surgical method worth applying and popularizing, and the advantages of minimally procedure duration, bar bending time, and duration of postoperative pain, compared with the traditional bar bending method.

Complications following metal bar removal after Nuss repair are rare in a duocentric retrospective evaluation.

PURPOSE: Minimally invasive pectus excavatum repair has gained widespread acceptance and its results and complications are well-described. However, there is a substantial debate on the risks and frequencies of complications following metal bar removal. We, therefore, aimed to analyse all complications that occurred during and after metal bar removal at our two paediatric surgical centres. METHODS: Bar removal surgeries were identified via procedural codes and electronic records were reviewed using a pre-specified data extraction chart. Both intra- and postoperative complications were included and the latter scored according to Clavien-Dindo. We analysed the influence of the pre-specified potential predictors age, sex, and the number of implanted metal bars on the occurrence of complications using logistic regression. RESULTS: We included 279 patients with a median age of 19 years (interquartile range 17-20 years). 15 patients experienced 17 complications. Of 11 postoperative complications, only an enlarging pleural effusion required a chest drain in local anaesthesia, resulting in a Claven-Dindo grade IIIa, whereas the remainder were classified as grade I. Neither age (adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.84-1.13, P = 0.73), nor sex (aOR 0.88, 95% CI 0.19-4.07, P = 0.87) or the number of bars (aOR 0.64, 95% CI 0.15-2.71, P = 0.547) did influence the occurrence of complications. CONCLUSION: Complications following metal bar removal were scarce in our duocentric retrospective series and usually of minor relevance. However, to address the perceived paucity of data on the frequency and severity of complications following metal bar removal, further studies, including large database research is necessary.

Impact of chest wall deformity on cardiac function by CMR and feature-tracking strain analysis in paediatric patients with Marfan syndrome.

OBJECTIVES: To evaluate systolic cardiac dysfunction in paediatric MFS patients with chest wall deformity using cardiac magnetic resonance (CMR) imaging and feature-tracking strain analysis. METHODS: Forty paediatric MFS patients (16 ± 3 years, range 8-22 years) and 20 age-matched healthy controls (16 ± 4 years, range 11-24 years) were evaluated retrospectively. Biventricular function and volumes were determined using cine sequences. Feature-tracking CMR was used to assess global systolic longitudinal (GLS), circumferential (GCS) and radial strain (GRS). A dedicated balanced turbo field echo sequence was used to quantify chest wall deformity by measuring the Haller index (HI). RESULTS: LV volumes and ejection fraction (EF) were similar in MFS patients and controls. There was a trend for lower right ventricular (RV) volume (75 ± 17 vs. 81 ± 10 ml/m2, p = 0.08), RV stroke volume (41 ± 12 vs. 50 ± 5 ml/m2, p < 0.001) and RVEF (55 ± 10 vs. 62 ± 6%, p < 0.01) in MFS patients. A subgroup of MFS patients had an increased HI compared to controls (4.6 ± 1.7 vs. 2.6 ± 0.3, p < 0.001). They demonstrated a reduced RVEF compared to MFS patients without chest wall deformity (50 ± 11% vs. 58 ± 8%, p = 0.01) and controls (p < 0.001). LV GLS was attenuated when HI ≥ 3.25 (- 16 ± 2 vs. - 18 ± 3%, p = 0.03), but not GCS and GRS. LV GLS (p < 0.01) and GCS (p < 0.0001) were attenuated in MFS patients compared to controls, but not GRS (p = 0.31). RV GLS was attenuated in MFS patients compared to controls (- 21 ± 3 vs. - 23 ± 3%, p < 0.05). CONCLUSION: Chest wall deformity in paediatric MFS patients is associated with reduced RV volume, ejection fraction and GLS. Feature-tracking CMR also indicates impairment of systolic LV function in paediatric MFS patients. KEY POINTS: • Paediatric Marfan patients demonstrate reduced RV volume and ejection fraction compared to healthy controls. • A concordant attenuation in RV global longitudinal strain was observed in Marfan patients, while the RV global circumferential strain was increased, indicating a possible compensatory mechanism. • Subgroup analyses demonstrated alterations in RV ejection fraction and RV/LV global strain parameters, indicating a possible association of severe chest wall deformity with biventricular dysfunction in paediatric Marfan patients.

Rescue Nuss procedure for inferior vena cava compression syndrome following posterior scoliosis surgery in Marfan syndrome.

PURPOSE: Scoliosis surgery in Marfan syndrome is common, even in the presence of a funnel chest. However, to date, no case has been reported with acute intra-/postoperative decompensation caused by vena cava compression following posterior spinal derotation and fusion. METHODS: A 15-year-old male patient with Marfan syndrome, a funnel chest and severe scoliosis was treated with surgery for the spinal deformity. Intraoperatively, the patient developed a clinically relevant compression of the inferior vena cava with severe circular depression. Postoperatively, a cava compression syndrome with severe pleural effusion, ascites and enormous swelling of the lower limbs was developed. A conservative treatment of the symptoms, consisting of thoracic drainage and negative fluid balance, failed. Subsequently, the patient was transferred to pediatric intensive care unit for further treatment. Echocardiography and a CT scan demonstrated cava compression syndrome. A rescue Nuss procedure of the funnel chest deformity was performed since conservative treatment failed. The clinical course proceeded without complications and with a decrease in clinical symptoms of inferior inflow congestion. The patient was discharged after almost 3 weeks. CONCLUSION: The problem of congenital stenosis of the inferior vena cava in Marfan syndrome has not yet been investigated. In the case of simultaneously existing funnel chest and scoliosis in Marfan syndrome, an interdisciplinary discussion is required to decide whether a repair of the funnel chest should be performed first in order to prevent a clinically relevant compression syndrome. For the detection of a preoperatively relevant stenosis of the inferior vena cava, an MRI or thoracic/abdominal CT should be used preoperatively.

Esophageal cancer with severe funnel chest treated by simultaneous funnel chest surgery and thoracoscopic esophagectomy: a case report.

BACKGROUND: Funnel chest is the most common chest deformity, occurring in 0.06-0.3% of the general population. When it occurs concomitantly with esophageal cancer, it hinders intrathoracic surgery that is necessary for treatment. Although there are a few reports of esophagectomy performed in patients with funnel chest, simultaneous treatment of esophageal cancer and funnel chest with funnel chest surgery (Nuss method) and esophagectomy has not been reported. We report the first case of advanced esophageal cancer complicated by severe funnel chest that was treated using the Nuss method and radical thoracoscopic esophagectomy. CASE PRESENTATION: A 59-year-old man was diagnosed with advanced thoracic esophageal cancer and severe funnel chest. Because his sternum was almost attached to the vertebral bone, thereby creating a narrow space in the mediastinum, esophageal surgery was expected to be complicated. After the patient underwent neoadjuvant chemotherapy, we used the Nuss method to reconstruct the chest and widen the mediastinum. Subsequently, radical thoracoscopic esophagectomy was performed with the patient in the left decubitus position without any difficulty, and the postoperative course was uneventful. CONCLUSION: Simultaneous funnel chest surgery (Nuss method) and thoracoscopic esophagectomy with the patient in the left decubitus position are recommended for esophageal cancer patients with severe funnel chest.

[Contribution of computer-aided design for the conception of custom-made implants in Pectus Excavatum surgical treatment. Experience of the Nantes plastic surgery unit]. / Apport de la conception assistée par ordinateur (CAO) à la réalisation des implants thoraciques sur mesure pour correction des pectus excavatum. Expérience du CHU de Nantes.

INTRODUCTION: Pectus excavatum is the most common congenital chest malformation and is a common reason for consultation in plastic surgery. Our attitude is most often a filling of the depression with a custom-made silicone prosthesis. The objective of this work was to evaluate the interest of computer-aided design (CAD) of implants compared to the conventional plaster molds method. PATIENTS AND METHODS: We have collected all the cases of custom-made silicone implants to treat funnel chests in our plastic surgery department. The quality of the results was evaluated by the patient, and in a blind manner by the surgical team using photographs and standardized surveys. The pre-operative delays, the operating time and length of hospital stays, the number of surgical recoveries, and the post-operative surgical outcomes were recorded. RESULTS: Between 1990 and 2016, we designed 29 silicone thoracic implants in our department. Before 2012, implants were made from plaster chest molds (n=13). After this date, implants were designed by CAD (n=16). Patients rated their results as "good" or "excellent" in 77% and 86% of cases respectively in the plaster and CAD groups. The surgical team's ratings for CAD implant reconstructions were better than in the plaster group: 8.17 versus 6.96 (P=0.001). CAD implants were significantly less detectable than the plaster group implants. The operating time was reduced in the CAO group: 60.2 compared to 74.7minutes in the plaster group (P=0.04), as was the length of hospitalization: 3.5 versus 5.3 days (P=0.01). There were no significant differences between the two groups in terms of post-operative complications. CONCLUSION: The management of pectus excavatum by a custom-made silicone implant is a minimally invasive method that provides good cosmetic results. The design of these implants is facilitated and qualitatively improved by CAD.

First Iranian Experience of the Minimally Invasive Nuss Procedure for Pectus Excavatum Repair: A Case Series and Literature Review.

Pectus excavatum is the most common congenital deformity of the chest wall. The most frequently used techniques include Ravitch (costochondral resection) and Nuss (minimally invasive pectus repair of pectus excavatum [MIRPE]). The Nuss technique includes using temporary metallic bars without costochondral resection to correct the chest wall deformity. Modified MIRPE can be learned easily and performed safely with few complications. There are no reports of successful MIRPE in Iran, although the Ravitch technique is well known. In the present study, we report the first Iranian experience with the modified Nuss procedure in 5 patients with pectus excavatum (age range=13-48 y). All the patients suffered from low self-esteem, and one of them complained of low exercise capacity and occasional chest pain. With single-lung ventilation and sternal elevation, an introducer was entered into the right thoracic cavity and retrosternal tunneling was performed under thoracoscopic vision. The introducer was passed to the left thoracic cavity and exited on the left thoracic wall. A titanium plate bar was implanted and fixed with stabilizers. There were no cases of mortality, and all the patients were discharged in good conditions within 2 weeks. Postoperative complications consisted of 1 case of pneumothorax and 2 cases of fixed bar protrusion. The present case series indicated that a skilled thoracoscopic surgeon is able to do the Nuss procedure in Iranian patients with symmetrical pectus excavatum with few complications. However, mixed or redo cases require more expertise.

Incidence and Classification of Chest Wall Deformities in Breast Augmentation Patients.

Although chest wall deformities (CWDs) are seen four times more often in males than in females, most patients who consult plastic surgery clinics in our country are females. Breast augmentation and augmentation mastopexy were performed with a total of 812 breast implants in 406 patients. Forty-three of these patients had various CWDs. The CWD patient ages ranged from 18 to 43 years. Patients were observed for 6 months to 8 years (mean of approximately 3 years). Pectus excavatum (PE) was present in 22 patients, pectus carinatum (PC) in five patients, Poland syndrome (PS) in two patients, sunken chest deformity (SCD) in three patients, barrel chest deformity (BCD) in five patients, body builder deformity (BBD) in three patients, and long upper chest wall (LCW) in three patients. None of the patients had functional or cardiac deformities. A total of 86 round, anatomically textured gel implants in various profiles were used within a range of implant volumes for all patients. There were no serious complications in the 43 CWD patients. The frequency of CWDs in the total population of 406 patients was approximately 10.6%. PE was present in 51% (22/43) of the patients with CWDs. The deformity rates among patients who underwent augmentation mammoplasty were as follows (%): PE, 5.4; PC, 1.23; PS, 0.5; SCD, 0.73; BCD, 1.23; BBD, 0.73; and LCW, 0.73. The three most common deformities observed in this study were PE, PC, and BCD. The least common deformity was PS. Patients with CWDs should be carefully evaluated preoperatively, and all the associated measurements and calculations must be meticulously performed. The implant selection may differ according to the deformity pattern. For example, in patients with PE, prostheses with larger base diameters cover the deformity better. Although high-profile prostheses are preferred on the affected side in cases of PS and SCD, low- or middle-profile prostheses are preferred on the opposite side. Despite this common consensus, there was an asymmetry of approximately 1 cm between the sides, as observed postoperatively. However, the patients did not express dissatisfaction with this situation. Low-profile prostheses should be preferred for PC and BCD protruding CWDs because asymmetry becomes more prominent and over-projection occurs more frequently in cases of high-profile prostheses. The BBD projection is also a problem. For this reason, high-profile prostheses should be preferred in these patients. It is possible to obtain satisfactory results by using appropriate breast implants in patients with CWDs. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Costal cartilage structural and functional changes in children with a funnel or keeled chest]. / Strukturnye i funktsional'nye izmeneniia rebernykh khriashchei pri voronkovidnoi i kilevidnoi deformatsii grudnoi kletki u detei.

Congenital chest wall deformities (CCWDs) in children are severe diseases leading to cosmetic defects and diseases of the respiratory and cardiovascular systems. The most common of these deformities are funnel-shaped (pectus excavatum, FD) and keeled (pectus carinatum, KD) ones. The pathogenesis of CCWDs and the role of costal cartilage structural and functional changes in their pathogenesis have now been not well studied, which makes it difficult to elaborate pathogenetic approaches to correcting these diseases. Analysis of the literature has shown that structural and functional changes occur in the matrix and chondrocytes from the costal cartilage in FD. Similar costal cartilage changes are observed in KD. It is still unknown exactly which pathological processes are present in the costal cartilage and how they result in the development of one or other type of CCWDs. The role of amianthoid transformation (AT) of costal cartilages in these processes is also unknown. It is not improbable that it is AT drastically changing the native cartilage matrix, which is one of the key mechanisms leading to changes in its properties and to the subsequent development of FD or KD.

A review of anesthetic techniques and outcomes following minimally invasive repair of pectus excavatum (Nuss procedure).

BACKGROUND: Pectus excavatum (PE) is the most common congenital chest wall deformity, occurring in 1 : 1000 children with a male to female ratio of 4 : 1. Several procedures have been described to manage this deformity, including cartilage resection with sternal osteotomy (the Ravitch procedure) and a minimally invasive repair technique (the Nuss procedure). While initially described as a nonthoracoscopic technique, the current surgical approach of the Royal Childrens Hospital involves thoracoscopic assistance. Postoperative pain is significant in patients undergoing the pectus repair and multiple analgesic regimens have been advocated with continuous thoracic epidural infusions and opioid infusions the most common. Some authors have advocated patient-controlled analgesia (PCA), paravertebral nerve blocks (PVNB), and wound infusion catheters as alternatives. AIMS: The primary aim of this study was to assess our experience with postoperative pain and analgesia requirements associated with the minimally invasive repair of pectus excavatum in children. METHODS: This is a retrospective cohort study with a contemporaneous comparison group examining patients treated between January 2005 and December 2015 for minimally invasive repair of pectus excavatum by the Nuss procedure. RESULTS: Two hundred and seventeen patients [mean age 14.9 (sd 1.9) years] with pectus excavatum treated at the Royal Childrens Hospital between 2005 and 2015 were identified. All patients were managed with thoracic epidural analgesia and intravenous morphine infusions. The epidural was effective in the postanesthesia care unit in 97.3% (failure to place an epidural rate was 4 (1.9%); no block on awakening 0.9%). A further 4 (1.8%) were removed within 24 h. The mean morphine equivalent dose in the first 24 h was 0.8 mg·kg-1 ·day-1 . PCA was continued for a mean of 3.8 days and the total mean morphine equivalent dose was 2.2 mg·kg-1 ·day-1 . Minor complications occurred in 67 (30.9%) with postoperative nausea and vomiting in 36 patients (16.6%) and urinary retention requiring an indwelling catheter in 40 patients (18.4%). CONCLUSION: An epidural-based analgesic regime is associated with low pain scores and few acute complications. The continuation of morphine analgesia after the first postoperative day is common but associated with an increased incidence of urinary retention and nausea and vomiting.

Electrocardiographic characteristics of patients with funnel chest before and after surgical correction using pectus bar: A new association with precordial J wave pattern.

OBJECTIVE: Abnormal ECG findings suggestive of cardiac disease are frequent in patients with funnel chest, although structural heart disease is rare. Electrocardiographic characteristics and changes following new surgical treatments in young adults are not described so far. The aim of the study was to analyze electrocardiographic characteristics of patients with funnel chest before and after minimally invasive funnel chest correction by the Nuss procedure. METHODS: Twenty-six patients with surgical correction of funnel chest using pectus bar were included. Twelve-lead ECGs before and later than one year after surgery were analyzed. RESULTS: In postoperative ECGs, amplitude of P wave in lead II and negative terminal amplitude of P wave in lead V1 decreased from 0.13 to 0.10mV (p=0.03), and from 0.10 to 0.04mV (p<0.001), respectively. Mean QRS duration decreased from 108ms to 98ms (p=0.003) after correction. A pathological left and right Sokolow-Lyon index was observed in 35% and 23% of patients before, versus 8% (p=0.04) and 0% (p=0.01) after correction, respectively. In contrast, the rate of patients with J wave pattern in precordial leads V4-V6 increased from 8% before to 42% after surgery (p=0.004). CONCLUSIONS: ECG abnormalities in patients with funnel chest are frequent, and can normalize after surgical correction by the Nuss procedure. De novo J wave pattern in precordial leads V4-V6 is a frequent finding after surgical funnel chest correction using pectus bar.

Ex vivo laser thermoplasty of whole costal cartilages.

BACKGROUND AND OBJECTIVE: To examine the possibilities of laser thermoplasty of whole costal cartilages for correction the human congenital chest wall deformities. STUDY DESIGN/MATERIALS AND METHODS: Ex vivo the samples of porcine costal cartilages were heated with lasers of differing wavelengths, including a 0.97-µm diode laser, a 1.56-µm erbium-doped quartz fiber laser, and a 1.68-µm fiber Raman laser. The dynamics of the temperature fields and the degradation of collagen in the laser-affected regions of samples were determined by using, respectively, thermometry, trypsin treatment, and light microscopy. Ex vivo the whole mechanically deformed costal cartilages of pigs were treated by laser radiation with wavelength 1.68-µm. The changes of cartilage shape were recorded at certain intervals over a 24-hour period by photographing them in a fixed position with a digital camera. RESULTS: Treatment of costal cartilage samples from 5 to 11 mm in thickness by laser radiation with 0.97, 1.56, and 1.68 µm wavelengths showed that the 1.68-µm radiation could produce the necessary nonuniform bulk heating of the exposed sample. The altered shape of costal cartilage proved to remain stable after treatment when the laser irradiation settings used provided for the heating of a broad region within the tissue to temperatures about 80°C. CONCLUSION: This study demonstrates the possibilities of laser thermoplasty of whole costal cartilages for treatment of human congenital chest wall deformities. The development of novel approaches based on laser cartilage engineering techniques will enable to treat the human congenital chest wall deformities.

Neither Carinatum nor Excavatum: Insights Regarding the Novel Postprematurity Thoracic Dysplasia and Traditional Harrison Grooves.

BACKGROUND/PURPOSE: In recent years, a new chest wall malformation (CWM), the postprematurity thoracic dysplasia (PPTD), was reported. It was characterized as an inward deviation of the anterior tips of the 6th ribs and a personal history of prematurity and respiratory distress. At the moment, PPTD's prevalence and etiology are yet to be defined. Thus, we aimed to explore and identify patients with a compatible morphology within a large cohort of patients with CWM. METHODS: Retrospective analysis of electronic health records including medical photographs of 4640 consecutive patients with chest wall malformations at our Pectus Clinic between 2002 and 2023. Patients presenting with bilateral inward curvature of the 6th to 8th ribs were included. Among the variables analyzed, the history of preterm birth and ventilatory support requirement were evaluated. RESULTS: From 2069 patients with non-excavated deformities, 29 (1.4%) patients presented a PPTD morphology. After excluding 12 for incomplete records, we found that 9 patients (52.9%) had a positive history of prematurity (group PT) and 8 (47.1%) didn't (group T). However, both groups showed a high incidence of respiratory comorbidities (PT: 89% vs. T: 76%, p = 0.91). The median age of deformity onset was 12 months (IQR 2; 12) and 24 months (IQR 1; 60) for the PT and T groups, respectively (p = 0.37). Both groups showed a low incidence of family history of CWM (PT: 38% and T: 14%, p = 0.57). CONCLUSIONS: In this retrospective study including 4640 patients with chest wall malformations, the presence of a phenotype described as postprematurity thoracic dysplasia was similarly distributed among patients with or without a history of prematurity. We hypothesize that this condition, different from pectus excavatum and carinatum, might correspond to the Harrison grooves, a deformity whose etiology was profusely discussed in the medical literature from the first half of the 20th century. TYPE OF STUDY: Comparative retrospective study. LEVEL OF EVIDENCE: III.

One- versus Two-Minute Intercostal Nerve Cryoanalgesia in Children Undergoing Surgery for Funnel Chest Deformity.

An inherent defect of the sternum and ribs results in the formation of a funnel-shaped anterior chest wall. The gold standard of surgical correction is the minimally invasive Nuss procedure, which might cause severe pain and carries the risk of sensory disturbances and chronic discomfort. Integrating cryoanalgesia with standard multimodal analgesia improves the outcomes of this procedure. Based on histological results, it was hypothesised that the time of cryo-application can be reduced from the current standard period of two minutes. The goal of this study was to evaluate the efficacy of a one-minute application compared with the routine two-minute method in the same patient, considering the subjective perception of pain and sensory disturbances. A total of 33 patients were included in this prospective study. The results show that the assessment of pain severity and sensory disturbances did not differ significantly in terms of the time of cryo-application during first 14 days after the surgical procedure. The one-minute cryo-application time for intraoperative intercostal nerve cryoablation prior to the Nuss procedure seems to be as safe and effective as the routinely used two-minute application time in regards to pain severity, sensory disturbances, and the risk of chronic pain development. Intercostal nerve cryoanalgesia is an essential element of multimodal analgesia.

Quality of life, psychological states, and personality traits in patients with pectus excavatum.

Objective: The quality of life (QOL) and psychological states of patients with pectus excavatum (PE) have yet to be well understood. This study aimed to evaluate the health-related QOL (HRQOL), psychological states, and personality traits of patients with PE, alongside the associations of these factors with the severity of PE. Methods: A cross-sectional evaluation was prospectively performed in patients scheduled to undergo PE repair surgery between July 2019 and April 2021. The primary outcome was the patients' HRQOL, and the secondary outcomes were depression, social anxiety, self-efficacy, and personality traits. Results: In total, 129 patients were subjected to analyses. Patients' HRQOL had a lower role component summary score (mean ± standard deviation: 41.8 ± 12.8, P < .001) than the general population controls. Patients' HRQOL had a significantly better physical component summary (54.0 ± 10.4, P < .001) and mental component summary (53.3 ± 8.8, P < .001) than that of the general population. Fourteen patients' (10.9%) and 56 patients' (43.4%) scores indicated the presence of depression and social anxiety disorder, respectively. Patients' self-efficacy (46.1 ± 11.4, P, .001) and level of extraversion (46.5 ± 11.8, P < .001) were lower than those of the general population. No significant correlation was found between the severity of PE and these scores. Conclusions: Our study revealed that patients with PE had decreased social-role QOL, depressive tendencies, increased social anxiety, lower self-efficacy, and introversion. No correlation between the severity of PE and the patients' psychological outcomes leads us to conclude that surgical implications of PE should not be decided solely by a physical index.

Lessons Learned after 176 Patients Treated with a Standardized Procedure of Thoracoscopic Cryoanalgesia during Minimally Invasive Repair of Pectus Excavatum.

BACKGROUND: Intrathoracic intercostal cryoanalgesia (Cryo) during minimally invasive repair of pectus excavatum (MIRPE) reports have been related to improved pain management, although its extent differs amongst studies. We aimed to report our experience using a standardized perioperative approach including Cryo during MIRPE, and compare our actual results with those of a previous thoracic epidural analgesia (TE) cohort. Lessons learned are summarized. METHODS: Retrospective study including patients undergoing Cryo during MIRPE between October 2018 and May 2023. Results with a standardized perioperative approach were analyzed. We then compared our Cryo cohort with a previous cohort of 62 patients who underwent TE and MIRPE between 2013 and 2018. Continuous variables were reported as mean and standard deviation, and as median (interquartile range) for variables with non-uniform distribution. RESULTS: We performed 176 Cryo during MIRPE (16.8 ± 4.6 years), with a mean postoperative length of stay (LOS) of 1.4 ± 0.8 days and a median total requirement of 7.5 (0.0; 15.0) oral morphine equivalents (OME) (mg). Patients with Cryo had a significantly lower mean LOS (1.4 ± 0.8 vs. 3.6 ± 1.0 days, p < 0.0001), and median total opioid requirement [7.5 (0.0; 15.0) vs. 77.4 (27.0; 115.5 OME (mg), p < 0.0001) compared to TE patients. Lessons learned included ensuring adequate contact of the cryoprobe with the target, proper exposition, and specialized multidisciplinary perioperative patient and family support, including psychology and physical therapy. CONCLUSIONS: In this study, we reported lessons learned after performing a standardized protocol of perioperative care in patients undergoing Cryo during MIRPE. This protocol enabled the achievement of a short LOS and low postoperative opioid requirement. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: III.

Proposing the Retrosternal Angle as a Diagnostic Measure for Banana Sternum in Pectus Excavatum.

BACKGROUND/PURPOSE: Anteriorly convex sternum in pectus excavatum, also known as banana sternum (BS), influences decision-making during repair and, especially, the need to cross bars. However, the definition of BS remains subjective. Thus, we aim to propose the retrosternal angle (RSA) as a diagnostic measure for the discrimination of BS. MATERIAL AND METHODS: Retrospective analysis of a cohort of patients who underwent a minimally invasive repair of pectus excavatum (MIRPE) between October 2016 and October 2023 at our Pectus Clinic. Five expert thoracic surgeons individually reviewed their medical photographs and chest CT scans assigning patients to BS or non-BS groups based on consensus (≥4 surgeons). RSA measurements were obtained by an independent thoracic surgeon. RESULTS: Among 283 cases analyzed, 50 (18%) were classified as BS and 233 (82%) as non-BS. No significant differences were found between groups in age (p = 0.62), Haller index (p = 0.11), or Correction index (p = 0.58). However, RSA was significantly lower in the BS group (141.2 ± 8.4° vs. 154.5 ± 10.3°, p < 0.0001). Receiver operating characteristic curve analysis revealed RSA as a reliable predictor of BS (AUC 0.85, p < 0.0001), with a threshold of 148.5° demonstrating 80% sensitivity and 77% specificity. Regarding potential clinical implications, 26/50 (52%) of patients defined as BS underwent bar crossing, compared with 45/232 (19%) of those not considered a BS (p < 0.0001). CONCLUSION: This study proposes an objective metric, the Retrosternal Angle, to assess BS in chest CT scans, with a threshold of 148.5° showing high sensitivity and specificity. External validation of this angle and threshold is warranted in future investigations. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: III.

Mitral Valve Regurgitation in Klippel-Feil Syndrome With Related Thoracic Deformity.

Klippel-Feil syndrome, characterized by congenital fusion of any 2 or more cervical vertebrae, is a rare disorder in which skeletal and other organ system-related abnormalities have been reported. This article reports a case of mitral valve regurgitation in a patient with Klippel-Feil syndrome and related thoracic deformity who underwent mitral valvuloplasty. Postoperatively, the mitral valve regurgitation disappeared, and there has been no recurrence for 3 years. This case highlights mitral valvuloplasty via median sternotomy as an excellent treatment for mitral valve regurgitation in a patient with thoracic deformity related to Klippel-Feil syndrome.