Pulmonary function after thoracoplasty for adolescent idiopathic scoliosis: a systematic review and meta-analysis.

PURPOSE: Thoracoplasty is a procedure which involves rib resection from the costovertebral junction to the apex of the rib hump deformity to address the cosmetic concerns of patients of scoliosis. There is conflicting literature on its effect on pulmonary function. The present meta-analysis was conducted to review and analyze the available literature and ascertain the effect of thoracoplasty on pulmonary function. METHODS: Search was conducted according to PRISMA guidelines on three databases. After analysis of all the search results by title, abstracts and full texts-10 studies were identified for inclusion in the review. We included studies which had analyzed preoperative and postoperative pulmonary function tests (PFTs) after thoracoplasty. Pooled estimates were calculated for pulmonary function, and effect of other factors was analyzed by subgroup analysis and meta-regression. RESULTS: The included studies were published between 1998 and 2019. A total of 385 patients were included in these studies, with a mean age of 15.01 years, with a female preponderance. Apprehension over appearance of rib hump was the most common indication for thoracoplasty. Percent-predicted forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV-1) were significantly decreased on follow-up. Anterior approach to corrective surgery and lower age were found to be associated with worse pulmonary function. Preoperative Cobb's angle was found to have significant impact on decrease in FEV-1 only, but not on other PFT parameters. CONCLUSION: Overall decrease in pulmonary function after thoracoplasty necessitates the need of adequate preoperative pulmonary function to mitigate its effect on patient well-being. Use of a posterior approach for corrective surgery when thoracoplasty is planned might lead to better outcomes. More research is needed to study effect of preoperative Cobb's angle on pulmonary function.

Complications of Chest Wall Resection in Conjunction with Pulmonary Resection.

Techniques for chest wall resection and reconstruction have evolved over the years. Chest wall resection in conjunction with pulmonary resection has several complications, including pulmonary and infectious. Risk factors for complications are related to the size of the defect, number of ribs resected, and the addition of a pulmonary resection. Material used for reconstruction does not impact the overall complication rate.

Thoracoplasty: Still relevant to current practice.

BACKGROUND: Management of residual pleural space remains a challenge in the practice of thoracic surgery. Options include thoracotomy with muscle flap/wound vac, Eloesser procedure, or thoracoplasty. We examine current practice and short-term outcomes of thoracoplasty in the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP). METHODS: A retrospective review of thoracoplasty procedures (by CPT® code 32900, 32905, or 32906) in the ACS NSQIP database from the years 2012 to 2017 was performed. The ACS NSQIP prospectively collects perioperative and rigorous 30-day outcome data for patients undergoing major thoracic surgical nationally. RESULTS: The dataset contained 131 thoracoplasties in patients with an average age of 48 years (SD 19), average BMI of 26 kg/m2 (SD 5), 48% female, and 21% of minority race. Forty percent of patients were ASA class III and 10% class IV-V. Five percent of the patients had muscle flap in addition to thoracoplasty. Median operative duration was 101 min (interquartile range 61-167) and 8% of patients required blood transfusion. The average length of hospital stay was 6 days (SD 9), and 93% of patients were discharged home. There was one death, and 23% experienced other major morbidity. Thirty-day readmission occurred in 8% of patients and 6% returned to the operating room within 30 days. Four percent of patients experienced respiratory failure, 4% sepsis, and 5% developed pneumonia. CONCLUSIONS: Short-term outcomes of current thoracoplasty demonstrate low mortality and morbidity. Thoracoplasty should remain in our armamentarium for managing residual pleural space.

Effectiveness and safety of a modified (rib ends fixed under transverse process) thoracoplasty for rib hump deformity in adults with severe thoracic scoliosis: A retrospective study.

Razor back deformity is one of the most noticeable problems of severe scoliosis. Thoracoplasty has been reported to be a useful approach to correct the rib hump deformity. However, the outcomes of thoracoplasty in patients with severe, rigid, thoracic scoliosis have not yet been evaluated.To evaluate the effectiveness and safety of a modified technique of thoracoplasty (rib ends fixed under transverse process) for rib hump deformity in adults with severe thoracic scoliosis and severe pulmonary dysfunction.Patients with severe thoracic scoliosis and severe pulmonary dysfunction who underwent staged surgical strategy including halo-pelvic traction, spinal osteotomy combined with the modified thoracoplasty were included. To avoid paradoxical breathing result from multiple rib resections and enlarge the capacity of thoracis, the ends after rib resection were fixed under transverse process compared with conventional thoracoplasty. Patients were excluded on the basis of pulmonary diseases and inadequate follow-up. Data on deformity correction and pulmonary complications were reviewed. A t test was performed on the pre- and postoperative data of pulmonary function, height of the rib hump deformity, and total lung area.Eighteen patients (5 men and 13 women) with a major thoracic curve of >130° were included. The mean age of patients was 25.3 ±â€Š3.6 years (range, 19-32 years), with an average length of follow-up of 30.2 months. After application of halo-pelvic traction, the mean major thoracic curve decreased from 168.2°â€Š±â€Š14.28° to 97.3°â€Š±â€Š10.75° and the thoracic kyphosis decreased from 159.4°â€Š±â€Š20.60° to 94.8°â€Š±â€Š9.58°. On average, 6.3 (range, 4-8) ribs were resected. The height of the rib hump decreased from 84.6 ±â€Š13.3 to 15.3 ±â€Š3.4 mm. The average predicted forced vital capacity (FVC%) before surgery was 37.2 ±â€Š13.30%, indicative of severe pulmonary impairment, with a small but non-significant improvement in the FVC% at the final follow-up. The mean total lung area increased from 2583.2 ±â€Š501.36 to 2890.1 ±â€Š537.30 mL at the last follow-up. No severe pulmonary complications occurred.Our modified approach to thoracoplasty procedure is effective and safe in correcting a razor back deformity in patients with severe, rigid, scoliosis, and severe pulmonary dysfunction, without causing any significant change in long-term pulmonary function.

Muscle flaps in pulmonary infections: a case series from Northeast India.

AIM: Treatment of complications due to pulmonary infections usually involves lung resection with or without debridement. Managing residual intrathoracic defects, chronic empyema, and bronchopleural fistulae after such resections poses unique challenges. METHODS: We retrospectively reviewed the data of all 9 patients referred to us with complications due to pulmonary infections, including the surgical procedures, flaps used, and their outcomes between 2018 and 2019. RESULTS: The mean age of the patients was 30 years (range 9?48 years). The primary disease was tuberculosis in 6 (66%) patients. Complications of primary infections were pneumothorax (n = 3), auto-pneumonectomy (n = 2), organized empyema (n = 3), and recurrent hemoptysis (n = 1). Initial interventions included lobectomy (n = 2), tracheoesophageal repair (n = 1), bronchial artery embolization (n = 1), intercostal tube drainage (n = 4), and decortication(n = 1). Complications after primary interventions included bronchopleural fistula (n = 4, 45%), recurrent empyema (n = 3, 33%), tracheal stump dehiscence (n = 1, 11%) and non-resolving hemoptysis (n = 1, 11%). Pathological microorganisms were isolated in 8 (88%) patients. Secondary corrective surgical interventions along with pedicled muscle flap interposition and reinforcement were undertaken. Nine flap procedures with or without thoracoplasty were performed. There was no open thoracostomy conversion. There was one death postoperatively. CONCLUSION: A locoregional pedicled flap with or without thoracoplasty is an effective option to manage complications of pulmonary infections. The cardiothoracic surgeon should have a knowledge of the locoregional flaps of the thorax and abdomen to address such complications.

Soft-Tissue Reconstruction after Composite Vertebrectomy and Chest Wall Resection for Spinal Tumors.

BACKGROUND: Oncologic resections involving both the spine and chest wall commonly require immediate soft-tissue reconstruction. The authors hypothesized that reconstructions of composite resections involving both the thoracic spine and chest wall would have a higher complication rate than reconstructions for resections limited to the thoracic spine alone. METHODS: The authors performed a retrospective analysis of all consecutive patients who underwent a thoracic vertebrectomy and soft-tissue reconstruction from 2002 to 2017. Patients were divided into two groups: those whose defect was limited to the thoracic spine and those who required a composite resection involving the chest wall. RESULTS: One hundred patients were included. Composite resection patients had larger defects, as indicated by a greater incidence of multilevel vertebrectomies (70.2 percent versus 17 percent; p = 0.001). Thoracic spine patients were older (58.2 ± 10.4 years versus 48.6 ± 13.9 years; p < 0.001) and had a greater incidence of metastatic disease (88.7 percent versus 38.3 percent; p = 0.001). Univariate and multivariate logistic regression analyses demonstrated that composite resections were not significantly associated with a higher rate of surgical, medical, or overall complications. Multivariate logistic regression analysis of composite resection subgroup demonstrated that flap separation of the spinal cord from the intrapleural space was protective against complications (OR, 0.22; 95 percent CI, 0.05 to 0.81; p = 0.03). CONCLUSIONS: Despite the large defect size in composite resection patients, there was no increase in complications compared to thoracic spine patients. In composite resection patients, separating the exposed spinal cord from the intrapleural space with well-vascularized soft tissue was protective against complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Unusual Complication of the Nuss Procedure: Fistulization of the Internal Thoracic Artery to the Pulmonary Artery.

Although minimally invasive repair of pectus excavatum has been shown to have a low complication rate in large series, several case reports have documented life-threatening complications, including bleeding and cardiac perforation. We present a rare case of an arteriovenous malformation from the internal thoracic artery to the pulmonary artery caused by occlusion of the internal thoracic artery by the Nuss bar followed by an unidentified angiogenic process. The patient became symptomatic and required transcatheter coil embolization.

Robotic Takedown of Internal Mammary Artery to Prevent Occlusion From Bars During Nuss Pectus Repair.

The Nuss procedure for repair of pectus excavatum involves the placement of substernal support bars that remain in place for 2 to 3 years. There are concerns about occlusion of the internal mammary artery due to the intrathoracic bars. It would be optimal to preserve one or more internal mammary arteries with the pectus repair. This report describes a 28-year-old man with severe symptomatic pectus excavatum who underwent Nuss repair. Robotic left internal mammary artery takedown was performed at the intercostal spaces planned for Nuss bars to prevent occlusion or damage from the bars.

Scoliosis Progression After the Nuss Procedure for Pectus Excavatum: A Case Report.

INTRODUCTION: Pectus excavatum and scoliosis are associated conditions with a high rate of coincidence. However, there are no reports to guide surgeons on the management of adolescents with moderate scoliosis and pectus excavatum, because there are conflicting conclusions in the literature regarding how the Nuss procedure with substernal bar affects scoliosis. CASES: In 2017, we encountered two patients with moderate scoliosis treated with a spinal orthosis. After undergoing the Nuss procedure for pectus excavatum, their scoliosis acutely progressed into surgical magnitude requiring posterior instrumented spinal fusion. The first patient progressed 26° despite the pre-Nuss radiographs showing him to be Risser 4/5, while the second patient also progressed 26° from the Nuss procedure. Both patients acknowledged noncompliance with brace wear because of discomfort after the Nuss procedure. However, their progression rate still doubles the rate of reported rapid accelerators, indicating that a significant component of curve progression is directly attributed to forces on the spine from the corrective maneuver with substernal bar. CONCLUSION: The purpose of this case report is to describe the features of these two patients to help with clinical decision-making in patients with moderate scoliosis (curves >25°) who are contemplating the Nuss procedure for correction of pectus excavatum. We caution patients and providers that spinal deformity could worsen with surgical intervention of the pectus excavatum via the Nuss procedure and necessitate scoliosis surgery.

Pulmonary Function After Convex Thoracoplasty in Adolescent Idiopathic Scoliosis Patients Treated by Posteromedial Translation.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To analyze the morbidity of thoracoplasty, and more specifically its effect on pulmonary function, after surgery with hybrid constructs using sublaminar bands in adolescent idiopathic scoliosis (AIS). BACKGROUND: Cosmetic concern is one of the main reasons to consider surgery in adolescent idiopathic scoliosis. Several studies have demonstrated significant improvement of self-image scores after thoracoplasty. However, consequences of thoracoplasty on pulmonary function (ie, pulmonary function tests [PFTs]) remain controversial. METHODS: After institutional review board approval, 96 consecutive AIS patients with thoracic curves (Lenke 1 and 2) were included between January 2014 and November 2015. All patients underwent low-dose stereoradiography with 3D reconstructions. Surgical procedure was the same in all patients: posterior correction using posteromedial translation technique with hybrid constructs (thoracic sublaminar bands and lumbar pedicle screws). Pulmonary function was explored with PFTs (forced vital capacity, forced expiratory volume in 1 second, and total lung capacity). Radiographic parameters and PFT results were compared between patients with and without thoracoplasty preoperatively and at two years postoperation. RESULTS: Mean age was 15 ± 2 years, and body mass index averaged 18.8 ± 2.6. Thirty-six patients (37.5%) underwent thoracoplasty. Both groups were comparable preoperatively regarding demographic data, radiographic parameters, and PFT results. No significant difference was found between groups regarding postoperative correction rates. At the two-year follow-up, PFT results were similar to the preoperative ones and no difference was observed between groups. However, pleural effusions were reported in 26 patients (72%) on chest radiographs. Only one pleural effusion due to thoracoplasty required drainage. CONCLUSION: Results of the current study demonstrated that thoracoplasty associated with posteromedial translation technique did not alter PFT results at two years postoperation. The morbidity of the procedure is limited, and it can therefore be considered in patients with high cosmetic demand and significant residual rib hump after main curve correction. However, hump height and pain evaluation would be interesting data in a prospective study. LEVEL OF EVIDENCE: Level IV.

Risk factors for pulmonary complications after posterior spinal instrumentation and fusion in the treatment of congenital scoliosis: a case-control study.

BACKGROUND: Although surgery prevents the progression of deformity and maintains the overall balance of the spine in congenital scoliosis (CS) patients, it is associated with a high risk of perioperative complications. Pulmonary complication is one of the most common complications. This retrospective study aimed to investigate the risk factors for pulmonary complications in CS patients after posterior spinal instrumentation and fusion. METHODS: Analysis of consecutive patients who underwent posterior spinal instrumentation and fusion for congenital scoliosis was performed. Preoperative clinical data, intraoperative variables, and perioperative radiographic parameters were collected to analyze the risk factors for pulmonary complications. Patients were separated into groups with and without postoperative pulmonary complications. Potential risk factors were identified by univariate testing. Multivariate logistic regression was used to evaluate independent predictors of pulmonary complications. RESULTS: Three hundred and twenty-three CS patients were included. Forty-five (13.9%) patients developed postoperative pulmonary complications, which included pleural effusion in 34 (75.6%) cases, pneumonia in 24 (53.3%) cases, pneumothorax in 3 (6.7%) cases, atelectasis in 4 (8.9%) cases, pulmonary edema in 2 (4.4%) cases, respiratory failure in 2 (4.4%) cases, and prolonged mechanical ventilation in 4 (8.9%) cases. The independent risk factors for development of pulmonary complications included age (Odds ratio (OR) = 1.088, P = 0.038), reoperation (OR = 5.150, P = 0.012), preoperative pulmonary disease (OR = 10.504, P = 0.004), correction rate (OR = 1.088, P = 0.001), middle thoracic screw-setting (OR = 12.690, P = 0.043), and thoracoplasty (OR = 5.802, P = 0.001). The area under the receiver operating characteristic (ROC) curve based on predicted probability of the logistic regression was 0.903. CONCLUSIONS: Age, reoperation, preoperative pulmonary disease, correction rate, middle thoracic screw-setting, and thoracoplasty were independent risk factors for pulmonary complications after posterior spinal instrumentation and fusion in CS patients.

Management of Postpneumonectomy Bronchopleural Fistula: From Thoracoplasty to Transsternal Closure.

Development of postpneumonectomy empyema with bronchopleural fistula is a life-threatening condition that requires prompt action. Although measures should be taken to prevent bronchopleural fistula at time of pneumonectomy, many patients experience this complication. Management focuses on drainage of the pleural space, control of the pleural infection including repair of the bronchopleural fistula, and obliteration of the residual pleural cavity. Multiple techniques and procedures have been developed over time to achieve these goals. Knowledge of the diverse therapeutic options is important to select the optimal treatment for these complex patients.

[Surgical treatment of pectus carinatum in children]. / Khirurgicheskoe lechenie kilevidnoi deformatsii grudnoi kletki u detei.

AIM: To improve the results of surgical treatment of pectus carinatum. MATERIAL AND METHODS: The work included 47 pectus carinatum patients aged 3-15 years for the period from 2000 to 2015. All patients were divided into 2 groups depending on surgical approach: control group - 23 (48.94%) children who underwent thoracoplasty by M.M. Ravitsh procedure with the use of device for pectus carinatum repair of our design; main group - 24 (51.06%) patients where our method of thoracoplasty based on changes of deformed ribs biomechanics was used. RESULTS: In control group good results were obtained in 15 (65.3%) patients, satisfactory - in 5 (21.7%) patients, recurrent deformation with all consequences was observed in 3 (13%) cases. Long-term results of surgical treatment by original method were followed-up in all 24 patients and good outcomes were obtained in 100% of children. CONCLUSION: 1) Intraoperative 'spring' - effect is a provoking risk factor of recurrent chest deformation. 2) The new surgical method based on breaking the ribs bodies in 'green branch' fashion provides good results and does not require external devices to hold sternal-rib complex in corrected position.

[Cytokines in surgery for pulmonary tuberculosis]. / Tsitokiny v kollapsokhirurgii tuberkuleza legkikh.

AIM: To evaluate the effect of various methods of thoracoplasty on local production of cytokines in patients with pulmonary tuberculosis. MATERIAL AND METHODS: The main group consisted of patients after traditional thoracoplasty. Thoracoplasty was compared with endoprosthesis of polypropylene mesh 'Surgipro - SPMM-149'. TNF-α and IL-10 cytokines in exudate from surgical area were measured by using of solid-phase enzyme immunoassay (OOO 'Vector-Best', Russia). RESULTS: It was revealed that local production of pro- and anti-inflammatory cytokines is more pronounced after thoracoplasty with polypropylene mesh 'Surgipro - SPMM-149'. Local cytokine balance changes towards inflammation were more pronounced after thoracoplasty with mesh implant and did not depend on the degree of drug sensitivity.

Revision of Failed Prior Nuss in Adult Patients With Pectus Excavatum.

BACKGROUND: Minimally invasive repair of pectus excavatum (MIRPE) has been extended to repair of defects in adults, with reported higher complication rates and outcome failures. The optimal revision for a prior failed MIRPE in an adult has not been identified. We review our experience for this adult population. METHODS: A retrospective review was performed of 129 patients (age ≥18 years) who underwent revision after a failed pectus excavatum (PE) repair from December 2010 through December 2016. RESULTS: In total, 47 of the 129 (36%) revision patients had a prior failed MIRPE, with 98% presenting for revision because of inadequate correction after their initial repair. The median age was 28 years (range, 18 to 54 years), and 77% were men. Thirty-one (66%) patients had indwelling pectus support bars at the revision procedure. Mean time from initial MIRPE to the revision procedure was 3.34 ± 2.9 years. A modified MIRPE was successful in 39 (83%) patients. Hybrid repair with the addition of osteotomy cuts and/or titanium plating was required in 8 patients for an adequate revision. Multiple (2 bars, 62%; 3 bars, 38%), shorter (median, 13.5 inches versus 15.0 inches) bars were used for the revision versus earlier repair. Substantial lysis of intrathoracic adhesions was required in 40 (85%) patients, with a median operative time for revision MIRPE of 169 ± 66 minutes; median operative time for hybrid procedures, 314 ± 74 minutes. CONCLUSIONS: A modified MIRPE can be successfully used in most adults to revise a failed prior MIRPE.

Surgical Treatment of Pleural Empyema - Our Results.

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce morbidity, mortality and duration of hospital stay. Unfortunately, advanced stages of empyema need to use extensive surgery - decortications or thoracoplasty. Early recognition of the parapneumonic effusion and the adequate treatment with thoracentesis or pleural drainage, which is minimally invasive, is possible not to prograde the process and not to become empyema. AIM: To analyze the results of the surgical treatment in patients with empyema treated at Clinic for thoracic surgery. MATERIAL AND METHODS: In the retrospective study we analyzed 234 patients with empyema which were treated at the Clinic for Thoracic Surgery in 5 year period (2011-2015). The mean age of the patients was 51.94 years. They were treated with pleural drainage, decortications or thoracoplasty. RESULTS: With pleural drainage were treated 165/234 (70.51%) patients, of which successfully were finished 124/165 (75.15%), but 41/165 (24.85%) were indicated after the decortications. A total of 108/234 (46.15%) were treated with decortications from which, primary decortications were indicated in 67/234 (28.63%) patients. 5/234 (2.14%) patients were treated with thoracoplasty - 3 of the patients with decortications and 2 with primary indicated thoracoplasty according to the local findings, long term untreated empyema and bad general condition. The Mean hospitalization was 17.4 days, of which 13.4 days after surgery. In the group with primary drainage it was detected a lethal outcome in 7/124 (5.64%) patients, 5/105 (4.76%) in the group with decortications and 2/5 (40%) in the group with thoracoplasty. CONCLUSION: Early detection of the parapneumonic effusion and the adequate treatment will prevent the appearance of empyema. If the empyema is detected it is necessary as early as possible to start the treatment with minimally invasive pleural drainage. In earlier stages it is possible to use less invasive decortications, using VATS than the open thoracotomy decortication which is more extensive surgical intervention.

[Differential approach for chest wall reconstruction for pectus excavatum in adults]. / Vybor metoda korrektsii voronkoobraznoi deformatsii grudnoi kletki u patsientov starshego vozrasta.

AIM: To perform the prospective non-randomized single-center trial of pectus excavatum correction in adults. MATERIAL AND METHODS: For the period March 2012 - March 2016 64 patients aged 18-44 years were treated. Median age was 23 years. Male/female ratio was 41/23. All patients were included into standard survey protocol: chest MDCT, MRI of thoracic spine, pulmonary function test, echocardiography. Quality of life and complications rate after the Nuss procedure (n=50, 78.1%, group 1) and radical thoracoplasty using nikelid-titanium bar (n=14, group 2) were evaluated. RESULTS: There was earlier recovery in the 1st group: 3 (2; 4) and 6 (5; 7) days after minimally invasive and radical thoracoplasty, respectively. Postoperative Dindo-Clavien I-IIIa complications developed in 46 (71.8%) patients. Most of them did not require additional procedures. CONCLUSION: Nuss procedure is safe method and can be performed with good results in adults.

Cardiac arrest without physical cardiac injury during Nuss repair of pectus excavatum.

BACKGROUND: Cardiac arrest is a lethal complication of Nuss repair of pectus excavatum which is strongly related to heart or big vessels injury. A rare case developed cardiac arrest without direct cardiac injury during Nuss procedure is presented in this article. CASE PRESENTATION: In July 2015, a previously healthy 18-year-old man undergoing Nuss repair for pectus excavatum developed cardiac arrest while the Nuss bar was being inserted into the chest. After successful resuscitation and exclusion of direct cardiac injury, the Nuss procedure was continued. The patient suffered a second cardiac arrest during rotation of the Nuss bar. This time, the patient had poor initial response to resuscitation and defibrillation until the retrosternal bar was removed. He ultimately recovered well from the episodes of cardiac arrest, but was unable to receive surgical correction of his pectus excavatum deformity. CONCLUSIONS: The possible mechanisms of cardiac arrest and lessons we can learn from this complication are discussed.