Outcomes in adult pectus excavatum patients undergoing Nuss repair.

Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.

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.

Pectus Excavatum: A Review of Diagnosis and Current Treatment Options.

Osteopathic medicine places a special emphasis on the musculoskeletal system, and understanding how chest wall structure may influence function is critical. Pectus excavatum is a common congenital chest wall defect in which the sternum is depressed posteriorly. Patients may present with complaints of chest wall discomfort, exercise intolerance, and tachycardia. The medical implications, diagnosis, and treatment options for patients with pectus excavatum are reviewed.

Nuss procedure for repair of pectus excavatum after failed Ravitch procedure in adults: indications and caveats.

BACKGROUND: Recurrence of pectus excavatum (PE) is not an uncommon problem after open repair using the Ravitch technique. The optimal approach for redo surgery is still under debate, especially in adults with less chest wall pliability. Aim of this study was to investigate the usefulness and efficacy of the minimally invasive Nuss technique for repair of recurrent PE after conventional open repair. METHODS: We performed a retrospective multicentre review of 20 adult patients from University Hospital Bern (n=6) and the US Mayo Clinic (n=14) who underwent minimally invasive repair of recurrent PE after unsuccessful prior Ravitch procedure. RESULTS: Mean patient age at primary open correction was 21 years, with recurrence being evident after a mean duration of 10.5 years (range, 0.25-47 years). Mean age at redo surgery using the Nuss technique was 31 years, with a mean Haller index of 4.7 before and 2.5 after final correction. Main reason for redo surgery was recurrent or persistent deformity (100%), followed by chest pain (75%) and exercise intolerance (75%). No major intraoperative or postoperative complications occurred and successful correction was possible in all patients. CONCLUSIONS: Although the procedure itself is more challenging, the minimally invasive Nuss technique can be safely and successfully used for repair of recurrent PE after failed open surgery. In our series final results were good to excellent in the majority of patients without major complications or recurrence.

Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults.

BACKGROUND: Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q). METHODS: Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores. RESULTS: Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system. CONCLUSIONS: Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.

Success of Minimally Invasive Pectus Excavatum Procedures (Modified Nuss) in Adult Patients (≥30 Years).

BACKGROUND: Minimally invasive repair of pectus excavatum (MIRPE) has become standard for pediatric and young adult patients, but its use for older adults is controversial. METHODS: We retrospectively reviewed electronic medical records of adults (≥18 years of age) who underwent MIRPE from January 1, 2010, through April 30, 2015, and collected demographic data, operative details, and information about outcomes. Cardiac function was measured before and after repair by intraoperative transesophageal echocardiography. We divided patients by age: 18 to 29 years of age and 30 years of age and older. RESULTS: Of 361 patients, 207 were 30 or older (mean, 40 years; range, 30 to 72 years; 71.5% men). Of the older patients, 151 had primary repairs. MIRPE was successfully used in 88.7% of patients older than 30 years of age versus 96.5% of those 18 to 29 years of age. For patients 30 years of age and older, open-cartilage resection, sternal osteotomy, or both was more common with increasing age (mean, 47.8 years versus 39.5 years; p = 0.0003) and higher mean Haller index (7.7 versus 5.5; p = 0.0254). Mean operative time for MIRPE was significantly longer for older patients (≥30 years of age) compared with younger adults (121 [60 to 224] minutes versus 111 [62 to 178] minutes; p = 0.0154). Right ventricular output increased 65.2% after repair in older adults. Although greater, the frequency of bar rotation requiring reoperation was not significantly increased in the older patients (p = 0.74). CONCLUSIONS: The majority of adult patients with PE can have successful repair with modified MIRPE. The use of cartilage or sternal osteotomy, or both, increased with patient age and defect severity.

Revision of failed, recurrent or complicated pectus excavatum after Nuss, Ravitch or cardiac surgery.

Pectus excavatum (PE) can recur after both open and minimally invasive repair of pectus excavatum (MIRPE) techniques. The cause of recurrence may differ based on the initial repair procedure performed. Recurrence risks for the open repair are due to factors which include incomplete previous repair, repair at too young of age, excessive dissection, early removal or lack of support structures, and incomplete healing of the chest wall. For patients presenting after failed or recurrent primary MIRPE repair, issues with support bars including placement, number, migration, and premature removal can all be associated with failure. Connective tissue disorders can complicate and increase recurrence risk in both types of PE repairs. Identifying the factors that contributed to the previous procedure's failure is critical for prevention of another recurrence. A combination of surgical techniques may be necessary to successfully repair some patients.

Successful Singleton and Twin Pregnancies With the Nuss Bars in Place.

Pectus excavatum (PE) occurs less commonly in women, and the implications on a pregnancy after repair during the period when support bars are in place are unknown. We present 2 cases: 1 with a successful twin gestation and another with a successful singleton gestation. These women carried the pregnancies to term and delivered their infants with the Nuss bars in place.

Surgical repair of pectus excavatum relieves right heart chamber compression and improves cardiac output in adult patients--an intraoperative transesophageal echocardiographic study.

BACKGROUND: Cardiac compression in pectus excavatum (PE) deformity and effect of PE surgery on cardiac function in adults have been debated. We examined the effect of PE correction on right heart size and cardiac output. METHODS: A retrospective evaluation was performed of 168 adult patients who underwent a modified Nuss PE repair with intraoperative transesophageal echocardiography from 2011 to 2014. Seventeen patients with prior PE repair undergoing bar removal acted as controls. RESULTS: Mean age was 33.0 years (range, 18 to 71 years). There was an increase in right atrium (15.1%), tricuspid annulus (10.9%), and right ventricular outflow tract (6.1%) size after surgery (all P < .0001). Right ventricular cardiac output measured in a subset of 42 patients improved by 38%. No change in chamber size or cardiac output occurred before and after bar removal surgery in the control group. CONCLUSIONS: Surgical correction of PE deformity caused a significant improvement in right heart chamber size and cardiac output.

Thoracoscopy for internal mammary node dissection of metastatic breast cancer.

INTRODUCTION: Diagnosis of metastatic breast carcinoma to the internal mammary lymph nodes is important both as a prognostic factor and for planning adjuvant chemoradiotherapy. Establishing lymph node dissection is often performed by Chamberlain's procedure, which involves intercostal incision with spreading of the pectoralis and the intercostal muscles and can be associated with complications, including bleeding from the internal mammary artery or damage to intercostal vessels and nerves. A technique is presented for video-assisted thoracoscopic internal mammary node dissection using both sentinel node evaluation and dissection. PATIENTS AND METHODS: This technique was performed on 2 female patients undergoing internal mammary node evaluation after they presented with invasive ductal breast carcinoma. RESULTS: Video-assisted dissection of the thoracoscopic internal mammary lymph nodes was successfully performed with no intraoperative complications. The postoperative course was uneventful. CONCLUSIONS: This approach can avoid damage to the internal mammary artery and intercostal spaces while providing useful information for the guidance of further therapy and achieving local control if clinically indicated.