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.

Novel index to estimate the cephalocaudal extent of the excavation in pectus excavatum: The Titanic index.

BACKGROUND/PURPOSE: Quantification of the severity of pectus excavatum deformities is currently performed using the Haller index (HI) and the Correction index (CI), amongst others. However, most indexes characterize the severity at the point of maximum excavation. We present a new index, the Titanic index (TI), aimed at the appraisal of the cephalocaudal extent of the excavation and its potential clinical use. MATERIALS AND METHODS: Retrospective analysis of a cohort of patients who underwent a minimally invasive repair of pectus excavatum (MIRPE) between July 2020 and April 2022 at a single center. We defined TI as the percentage of the sternum that lied behind the anterior costal line observed in the CT. Demographics, HI, CI, and TI calculated based on computed tomography images (CT) were analyzed. Also, we compared the severity indexes of two groups of patients divided by the number of implants introduced per patient (group A: two implants, and group B: more than two). RESULTS: Seventy-eight patients (92% male) were included, with a mean age of 17.2 ± 4.8 years. The mean TI was 37%. Albeit weak, we identified significant correlations between the TI and the HI and, more closely, to the CI. Two implants were introduced in 37 (47%) patients, and more than two in 41 (53%) patients. Compared to patients with two implants, the group of patients who received more than two implants were older and showed worse thoracic indexes. Using receiver operating characteristic curve analysis, we identified the TI as a better predictor of the need for more than two implants than HI and CI. In this regard, a TI larger than 66.5% had a sensitivity of 93% and a specificity of 92%. CONCLUSION: We propose a novel index for the categorization of the severity of pectus excavatum. This index might be useful in planning the number of implants required for complete thoracic remodeling during MIRPE. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective Comparative Study.

Determinants of success associated with vacuum bell treatment of pectus excavatum.

BACKGROUND/PURPOSE: We explored determinants of success in a large cohort of patients with pectus excavatum submitted to vacuum bell treatment and compared groups with satisfactory versus unsatisfactory outcomes. METHODS: Retrospective case-control study in a single center between May 2013 and January 2020, including patients with pectus excavatum treated with vacuum bell. We classified patients according to their status at closure of data registry (surveillance; withdrawal; complete correction; failure) and according to Obermeyer's classification of degrees of pectus excavatum correction. Determinants of success were calculated using receiver operating characteristic curves. RESULTS: Overall, 186 patients were included. Complete correction was achieved by 17% of the cases, while 45% remained under surveillance. Failure rates were low (n = 9; 5%), whereas withdrawal rates were 34%. Based on Obermeyer's classification of degree of excavation correction, 35% had excellent/good, 25% fair, and 40% poor/worse results. When comparing patients with good/excellent results with those with unsatisfactory results, patients with good/excellent results had a longer treatment duration [19.0 (13.0; 28) months vs. 13.0 (6.5; 22.5) months, p<0.0001], and lower initial pectus depth [1.6 (1.2; 2.0) cm, vs. 2.0 (1.5; 2.6) cm, p = 0.001]. Using ROC curves, the best determinants of success were an initial pectus depth ≤ 1.8 cm and a length of treatment > 12 months. CONCLUSION: One-third of patients in treatment with a vacuum bell achieved excellent or good outcomes in our cohort. Determinants of success included an initial pectus depth of 1.8 cm or less and a minimum length of treatment of 12 months. TYPE OF STUDY: retrospective comparative study LEVEL OF EVIDENCE: III.

Remote treatment of pectus carinatum (Telepectus) during the COVID-19 pandemic.

BACKGROUND/PURPOSE: To report telemedicine's feasibility and satisfaction rates for treating patients with pectus carinatum using a dynamic compressor system. We analyzed treatment adherence in comparison with the previous, non-pandemic year. MATERIALS AND METHODS: Retrospective analysis including patients with pectus carinatum under treatment with a dynamic compressor system using telemedicine at the chest wall centers from two hospitals, private and public, between April and July 2020. A free video conference platform for teleconsultations was employed. We evaluated the incidence of pectus cases with telemedicine, the number of dynamic compressor system prescriptions, the number of patients in the correction phase, and the number who ended treatment. To assess adherence, we compared our cohort with an in-person cohort during the same time frame of the previous, non-pandemic year. In addition, we performed a patient satisfaction survey comprising questions related to socioeconomic status, the likeability of telemedicine, simplicity of modification of the system, and desire to continue with telepectus after the pandemic. RESULTS: One hundred and thirty-six telepectus consultations were performed in 76 patients. During this time frame, 15 patients started using the dynamic compressor system. Compared to the previous, non-pandemic year, the number of consultations per patient was similar (2019: 1.92 ± 1 .0 vs. 2020: 1.79 ± 0.8, p = 0.32), and there was a significant reduction in the number of dropouts with the use of telemedicine (9% vs. 1%, p = 0.025). Fifty-nine patients answered the satisfaction survey. All of them solved their doubts through telemedicine. Overall, 95% found telemedicine comfortable. Of note, those with a lower income evidenced the highest intention in continuing with telemedicine. CONCLUSIONS: We demonstrated the feasibility of remote care of patients with pectus carinatum using a dynamic compressor system with a similar frequency of consultations compared to in-person medical care. Telepectus patients revealed a high rate of satisfaction irrespective of their socioeconomic status. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Retrospective study.

Usefulness of strain cardiac magnetic resonance for the exposure of mild left ventricular systolic abnormalities in pectus excavatum.

BACKGROUND: Systolic dysfunction in pectus excavatum (PEX) is usually very subtle and mainly focused on the right ventricle (RV), leading to normal or unremarkable cardiac imaging findings unless involving exercise stress. OBJECTIVES: We evaluated systolic function in PEX using longitudinal strain cardiac magnetic resonance (CMR), a validated parameter for the assessment of the systolic deformation of subendocardial fibers. METHODS: This prospective registry comprised consecutive patients with PEX who were referred to CMR to define treatment strategies or to establish surgical candidacy. We also included a control group of 15 healthy volunteers without chest wall abnormalities. Using dedicated software, we evaluated the endocardial global longitudinal strain (GLS) of both ventricles and the endocardial global circumferential strain (GCS) of the left ventricle (LV). RESULTS: A total of 50 patients with PEX comprised the study population, with a mean age of 19.9 ± 8.0 years. The right ventricular ejection fraction (RVEF) of patients with PEX was significantly lower compared to the control group both at end-expiration (59.5 ± 6.8 vs. 64.7 ± 4.7%, p = 0.008) and end-inspiration (56.7 ± 7.2%, vs. 62.7 ± 4.4, p = 0.004); as well as the pulmonary stroke distance (12.6 ± 2.5, vs. 15.0 ± 2.0 cm, p = 0.001). The LV volumetric analysis revealed no differences between PEX and the control group (p > 0.05 for all) regardless of the respiratory cycle, with a mean expiratory LV ejection fraction (LVEF) of 61.4 ± 6.0%. In contrast, the GLS of the LV was significantly lower in PEX compared to controls (-21.2 ± 3.2 vs. -23.7 ± 3.0%, p = 0.010), whereas GCS was similar either at expiration (-28.5 ± 4.0%, vs. -29.5 ± 2.8, p = 0.38) or inspiration (-29.3 ± 4.1%, vs.-28.9 ± 2.3, p = 0.73). CONCLUSIONS: In this study, we demonstrated that longitudinal strain analysis might enable the detection of very subtle left ventricular systolic function abnormalities in patients with PEX, that are commonly overlooked using the conventional assessment. LEVEL OF EVIDENCE: II.

Resorbable airway splint, stents, and 3D reconstruction and printing of the airway in tracheobronchomalacia.

Tracheobronchomalacia (TBM) is the most common tracheobronchial obstruction. Most cases are mild to moderate; therefore, they do not need surgical treatment. Severe tracheomalacia, however, represents a diagnostic and therapeutic challenge since they are very heterogeneous. In the armamentarium of resources for the treatment of dynamic airway collapse, splints and stents are two underused strategies and yet, they may represent the best alternative in selected cases. Lately, computed tomography 3D reconstruction of the airway has been used for the design of virtual models that can be 3D-printed for the creation of novel devices to address training, simulation, and biotechnological implants for refractory and severe airway malformations. This manuscript examines the role of resorbable stents, splints, and the 3D reconstruction and printing of the pediatric airway in tracheobronchomalacia.

Implementation and acceptance rates of a specially designed vacuometer for the vacuum bell treatment of pectus excavatum.

BACKGROUND / PURPOSE: To report the implementation of a specially designed vacuometer for the ambulatory measurement of the exact negative pressure self-applied by the patient when using the vacuum bell for the treatment of pectus excavatum and to analyze patient satisfaction with the device, by conducting a survey. METHODS: Between October 2018 and June 2020, all patients with pectus excavatum who received a vacuum bell at our Pectus Clinic were provided with a specially designed pectus vacuometer for their personal use. We described the vacuometer, the fundamentals of its development, and the utilization protocol. A survey was conducted evaluating comfort, clarity of instructions, usefulness, simplicity of connection, and likeability. The level of satisfaction was assessed using a Likert scale ranging from 1 (very negative experience) to 5 (very positive experience). The occurrence of skin lesions provoked by the application of the vacuum bell was registered. RESULTS: From 72 submitted surveys, 54 patients answered. Patient demographics comprised 44 (81.5%) males and a mean age of 12.6 ± 6.0 years. The mean initial external pectus depth was 2.0 ± 0.7 cm and the mean duration of treatment was 13.2 ± 8.6 months. No skin lesions were detected while using the vacuum bell and the vacuometer. The mean general satisfaction score was 4.4 ± 0.7 and 83.3% of the respondents did not have any inconvenience with the vacuometer. A patient who considered himself cured was the only dropout during the study. CONCLUSIONS: In this study, we described the feasibility and fundamentals of the application of a specifically designed vacuometer for ambulatory use as an adjunct to the treatment of pectus excavatum with a vacuum bell, and demonstrated a high satisfaction level with the device. In addition, the vacuometer might help avoid skin lesions secondary to the vacuum bell and foster adhesion to treatment. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: IV.

Surgical Planning, Simulation, and Prosthesis Customization for Complex Chest Wall Malformations.

Despite the emergent application of 3-dimensional technology for thoracic reconstructions, reports regarding its use for the resolution of the heterogeneous subgroup of complex chest wall malformations are lacking. We aim to report a novel, standardized process of personalized repair of complex chest wall malformations comprising multidisciplinary, comprehensive surgical planning; surgical simulation on a 3-dimensionally printed scale model of the area of interest; manufacturing of customized prostheses; and surgical repair according to plan. We propose this therapeutic strategy for the resolution of such a wide variety of chest wall deformities to reduce improvisation and enhance outcomes.

From bench to bedside: 3D reconstruction and printing as a valuable tool for the chest wall surgeon.

BACKGROUND/PURPOSE: The development of computer-aided design/manufacturing and digital image technology shows promise to revolutionize several medical and surgical fields. In this context, we propose a different approach for minimally invasive repair of pectus excavatum (MIRPE) including preoperative planning, ambulatory template fitting, and implant customization. METHODS: We prospectively collected data on 130 consecutive patients who underwent a novel process of implant customization for MIRPE between November 2015 and September 2019 at our institution. This process consisted of: 1) preoperative planning using 3D computed tomography scan reconstruction and 3D printing of the implant template, 2) an ambulatory fitting session with the template, and 3) manufacture of a custom made, prebent, metallic implant based on the 3D printed templates. We described the process in detail and analyzed the "implant-deformity" match, need for rebending, modification of the curvature or shape of the pectus implant intraoperatively, and accuracy of the number of bars planned preoperatively. RESULTS: Preoperative planning including 3D reconstruction and printing resulted in a 92.3% optimal "implant-deformity" anatomic match. Minimal rebending without flipping of the implants was required in 5.4% of the patients. In two cases (1.5%), the implants were too short, and they tended to sink into the intercostal space, and in one case (0.8%), the patient's chest was extremely asymmetric, and the implant had to be removed and rebent intraoperatively. The number of implants planned preoperatively was precise in 100%. CONCLUSIONS: In this study, we demonstrated that minimally invasive repair of pectus excavatum assisted by preoperative planning, ambulatory template fitting, and implant customization enables an excellent anatomic match, leading to minimal rebending, and avoiding implant flipping or removal after retrosternal passage as well as accuracy in the number of bars programmed preoperatively. TYPE OF STUDY: Prospective registry. LEVEL OF EVIDENCE: III.

Safety-string: A handy maneuver to control pectus bar removal bleeding complications.

The pectus bar removal procedure is often considered a simple, straightforward surgery with a low incidence of complications. However, life-threatening bleeding complications have been reported requiring major measures for hemostatic control. Our objective is to share a simple maneuver that our group has systematically included in the bar removal procedure to facilitate bleeding control in case hemorrhage occurs.

Lessons Learned After 101 Cases of Single-Site Magnetic-Assisted Cholecystectomy in Children.

BACKGROUND / PURPOSE: The aim of this report is to present our experience with a magnetic-assisted single-site cholecystectomy technique ("magnachole") in pediatric patients. METHODS: We performed a retrospective chart review of all patients who underwent magnachole between 2009 and 2019. We evaluated patients' demographics, diagnosis, operative time, complications, conversion rate and length of stay. Additionally, simple lineal regression analysis was conducted to determine if the surgeon's experience, the patient's age at surgery, the patient's gender or the patient's body weight affected operative time. RESULTS: A total of 101 patients were operated during the analyzed period. The mean age at surgery was 12.6 (range 4 to 19) years, and the mean body weight was 53.7 (range 13.5 to 123) kg. The most frequent indication (91%) was symptomatic cholelithiasis. Mean operative time was 85 (range 45 to 240) min. The mean operative time decreased by 22.7 min (p < 0.001, 95% [CI] 10.35 to 35.13) when we compared the first 51 cases to the last 50 cases. Simple lineal regression showed a reduction of 2.6 min in operative time per year. Age at surgery, gender, and weight did not influence operative time. There were no intraoperative complications. Only 1 case required an additional port to complete the operation. There were no conversions to open cholecystectomy. Median length of stay was 26 h (range 10 to 168). CONCLUSION: The magnachole technique is safe and effective, and has become our preferred surgical approach for children who need a cholecystectomy. As expected, the operative time decreased as surgeons gain experience with the technique. The technique is feasible regardless of the patient's body habitus. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level IV.

Diastolic and Systolic Cardiac Dysfunction in Pectus Excavatum: Relationship to Exercise and Malformation Severity.

PURPOSE: To explore stress echocardiographic findings among patients with pectus excavatum (PEX) and their relationship with malformation severity. MATERIALS AND METHODS: A prospective registry involving consecutive patients with a diagnosis of isolated PEX referred to undergo chest CT and stress echocardiography to evaluate surgical candidacy and/or to define treatment strategies was developed. Malformation indexes were evaluated using chest CT. RESULTS: This study included 269 patients with PEX (19.7 years ± 7.8 [standard deviation]; 245 men) and 35 healthy volunteers (20.7 years ± 6.1; 21 men). Patients with PEX achieved a lower maximal workload (PEX group, 8.2 metabolic equivalents ± 1.7; control group, 11.8 metabolic equivalents ± 5.5; P < .0001). This study identified evidence of abnormal right ventricular diastolic function in 29% of patients with PEX and identified no evidence of this among those in the control group (P < .0001). Healthy controls showed a 37% increment in the tricuspid area during exercise, compared with 4% in patients with PEX (P = .002). Right ventricular systolic function was significantly lower in patients with PEX than in controls, both measured using tricuspid annulus plane systolic excursion (stress, 25.0 mm ± 5.5 vs 35.4 mm ± 3.7; P < .0001), and the tricuspid systolic wave was also smaller (stress, 16.9 cm/sec ± 4.5 vs 20.5 cm/sec ± 3.9; P < .0001). During stress, significant associations were detected between malformation indexes with right ventricular systolic and diastolic findings (P < .05 for all). CONCLUSION: This study identified evidence of diverse adverse functional and morphologic cardiac manifestations in PEX, involving signs of abnormal diastolic and systolic right ventricular function and compression of the atrioventricular groove, which worsened during stress and were related to malformation severity.© RSNA, 2020: An earlier incorrect version of this article appeared online. This article was corrected on October 19, 2020.

Erratum: Diastolic and Systolic Cardiac Dysfunction in Pectus Excavatum: Relationship to Exercise and Malformation Severity.

[This corrects the article DOI: 10.1148/ryct.2020200011.].

Magnetic Compression Anastomosis (Magnamosis) for Functional Undiversion of Ileostomy in Pediatric Patients.

INTRODUCTION: Magnamosis forms a compression anastomosis using self-aligning magnetic Harrison rings. The device has been approved by the Food and Drug Administration for first-in-human testing and has been applied in adults for intestinal anastomosis during urologic reconstructions. We now report the first cases of magnamosis to functionally undivert the fecal stream from a previously created loop ileostomy in pediatric patients. MATERIALS AND METHODS: Case 1: A 4-year-old male underwent a diverting loop ileostomy for malignant bowel obstruction. The obstruction gradually resolved with chemotherapy, and persistently high stomal output and malnutrition prompted undiversion. Case 2: A 16-year-old female with iloecolonic polyposis underwent ileoproctectomy with J pouch and diverting ileostomy. The magnamosis functional undiversion (FUN) technique involves introducing a Harrison ring through each stomal limb under general anesthesia with X-ray guidance. Magnets are each tied with sutures that exit the stoma and are then tied to each other externally. The device is removed when patency is detected. RESULTS: The introduction procedure took less than 20 minutes and there were no complications. Enteral feeding was initiated 24 and 6 hours postoperatively, and distal passage of stool occurred by the fourth and fifth days, respectively. Magnets were removed 14 and 15 days postoperatively, without evidence of leak. CONCLUSION: We conclude that the magnamosis undiversion procedure is a safe, minimally invasive way to gradually refunctionalize the excluded distal bowel after previous diverting ostomy.