Novel techniques and future developments in minimally invasive pectus repair.

After the paradigm shift in the treatment of excavated deformities caused by the introduction of the Nuss technique in 1998, several innovative technical modifications and new treatment modalities have radically changed the surgical approach of pectus excavatum in the last couple of years. These new trends attain different topics. On one hand, the use of three-dimensional (3D) printing and implant customization surge as a possibility for a wider audience as 3D printers become available with lower costs. They provide the surgeon with new elements that enable precise planning, simulation, and customized prostheses amidst a tendency to abandon standardization and incorporate personalized medicine. Another topic comprises mandatory sternal elevation, in the continuous search for safety first always. Complete thoracic remodeling as a goal of repair instead of addressing only focal depressions, leaving the upper chest or focal protrusions unresolved. Finally, although the current surgical approach has evolved significantly, many groups still use lateral stabilizers or direct implant fixation with sutures or wires to the ribs. These systems continue to prove unreliable in preventing implant displacement. Fortunately, the bridge technique, described in this review, has come to address this sometimes fatal issue with encouraging results. We provide an updated overview of the latest developments regarding these concepts, related to the current state-of-the-art of the treatment of pectus excavatum.

Randomized comparison of oblique and perpendicular stabilizers for minimally invasive repair of pectus excavatum.

OBJECTIVES: Bar dislocation is one of the most feared complications of the minimally invasive repair of pectus excavatum. METHODS: Prospective randomized parallel-group clinical trial intending to assess whether oblique stabilizers can reduce bar displacement in comparison with regular stabilizers used in minimally invasive repair of pectus excavatum. Additionally, we evaluated pain, quality of life and other postoperative complications. Participants were randomly assigned to surgery with perpendicular (n = 16) or oblique stabilizers (n = 14) between October 2017 and September 2018 and followed for 3 years. Bar displacements were evaluated with the bar displacement index. Pain scores were evaluated through visual analogue scale and quality of life through the Pectus Excavatum Evaluation Questionnaire. RESULTS: Control group average displacement index was 17.7 (±26.7) and intervention group average displacement index was 8.2 (±10.9). There was 1 reoperation in each group that required correction with 2 bars. Bar displacement was similar among groups (P = 0.12). No other complications were recorded. There was no statistically significant difference on pain score. There was a significant difference between pre- and postoperative composite scores of the participants' body image domain and psycho-social aspects in both groups. The difference between the pre- and postoperative participants' perception of physical difficulties was greater and statistically significant in the intervention group. CONCLUSIONS: There was no statistical difference in the use of perpendicular or oblique stabilizers, but the availability of different models of stabilizers during the study suggested that this can be advantageous. The trial is registered at ClinicalTrials.gov, number NCT03087734.

Augmentation mammoplasty and autologous fat transplantation: an alternative for the treatment of hypomastia and mild pectus excavatum - Case report / Mamoplastia de aumento e transplante de gordura autóloga: uma alternativa para o tratamento da hipomastia e pectus excavatum leve - Relato de caso

Pectus excavatum(PE) is a congenital chest deformity characterized by deep depression in the sternum. Autologous fat transplantation has been used for aesthetic purposes, mainly on the face, and has recently gained relevance in thoracic and breast surgeries. The present study aims to present a case of mild PE associated with hypomastia. A 24-year-old female patient attended the consultation for breast augmentation due to hypomastia, but the clinical examination also revealed an associated mild PE that the patient did not notice. Surgical planning included breast augmentation and autologous fat transfer. A 260ml silicone breast implant was used, and 250ml of fat was injected in the sternal region and the lower medial contour of the breasts. There were no complications during the 12-month follow-up period. The combination of augmentation mammoplasty and fat transplantation in treating PE deformity proved to be a minimally invasive, good, safe option with high patient satisfaction.

Pectus excavatum (PE) é uma deformidade torácica congênita, caracterizada como uma depressão profunda no esterno. O transplante autólogo de gordura tem sido utilizado para fins estéticos, principalmente na face, e recentemente ganhou relevância nas cirurgias torácica e das mamas. O objetivo do presente estudo é apresentar um caso de PE leve associado a hipomastia. Uma paciente de 24 anos compareceu à consulta para mamoplastia de aumento por hipomastia, mas o exame clínico também revelou um PE leve associado que não foi percebido pela paciente. O planejamento cirúrgico incluiu a mamoplastia de aumento e a transferência de gordura autóloga. Foi utilizado um implante mamário de silicone de 260ml, e uma quantidade total de 250ml de gordura foi injetada na região esternal e no contorno medial inferior das mamas. Não houve complicações durante o período de acompanhamento de 12 meses. A associação de mamoplastia de aumento e transplante de gordura no tratamento da deformidade de PE revelou-se uma opção minimamente invasiva, boa, segura e com alta satisfação da paciente.

Repercusiones cardíacas en pacientes con pectus excavatum: puesta al día. Segunda parte / Cardiac repercussions in patients with pectus excavatum: update. Part two / Repercussões cardíacas em pacientes com pectus excavatum: atualização. Parte dois

El pectus excavatum (PEX) es una deformación de la pared torácica que obedece a una alteración de los cartílagos costales con el consiguiente hundimiento del esternón. Históricamente, se clasificaba como un defecto únicamente estético o cosmético, sin embargo, en los últimos años se han desarrollado nuevos métodos de estudio para la valoración de las repercusiones de esta patología. Existe cada vez más bibliografía que demuestra importantes repercusiones funcionales. Se realizó una puesta al día de las repercusiones cardíacas de la patología y un análisis de los artículos más relevantes de los últimos años. La evidencia actual permite afirmar que existe una afectación cardíaca por compresión esternal en la mayoría de los pacientes con PEX. Las afectaciones incluyen alteraciones anatomofuncionales (trastornos del ritmo, disminución del llenado ventricular), del volumen sistólico, aumento de la presión de la aurícula derecha, valvulopatías, compresión del ventrículo derecho, derrame pericárdico, entre otras. Todo lo cual permite concluir que el PEX puede presentar importantes alteraciones cardíacas que deben ser tenidas en cuenta a la hora de valorar los pacientes con esta patología.

Pectus excavatum (PEX) is a deformation of the chest wall caused by an alteration of the costal cartilages with the consequent collapse of the sternum. Historically, it had been classified as a solely aesthetic or cosmetic defect, however, in recent years new study methods have been developed to assess the repercussions of this pathology, with increasing bibliography showing important functional consequences. We updated the cardiac pathological repercussions and analyzed the most relevant articles of recent years. The current evidence suggests that there is cardiac involvement due to sternal compression in most patients with PEX. These affectations include anatomical functional alterations: rhythm disorders, decreased ventricular filling, decreased stroke volume, increased right atrial pressure, valve disease, right ventricular compression, pericardial effusion, among others. All of which enables us to conclude that PEX can present important cardiac alterations that must be taken into account when assessing patients with this pathology.

Pectus excavatum (PEX) é uma deformação da parede torácica decorrente de uma alteração das cartilagens costais com consequente colapso do esterno. Historicamente, foi classificado como um defeito exclusivamente estético ou cosmético, porém, nos últimos anos, novos métodos de estudo foram desenvolvidos para avaliar as repercussões dessa patologia, com crescente bibliografia mostrando importantes repercussões funcionais. Foi realizada uma atualização das repercussões cardíacas da patologia e análise dos artigos mais relevantes dos últimos anos. As evidências atuais permitem afirmar que há acometimento cardíaco por compressão esternal na maioria dos pacientes com PEX. As afecções incluem alterações anatomofuncionais: distúrbios do ritmo, diminuição do enchimento ventricular, diminuição do volume sistólico, aumento da pressão atrial direita, doença valvular, compressão do ventrículo direito, derrame pericárdico, entre outras. Tudo isso permite concluir que o PEX pode apresentar alterações cardíacas importantes que devem ser levadas em consideração na avaliação de pacientes com essa patologia.

STERNUM TOMOGRAPHIC EVALUATION IN PECTUS PATIENTS: ANALYSIS OF SAGITAL PARAMETERS.

Objective: To evaluate the sagittal tomographic reformatting of the sternum using unpublished radiographic parameters (indexes and angles), comparing them between the different types of pectus, and controls. Methods: 44 patients with pectus deformities and controls underwent chest CT for analysis. The types of pectus were classified into: inferior pectus carinatum (IPC), superior (SPC) and lateral (LPC), and broad (BPE) and localized pectus excavatum (LPE). The following tomographic parameters were created and measured: (1) spine-manubrium-sternum index (SMS); (2) column-sternum index (CSI); (3) manubrium-sternal angle (MSA); (4) inferior manubrium angle (IMA); and (5) inferior sternum angle (ISA). Statistical analysis was performed between the pectus and control groups, and between the different types of pectus. Results: There was a significant difference between: a) pectus excavatum and pectus carinatum when analyzing the SMS, CSI, MSA and ISA indexes. b) LPE and control group for SMS and ISA. c) LPC and LPE, and LPC and BPE for SMS; d) BPE and LPC for CSI; e) IPC and LPE, and IPC and BPE for ISA; f) SPC and LPE, and SPC and BPE for IMA. Conclusion: The radiographic indexes and angles created provided differentiation parameters between patients with different types of pectus, and between these and controls. Level of Evidence II, Prognostic Studies.

Objetivos: Avaliar a reformatação tomográfica sagital do esterno por meio de parâmetros radiográficos inéditos (índices e ângulos), comparando-os entre os diferentes tipos de pectus e controles. Métodos: 44 pacientes com deformidades pectus e controles foram submetidos à TC do tórax para análise. Os tipos de pectus foram classificados em: pectus carinatum inferior (PCI), superior (PCS) e lateral (PCL), e pectus excavatum amplo (PEA) e localizado (PEL). Foram criados e mensurados os seguintes parâmetros tomográficos: (1) índice coluna-manúbrio-esterno (CME); (2) índice coluna-esterno (CE); (3) ângulo manúbrio-esternal (AME); (4) ângulo inferior do manúbrio (AIM); e (5) ângulo inferior do esterno (AIE). Foi realizada análise estatística entre os grupos pectus e controle, e entre os diferentes tipos de pectus. Resultados: Houve diferença significativa entre: a) pectus excavatum e pectus carinatum quando analisados os índices CME, CE, AIM e AIE; b) PEL e grupo controle para CME e AIE; c) PCL e PEL, e PCL e PEA para o CME; d) PEA e PCL para CE; e) PCI e PEL, e PCI e PEA para AIE; f) PCS e PEL, e PCS e PEA para AIM. Conclusões: Os índices e ângulos radiográficos criados forneceram parâmetros de diferenciação entre pacientes com diferentes tipos de pectus, e entre estes e controles. Nível de Evidência II, Estudos Prognósticos.

Repercusiones pulmonares en pacientes con pectus excavatum: puesta al día / Pulmonary consequences on patients with pectus excavatum: update / Repercussões pulmonares em pacientes com pectus excavatum: atualização

El pectus excavatum (PEX) es una deformación de la pared torácica que obedece a una alteración de los cartílagos costales con el consiguiente hundimiento del esternón. Históricamente se clasificaba como un defecto únicamente estético o cosmético, sin embargo en los últimos años se han desarrollado nuevos métodos de estudio para la valoración de las repercusiones de esta patología, y existe cada vez más bibliografía que demuestra importantes repercusiones funcionales. Se realizó una puesta al día de las repercusiones pulmonares de la patología y análisis de los artículos más relevantes de los últimos años. Los síntomas respiratorios son frecuentes, estando presentes en más de la mitad de los pacientes. Se ha demostrado una disminución de la CVF, VEF1 y PEF25%-75%; así como la presencia de un patrón restrictivo y/o obstructivo, un aumento del VR y una alteración de la dinámica respiratoria. Se ha objetivado la afectación del PEX sobre la función pulmonar, determinando categóricamente que esta patología presenta una importante repercusión funcional.

Pectus excavatum (PEX) is a thoracic wall malformation due to an alteration of the costal cartilages with subsequent sinking of the sternum. Historically, it was considered a mere aesthetic or cosmetic defect, however, in recent years, new assessment methods have been developed to evaluate the repercussions of this pathology, and there is an increasing literature that demonstrates important functional consequences. We carried out an update of this pathology's pulmonary repercussions and analyzed the most relevant articles of the recent years. Respiratory symptoms are frequent, present in more than half of the patients. A decrease in FVC, FEV1 and PEF25%-75% has been shown; as well as the presence of a restrictive and/or obstructive pattern, an increase in RV and an alteration in respiratory dynamics. The affectation of PEX on pulmonary function has been objectified, and it has been determined categorically that this pathology has important functional consequences.

Pectus excavatum (PEX) é uma deformação da parede torácica devido a uma alteração das cartilagens costais com consequente afundamento do esterno. Historicamente, foi classificado como um defeito exclusivamente estético ou cosmético, porém, nos últimos anos, novos métodos de estudo foram desenvolvidos para avaliar as repercussões dessa patologia, e há uma literatura crescente que demonstra importantes repercussões funcionais. Foi realizada uma atualização das repercussões pulmonares da patologia e análise dos artigos mais relevantes dos últimos anos. Os sintomas respiratórios são frequentes, estando presentes em mais da metade dos pacientes. Foi demonstrada uma diminuição da CVF, VEF1 e PEF25-75%; bem como a presença de padrão restritivo e/ou obstrutivo, aumento do VD e alteração da dinâmica respiratória. A afetação do PEX na função pulmonar tem sido objetivada, determinando categoricamente que esta patologia apresenta importante repercussão funcional.

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.

Sternum tomographic evaluation in pectus patients: analysis of sagital parameters / Avaliação tomográfica de pacientes com pectus: novos índices e ângulos sagitais

ABSTRACT Objective: To evaluate the sagittal tomographic reformatting of the sternum using unpublished radiographic parameters (indexes and angles), comparing them between the different types of pectus, and controls. Methods: 44 patients with pectus deformities and controls underwent chest CT for analysis. The types of pectus were classified into: inferior pectus carinatum (IPC), superior (SPC) and lateral (LPC), and broad (BPE) and localized pectus excavatum (LPE). The following tomographic parameters were created and measured: (1) spine-manubrium-sternum index (SMS); (2) column-sternum index (CSI); (3) manubrium-sternal angle (MSA); (4) inferior manubrium angle (IMA); and (5) inferior sternum angle (ISA). Statistical analysis was performed between the pectus and control groups, and between the different types of pectus. Results: There was a significant difference between: a) pectus excavatum and pectus carinatum when analyzing the SMS, CSI, MSA and ISA indexes. b) LPE and control group for SMS and ISA. c) LPC and LPE, and LPC and BPE for SMS; d) BPE and LPC for CSI; e) IPC and LPE, and IPC and BPE for ISA; f) SPC and LPE, and SPC and BPE for IMA. Conclusion: The radiographic indexes and angles created provided differentiation parameters between patients with different types of pectus, and between these and controls. Level of Evidence II, Prognostic Studies.

RESUMO Objetivos: Avaliar a reformatação tomográfica sagital do esterno por meio de parâmetros radiográficos inéditos (índices e ângulos), comparando-os entre os diferentes tipos de pectus e controles. Métodos: 44 pacientes com deformidades pectus e controles foram submetidos à TC do tórax para análise. Os tipos de pectus foram classificados em: pectus carinatum inferior (PCI), superior (PCS) e lateral (PCL), e pectus excavatum amplo (PEA) e localizado (PEL). Foram criados e mensurados os seguintes parâmetros tomográficos: (1) índice coluna-manúbrio-esterno (CME); (2) índice coluna-esterno (CE); (3) ângulo manúbrio-esternal (AME); (4) ângulo inferior do manúbrio (AIM); e (5) ângulo inferior do esterno (AIE). Foi realizada análise estatística entre os grupos pectus e controle, e entre os diferentes tipos de pectus. Resultados: Houve diferença significativa entre: a) pectus excavatum e pectus carinatum quando analisados os índices CME, CE, AIM e AIE; b) PEL e grupo controle para CME e AIE; c) PCL e PEL, e PCL e PEA para o CME; d) PEA e PCL para CE; e) PCI e PEL, e PCI e PEA para AIE; f) PCS e PEL, e PCS e PEA para AIM. Conclusões: Os índices e ângulos radiográficos criados forneceram parâmetros de diferenciação entre pacientes com diferentes tipos de pectus, e entre estes e controles. Nível de Evidência II, Estudos Prognósticos.

BROAD PECTUS EXCAVATUM TREATMENT: LONG TERM RESULTS OF A BRAZILIAN TECHNIQUE.

OBJECTIVE: This study aims the treatment results of broad pectus excavatum after a long-term follow-up and skeletal maturity. METHODS: Eighty-four children and adolescents with broad-type pectus excavatum were selected for evaluation after treatment with a dynamic orthosis that applies compression to the lower rib projections and prescription of exercises. The broad pectus excavatum was defined as a deformity that the depressed area was greater and covered the area above and below the nipple line. All patients were evaluated for more than 1 year after the end of treatment and skeletal maturity. Post-treatment results were categorized as mild, moderate and severe. Statistic correlations between results and deformity flexibility, deformity severity, and adherence to treatment were assessed. RESULTS: The mean age at the beginning of treatment was 13.3 years, and the follow-up duration was 25.7 months after suspension of orthosis use. Forty-eight percent of patients showed good results. With regular use of orthoses and performance of exercises, this rate increased to 70% (p < 0,001). Mild cases showed more success than severe cases (p = 0,007). Initial flexibility didn't influence the results (p = 0,63). CONCLUSION: Treatment of broad pectus excavatum with orthoses and exercises led to good definitive results in most resilient patients, especially in those with mild deformities. Level of Evidence V, Expert Opinion.

OBJETIVO: Estudar os resultados de longo prazo e com seguimento até a maturidade esquelética do tratamento do pectus excavatum amplo. MÉTODOS: 84 crianças e adolescentes foram tratados com uma órtese que aplicacompressão nas saliências costais inferiores, associada a exercícios específicos. A deformidade foi classificada como ampla quando a depressão tem maior extensão e abrange uma área acima e abaixo da linha mamilar. Os resultados foram categorizados em ruim, regular ou bom, sendo correlacionados estatisticamente com a flexibilidade, a gravidade da deformidade e a adesão ao tratamento, com avaliação um ano após o fim do tratamento e na maturidade esquelética. RESULTADOS: A idade média no início do tratamento foi de 13,7 anos e o seguimento médio foi de 25.7 meses após a suspensão do uso da órtese. 48% dos casos apresentaram sucesso com o tratamento, mas quando os exercícios e o uso da órtese foram regulares, esta taxa aumentou para 70% (p < 0,001). Os casos mais leves tiveram maior sucesso que os de maior gravidade (p = 0,007), mas a flexibilidade inicial não influenciou os resultados (p = 0,63). CONCLUSÃO: O tratamento do pectus excavatum amplo com o uso de órtese e exercícios apresentou bons resultados definitivos na maioria dos pacientes resilientes, em especial nos casos mais leves. Nível de Evidência V, Opinião do Especialista.

Broad pectus excavatum treatment: long term results of a brazilian technique / Tratamento do pectus excavatum amplo: resultados a longo prazo de uma técnica brasileira

ABSTRACT Objective: This study aims the treatment results of broad pectus excavatum after a long-term follow-up and skeletal maturity. Methods: Eighty-four children and adolescents with broad-type pectus excavatum were selected for evaluation after treatment with a dynamic orthosis that applies compression to the lower rib projections and prescription of exercises. The broad pectus excavatum was defined as a deformity that the depressed area was greater and covered the area above and below the nipple line. All patients were evaluated for more than 1 year after the end of treatment and skeletal maturity. Post-treatment results were categorized as mild, moderate and severe. Statistic correlations between results and deformity flexibility, deformity severity, and adherence to treatment were assessed. Results: The mean age at the beginning of treatment was 13.3 years, and the follow-up duration was 25.7 months after suspension of orthosis use. Forty-eight percent of patients showed good results. With regular use of orthoses and performance of exercises, this rate increased to 70% (p < 0,001). Mild cases showed more success than severe cases (p = 0,007). Initial flexibility didn't influence the results (p = 0,63). Conclusion: Treatment of broad pectus excavatum with orthoses and exercises led to good definitive results in most resilient patients, especially in those with mild deformities. Level of Evidence V, Expert Opinion.

RESUMO Objetivo: Estudar os resultados de longo prazo e com seguimento até a maturidade esquelética do tratamento do pectus excavatum amplo. Métodos: 84 crianças e adolescentes foram tratados com uma órtese que aplicacompressão nas saliências costais inferiores, associada a exercícios específicos. A deformidade foi classificada como ampla quando a depressão tem maior extensão e abrange uma área acima e abaixo da linha mamilar. Os resultados foram categorizados em ruim, regular ou bom, sendo correlacionados estatisticamente com a flexibilidade, a gravidade da deformidade e a adesão ao tratamento, com avaliação um ano após o fim do tratamento e na maturidade esquelética. Resultados: A idade média no início do tratamento foi de 13,7 anos e o seguimento médio foi de 25.7 meses após a suspensão do uso da órtese. 48% dos casos apresentaram sucesso com o tratamento, mas quando os exercícios e o uso da órtese foram regulares, esta taxa aumentou para 70% (p < 0,001). Os casos mais leves tiveram maior sucesso que os de maior gravidade (p = 0,007), mas a flexibilidade inicial não influenciou os resultados (p = 0,63). Conclusão: O tratamento do pectus excavatum amplo com o uso de órtese e exercícios apresentou bons resultados definitivos na maioria dos pacientes resilientes, em especial nos casos mais leves. Nível de Evidência V, Opinião do Especialista.

Localized pectus excavatum treated with brace and exercise: long term results of a brazilian technique / Tratamento do pectus excavatum localizado com órtese e exercícios: resultados de longo prazo de uma técnica brasileira

ABSTRACT Objective: Pectus excavatum is a deformity that affects aesthetics and causes emotional disorders. Surgical correction is well established, but conservative treatment is less common. We investigated the long-term results of using a brace and performing specific physical exercises to treat localized pectus excavatum, a type of deformity in which the depressed area is restricted to the midline region along the nipple line. Methods: We selected 115 patients (mean age 12.8 years), with a minimum follow-up of 36 months, who were evaluated more than one year after the end of treatment and skeletal maturity. Results were correlated with deformity flexibility, severity, regular use of the device, and performance of specific exercises. The chi-square (χ2) and the Cochran-Mantel-Haenszel tests were used for statistical analysis. Results: Treatment was successful in 58% of patients, however, when exercises were performed and the brace was used regularly by patients with flexible deformities, the rate increased to 83% (p = 0.005). Severity and adherence to treatment greatly impacted successful treatment (p = 0.009 and < 0.001, respectively). Conclusion: The proposed treatment method was effective for correction or partial correction of the deformity in motivated patients followed up until skeletal maturity, especially when started early in milder and more flexible deformities. Level of Evidence V, Expert opinion.

RESUMO Objetivo: O pectus excavatum é uma deformidade importante por comprometer a estética e causar distúrbios emocionais. A sua correção cirúrgica é bem estabelecida, mas o tratamento conservador é menos familiar. Investigamos os resultados de longo prazo do tratamento do pectus excavatum localizado (deformidade restrita a linha média e na linha mamilar) com uso de órtese e exercícios físicos específicos. Métodos: Selecionamos 115 pacientes (média de 12,8 anos) com seguimento mínimo de 36 meses, sendo avaliados mais de um ano após o término do tratamento e maturidade esquelética. Os resultados foram relacionados estatisticamente (qui-quadrado e Cochran-Mantel-Haenszel) com a flexibilidade da deformidade, a gravidade, o uso regular da órtese e a realização de exercícios específicos. Resultados: O tratamento foi bem-sucedido em 58% dos pacientes, mas quando o uso da órtese e os exercícios foram regulares em pacientes com deformidades flexíveis, essa taxa aumentou para 83% (p = 0,005). A gravidade e a adesão ao tratamento tiveram grande impacto no sucesso do tratamento (p = 0,009 e <0,001, respectivamente). Conclusão: O método de tratamento proposto foi eficaz para correção total ou parcial da deformidade em pacientes motivados acompanhados até a maturidade esquelética, principalmente quando a terapêutica foi iniciada precocemente em deformidades mais leves e flexíveis. Nível de Evidência V, Opinião do especialista.

LOCALIZED PECTUS EXCAVATUM TREATED WITH BRACE AND EXERCISE: LONG TERM RESULTS OF A BRAZILIAN TECHNIQUE.

OBJECTIVE: Pectus excavatum is a deformity that affects aesthetics and causes emotional disorders. Surgical correction is well established, but conservative treatment is less common. We investigated the long-term results of using a brace and performing specific physical exercises to treat localized pectus excavatum, a type of deformity in which the depressed area is restricted to the midline region along the nipple line. METHODS: We selected 115 patients (mean age 12.8 years), with a minimum follow-up of 36 months, who were evaluated more than one year after the end of treatment and skeletal maturity. Results were correlated with deformity flexibility, severity, regular use of the device, and performance of specific exercises. The chi-square (χ2) and the Cochran-Mantel-Haenszel tests were used for statistical analysis. RESULTS: Treatment was successful in 58% of patients, however, when exercises were performed and the brace was used regularly by patients with flexible deformities, the rate increased to 83% (p = 0.005). Severity and adherence to treatment greatly impacted successful treatment (p = 0.009 and < 0.001, respectively). CONCLUSION: The proposed treatment method was effective for correction or partial correction of the deformity in motivated patients followed up until skeletal maturity, especially when started early in milder and more flexible deformities. Level of Evidence V, Expert opinion.

OBJETIVO: O pectus excavatum é uma deformidade importante por comprometer a estética e causar distúrbios emocionais. A sua correção cirúrgica é bem estabelecida, mas o tratamento conservador é menos familiar. Investigamos os resultados de longo prazo do tratamento do pectus excavatum localizado (deformidade restrita a linha média e na linha mamilar) com uso de órtese e exercícios físicos específicos. Métodos: Selecionamos 115 pacientes (média de 12,8 anos) com seguimento mínimo de 36 meses, sendo avaliados mais de um ano após o término do tratamento e maturidade esquelética. Os resultados foram relacionados estatisticamente (qui-quadrado e Cochran-Mantel-Haenszel) com a flexibilidade da deformidade, a gravidade, o uso regular da órtese e a realização de exercícios específicos. RESULTADOS: O tratamento foi bem-sucedido em 58% dos pacientes, mas quando o uso da órtese e os exercícios foram regulares em pacientes com deformidades flexíveis, essa taxa aumentou para 83% (p = 0,005). A gravidade e a adesão ao tratamento tiveram grande impacto no sucesso do tratamento (p = 0,009 e <0,001, respectivamente). CONCLUSÃO: O método de tratamento proposto foi eficaz para correção total ou parcial da deformidade em pacientes motivados acompanhados até a maturidade esquelética, principalmente quando a terapêutica foi iniciada precocemente em deformidades mais leves e flexíveis. Nível de Evidência V, Opinião do especialista.

Pectus excavatum and Pectus carinatum in dogs

Background: Deformities of the anterior thoracic wall are called pectus: pectus excavatum and pectus carinatum. Pectusexcavatum is characterised by dorsal deviation of the caudal region of the sternum while pectus carinatum consists ofprotrusion of the sternum and/or adjacent cartilage. Both defects may remain symptom-free, but respiratory and cardiacabnormalities have been reported. Another deformity observed in dogs is the swimming dog syndrome, which consists ofthe lateral opening of the thoracic and pelvic limbs, associated with the pedalling movement. These disorders are frequentlyreported in medical practice, are considered rare among canines. This report aims to describe a case of pectus excavatumassociated with the swimming dog syndrome (Case 1) and another case of pectus carinatum (Case 2).Cases: Case 1. An approximately 45-day-old male American Pitbull canine had difficulty standing. Physical examinationrevealed hyperextension of the thoracic and pelvic limb joints and flattening of the thorax. After radiographic examination, pectus excavatum and the swimming dog syndrome were confirmed. The conservative treatment with splinting andhydrotherapy was chosen. At the 3-month follow-up, slight improvement in the limbs and irregular and unsatisfactorygrowth of the thorax leading to episodes of dyspnoea were observed. Case 2. A female Pug, approximately 2 months old,had a thorax deformity. Physical examination revealed thorax protrusion, confirmed on radiography as pectus carinatum.Conservative therapy was provided using compressive bandage. One month later, the tutor reported improvement in thecondition and absence of respiratory changes.Discussion: Pectus deformities has low incidence, and cases to pectus carinatum, there is a sexual predisposition, that is,males are more predisposed, differing from Case 2, a female dog. In the cases of pectus excavatum, no genetic alterationwas directly related to its occurrence...(AU)

Pectus excavatum and Pectus carinatum in dogs

Background: Deformities of the anterior thoracic wall are called pectus: pectus excavatum and pectus carinatum. Pectusexcavatum is characterised by dorsal deviation of the caudal region of the sternum while pectus carinatum consists ofprotrusion of the sternum and/or adjacent cartilage. Both defects may remain symptom-free, but respiratory and cardiacabnormalities have been reported. Another deformity observed in dogs is the swimming dog syndrome, which consists ofthe lateral opening of the thoracic and pelvic limbs, associated with the pedalling movement. These disorders are frequentlyreported in medical practice, are considered rare among canines. This report aims to describe a case of pectus excavatumassociated with the swimming dog syndrome (Case 1) and another case of pectus carinatum (Case 2).Cases: Case 1. An approximately 45-day-old male American Pitbull canine had difficulty standing. Physical examinationrevealed hyperextension of the thoracic and pelvic limb joints and flattening of the thorax. After radiographic examination, pectus excavatum and the swimming dog syndrome were confirmed. The conservative treatment with splinting andhydrotherapy was chosen. At the 3-month follow-up, slight improvement in the limbs and irregular and unsatisfactorygrowth of the thorax leading to episodes of dyspnoea were observed. Case 2. A female Pug, approximately 2 months old,had a thorax deformity. Physical examination revealed thorax protrusion, confirmed on radiography as pectus carinatum.Conservative therapy was provided using compressive bandage. One month later, the tutor reported improvement in thecondition and absence of respiratory changes.Discussion: Pectus deformities has low incidence, and cases to pectus carinatum, there is a sexual predisposition, that is,males are more predisposed, differing from Case 2, a female dog. In the cases of pectus excavatum, no genetic alterationwas directly related to its occurrence...

Use of the bilateral erector spinae (ESP) block for postoperative analgesia following the removal of the Nuss bar: case report / Uso del bloqueo erector de la espina bilateral como método analgésico posoperatorio en el retiro de barra de Nuss: Reporte de caso

Abstract Introduction: The erector spinae plane (ESP) block is a relatively new interfascial block about which several applications have been described, both in abdominal and thoracic surgical procedures. Case presentation: A 17-year old patient programed for removal of a Nuss bar through mini-thoracotomy. Following the induction with anesthesia, a US-guided bilateral ESP block was administered; no pain was reported during the immediate postoperative period and over the 48-hour follow-up. Conclusion: Bilateral ESP block seems to be promising, easy to administer, and an acceptable alternative to the epidural catheter (the gold standard in the management of analgesia for thoracic surgery), providing adequate and opiate-free analgesia.

Resumen Introducción: El bloqueo erector de la espina (ESP) es un bloqueo interfascial relativamente nuevo, sobre el cual se han descrito diferentes aplicaciones, tanto en cirugías abdominales como torácicas. Presentación del caso: Paciente de 17 años programado para el retiro de una barra de Nuss por minitoracotomía, a quien, después de la inducción anestésica, se le realizó un bloqueo ESP bilateral guiado con ecografía, y en su posoperatorio inmediato y seguimiento a las 48 horas no reportó dolor alguno. Conclusión: El bloqueo ESP bilateral parece ser prometedor, de fácil realización y apunta a ser una alternativa aceptable al catéter epidural (estándar de oro en el manejo analgésico en cirugías de tórax), por la cual se obtiene analgesia adecuada y libre de opioides.

Back to the future: a case series of minimally invasive repair of pectus excavatum with regular instruments / De volta para o futuro: série de casos de reparo minimamente invasivo do pectus excavatum com instrumentos comuns

ABSTRACT Objective: Minimally invasive repair of pectus excavatum (MIRPE) is a surgical treatment for PE. During the procedure, a specialized introducer is used to tunnel across the mediastinum for thoracoscopic insertion of a metal bar. There have been reported cases of cardiac perforation during this risky step. The large introducer can be a dangerous lever in unskilled hands. We set out to determine the safety and feasibility of using regular instruments (i.e., not relying on special devices or tools) to create the retrosternal tunnel during MIRPE. Methods: This was a preliminary study of MIRPE with regular instruments (MIRPERI), involving 28 patients with PE. We recorded basic patient demographics, chest measurements, and surgical details, as well as intraoperative and postoperative complications. Results: Patients undergoing MIRPERI had Haller index values ranging from 2.58 to 5.56. No intraoperative complications occurred. Postoperative complications included nausea/vomiting in 8 patients, pruritus in 2, and dizziness in 2, as well as atelectasis, pneumothorax with thoracic drainage, pleural effusion, and dyspnea in 1 patient each. Conclusions: In this preliminary study, the rate of complications associated with MIRPERI was comparable to that reported in the literature for MIRPE. The MIRPERI approach has the potential to improve the safety of PE repair, particularly for surgeons that do not have access to certain special instruments or have not been trained in their use.

RESUMO Objetivo: O minimally invasive repair of pectus excavatum (MIRPE, reparo minimamente invasivo do pectus excavatum) é um tratamento cirúrgico do PE. Durante o procedimento, utiliza-se um introdutor específico a fim de criar um túnel mediastinal para a colocação toracoscópica de uma barra metálica. Já houve casos relatados de perfuração cardíaca durante essa etapa arriscada. O introdutor grande pode ser uma perigosa alavanca em mãos inábeis. Propusemo-nos a determinar a segurança e viabilidade do uso de instrumentos comuns (isto é, sem contar com dispositivos ou ferramentas especiais) para criar o túnel retroesternal durante o MIRPE. Métodos: Estudo preliminar sobre o MIRPE with regular instruments (MIRPERI, MIRPE com instrumentos comuns), envolvendo 28 pacientes com PE. Foram registrados dados demográficos básicos dos pacientes, medições torácicas e detalhes cirúrgicos, bem como complicações intra e pós-operatórias. Resultados: Os pacientes submetidos ao MIRPERI apresentavam índice de Haller entre 2,58 e 5,56. Não ocorreram complicações intraoperatórias. As complicações pós-operatórias incluíram náusea/vômito em 8 pacientes, prurido em 2 e tontura em 2, bem como atelectasia, pneumotórax com drenagem torácica, derrame pleural e dispneia em 1 paciente cada. Conclusões: Neste estudo preliminar, a taxa de complicações associadas ao MIRPERI foi comparável à relatada na literatura para o MIRPE. A abordagem de MIRPERI tem o potencial de melhorar a segurança do reparo do PE, particularmente para cirurgiões que não têm acesso a certos instrumentos especiais ou não foram treinados para utilizá-los.

Combined mitral valve replacement and ravitch procedures in a patient with previous pneumonectomy: case report and review of the literature

Abstract Introduction: Significant anatomical and functional changes occur following pneumonectomy. Mediastinal structures displace toward the side of the resected lung, pulmonary reserve is reduced. Owing to these changes, surgical access to heart and great vessels becomes challenging, and there is increased risk of postoperative pulmonary complications. Methods: We performed a mitral valve replacement combined with a Ravitch procedure in a young female with previous left pneumonectomy and pectus excavatum. Results: She was discharged on postoperative day 9 and remains symptom-free 3 months after surgery. Conclusion: Thorough preoperative evaluation and intensive respiratory physiotherapy are essential before performing cardiac operations on patients with previous pneumonectomy.

The Vacuum Bell device as a sternal lifter: An immediate effect even with a short time use.

BACKGROUND: To minimize cardiac perforation during the minimally invasive repair of pectus excavatum (MIRPE), several surgeons have suggested using a suction device to intraoperatively lift the sternum. Whether or not this technique is effective for all PE patients is not yet known. As such, our aim was to quantify the extent to which a suction device is capable of lifting the sternum with a short duration of use. METHODS: 30 PE patients received a low-dose CT scan as part of standard PE evaluation. A Vacuum Bell suction was then applied for only two minutes, and a repeat CT scan was obtained only at the deepest point of the chest wall deformity. We compared chest dimensions before and after Vacuum Bell suction. RESULTS: The Vacuum Bell lifted the sternum in all 29 patients included in the analysis. The absolute change in depth ranged from 0.29 to 23.67mm (M=11.02, SD=6.05). The average improvement in Haller index was 0.76. The suction was most effective for individuals with low BMI and smaller chest depths. Efficacy was not associated with gender, age, or chest morphology. CONCLUSIONS: The Vacuum Bell device effectively lifted the sternum in PE patients with different demographics and chest morphologies. Future research is needed to address whether or not the device reduces risk of cardiac perforation during MIRPE. LEVELS OF EVIDENCE: Prognosis Study Level IV.

Capacidade funcional de exercício e função pulmonar em pacientes submetidos a um programa de reabilitação precoce após técnica de Nuss: um estudo controlado randomizado / Functional exercise capacity and lung function in patients undergoing an early rehabilitation program after the Nuss procedure: a randomized controlled trial

Pectus excavatum é a deformidade congênita na parede torácica anterior mais comum e seu tratamento é essencialmente cirúrgico. Tratamentos cirúrgicos e repouso prolongado no leito levam a alterações metabólicas, músculoesqueléticas, cardiovasculares e respiratórias, que podem prolongar o tempo necessário para a recuperação funcional dos pacientes no pós-operatório, aumentar o tempo de internação e os custos em saúde. A reabilitação precoce após cirurgias, com a realização de exercícios físicos e respiratórios, reduzir estes efeitos adversos, garante melhor recuperação pós-operatória, com aumento da independência dos pacientes, maior bem-estar psicológico e melhores resultados funcionais. O objetivo deste estudo foi avaliar se os pacientes submetidos a reabilitação precoce após correção cirúrgica de Pectus excavatum pela técnica de Nuss apresentam melhor capacidade funcional de exercício e função pulmonar no dia da alta hospitalar quando comparados com os pacientes submetidos a cuidados convencionais. Os Candidatos a correção cirúrgica foram alocados aleatoriamente em 2 grupos: o grupo reabilitação precoce (GRP), que iniciou a intervenção logo após a cirurgia e o grupo de cuidados convencionais (GC), que recebeu os cuidados de rotina da instituição. O teste de função pulmonar por meio da espirometria simples e a avaliação da capacidade funcional de exercício pelo teste de caminhada de seis minutos (TC6), foram realizados antes da cirurgia (pré-operatório) e no dia da alta hospitalar (pós-operatório). Quarenta pacientes foram analisados, 20 em cada grupo. No teste de função pulmonar, todos os pacientes apresentaram redução significativa dos valores de CVF, VEF1 e PFE no pós-operatório, sem diferença entre os grupos. Todos os pacientes apresentaram redução significativa da distância percorrida no TC6 pós-operatório comparada com a distância percorrida no pré-operatório (p < 0,005). Houve diferença estatisticamente significante entre o...

Pectus excavatum is the most common congenital chest wall deformity and its treatment is essentially surgical. Surgical treatments and postoperative bed rest lead to metabolic, musculoskeletal, cardiovascular and respiratory alterations, with the possibility of prolonging the time required for postoperative patient recovery, increasing hospitalization time and health expenditure. Early rehabilitation after surgeries, which involves physical and breathing exercises, reduces these adverse effects and ensure better postoperative recovery, with increased independence of patients, greater psychological well-being and better functional outcomes. The objective of this study was to assess whether patients undergoing early rehabilitation after Pectus excavatum repair using the Nuss procedure have better functional exercise capacity and lung function on hospital discharge day compared with patients undergoing conventional care. Patients were randomly allocated into two groups: the early rehabilitation group (ERG) which started rehabilitation after surgery and the group of conventional care (CG) which received routine care of the institution. The lung function was assessed by simple spirometry and the functional exercise capacity by the 6-minute walk test (6MWT) were performed before surgery (preoperative) and in hospital discharge day (postoperative). Forty patients were evaluated, 20 in each group. All patients presented a significant reduction in FVC, FEV1 and PEF in the postoperative lung function test and there was no statistically significant difference between groups. All patients showed significant reduction in postoperative distance walked in 6MWT compared with the preoperative distance (p < 0.005). There was statistically significant different in functional exercise capacity between the ERG and CG in the postoperative evaluation (506.26 ± 66.54 vs 431.11 ± 75.61, p=0.02) and the difference between distance walked in the preoperative and postoperative period...

Nuss procedure for Pectus excavatum repair: critical appraisal of the evidence / Procedimento de Nuss para correção de Pectus excavatum: avaliação crítica da evidência

Objective: To evaluate the effectiveness and safety of correction of pectus excavatum by the Nuss technique based on the available scientific evidence. Methods: We conducted an evidence synthesis following systematic processes of search, selection, extraction and critical appraisal. Outcomes were classified by importance and had their quality assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: The process of selection of items led to the inclusion of only one systematic review, which synthesized the results of nine observational studies comparing the Nuss and Ravitch procedures. The evidence found was rated as poor and very poor quality. The Nuss procedure has increased the incidence of hemothorax (RR = 5.15; 95% CI: 1.07; 24.89), pneumothorax (RR = 5.26; 95% CI: 1.55; 17.92) and the need for reintervention (RR = 4.88; 95% CI: 2.41; 9.88) when compared to the Ravitch. There was no statistical difference between the two procedures in outcomes: general complications, blood transfusion, hospital stay and time to ambulation. The Nuss operation was faster than the Ravitch (mean difference [MD] = -69.94 minutes, 95% CI: -139.04, -0.83). Conclusion: In the absence of well-designed prospective studies to clarify the evidence, especially in terms of aesthetics and quality of life, surgical indication should be individualized and the choice of the technique based on patient preference and experience of the team. .

Objetivo: avaliar a efetividade e segurança da correção de pectus excavatum, através da técnica de Nuss, com base nas evidências científicas disponíveis. Métodos: realizou-se uma síntese de evidências seguindo processos sistemáticos de busca, seleção, extração e avaliação crítica. Os desfechos foram classificados pela importância e tiveram sua qualidade avaliada pela ferramenta Grading of Recommendations Assessment, Development and Evaluation (GRADE). Resultados: O processo de seleção dos artigos culminou na inclusão de apenas uma revisão sistemática, a qual sintetizou os resultados de nove estudos observacionais comparando o procedimento de Nuss e ao de Ravitch. A evidência encontrada foi classificada como baixa e muito baixa qualidade. O procedimento de Nuss causou maior incidência de hemotórax (RR=5,15; IC95%: 1,07; 24,89), pneumotórax (RR=5,26; IC95%: 1,55; 17,92) e necessidade de reintervenção operatória (RR=4,88; IC95%: 2,41; 9,88) quando comparado ao de Ravitch. Não houve diferença estatística entre os dois procedimentos nos desfechos: complicações gerais, transfusão de sangue, tempo de hospitalização e tempo para deambulação. A operação de Nuss foi mais rápida que a de Ravitch (diferença média [MD] = -69,94 minutos; IC95%: -139,04, -0,83). Conclusão: Na ausência de estudos prospectivos bem delineados para clarificar a evidência, sobretudo quanto à estética e à qualidade de vida, a indicação operatória deve ser individualizada e a escolha da técnica baseada na preferência do paciente e experiência da equipe. .