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1.
Probl Sotsialnoi Gig Zdravookhranenniiai Istor Med ; 27(Special Issue): 687-692, 2019 Aug.
Artigo em Russo | MEDLINE | ID: mdl-31747162

RESUMO

Today, in our country, as well as throughout the world, there is no single approach to the tactics of managing patients with deformations of the anterior chest wall. These patients constitute a large and heterogeneous group. The team acquired great experience in treating children with pectus excavatum and pectus carinatum, as well as a unique experience in the surgical treatment of pediatric thoracic outlet syndrome and sternum clefts. Now in the world there are a lot of surgical methods used for the correction of congenital deformities of the chest wall, however, the majority of them are extremely traumatic for the patient, and the postoperative scar often presents a minor cosmetic problem than the deformation itself. In addition, almost all methods require the use of expensive technologies, the patient's long hospital stay and the use of potent drugs. As for the children with thoracic outlet syndrome and sternum clefts, these patients are extremely difficult in terms of timely diagnosis and surgical care, due to the fact that pediatric surgeons and pediatricians are very little aware of this pathology. The team of authors developed a number of techniques, based on the collaborative work of surgeons, anesthesiology and resuscitation specialists and pediatric services. They resulted in successful surgical correction of these malformations and gave patients the opportunity to lead a normal life.


Assuntos
Tórax em Funil , Procedimentos Cirúrgicos Minimamente Invasivos , Anormalidades Musculoesqueléticas , Parede Torácica , Criança , Tórax em Funil/cirurgia , Humanos , Esterno , Tecnologia , Parede Torácica/cirurgia , Resultado do Tratamento
2.
J Surg Res ; 244: 231-240, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31301479

RESUMO

BACKGROUND: Pectus excavatum is a common congenital chest wall deformity often repaired during adolescence, although a subset of patients undergo repair as adults. The goal of our study was to determine the effects of age at repair and repair technique on short-term surgical outcomes. MATERIALS AND METHODS: We performed a cohort study of patients in the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project pediatric (age<18 y) and adult databases who underwent pectus excavatum repair. The primary outcome was the incidence of 30-d complications. Secondary outcomes included length of stay, reoperation, and readmission. Multivariable logistic regression was used to estimate the independent effects of patient age and type of repair on postoperative outcomes. RESULTS: Of the 2268 subjects included, 2089 (92.1%) were younger than 18 y. Overall, 3.4% of patients suffered a 30-d complication, and the risk was similar between age groups (risk ratio [RR], 0.69; 95% confidence interval [CI], 0.08-5.03; P = 0.731). Steroid therapy was an independent risk factor for complications (RR, 8.0; 95% CI, 1.9-19.7; P = 0.006). Median length of stay was 4 d (interquartile range, 3-5) and was similar between age groups. Risk for readmission and reoperation were 2.8% and 1.5%, respectively, and were similar for pediatric and adult patients. When comparing minimally invasive repair with and without thoracoscopy, risk for 30-d complications was lower among patients repaired with thoracoscopy (RR, 0.56; CI, 0.32-0.96; P = 0.034). CONCLUSIONS: Pediatric and adult patients experience comparable rates of postoperative complications, readmission, and reoperation after pectus excavatum repair. Use of thoracoscopy during minimally invasive repair is associated with lower risk of complications. These findings suggest that thoracoscopy should be used routinely for minimally invasive repair of pectus excavatum.


Assuntos
Tórax em Funil/cirurgia , Procedimentos Ortopédicos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Toracoscopia/efeitos adversos , Adolescente , Adulto , Fatores Etários , Criança , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Reoperação/normas , Fatores de Tempo , Adulto Jovem
3.
J Laparoendosc Adv Surg Tech A ; 29(10): 1244-1251, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31259649

RESUMO

Introduction: Cryoanalgesia has been applied to minimally invasive repair of pectus excavatum (MIRPE). After implementation of cryoanalgesia at our institution, we had several cases of delayed postoperative pneumothorax. The purpose of this study was to critically evaluate the complications and efficacy of cryoanalgesia in MIRPE. Materials and Methods: We performed a single institution retrospective review of pediatric patients undergoing MIRPE from June 2017 to July 2018. Multimodal (MM) analgesia was used in all patients. In addition, most patients received either cryoanalgesia or elastomeric pain pumps (EPPs) as adjuncts to postoperative analgesia. Primary outcome was clinically significant late pneumothorax. Secondary outcomes included length of stay, pain scores, opiate use, and bar displacement requiring reoperation. Results: A total of 101 patients undergoing MIRPE were included: 45 had cryoanalgesia + MM, 45 EPP + MM, and 11 MM alone. Postoperative tube thoracostomy was placed in 5 patients with cryoanalgesia (4 pneumothorax; 1 effusion), 1 patient with EPP (1 pneumothorax), and none in MM alone (P = .25). Pain scores at discharge were similar in all groups. Cryoanalgesia patients received less overall inpatient opioids than other groups (P < .05). No patient required reoperation for bar displacement. Conclusion: Cryoanalgesia is an effective therapy for pain control in MIRPE. Because thermal injury can occur on the lung and chest wall with cryoanalgesia, we implemented techniques to limit and prevent this injury. Cryoanalgesia offers a safe alternative for postoperative analgesia with significant reduction in inpatient opioid requirement. Larger prospective studies are required to assess the long-term impact and complications of cryoanalgesia.


Assuntos
Crioterapia/métodos , Tórax em Funil/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Procedimentos Ortopédicos , Dor Pós-Operatória/terapia , Adolescente , Analgésicos Opioides/uso terapêutico , Criança , Terapia Combinada , Crioterapia/efeitos adversos , Feminino , Seguimentos , Humanos , Masculino , Dor Pós-Operatória/diagnóstico , Pneumotórax/epidemiologia , Pneumotórax/etiologia , Pneumotórax/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Resultado do Tratamento
4.
Interact Cardiovasc Thorac Surg ; 29(4): 497-502, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31199434

RESUMO

The aim of the review was to evaluate the routine use of sternal elevation techniques (SETs) during minimally invasive repair of pectus excavatum (MIRPE, the Nuss procedure). We performed a review of the literature between January 1998 and September 2018 with focus on different methods of SET during MIRPE. Reported effects and side effects were evaluated and compared with our own experience concerning the routine use of the vacuum bell for sternal elevation during MIRPE during the last 13 years. SET is more often used in adult patients than in adolescents. SET improves visualization and safety of MIRPE. Advancement of the pectus introducer, retrosternal dissection and placement of the pectus bar are easier. The risk of cardial and/or pericardial lesion is reduced significantly. Different types of retractors, a crane combined with a wire and/or customized hooks are reported to be used as SET. Furthermore, routine use of a subxiphoid incision is reported. However, more technical equipment, and in some SETs additional incisions are necessary. In contrast, no additional skin incision is necessary for the vacuum bell. The routine intraoperative use of the vacuum bell was safe and effective in 131 patients. It facilitates the retrosternal dissection and the insertion of the pectus bar like other SETs. Besides a temporary mild hematoma, no relevant side effect was observed. In conclusion, an increasing number of authors report on the routine use of SET during MIRPE to improve safety of the procedure. We recommend the routine intraoperative use of the vacuum bell during MIRPE.


Assuntos
Tórax em Funil/cirurgia , Esterno/cirurgia , Toracoplastia/métodos , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Vácuo
5.
Semin Pediatr Surg ; 28(3): 172-177, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31171153

RESUMO

In 1998, Donald Nuss changed the way the world thought about the surgical repair of pectus excavatum. The new operation adheres to sound orthopedic fundaments, but has a significantly higher learning curve than other operations in pediatric surgery. Variations in pectus excavatum type, severity, symmetry and chest wall pliability bring challenges. This article will detail common error traps and ways to avoid them when performing the Nuss procedure. As recent publications have shown, an operation done more than 50,000 times across the world may bring to light infrequent but devastating outcomes that may be preventable. The critical view of safety for pectus repair is discussed, as are areas where a culture of safety could optimize results on a larger scale. We will review potential opportunities to improve outcomes by identifying error traps in the preoperative, intraoperative, and postoperative care of patients undergoing the Nuss procedure.


Assuntos
Tórax em Funil/cirurgia , Complicações Intraoperatórias/terapia , Erros Médicos , Procedimentos Ortopédicos/normas , Segurança do Paciente/normas , Complicações Pós-Operatórias/terapia , Adolescente , Animais , Criança , Pré-Escolar , Tórax em Funil/diagnóstico , Humanos , Complicações Intraoperatórias/etiologia , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/métodos , Complicações Pós-Operatórias/etiologia
6.
J Laparoendosc Adv Surg Tech A ; 29(6): 865-868, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30946004

RESUMO

Background: Pectus excavatum is an anomaly of chest wall development in which anterior ribs curve inward and the sternum is displaced toward the vertebral column. The Nuss procedure is a minimally invasive technique in which one or more metal bars are implanted to brace the sternum in a corrected position. Over time, the chest wall remodels into an anatomically corrected shape and the bar(s) are removed at a later date. During the procedure, passage of an introducer instrument and then the repair bar(s) may shear the intercostal muscles from the adjacent ribs. This creates larger than necessary defects in the chest wall, improper or unstable bar placement, and inadequate repair. Instrument Design: We report a new surgical instrument for guiding the introducer through the contralateral chest wall. This capture-guidance instrument (CGI) redirects and channels forces to keep the introducer true while preventing muscle stripping during passage of the introducer and repair bar(s). Instrument Use: The CGI has been piloted at two pectus centers with a notable decrease in intercostal muscle stripping. Conclusion: The CGI addresses the problem of shear and intercostal muscle stripping during traversal of the chest as part of Nuss repair of pectus excavatum.


Assuntos
Tórax em Funil/cirurgia , Músculos Intercostais/lesões , Complicações Intraoperatórias/prevenção & controle , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Ortopédicos/instrumentação , Adolescente , Feminino , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/métodos , Resultado do Tratamento
7.
J Pediatr Surg ; 54(11): 2250-2256, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30935731

RESUMO

PURPOSE: Minimally-invasive repair of pectus excavatum by the Nuss procedure is associated with significant postoperative pain, prolonged hospital stay, and high opiate requirement. We hypothesized that intercostal nerve cryoablation during the Nuss procedure reduces hospital length of stay (LOS) compared to thoracic epidural analgesia. DESIGN: This randomized clinical trial evaluated 20 consecutive patients undergoing the Nuss procedure for pectus excavatum between May 2016 and March 2018. Patients were randomized evenly via closed-envelope method to receive either cryoanalgesia or thoracic epidural analgesia. Patients and physicians were blinded to study arm until immediately preoperatively. SETTING: Single institution, UCSF-Benioff Children's Hospital. PARTICIPANTS: 20 consecutive patients were recruited from those scheduled for the Nuss procedure. Exclusion criteria were age < 13 years, chest wall anomaly other than pectus excavatum, previous repair or other thoracic surgery, and chronic use of pain medications. MAIN OUTCOMES AND MEASURES: Primary outcome was postoperative LOS. Secondary outcomes included total operative time, total/daily opioid requirement, inpatient/outpatient pain score, and complications. Primary outcome data were analyzed by the Mann-Whitney U-test for nonparametric continuous variables. Other continuous variables were analyzed by two-tailed t-test, while categorical data were compared via Chi-squared test, with alpha = 0.05 for significance. RESULTS: 20 patients were randomized to receive either cryoablation (n = 10) or thoracic epidural (n = 10). Mean operating room time was 46.5 min longer in the cryoanalgesia group (p = 0.0001). Median LOS decreased by 2 days in patients undergoing cryoablation, to 3 days from 5 days (Mann-Whitney U, p = 0.0001). Cryoablation patients required significantly less inpatient opioid analgesia with a mean decrease of 416 mg oral morphine equivalent per patient (p = 0.0001), requiring 52%-82% fewer milligrams on postoperative days 1-3 (p < 0.01 each day). There was no difference in mean pain score between the groups at any point postoperatively, up to one year, and no increased incidence of neuropathic pain in the cryoablation group. No complications were noted in the cryoablation group; among patients with epidurals, one patient experienced a symptomatic pneumothorax and another had urinary retention. CONCLUSIONS AND RELEVANCE: Intercostal nerve cryoablation during the Nuss procedure decreases hospital length of stay and opiate requirement versus thoracic epidural analgesia, while offering equivalent pain control. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level I.


Assuntos
Analgésicos Opioides/uso terapêutico , Criocirurgia , Tórax em Funil/cirurgia , Nervos Intercostais/cirurgia , Tempo de Internação/estatística & dados numéricos , Criocirurgia/efeitos adversos , Criocirurgia/métodos , Criocirurgia/estatística & dados numéricos , Humanos , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/métodos , Procedimentos Ortopédicos/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico
8.
J Pediatr Surg ; 54(7): 1500-1504, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30967247

RESUMO

BACKGROUND: Complex wounds associated with the Nuss procedure are a resource intensive complication that may lead to significant morbidity with potential removal of the implanted device and abandonment of the repair. We report our management technique of this complication utilizing microdeformational wound therapy (MDWT) that is safe, is efficacious and allows for salvage of the repair. OPERATIVE TECHNIQUE: We defined a complex wound as a wound that became suppurative and drained in the postoperative period and failed to resolve with a trial of conventional wound management and antibiotics. Upon recognition of a complex wound, we recommend an initial operative wound debridement. This allows wound cultures, wound assessment and precise initiation of MDWT. It is not uncommon to have exposed hardware in the wound early in the course of therapy. Metal allergy must be excluded. The patient is transitioned to oral antibiotics following resolution of the acute process. MDWT is performed until the wounds are completely epithelialized with no clinical signs of drainage or infection. The average length of MDWT in our patients was 39 days. Following complete wound healing the patients are maintained on antibiotics until implant removal. CONCLUSIONS: The use of microdeformational wound therapy in complex wounds associated with the Nuss procedure is a safe and effective modality. The technique may reduce the likelihood of implant removal with potential recurrent pectus excavatum. TYPE OF STUDY: Operative technique. LEVEL OF EVIDENCE: Level IV, case series with no comparison group.


Assuntos
Tórax em Funil/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Ferida Cirúrgica/etiologia , Ferida Cirúrgica/terapia , Adolescente , Antibacterianos/uso terapêutico , Desbridamento , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Reepitelização , Terapia de Salvação , Supuração/etiologia , Supuração/terapia
10.
J Pediatr Surg ; 54(10): 1976-1983, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30922685

RESUMO

PURPOSE: The purpose of this study was to determine outcomes of an enhanced recovery pathway (ERP) for minimally invasive repair of pectus excavatum (MIRPE) at a high volume center, hypothesizing it is associated with decreased opioid requirement and shorter hospital stay. METHODS: Patients were categorized into pre-ERP (1998-2006), transition (2007-2011), and ERP (2012-2017) cohorts. Data were abstracted from medical records. Univariate and multivariable analyses compared opioid utilization, length of stay (LOS), and complications between cohorts. Opioids were converted to morphine daily dose per kilogram (MEDD/kg). RESULTS: Of 436 patients, 186 were ERP, 104 were transition, and 146 were pre-ERP. ERP was associated with decreased hospital opioid utilization (mean MEDD/kg 0.5 ±â€¯0.2 vs 0.7 ±â€¯0.4 vs 0.7 ±â€¯0.8 p < .001) and shorter median LOS (3 vs 4 vs 5 days, p < .001) despite equivalent pain scores at discharge (2.7 ±â€¯0.1 vs 2.8 ±â€¯0.2 vs 2.9 ±â€¯0.3, p = .73). Most ERP patients (76%) had LOS ≤3 days. Differences in LOS between ERP, transition, and pre-ERP persisted on multivariable analysis after adjusting for confounding factors. Post-operative complications were rare and not different between groups (p > .05). CONCLUSIONS: Implementation of our ERP was associated with decreased opioid requirement and shorter hospital stay. ERPs are a valuable tool in pediatric surgery given the current emphasis on optimizing opioid and resource utilization. LEVELS OF EVIDENCE: Level III (Retrospective comparative study).


Assuntos
Analgésicos Opioides/uso terapêutico , Tórax em Funil/cirurgia , Laparoscopia/métodos , Tempo de Internação/tendências , Dor Pós-Operatória/tratamento farmacológico , Recuperação de Função Fisiológica/efeitos dos fármacos , Toracoplastia/métodos , Adolescente , Adulto , Criança , Feminino , Humanos , Incidência , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Dor Pós-Operatória/epidemiologia , Alta do Paciente/tendências , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
11.
Nan Fang Yi Ke Da Xue Xue Bao ; 39(2): 249-252, 2019 02 28.
Artigo em Chinês | MEDLINE | ID: mdl-30890516

RESUMO

OBJECTIVE: To review the experience with Wang procedure for treatment of pectus excavatum in young children. METHODS: The clinical data of 21 children with a mean age of 3.3 ± 1.1 years (ranging from 1.5-6 years) undergoing Wang procedure for pectus excavatum were analyzed. A longitudinal incision (1 to 2 cm) was made in the front of the xiphoid, and two tunnels were created using steel bars beneath the muscles on two sides of the chest wall. The fibrous tissue between the diaphragm and the sternum was dissociated, and the steel wires were sutured through the deformed chest wall. After the steel bar was placed in the tunnels, the wires were pulled and fixed in the middle of the bar, and the incision was sutured. RESULTS: All the operations were performed using 3 wires and 1 steel bar. The operation time was 25 to 51 (38.1 ± 9.6) min with an intraoperative bleeding volume of 5 to 10 (7.1±1.5) mL. The time of hospitalization of the patients ranged from 6 to 10 days (mean 8.1±1.3 days). In all the patients, the incision healed smoothly without serious pain or obvious complications. All the patients were followed up for 1 to 13 months after the operation. During the follow- up, no recess recurred and no such complications as bar displacement or transposition occurred. According to the evaluation criteria after pectus excavatum operation, 13 cases had a total score of 9, and 8 had a total score of 8. The overall effect was satisfactory, and there were no cases rated as basically satisfactory or unsatisfactory. CONCLUSIONS: Wang procedure is a good option for treatment of pectus excavatum in young children.


Assuntos
Tórax em Funil/cirurgia , Fixadores Internos , Procedimentos Ortopédicos/métodos , Parede Torácica , Processo Xifoide/cirurgia , Fios Ortopédicos , Criança , Pré-Escolar , Diafragma , Humanos , Duração da Cirurgia , Procedimentos Ortopédicos/instrumentação , Estudos Retrospectivos , Resultado do Tratamento
12.
J Bras Pneumol ; 45(1): e20170373, 2019 Feb 11.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30758428

RESUMO

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.


Assuntos
Tórax em Funil/cirurgia , Toracoscopia/instrumentação , Adolescente , Adulto , Feminino , Tórax em Funil/diagnóstico por imagem , Humanos , Complicações Intraoperatórias , Masculino , Ilustração Médica , Complicações Pós-Operatórias , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Risco , Esterno/cirurgia , Toracoscopia/efeitos adversos , Toracoscopia/métodos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto Jovem
13.
Medicine (Baltimore) ; 98(6): e14387, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30732178

RESUMO

This study was aimed to review the current experience regarding the correction of pectus excavatum by Nuss procedure with nonthoracoscopic assistance using trans-esophageal echocardiography monitoring.A total of 172 patients with pectus excavatum were surgically treated from August 2011 to August 2016. The sample size comprised 131 boys and 41 girls and the average age was 13 years and 2 months. A total of 144 cases were initially operated on, whereas 13 subjects exhibited postoperative recurrence following Ravitch repair of a pectus excavatum deformity and 15 cases experienced a history of median sternotomy. The intraoperative Haller index ranged from 3.6 to 14.2 (mean 4.1). The intraoperative TEE monitoring was conducted with middle-esophageal 4-champer view and middle-esophageal Aortic short axis view to detect the injury of heart and of the large vessels by the introducer and Nuss steel bars.The operation conducted in all patients was successful in the absence of severe complications. The time of operation ranged from 38 to 80 minutes (mean 50 minutes). The bleeding volume during the procedure was between 10 and 40 mL (mean 15 mL). The time from operation to discharge was from 5 to 7 days (mean 6 days). Pneumothorax occurred in 25 cases following the termination of the operation, including 9 cases of needle puncture aspiration and 6 cases of closed drainage. Pleural effusion occurred in 4 cases. No patients suffered from wood infection. Effusion occurred in 9 cases following 6 to 23 months, whereas dressing changes and surgical debridement were evident in 2 and 7 cases, respectively. The bars were removed in 82 of the 172 patients within 3 years. The progression of the thoracic wall was assessed for the period of 8 to 68 months following the surgery, during the follow-up period. The average time period of follow-up was 32 months.Nuss procedure with nonthoracoscopic assistance with trans-esophageal echocardiography monitoring for the correction of pectus excavatum was safe for all of the cases investigated. It exhibited lesser trauma and required a shorter time period.


Assuntos
Ecocardiografia Transesofagiana/métodos , Tórax em Funil/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Adolescente , Perda Sanguínea Cirúrgica , Criança , Humanos , Tempo de Internação , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Duração da Cirurgia , Derrame Pleural/epidemiologia , Pneumotórax/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adulto Jovem
14.
J Pediatr Surg ; 54(11): 2261-2267, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30732932

RESUMO

BACKGROUND: Objective preoperative assessment of pectus excavatum (PE) deformity in patients is limited to preoperative measurement of severity using computed tomography (CT) or magnetic resonance imaging (MRI). Postoperative assessment is currently subjective as postoperative CT scans are not recommended in light of radiation exposure and high cost to families. White Light Scanning (WLS) is a novel 3D imaging modality that offers an alternative that is a quick, nonionizing, inexpensive, and safe strategy for measurement both pre- and postsurgery. Our prior investigation demonstrated the feasibility of using WLS to measure PE deformity and showed very strong correlation of a new WLS-derived PE severity index, the Hebal-Malas Index (HMI), with CT-derived HI. The purpose of this study was to demonstrate use of WLS to assess extent of correction of PE deformities after the Nuss procedure. METHODS: WLS scan data were gathered prospectively in pediatric patients with PE from 2015 to 2018. HMI was obtained from the preoperative and postoperative WLS scans. Analysis assessed the differences of preoperative and postoperative HMI. Preoperative CT-derived HI was collected from the medical record and estimated postoperative Haller Index was calculated from HMI and correlation of HMI and HI using historical data. RESULTS: A total of 71 patients received a preoperative CT scan and underwent surgery for PE. Of those, 63 (89%) received WLS preoperatively and 51 (72%) had complete preoperative and postoperative WLS data. The average postoperative decrease in the WLS-derived HMI was 0.35 (SD: 0.15) and 1.73 (SD: 1.03) in WLS-estimated HI. CONCLUSIONS: WLS is highly effective in objectively quantifying the extent of surgical correction in PE patients. LEVEL OF EVIDENCE: IV TYPE OF STUDY: Diagnostic Study.


Assuntos
Tórax em Funil/diagnóstico por imagem , Imagem Tridimensional/métodos , Criança , Tórax em Funil/patologia , Tórax em Funil/cirurgia , Humanos , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Índice de Gravidade de Doença , Resultado do Tratamento
15.
Cir Pediatr ; 32(1): 2-5, 2019 Jan 21.
Artigo em Espanhol | MEDLINE | ID: mdl-30714693

RESUMO

OBJECTIVE: The Haller index (HI) is widely used to indicate surgical intervention in patients with pectus excavatum (PE). However, in patients with an atypical thoracic morphology, the severity of the defect can be incorrectly estimated. We propose comparing this index with the correction index (CI). MATERIAL AND METHODS: We analyzed clinical data and CT scans of 50 patients who consulted for PE in our center between 2010 and 2017. Haller index (HI), Correction index (CI) and ideal thoracic index (ITI) were calculated for each patient. The ITI allowed dividing the sample into two groups based on the thoracic morphology by excluding the PE component, therefore separating those with thorax too wide or too narrow from the standard patients. A standard group (36 patients) and a non-standard group (14 patients) were generated, among which the HI and the CI were correlated. RESULTS: The mean HI and CI of all patients were 3.99 and 27%, respectively. 31 of the 50 patients (62%) underwent intervention, 8 of them with an HI below 3.25. When comparing both groups, there was a moderate correlation between HI and CI in the standard group (Spearman r 0.799, p <0.01) and a greater correlation in the non-standard group (Spearman r 0.858, p <0.01).ween the scale and the presence of foreign body, except for SCORE 1, which was 57% what we attribute to an information bias. If the foreign body were not nuts, inorganic or bone, its aspiration was very unlikely, that is why we included it in the SCORE with -1. CONCLUSION: In our cohort, correlation of HI and CI was not different between both groups of patients. The CI did not prove its superiority when compared to HI in the surgical indication of patients with PE.


Assuntos
Tórax em Funil/patologia , Tomografia Computadorizada por Raios X/métodos , Adolescente , Criança , Feminino , Tórax em Funil/diagnóstico por imagem , Tórax em Funil/cirurgia , Humanos , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença
16.
J Plast Reconstr Aesthet Surg ; 72(6): 1025-1029, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30638895

RESUMO

BACKGROUND: The aim of this study was to demonstrate the feasibility and safety of the Nuss procedure for patients with pectus excavatum (PE) with a history of intrathoracic surgery. PATIENTS: From April 2010 to December 2013, we performed 6 cases of PE repair in patients with a history of intrathoracic surgery. The causes of previous operations were congenital cystic adenomatoid malformation in 4 patients and congenital diaphragmatic hernia in 2. The patients' median age was 5 years (range, 4-9 years) and median preoperative pectus severity index was 4.63 (range, 3.42-10.03). Their intraoperative and postoperative courses were reviewed retrospectively. RESULTS: The mean overall operation time was 127.5 ±â€¯17.0 minutes, and the mean operation time for endoscopic pneumolysis was 28.8 ±â€¯12.3 minutes. Intraoperative exploration for pleural adhesion revealed that the endoscopic approach in the previous operation was associated with low pleural adhesion, and the open thoracotomy or laparotomy approach was associated with low to high pleural adhesion. One patient developed a pneumothorax on the first postoperative day. All the other patients had uneventful postoperative courses. All the patients received bar removal 2-3 years after bar insertion. One patient developed atelectasis after bar removal. All the other patients had an uneventful postoperative course. The mean postoperative follow-up time after bar removal was 20.1 ±â€¯14.7 months. CONCLUSIONS: History of intrathoracic surgery seems not a contraindication for the Nuss procedure. However, perioperative complications should be carefully monitored in both the bar insertion and removal operations.


Assuntos
Malformação Adenomatoide Cística Congênita do Pulmão/cirurgia , Tórax em Funil , Hérnias Diafragmáticas Congênitas/cirurgia , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Torácicos , Parede Torácica , Criança , Pré-Escolar , Feminino , Tórax em Funil/etiologia , Tórax em Funil/cirurgia , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Procedimentos Cirúrgicos Torácicos/métodos , Parede Torácica/patologia , Parede Torácica/cirurgia , Resultado do Tratamento
17.
J Pediatr Surg ; 54(4): 663-669, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30686518

RESUMO

PURPOSE: Management of postoperative pain is a significant challenge following the Nuss procedure. Epidurals, PCAs, and newer analgesia modalities have been used elsewhere without demonstrating consistent improvement in the reported length of hospital stays (LOS). We reviewed a large single surgeon experience identifying three different methods of analgesia used over time to highlight marked improvement in patient LOS. METHODS: IRB approval was obtained and patient clinical information was retrospectively reviewed from 2001 to 2017. The primary outcome variable was length of hospital stay. An expanded preoperative consultation reviews the issue of pain, the negative impact of anxiety on recovery, and our current success of shortened hospital stays with our patients. RESULTS: One hundred and seventy-three patients representing three different analgesia approaches had a LOS of 4.4 days (epidural); 2.2 days (PCA/intercostal nerve block); and 1.6 days (scheduled oral pain meds/intercostal nerve blocks). The current LOS for patients is 1.0 day. Patients successfully stop using narcotics by the end of the first week postoperatively. CONCLUSIONS: Intraoperative intercostal nerve blocks, scheduled postoperative pain medications, and enhanced preoperative consultation aimed to educate patients about anxiety and reframe patient pain expectations have collectively decreased LOS, and reduced postoperative narcotic usage. TYPE OF STUDY: Clinical research LEVEL OF EVIDENCE: Level III.


Assuntos
Analgesia/métodos , Ansiedade/tratamento farmacológico , Tórax em Funil/cirurgia , Tempo de Internação/estatística & dados numéricos , Dor Pós-Operatória/terapia , Toracoscopia/efeitos adversos , Adolescente , Adulto , Criança , Feminino , Humanos , Masculino , Entorpecentes/uso terapêutico , Manejo da Dor/métodos , Medição da Dor , Estudos Retrospectivos , Toracoscopia/psicologia , Adulto Jovem
18.
Medicine (Baltimore) ; 98(3): e13874, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30653093

RESUMO

RATIONALE: Pectus excavatum (PE) is normally an isolated congenital disorder, but it can also occur with congenital heart defect (CHD). The optimal strategy for the management of children with PE and concurrent CHD remains under debate. The surgical strategy has evolved over the last 20 years from staged repair to simultaneous repair of both defects. We present a case of using the Nuss procedure for PE during atrial septal defect (ASD) closure through a minimal right oblique infra-axillary thoracotomy. To our knowledge, this is the first report to describe the correction of PE and CHD by this approach. PATIENT CONCERNS: A 3.6-year-old patient weighing 13 kg was admitted for elective repair of PE and an ASD. DIAGNOSES: Clinically, the patient had typical features of PE with chest computed tomography (CT) revealing a Haller index of 4.4 and a grade 2 systolic murmur being heard the loudest at the 2nd-3rd intercostal space, abutting the left sternal border. Echocardiography confirmed a 2-hole secundum ASD with the upper defect being 8 mm, the lower defect 5 mm, and the 2 holes being 5-mm apart, which was deemed unsuitable for interventional closure. INTERVENTIONS: After discussion with and consent from the family, the child underwent concomitant surgery for both defects. We performed an ASD repair under cardiopulmonary bypass (CPB) on the beating heart through the right oblique infra-axillary thoracotomy, and then, the standard Nuss procedure was performed using a 9-inch bar. OUTCOMES: Satisfactory ASD closure was confirmed by postoperative echocardiography. Satisfactory PE correction was confirmed by physical examination and postoperative chest radiography. The postoperative recovery process was uneventful, and the patient was discharged 6 days postoperatively. LESSONS: This case shows that in carefully selected cases with concomitant PE and ASD, a combination of the Nuss procedure and ASD repair by CPB through infra-axillary thoracotomy can be safely performed, avoiding sternal incision, which leads to bleeding and sternal dehiscence, and results in better aesthetic and surgical outcomes.


Assuntos
Tórax em Funil/cirurgia , Comunicação Interatrial/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Toracotomia/métodos , Pré-Escolar , Terapia Combinada/métodos , Ecocardiografia/métodos , Humanos , Masculino , Período Pós-Operatório , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
19.
Ann Thorac Surg ; 108(1): e19-e20, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30597141

RESUMO

Use of continuous erector spinae plane (ESP) blocks for pectus excavatum repair may be a valuable alternative to thoracic epidural placement. This report describes the successful use of bilateral ESP blocks in 2 patients with complex medical histories in which thoracic epidural placement was either contraindicated or unsuccessful. The benefits of continuous ESP blocks in this subset of patients include pain control with a focus on opioid sparing, early extubation, decreased atelectasis, improved mobilization and physical therapy, and decreased length of hospital stay.


Assuntos
Tórax em Funil/cirurgia , Bloqueio Nervoso/métodos , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Manejo da Dor
20.
J Cardiothorac Surg ; 14(1): 4, 2019 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-30621729

RESUMO

BACKGROUND: The effects of the Nuss procedure on chest wall motion and spirometry have previously been described; we aimed to describe the effects of removal of the Nuss bar. METHODS: We studied 9 patients just prior to and 6 weeks after Nuss bar removal. Regional chest volume changes, synchrony of respiratory movement and spirometry were recorded using optoelectronic plethysmography (OEP) and compared. Recordings were performed at rest and exercise during cycle ergometry. RESULTS: There were small but statistically significant changes in tidal volumes of the diaphragmatic ribcage compartment during exercise (+ 48 ml, p = 0.038, Cohen's d = 0.12) and percentage contribution of the diaphragmatic ribcage to total tidal volumes at rest (+ 2.7 percentage points, p = 0.038, Cohen's d = 0.12). Synchrony of respiratory movements at rest and during exercise was unchanged following Nuss bar removal. There were no significant changes in spirometry and exercise capacity. CONCLUSIONS: The effects of Nuss bar removal on diaphragmatic ribcage motion are detectable but small and unlikely to be of clinical significance. No change in exercise capacity should be expected after Nuss bar removal. TRIAL REGISTRATION: Registered at ClinicalTrials.gov, identifier NCT02958683 , registered 5th August 2016, first patient enrolled July 2016, retrospectively registered.


Assuntos
Remoção de Dispositivo , Diafragma/fisiopatologia , Tórax em Funil/cirurgia , Movimento , Caixa Torácica/fisiopatologia , Cavidade Torácica/patologia , Parede Torácica/fisiopatologia , Adolescente , Estudos de Coortes , Tolerância ao Exercício , Humanos , Masculino , Tamanho do Órgão , Dispositivos de Fixação Ortopédica , Período Pós-Operatório , Período Pré-Operatório , Mecânica Respiratória , Volume de Ventilação Pulmonar , Adulto Jovem
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