Chondrotomy and sternotomy combined with the Nuss procedure for severe asymmetric pectus excavatum: how to do it.

The correction of severe asymmetric pectus excavatum is still challenging, especially for adults with a rigid thorax. For the repair of asymmetric cases, we introduce our surgical techniques added to the Nuss procedure. Chondrotomy of the depressed and deformed costal cartilage to elevate the depressed side was performed in a 42-year-old female patient. The depressed chest wall was directly elevated using pectus bars. Her sternal rotation angle improved from 27° to 15° after bar removal. In a 26-year-old male patient, oblique sternotomy and chondrotomy were performed. The sternal rotation angle improved from 26° to 9° postoperatively. These techniques were effective for correcting severe asymmetric pectus excavatum in adults.

Analysis of chest wall elevation after the Nuss procedure using 3D body scanning technique in patients with pectus excavatum.

PURPOSE: For the evaluation of the chest wall deformity, we adopted a non-invasive 3D body scanning system. The objective of this study is to evaluate surgical effect on the whole thorax using 3D scanning technique before and after Nuss procedure. METHODS: We performed 3D body scanning using Structure Sensor (Occipital Inc, USA) in 11 symmetric patients (average age 13 ± 3.2) under general anesthesia before and after Nuss procedure. Using the scanned data, the improved chest wall was analyzed using 3D-Rugle (Medic Engineering, Japan) imaging software. Preoperative and postoperative 3D data were super-imposed and a thoracic elevating distance in the line of the axial and sagittal section through the deepest point was calculated. Pre- and postoperative external sternal angle (ESA) were calculated from the scanned data. RESULTS: Mean thoracic elevation distance at the deepest point was 38.6 ± 6.1 mm and it was 28.4 ± 5.1 mm and 19.4 ± 4.9 mm at 4 cm and 8 cm cranial side, respectively. Average ESA improved from 3.9 ± 1.6 degrees to 15.0 ± 1.1 degrees after the operation. CONCLUSION: Chest depression was effectively elevated 39 mm at the deepest point after Nuss procedure. An indirect elevation effect by pectus bars was found on the wide area of the anterior chest.

Close relationship between the short round ligament and the ovarian prolapsed inguinal hernia in female infants.

PURPOSE: The aim of this study was to clarify the relationship between the length of the round ligament and the presence of a patent processus vaginalis (PV) based on the hypothesis that a short round ligament is the cause of ovarian inguinal hernia in female infants. METHODS: Between April 2011 and March 2017, 132 girls underwent laparoscopic surgery for inguinal hernia. Before surgery, the presence of ovarian prolapse was diagnosed. We observed the internal inguinal ring laparoscopically and examined the diameter of the PV orifice as well as the round ligament length. Medical records and video records were reviewed to evaluate PV patency and round ligament length. RESULTS: Seventeen of the 132 cases had an ovarian inguinal hernia; all of them were infants. In all infants, with or without a prolapsed ovary, the round ligament was short, causing the ovary and fallopian tube to be close to the hernia orifice over the pelvic brim. In girls aged over 12 months, the round ligament lengths on the hernia side, contralateral open PV side, and contralateral closed PV side were 33.0 ± 9.3, 36.8 ± 7.5, and 41.4 ± 8.5 mm, respectively. The round ligament length in open PV was significantly shorter than in the closed PV, but the difference was smaller in older patients. CONCLUSION: The round ligament, which is the female gubernaculum in the fetus, was shorter in the open PV than in the closed PV in younger girls. The short round ligament results in the ovarian prolapsed hernia.

Pulmonary function in children with Pectus excavatum and post-operative changes after nuss procedure.

PURPOSE: The aim of this study was to show the difference between the pulmonary function of children with mild or severe types of pectus excavatum (PE) and post-operative changes in their predicted vital capacity (%VC) following Nuss procedure. PATIENTS AND METHODS: One hundred and twenty-four of the 208 children who underwent Nuss procedure for PE between January 2007 and March 2016 were deemed eligible for this study and evaluated retrospectively. A spirometry was performed on these children on four occasions: before operation; pre-bar removal; and 1 month and 1 year after bar removal. Ninety-seven of the children who were more than 7 years of age were divided using the Haller Index (HI) into a mild group (n = 54) and a severe group (n = 43) and compared. The children were also divided into three groups based on their age and their %VC was compared at each follow-up occasion. RESULTS: The severe group showed a significantly lower %VC and peak expiratory flow rate than the mild group. %VC change after bar removal showed significantly lower in group aged 11 or over. 43 of the children had spirometry data recorded 1 year after bar removal which, compared with 1 month after bar removal, showed a significant higher %VC in groups aged of 10 or under. CONCLUSION: Nuss procedure in children aged of 10 or under proved to be an advantage in the post-operative pulmonary function.

Carcinogenic Potential of Biliary Epithelium of Congenital Choledochal Cyst Model in Rats: A Special Reference to HDAC Expression.

BACKGROUND/AIMS: Pancreaticobiliary maljunction (PBM) is well known to have carcinogenic potential. The goal of this study was to clarify the carcinogenic potential of the epithelium of choledochal cyst particularly by paying attention of HDAC1 and COX-2 expressions. METHODOLOGY: Six-week male Lewis rats were divided into two groups; 1) single dose of dibutyltin dichloride (8 mg/kg) was administered intravenously (DBTC group), 2) saline administration was done with the same manner (control group). Morphological changes of biliary tract and expressions of carcinogenesis-related genes, Ki67, HDAC1 and cyclooxygenase-2 (COX-2) were examined immunohistochemically after administration. RESULTS: In the DBTC group, the bile duct had been gradually dilated on day 3 after administration and the biliary epithelium of dilated bile duct was papillary proliferated on day 7. Ki67 and COX-2 expressions gradually increased and reached the highest value of 6.0% and 3.6% on day 14, respectively. HDAC1 expression increased at the early postoperative period prior to other oncogene, and reached the highest level of 15% on day 7. CONCLUSIONS: These findings suggested that HDAC1 played an important role in carcinogenesis of PBM through the regulation of COX-2.

Rib osteotomy with the Nuss procedure for the repair of adult pectus excavatum.

For the Nuss procedure in adult patients with pectus excavatum, sufficient sternal elevation is difficult due to the rigid chest wall. To solve the problem, we present a novel rib osteotomy procedure. From the skin incisions on the lateral chest which are the common approach for the Nuss procedure, a surgical drill is used to incise bilateral anterior half of the rib cortex after installing the pectus bars. Osteotomy is done on the ribs next to the points where the bars penetrate the intercostal muscle. After making rib osteotomy, the ribs bend spontaneously like greenstick fracture. Elevation of the stiff anterior chest wall can be achieved by this procedure. Rib osteotomy is also beneficial for pain relief due to the reduction of the strain to the ribs. It could be expected that regression after bar removal is avoided.

Anterior chest wall regression after Nuss bar removal in adult patients with pectus excavatum.

OBJECTIVE: Pectus excavatum repair with the Nuss procedure can be successfully performed in adults. After removing the pectus bars, the anterior chest wall may regress to some degree. The purpose of this study was to clarify the amount of improvement and regression of the chest wall after bar removal. METHODS: In 45 adult patients who underwent the Nuss procedure, the sternovertebral distance (SVD) on lateral chest X-ray was measured (A) before the Nuss procedure, (B) before bar removal, and (C) after bar removal. The average SVD was compared, and the difference between A and C suggesting final sternal elevation and B and C suggesting regression was calculated. The correlation between the duration of bar in situ and the amount of regression was analyzed. RESULTS: The average period of bar in situ was 34.9 ± 5.0 (range 23-45) months. The average SVD-A, SVD-B, and SVD-C values were 58.9 ± 20.0, 89.3 ± 19.1, and 81.6 ± 20.1 mm, respectively, with significant differences among them. Final sternal elevation was 22.7 ± 17.4 mm, and average regression was 7.6 ± 8.6 mm. The correlation coefficient between the duration of bar in situ and the amount of regression was 0.119, suggesting no clear correlation. CONCLUSIONS: In spite of some degree of chest wall regression after bar removal, the Nuss procedure was effective for adult patients with pectus excavatum. The period of bar in situ and chest wall regression had little correlation.

Recurrence of pectus excavatum in long-term follow-up after the Nuss procedure in young children based on the radiographic Haller index.

BACKGROUND/PURPOSE: To show the changes of the thorax after bar removal in young children with pectus excavatum in long-term postoperative follow-up. METHODS: A total of 173 patients who underwent Nuss procedure under the age of 10 years from January 2005 to December 2013 and underwent bar removal were retrospectively reviewed. Then, Patients who were followed-up for more than 5 years after bar removal were selected and assessed. All patients were evaluated with the Haller index (HI) by chest computed tomography before the Nuss procedure. Follow-up after bar removal was done by two-view radiography. Radiographic HI (rHI) change was evaluated from before bar removal, to immediately after bar removal, and 3 years and 5 years after bar removal. RESULTS: Forty-two patients (35 boys, 7 girls) were followed-up for more than 5 years after bar removal. The average age at the Nuss procedure was 6.1 ±â€¯1.3 years, and the average HI was 5.07 ±â€¯1.54. The average age at bar removal was 8.5 ±â€¯1.2 years. The average rHI was 2.47 ±â€¯0.33 before bar removal, 2.75 ±â€¯0.50 immediately after bar removal, 3.24 ±â€¯0.64 at 3 years after bar removal, and 3.46 ±â€¯0.91 at 5 years after bar removal. The rHI value increased significantly between all periods. CONCLUSIONS: The Nuss procedure for young children may have the risk of recurrence during growth after bar removal. LEVEL OF EVIDENCE: Level IV.

Correlation of asymmetric chest wall deformity and growth in patients with pectus excavatum.

PURPOSE: Pectus excavatum involves wide range of chest wall depression. The degree of depression or asymmetry varies between young and adolescent patients. It has not been clear how the deformity progresses as patients grow. To elucidate the change of asymmetric deformity, preoperative computed tomography (CT) scan was evaluated according to different age groups. METHODS: Preoperative CT scans of 154 patients with pectus excavatum were collected and analyzed using Haller's CT index, asymmetric index and sternal rotation angle. Patients were divided into 5 age groups as follows; group 1: 4-6 y (n=53), group 2: 7-9 y (n=25), group 3: 10-12 y (n=25), group 4: 13-15 y (n=23), group 5: 16-23 y (n=28). The degree of asymmetric chest wall deformity was expressed using sternal rotation angle as follows; symmetrical (-5º to +5º), left-mild (-5º to -15º), right-mild (+5º to +15º), right-moderate (+15º to +25º) and right-severe (over +25º). RESULTS: As the age of patients increased, asymmetric index increased from 1.025±0.065 in group 1 to 1.124±0.111 in group 5 and sternal rotation angle also increased from 6.11±8.61 in group 1 to 15.41±11.98 in group 5. In these two parameters, significant difference was seen between group 1 and 4, group 2 and 4, group 1 and 5 and group 2 and 5. However, average CT index revealed no significant difference in any age groups. In group 1, 83% of patients were classified in symmetrical or left- and right-mild. The incidence of right-moderate plus right-severe was 17% in group 1, 20% in group 2, 40% in group 3, 52.1% in group 4 and 50% in group 5. CONCLUSIONS: The degree of chest depression did not show any change in all age groups. Asymmetric deformity on the right side progressed around the age of 10 to 12. Half of patients over the age of 13 showed moderate or severe asymmetry. These results were suggestive to consider the optimum age for the correction of pectus excavatum.

Successful preemptive surgical division of type 2-congenital extrahepatic portosystemic shunt in children.

PURPOSE: A congenital extrahepatic portosystemic shunt (CEPS) is a rare abnormality. The shunts are classified into 2 types. Of these, a type 2-shunt is a side-to-side one, which may be treated by a simple shunt division. The aim of this retrospective study was to clarify the effects of a surgical shunt division on 4 children with type 2-CEPS. PATIENTS: Between June 2002 and June 2008, 4 children with type 2-CEPS underwent a surgical shunt division. Various clinical factors of each patient, including shunt types, shut ratios evaluated by portal scintigraphy using (123)I-iodoamphetamine, serum levels of ammonia and total bile acids before and after surgery were evaluated. FINDINGS: Two children had a conventional open surgery and the other two had a laparoscopic surgery. The serum levels of ammonia as well as total bile acids of these children decreased significantly to the normal levels within a month after the surgical shunt divisions. All the children had a better clinical course. CONCLUSIONS: A shunt division, especially by laparoscopic surgery, is an effective therapy for type 2-CEPS. To the best of our knowledge by reviewing literatures, our cases are the youngest ones treated by laparoscopic shunt division.