MennatAllah M. Ewais

Hybrid Technique for Repair of Recurrent Pectus Excavatum After Failed Open Repair

BACKGROUND Successful repair of recurrent pectus excavatum (PE) after failed open procedure has been reported using minimally invasive repair (MIRPE) and open approaches. Neither approach alone may be adequate for some patients. A hybrid technique for repair is presented for revision of recurrent PE. METHODS A retrospective review of adults undergoing repair for recurrent PE after prior open repair from January 2010 to June 2014 was performed. RESULTS Seventy-three adult patients underwent repair for recurrent PE, with 48 patients (65.8%) undergoing repair for recurrence after at least one prior open PE repair. Mean patient age was 34.5 years (range, 19 to 54 years); mean Haller index was 4.7 (range, 2.8 to 14.7). Fourteen (29%) recurrences with adequate chest wall pliability and no malunion were repaired with MIRPE alone; 34 patients (71%) underwent a hybrid procedure for repair (20 for PE recurrence alone; 14 for PE with acquired thoracic dystrophy). All had at least two support bars placed, and 11 patients (23%) had three bars placed. Mean hospitalization for MIRPE was 5 days, for hybrid was 7 days, and for hybrid because of acquired thoracic dystrophy was 10 days. One patient died of unexpected out-of-hospital arrest; there was one emergent conversion to open sternotomy for bleeding. CONCLUSIONS Most recurrent PE may be repaired with excellent results and minimal complications. Those with adequate chest pliability and no malunion are candidates for MIPRE alone. A hybrid procedure with thoracoscopic support bars combined with sternal elevation, multiple open osteotomies, and chest wall fixation is appropriate for recurrences associated with malunion or fixation of the anterior chest and failure to lift with MIRPE.

Pectus Excavatum: A Review of Diagnosis and Current Treatment Options

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

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

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

Thoracoscopy for Internal Mammary Node Dissection of Metastatic Breast Cancer

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

Outcomes in adult pectus excavatum patients undergoing Nuss repair

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

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

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

Descending aortic replacement after Nuss for pectus excavatum in a Marfan patient-Case report.

INTRODUCTION The Nuss procedure for pectus excavatum (PE) repair has been successfully performed in Marfan syndrome (MFS) patients however there is concern for future risk of aortic dilation/rupture and need for emergent access with support bars in place. CASE PRESENTATION We present a 45 year-old male with MFS that required descending aortic replacement shortly after modified Nuss repair. DISCUSSION The majority of MFS patients have severe PE and repair with the Nuss procedure is not uncommon. The risk for life threatening aortic dilation, dissection, or rupture in such patients is a concern when utilizing this technique. Our work has been reported in line with the CARE criteria. CONCLUSION Nuss repair should be considered in MFS patients with technique modifications and careful consideration of future risk of aortic dilation and rupture.

Successful Singleton and Twin Pregnancies With the Nuss Bars in Place

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