Nezih Onur Ermerak

Quality of life improves after minimally invasive repair of pectus excavatum

Background Pectus excavatum is the most common chest wall deformity. This deformity may cause physical limitations and psychosocial problems. In this study, we aimed to investigate the effect of minimally invasive repair of pectus excavatum on the quality of life. Methods This study included 88 patients, aged 18.44 ± 3.93 years (85.2% male), who underwent minimally invasive repair of pectus excavatum; 40.9% had an associated anomaly or disease, and 17.0% had scoliosis. The patients and their parents completed the patient and parent forms of the Nuss questionnaire modified for adults preoperatively and 6 months after the operation. Results The patients’ median Nuss score increased from 31 (interquartile range 31–35) preoperatively to 43 (interquartile range 43–46) at 6 months after the operation (p = 0.000). The parents’ preoperative score of 33 (interquartile range 29–36) increased to 38 (interquartile range 34–41; p = 0.000). Improvements in the physical and psychosocial component scores of the Nuss questionnaire were also significant in the patient (p = 0.000, p = 0.000, respectively) and parent forms (p = 0.005, p = 0.000, respectively). Conclusions Minimally invasive repair of pectus excavatum significantly improved the physical and psychosocial wellbeing of patients. Longitudinal studies are needed to determine the long-term changes related to quality of life.

Pulmonary endarterectomy for chronic thrombo-embolic pulmonary hypertension: an institutional experience.

OBJECTIVE Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thrombo-embolic pulmonary hypertension (CTEPH). The aim of this study was to review our initial experience since the implementation of our program. METHODS Data were collected prospectively on all patients who underwent PEA between March 2011 and March 2012. RESULTS Forty-nine patients (20 male, 29 female, mean age 47.7 years) underwent surgery. The preoperative New York Heart Association class distribution showed the majority to be in class III or IV (n = 40). Mortality rate was 14.2% (n = 7) and the morbidity rate was 26.5% (n = 13). After PEA, the durations of mechanical ventilation, intensive care stay and hospital stay before discharge were 49.7 ± 46.1 h, 6.5 ± 5.0 days and 12.9 ± 7.5 days, respectively. The systolic and mean pulmonary artery pressure (PAP) fell significantly from 87.0 ± 26.6 mmHg and 53.8 ± 14.5 before, to 41.5 ± 12.4 mmHg and 28.5 ± 10.5 after surgery (P < 0.001 and P < 0.001, respectively). Pulmonary vascular resistance (PVR) also improved significantly from 808 ± 352.0 to 308 ± 91 dyn•s•cm(-5) (P < 0.001). Univariate analysis showed that preoperative systolic PAP, tricuspid annular plane systolic excursion, right atrial volume, right atrial pressure, forced expiratory volume in 1 s, forced vital capacity, preoperative PVR, postoperative PVR, the duration of circulatory arrest and postoperative use of extracorporeal membrane oxygenation were risk factors for mortality (P < 0.05). According to multivariate analyses, only prolonged mechanical ventilation was selected as predictive risk factor for morbidity (P = 0.005). After a median follow-up of 6.1 months, two patients died due to cerebrovascular disease and one patient needed targeted pulmonary hypertension therapy. The rest of the 39 patients showed marked improvements in their clinical status. CONCLUSIONS Starting a pulmonary endarterectomy program with acceptable mortality and morbidity rates and satisfactory early-term outcomes increases awareness of the CTEPH and surgery. Preoperative factors can primarily predict postoperative outcome after PEA. Identifying the risk factors in order to achieve a good result is important for the success of a PEA program. Therefore all patients diagnosed with CTEPH should be referred for consideration of PEA in a specialized centre.

Do Nuss bars compromise the blood flow of the internal mammary arteries

OBJECTIVES Minimally invasive repair of pectus excavatum, the so-called Nuss procedure, has become a popular technique in recent years. The internal mammary arteries (IMAs) lie on the posterolateral surface of the sternum, and the Nuss bar is likely to obstruct the blood flow in these arteries. This obstruction could become important in the later stages of the lives of these young people if they were to require coronary artery bypass grafting. The goal of this study is to investigate the extent of obstruction of the IMAs caused by Nuss bars. METHODS Data were collected prospectively on all patients who underwent the Nuss procedure between October 2011 and May 2012. Patients with a history of pectus excavatum repair by open surgery and those who were younger than 16 years of age were excluded. Computed tomography-angiography (CTA) was performed for the detection of IMA blood flow preoperatively and on the 10th postoperative day. Blood flow in the IMAs was evaluated blindly by two radiologists and classified as blood flow unaffected (group I) or affected (group II) by comparing the assessment of preoperative and postoperative CTAs. The patients in group II were also categorized as having blood flow obstructed bilaterally, blood flow obstructed unilaterally and others (diminished unilaterally/diminished on one side or obstructed on the other side). RESULTS Thirty-four patients (31 male and three female; mean age 20.7 ± 4.2 years) underwent surgery. Blood flow was affected in 15 patients (44%), with bilateral obstruction in five, unilateral obstruction in seven, and unilateral diminished flow in two patients. In one patient, blood flow was diminished on one side and obstructed on the other. There was no significant difference between unaffected group I patients and affected group II patients in terms of sex, age, type of deformity, Haller index and the number of bars placed. CONCLUSIONS Nuss bars cause pressure on the IMAs, but a risk factor for this effect could not be identified. This is a relatively common clinical consequence of minimally invasive repair of pectus excavatum, and the long-term effects will be apparent following bar removal.

Validity and Reliability of the Turkish Version of the Nuss Questionnaire Modified for Adults

Background Pectus excavatum (PE) is the most common chest wall deformity. The Nuss Questionnaire modified for Adults (NQmA) is a disease-specific health-related quality of life assessment tool for patients with pectus deformities. The aim of this study is to adapt the NQmA into Turkish. Methods Two hundred and sixty-five patients with PE were participated, with an age range of 14 to 29 years. All patients underwent a physical examination and had not undergone corrective surgery. The Turkish version of the NQmA was completed by patients and their parents. Results The content validity index based on expert opinions was 91% for the patient questionnaire and 96% for the parent questionnaire. The Cronbach’s alpha value for the NQmA was found to be 0.805 for the patient questionnaire and 0.800 for the parent questionnaire. Exploratory factor analysis was used to assess construct validity. Two factors explained 51.1% of the total variance in the patient questionnaire (psychosocial: 31.145%, Cronbach’s alpha=0.818; physical: 19.955%, Cronbach’s alpha=0.862). In the parent questionnaire, two factors explained 51.422% of the total variance (psychosocial: 26.097%, Cronbach’s alpha=0.743; physical: 25.325%, Cronbach’s alpha=0.827). Construct validity was confirmed by confirmatory factor analysis. Conclusion The Turkish version of the NQmA was found to be valid and reliable for the assessment of quality of life in patients with PE.

Risk of serious perioperative complications with removal of double bars following the Nuss procedure

Objectives The aim of this study is to present our experience with Nuss bar removal and evaluate potential risk factors. The Nuss procedure requires an operation to remove the bar 2-3 years after the initial correction. Although removal of the bar is generally believed to be safe, perioperative complications including major bleeding can occur. Methods All cases involving removal of the Nuss bar done since April 2007 were recorded in a prospective database. Data were collected on the amount of blood loss, the number of diagnostic interventions, operative management and postoperative course. Results Of a total of 246 (162 with single bars, 80 with double bars, 4 with triple bars) cases, 43 patients (17.5%) experienced perioperative complications. Five patients underwent secondary postoperative interventions; one patient required same-session emergency video-assisted thoracic surgery (VATS) due to major bleeding. Patients who had complications were significantly older than patients with no complications (20.5 ± 6.5 years vs 17.2 ± 5.9 years, P = 0.002). People having double bars removed were significantly more likely to have perioperative complications (12% vs 27%, P = 0.03) and complications requiring secondary interventions (n = 1 for a single bar, n = 5 for double bars, P = 0.01). Conclusions Major complications after removal of the Nuss bar occur with some frequency. Although the double-bar removals in our cohort were associated with major complications, the reasons are poorly understood. Immediate management of the complications may require multidisciplinary care. Multicentric pooling of cases is needed for better risk stratification.

Previously Complicated Nuss Procedure Does Not Preclude Blind Removal of the Bar.

BACKGROUND Nuss procedure has become the procedure of choice for well-selected patients with pectus excavatum. Perioperative complications may pose difficulty during the subsequent bar removal due to adhesions and tissue plane disruptions during the initial surgery and repair. This report describes bar removal experience in patients whose Nuss procedures were complicated by cardiac injury, pericardial breach, and lung parenchyma/diaphragm injury during the initial procedure. METHODS A total of 529 patients who underwent Nuss procedure between 2007 and 2014 were recorded in a prospective database. Twenty patients with complications (cardiac injury [n = 1], pericardial breach [n = 3], and lung parenchyma/diaphragm injury [n = 16]) were identified. All bars were removed via subcutaneous tissue dissection, without intrathoracic visualization. RESULTS Average duration of bars was 36 months (±16 months). All bar removal procedures were completed without any need for extra interventions with negligible blood loss. Eighteen patients were able to be discharged within 2 postoperative days. CONCLUSION Blind bar removal in patients with previously complicated Nuss procedure seems safe and no other interventions (videothoracoscopy, subxiphoid incision, etc.) during bar removal seem to be necessary.

Feasibility and Complications in Concomitant Lung Resection With Minimally Invasive Repair of Pectus Excavatum

Minimally invasive repair of pectus excavatum (MIRPE) is the procedure of choice in experienced centers and can be offered in combination with other thoracic procedures. Between 2001 and 2013, 3 cases involving MIRPE and lung surgery were done in our clinic. While postoperative course of 2 procedures (MIRPE and video-assisted thoracoscopic surgery [VATS] segmentectomy and MIRPE and VATS bullectomy) were uncomplicated, the MIRPE and VATS lung biopsy patient developed major complications arising from prolonged air leak and was ultimately managed with an Eloesser flap. In carefully selected cases, simultaneous lung surgery and MIRPE can be done safely but problems of lung reexpansion, long-term drainage, and infection should be kept in mind.

Reconstruction of sternal cleft with autologous cartilage graft in an adult

Sternal cleft is a rare chest wall deformity associated with various malformations. Primary closure is the gold standard in the newborn period. Alternative techniques are possible for older patients. A 23-year-old woman with a partial sternal cleft and no additional deformity, underwent reconstruction using costal cartilage grafts. Postoperative physical and functional were excellent.

Refractory invasive aspergillosis controlled with posaconazole and pulmonary surgery in a patient with chronic granulomatous disease: case report.

Invasive aspergillosis is an important cause of morbidity and mortality in immunocompromised patients. Among primary immunodefiencies, chronic granulomatous disease (CGD) has the highest prevalence of invasive fungal diseases. Voriconazole is recommended for the primary treatment of invasive aspergillosis in most patients. In patients whose aspergillosis is refractory to voriconazole, therapeutic options include changing class of antifungal, for example using an amphotericin B formulation, an echinocandin, combination therapy, or further use of azoles. Posaconazole is a triazole derivative which is effective in Aspergillosis prophylaxis and treatment. Rarely, surgical therapy may be needed in some patients. Lesions those are contiguous with the great vessels or the pericardium, single cavitary lesion that cause hemoptysis, lesions invading the chest wall, aspergillosis that involves the skin and the bone are the indications for surgical therapy.Chronic granulomatous disease (CGD) is an inherited immundeficiency caused by defects in the phagocyte nicotinamide adenine dinucleotidephosphate (NADPH) oxidase complex which is mainstay of killing microorganisms. CGD is characterized by recurrent life-threatening bacterial and fungal infections and by abnormally exuberant inflammatory responses leading to granuloma formation, such as granulomatous enteritis, genitourinary obstruction, and wound dehiscence. The diagnosis is made by neutrophil function testing and the genotyping.Herein, we present a case with CGD who had invasive pulmonary aspergillosis refractory to voriconazole and liposomal amphotericine B combination therapy that was controlled with posaconazole treatment and pulmonary surgery.

Total Rib Resection Via Uniportal Thoracoscopic Approach

In this report, we present a case specifying the availability of uniportal thoracoscopic resection of a total rib safely without the need for conventional thoracotomy. The favorable outcome of this case suggests that the uniportal thoracoscopic technique described here is a safe and successful approach for resection of costal lesions with good cosmetic results. To our knowledge, this is the first case reporting the entire rib resection via uniportal thoracoscopic approach.