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Ten-year experience with staged management of pectus carinatum: Results and lessons learned

      Abstract

      Introduction

      : We report pectus carinatum management over a 10+year period.

      Methods

      : Staged management, with initial bracing and operation for failure or special circumstances, was employed. A newer brace and a minimally invasive operation for PC (the Abramson procedure) were introduced during the study period.

      Results

      : Of 695 consenting patients from 2008 to 2018, 265 (38%) were observed. Of 430 treated, 339 (79%) had bracing only; 65 (15%) underwent surgery without a trial of bracing, while 26(5%) underwent surgery after a failed attempt at bracing. Of 364 bracing patients, 144 (40%) were successful, 77 (21%) are ongoing, 25 (7%) failed, and 118 (32%) dropped out. Recurrence was noted in 17 (5%), an average 5.4 months later. Two (0.4%) overcorrected to pectus excavatum (PE). Successful patients experienced a 50% decrease in pressure of correction (POC) beginning one month after starting treatment. Brace failure patients did not. Reported compliance with brace utilization (hours/day) was similar. Surgery was required in 91 patients. Open operations were performed in 61 (67%), Abramson operations in 23 (25%), and Nuss procedure in 7 (8%) who developed excavatum over correction following bracing or who had mixed deformity, with excavatum one side of the sternum and carinatum on the other. Twenty-four (36%) of the surgeries for PC occurred after an attempt at bracing. All obtained good initial results by operation. No recurrence was noted after open operation and 3 (13%) after Abramson. Open complications included 1 (2%) infection. Abramson's operation required 11 (48%) revisions, 6 (26%) early bar removals, and had 3 (13%) infections.

      Conclusion

      : Brace treatment for PC can be guided by pressure of correction, which fell by more than half in successfully treated patients. POC did not fall in patients who failed. If POC does not fall, surgery should be considered. Open repair of Pectus Carinatum is generally successful, while the Abramson operation has a significant rate of complications with the implants currently available in the U.S.

      Levels of Evidence

      : Level III – Retrospective comparative study.

      Keywords

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      References

        • Cohee A.S.
        • Lin J.R.
        • Frantz F.W.
        • Kelly Jr., R.E.
        Staged management of pectus carinatum.
        J Pediatr Surg. 2013; 48: 315-320
        • Martinez-Ferro M.
        • Fraire C.
        • Bernard S.
        Dynamic compression system for the correction of pectus carinatum.
        J Pediatr Surg. 2008; 17: 194-200
        • Abramson H.
        A minimally invasive technique to repair pectus carinatum. preliminary report.
        Arch Bronconeumol. 2005; 41: 349-351
        • Abramson H.
        • D'Agostino J.
        • Wuscovi S.
        A 5-year experience with a minimally invasive technique for pectus carinatum repair.
        J Pediatr Surg. 2009; 44: 118-124
        • Biffl W.L.
        • Spain D.A.
        • Reitsma A.m.
        • et al.
        Responsible development and application of surgical innovations: a position statement of the Society of University Surgeons.
        J Am Coll Surg. 2008; 206: 1204-1209
        • Kelly Jr., R.E.
        • Martinez-Ferro M.
        Chest wall deformities. chapter 20. pediatric surgery.
        7th ed. Elsevier, Edinburgh2020
        • Haje S.A.
        • de Podestá Haje D.
        Orthopedic approach to pectus deformities: 32 years of studies.
        Rev Bras Ortop. 2015; 44 (eCollection 2009 Jan): 191-198https://doi.org/10.1016/S2255-4971(15)30067-7
        • Haje S.A.
        • Bowen J.R.
        Preliminary results of orthotic treatment of pectus deformities in children and adolescents.
        J Pediatr Orthop. 1992; 12: 795-800
        • Lee R.T.
        • Moorman S.
        • Schneider M.
        • Sigalet D.L.
        Bracing is an effective therapy for pectus carinatum: interim results.
        J Pediatr Surg. 2013; : 184-190
        • Sesia S.B.
        • Holland-Cunz S.
        • Hacker F.M.
        Dynamic compression system: an effective nonoperative treatment for Pectus carinatum: a single center experience in Basel, Switzerland.
        Eur J Pediatr Surg. 2016; : 1-5
        • Emil S.
        • Sevigny M.
        • Montpetit K.
        • Baird R.
        • Laberge J.M.
        • Goyette J.
        • Finlay I.
        • Courchesne G...
        Success and duration of dynamic bracing for pectus carinatum: a four-year prospective study.
        J Pediatr Surg. 2017; 52: 124-129
        • de Beer S.A.
        • Blom Y.E.
        • Lopez M.
        • de Jong J.R.
        Measured dynamic compression for pectus carinatum: a systematic review.
        Semin Pediatr Surg. 2018; 27: 175-182https://doi.org/10.1053/j.sempedsurg.2018.06.001
        • Bugajski T.
        • Murari K.
        • Lopushinsky S.
        • Schneider M.
        • Ronsky J.
        Bracing of pectus carinaturm: a quantitative analysis.
        J Pediatr Surg. 2018; 53: 1014-1019
        • Moon D.H.
        • Kang M.K.
        • Lee H.S.
        • Lee S.
        Long-term results of compressive brace therapy for pectus carinatum.
        Thorac Cardiovasc Surg. 2019; 67: 67-72https://doi.org/10.1055/s-0038-1669927
        • Fonkalsrud E.W.
        • Anselmo D.M.
        Less Extensive techniques for repair of pectus carinatum: the undertreated chest deformity.
        J Am Coll Surg. 2004; 198: 898-905
        • Fonkalsrud E.W.
        Surgical Correction of Pectus Carinatum: lessons Learned from 260 Patients.
        J Pediatr Surg. 2008; 43: 1235-1243
        • Poola A.S.
        • Pierce A.L.
        • Orrick B.A.
        • et al.
        A single-center experience with dynamic compression bracing for children with pectus carinatum.
        Eur. J. Pediatr Surg. 2018; 28: 12-17
        • Paulson J.F.
        • Ellis K.
        • Obermeyer R.J.
        • Kuhn M.A.
        • Frantz F.W.
        • McGuire M.M.
        • Ortiz E.
        • Kelly Jr., R.E.
        Development and validation of the Pectus Carinatum Body Image Quality of Life (PeCBI-QOL) questionnaire.
        J Pediatr Surg. 2019; 54 (doi: 0.1016/j.jpedsurg.2019.03.019. Epub 2019 Apr 24): 2257-2260
        • Tikka T.
        • Kalkat M.
        • Bishay E.
        • et al.
        A 20-year review of pectus surgery: an analysis of factors predictive of recurrence and outcomes.
        Interact CardioVasc Thorac Surg. 2016; : 1-6
        • Schaarschmidt K.
        • Lempe-Sellin M.
        • Schlesinger F.
        • Jaeschke U.
        • Polleichtner S.
        New Berlin-Buch “Reversed Nuss,” Endoscopic Pectus Carinatum Repair Using Eight-Hole Stabilizers, Submuscular CO(2), and Presternal Nuss Bar Compression: first Results in 35 Patients.
        J Laparoendosc Adv Surg Tech A. 2011; 21: 283-286
        • Katrancioglu O.
        • Akkas Y.
        • Karadayi S.
        • et al.
        Is the Abramson technique effective in pectus carinatum repair?.
        Asian J Surg. 2016; https://doi.org/10.1016/j.asjsur.2016.09.008
        • Suh J.W.
        • Joo S.
        • Lee G.D.
        • Haam S.J.
        • Lee S.
        Minimally invasive repair of pectus carinatum in patients unsuited to bracing therapy.
        Korean J Thorac Cardiovasc Surg. 2016; 49: 92-98
        • Özkaya M.
        • Bilgin M.
        Minimally invasive repair of pectus carinatum: a retrospective analysis based on a single surgeon's 10 years of experience.
        Gen Thorac Cardiovasc Surg. 2018; 66: 653-657https://doi.org/10.1007/s11748-018-0975-1
        • Yuksel M.
        • Lacin T.
        • Ermerak N.O.
        • Sirzai E.Y.
        • Sayan B.
        Minimally Invasive Repair of Pectus Carinatum.
        Ann Thorac Surg. 2018; 105 (Epub 2018 Jan 9. PubMed PMID: 29325984): 915-923https://doi.org/10.1016/j.athoracsur.2017.10.003
        • Muntean A.
        • Stoica I.
        • Saxena A.K.
        Pigeon chest: comparative analysis of surgical techniques in minimal access repair of pectus carinatum (MARPC).
        World J Pediatr. 2018; 14: 18-25
        • Port E.
        • Hebal F.
        • Hunter C.J.
        • Malas B.
        • Reynolds M.
        Measuring the impact of brace intervention on pediatric pectus carinatum using white light scanning.
        J Pediatr Surg. 2018; 53: 2491-2494https://doi.org/10.1016/j.jpedsurg.2018.08.016
        • Kelly Jr., R.E.
        • Obermeyer R.J.
        • Kuhn M.A.
        • Frantz F.W.
        • Obeid M.F.
        • Kidane N.
        • McKenzie F.D.
        Use of an optical scanning device to monitor the progress of noninvasive treatments for chest wall deformity: a pilot study.
        Korean J Thorac Cardiovasc Surg. 2018; 51 (Published on line 2018 Dec): 390-394https://doi.org/10.5090/kjtcs.2018.51.6.390