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Pectus excavatum and scoliosis: a review about the patient’s surgical management

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Abstract

Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine. This review article aims to perform an updated overview of the literature about the effect of pectus excavatum correction at the spine and the management of patients with both pectus excavatum and scoliosis. Although acquired scoliosis has been rarely reported after a Nuss procedure, studies show that the Nuss procedure can have a beneficial effect in mild coexisting scoliosis especially when it is performed during the adolescence. The management of cases presented with both pectus excavatum and scoliosis depends on the severity of pre-operative scoliosis and demands detailed evaluation of the spine pre and postoperatively. In the rare condition of post-operative scoliosis following a Nuss procedure, the removal of the metallic bar and conservative measures may have satisfactory results on the spine.

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References

  1. Marks MW, Iacobucci J. Reconstruction of congenital chest wall deformities using solid silicone onlay prostheses. Chest Surg Clin N Am. 2000;10(2):341–55 (vii).

    CAS  PubMed  Google Scholar 

  2. Fibla JJ, Molins L. Minimally invasive treatment of pectus excavatum. Minerva Chir. 2016;71(1):38–45.

    PubMed  Google Scholar 

  3. Shamberger RC. Congenital chest wall deformities. Curr Probl Surg. 1996;33(6):469–54242.

    CAS  PubMed  Google Scholar 

  4. Fonkalsrud EW. Current management of pectus excavatum. World J Surg. 2003;27(5):502–8.

    PubMed  Google Scholar 

  5. Kuru P, Bostanci K, Ermerak NO, et al. Quality of life improves after minimally invasive repair of pectus excavatum. Asian Cardiovasc Thorac Ann. 2015;23(3):302–7.

    PubMed  Google Scholar 

  6. Ghionzoli M, Martin A, Bongini M, et al. Scoliosis and pectus excavatum in adolescents: does the Nuss procedure affect the scoliotic curvature? J Laparoendosc Adv Surg Tech A. 2016;26(9):734–9.

    PubMed  Google Scholar 

  7. Wang Y, Chen G, Xie L, et al. Mechanical factors play an important role in pectus excavatum with thoracic scoliosis. J Cardiothorac Surg. 2012;7:118.

    PubMed  PubMed Central  Google Scholar 

  8. Nakaoka T, Uemura S, Yano T, et al. Does overgrowth of costal cartilage cause pectus excavatum? A study on the lengths of ribs and costal cartilages in asymmetric patients. J Pediatr Surg. 2009;44(7):1333–6.

    PubMed  Google Scholar 

  9. Park CH, Kim TH, Haam SJ, Lee S. Rib overgrowth may be a contributing factor for pectus excavatum: Evaluation of prepubertal patients younger than 10years old. J Pediatr Surg. 2015;50(11):1945–8.

    PubMed  Google Scholar 

  10. Kondo S, Takagi D, Osaga S, et al. The costochondral length in patients with pectus excavatum is longer than that of the normal thorax. Pediatr Surg Int. 2020;36(3):305–16.

    PubMed  Google Scholar 

  11. Sharma G, Carter YM. Pectus excavatum. StatPearls. Treasure Island: StatPearls Publishing; 2019.

    Google Scholar 

  12. Gokhale J, Selbst SM. Chest pain and chest wall deformity. Pediatr Clin N Am. 2009;56(1):49–65 (x).

    Google Scholar 

  13. Felts E, Jouve J-L, Blondel B, et al. Child pectus excavatum: correction by minimally invasive surgery. Orthop Traumatol Surg Res OTSR. 2009;95(3):190–5.

    CAS  PubMed  Google Scholar 

  14. Iida H. Surgical repair of pectus excavatum. Gen Thorac Cardiovasc Surg. 2010;58(2):55–61.

    PubMed  Google Scholar 

  15. Robicsek F, Watts LT, Fokin AA. Surgical repair of pectus excavatum and carinatum. Semin Thorac Cardiovasc Surg. 2009;21(1):64–75.

    PubMed  Google Scholar 

  16. Nuss D, Kelly RE, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg. 1998;33(4):545–52.

    CAS  PubMed  Google Scholar 

  17. Nuss D, Kelly RE. Minimally invasive surgical correction of chest wall deformities in children (Nuss procedure). Adv Pediatr. 2008;55:395–410.

    PubMed  Google Scholar 

  18. Prats MR, González LR, Venturelli MF, et al. Minimally invasive correction of pectus excavatum among adults. Report of eighteen cases. Rev Med Chil. 2009;137(12):1583–90.

    Google Scholar 

  19. Kuenzler KA, Stolar CJH. Surgical correction of pectus excavatum. Paediatr Respir Rev. 2009;10(1):7–11.

    PubMed  Google Scholar 

  20. Hanna WC, Ko MA, Blitz M, et al. Thoracoscopic Nuss procedure for young adults with pectus excavatum: excellent midterm results and patient satisfaction. Ann Thorac Surg. 2013;96(3):1033–6 (discussion 1037-1038).

    PubMed  Google Scholar 

  21. Ewais MM, Chaparala S, Uhl R, Jaroszewski DE. Outcomes in adult pectus excavatum patients undergoing Nuss repair. Patient Relat Outcome Meas. 2018;9:65–90.

    PubMed  PubMed Central  Google Scholar 

  22. Robicsek F, Hebra A. To nuss or not to nuss? Two opposing views. Semin Thorac Cardiovasc Surg. 2009;21(1):85–8.

    PubMed  Google Scholar 

  23. Mao YZ, Tang S, Li S. Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis. J Pediatr Surg. 2017;52(10):1545–52.

    PubMed  Google Scholar 

  24. Mavanur A, Hight DW. Pectus excavatum and carinatum: new concepts in the correction of congenital chest wall deformities in the pediatric age group. Conn Med. 2008;72(1):5–11.

    PubMed  Google Scholar 

  25. Ravitch MM. The operative treatment of pectus excavatum. Ann Surg. 1949;129(4):429–44.

    CAS  PubMed  PubMed Central  Google Scholar 

  26. Hebra A, Calder BW, Lesher A. Minimally invasive repair of pectus excavatum. J Vis Surg. 2016;2:73.

    PubMed  PubMed Central  Google Scholar 

  27. Buziashvili D, Gopman JM, Weissler H, et al. An evidence-based approach to management of pectus excavatum and carinatum. Ann Plast Surg. 2019;82(3):352–8.

    CAS  PubMed  Google Scholar 

  28. Swanson JW, Avansino JR, Phillips GS, et al. Correlating Haller Index and cardiopulmonary disease in pectus excavatum. Am J Surg. 2012;203(5):660–4.

    PubMed  Google Scholar 

  29. Haller JA, Kramer SS, Lietman SA. Use of CT scans in selection of patients for pectus excavatum surgery: a preliminary report. J Pediatr Surg. 1987;22(10):904–6.

    PubMed  Google Scholar 

  30. Poston PM, Patel SS, Rajput M, et al. The correction index: setting the standard for recommending operative repair of pectus excavatum. Ann Thorac Surg. 2014;97(4):1176–9 (discussion 1179-1180).

    PubMed  Google Scholar 

  31. Sujka JA, St Peter SD. Quantification of pectus excavatum: anatomic indices. Semin Pediatr Surg. 2018;27(3):122–6.

    PubMed  Google Scholar 

  32. Fagelman KM, Methratta S, Cilley RE, et al. The Depression Index: an objective measure of the severity of pectus excavatum based on vertebral diameter, a morphometric correlate to patient size. J Pediatr Surg. 2015;50(7):1130–3.

    PubMed  Google Scholar 

  33. de Araújo MEA, da Penha AP, Westphal FL, et al. Nuss procedure for pectus excavatum repair: critical appraisal of the evidence. Rev Col Bras Cir. 2014;41(6):400–5.

    PubMed  Google Scholar 

  34. Lopushinsky SR, Fecteau AH. Pectus deformities: a review of open surgery in the modern era. Semin Pediatr Surg. 2008;17(3):201–8.

    PubMed  Google Scholar 

  35. Park HJ, Sung S-W, Park J-K, et al. How early can we repair pectus excavatum: the earlier the better? Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg. 2012;42(4):667–72.

    Google Scholar 

  36. Pawlak K, Gąsiorowski Ł, Gabryel P, et al. Early and late results of the Nuss procedure in surgical treatment of pectus excavatum in different age groups. Ann Thorac Surg. 2016;102(5):1711–6.

    PubMed  Google Scholar 

  37. Park HJ, Kim JJ, Park JK, Moon SW. Effects of Nuss procedure on thoracic scoliosis in patients with pectus excavatum. J Thorac Dis. 2017;9(10):3810–6.

    PubMed  PubMed Central  Google Scholar 

  38. Kim DH, Hwang JJ, Lee MK, et al. Analysis of the Nuss procedure for pectus excavatum in different age groups. Ann Thorac Surg. 2005;80(3):1073–7.

    PubMed  Google Scholar 

  39. Protopapas AD, Athanasiou T. Peri-operative data on the Nuss procedure in children with pectus excavatum: independent survey of the first 20 years’ data. J Cardiothorac Surg. 2008;3:40.

    PubMed  PubMed Central  Google Scholar 

  40. Esteves E, Paiva KCC, Calcagno-Silva M, et al. Treatment of pectus excavatum in patients over 20 years of age. J Laparoendosc Adv Surg Tech A. 2011;21(1):93–6.

    PubMed  Google Scholar 

  41. Ravenni G, Actis Dato GM, Zingarelli E, et al. Nuss procedure in adult pectus excavatum: a simple artifice to reduce sternal tension. Interact Cardiovasc Thorac Surg. 2013;17(1):23–5.

    PubMed  PubMed Central  Google Scholar 

  42. Velazco CS, Arsanjani R, Jaroszewski DE. Nuss procedure in the adult population for correction of pectus excavatum. Semin Pediatr Surg. 2018;27(3):161–9.

    PubMed  Google Scholar 

  43. Densmore JC, Peterson DB, Stahovic LL, et al. Initial surgical and pain management outcomes after Nuss procedure. J Pediatr Surg. 2010;45(9):1767–71.

    PubMed  Google Scholar 

  44. Futagawa K, Suwa I, Okuda T, et al. Anesthetic management for the minimally invasive Nuss procedure in 21 patients with pectus excavatum. J Anesth. 2006;20(1):48–50.

    PubMed  Google Scholar 

  45. Muhly WT, Beltran RJ, Bielsky A, et al. Perioperative management and in-hospital outcomes after minimally invasive repair of pectus excavatum: a multicenter registry report from the society for pediatric anesthesia improvement network. Anesth Analg. 2019;128(2):315–27.

    PubMed  Google Scholar 

  46. Bouchard S, Hong AR, Gilchrist BF, Kuenzler KA. Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum. Semin Pediatr Surg. 2009;18(2):66–72.

    PubMed  Google Scholar 

  47. Park HJ, Lee SY, Lee CS, et al. The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients. Ann Thorac Surg. 2004;77(1):289–95.

    PubMed  Google Scholar 

  48. Shah M, Frye R, Marzinsky A, et al. Complications associated with bar fixation following Nuss repair for pectus excavatum. Am Surg. 2016;82(9):781–2.

    PubMed  PubMed Central  Google Scholar 

  49. Johnson JN, Hartman TK, Pianosi PT, Driscoll DJ. Cardiorespiratory function after operation for pectus excavatum. J Pediatr. 2008;153(3):359–64.

    PubMed  Google Scholar 

  50. Chen Z, Amos EB, Luo H, et al. Comparative pulmonary functional recovery after Nuss and Ravitch procedures for pectus excavatum repair: a meta-analysis. J Cardiothorac Surg. 2012;7(1):1–9.

    CAS  Google Scholar 

  51. Zhong W, Ye J, Feng J, et al. Effects of pectus excavatum on the spine of pectus excavatum patients with scoliosis. J Healthc Eng. 2017;2017:5048625.

    PubMed  PubMed Central  Google Scholar 

  52. Jaroszewski D, Notrica D, McMahon L, et al. Current management of pectus excavatum: a review and update of therapy and treatment recommendations. J Am Board Fam Med. 2010. https://doi.org/10.3122/jabfm.2010.02.090234.

    Article  PubMed  Google Scholar 

  53. Hong J-Y, Suh S-W, Park H-J, et al. Correlations of adolescent idiopathic scoliosis and pectus excavatum. J Pediatr Orthop. 2011;31(8):870–4.

    PubMed  Google Scholar 

  54. Frick SL. Scoliosis in children with anterior chest wall deformities. Chest Surg Clin N Am. 2000;10(2):427–36.

    CAS  PubMed  Google Scholar 

  55. Waters P, Welch K, Micheli LJ, et al. Scoliosis in children with pectus excavatum and pectus carinatum. J Pediatr Orthop. 1989;9(5):551–6.

    CAS  PubMed  Google Scholar 

  56. Niedbala A, Adams M, Boswell WC, Considine JM. Acquired thoracic scoliosis following minimally invasive repair of pectus excavatum. Am Surg. 2003;69(6):530–3.

    PubMed  Google Scholar 

  57. Ye J-D, Lu G-P, Feng J-J, Zhong W-H. Effect on chest deformation of simultaneous correction of pectus excavatum with scoliosis. J Healthc Eng. 2017;2017:8318694.

    PubMed  PubMed Central  Google Scholar 

  58. Tomaszewski R, Wiktor Ł, Machała L. Evaluation of thoracic vertebrae rotation in patients with pectus excavatum. Acta Orthop Traumatol Turc. 2017;51(4):284–9.

    PubMed  PubMed Central  Google Scholar 

  59. Negrini S, Donzelli S, Aulisa AG, et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018;13:3.

    PubMed  PubMed Central  Google Scholar 

  60. SOSORT guideline committee, Weiss H-R, Negrini S, et al. Indications for conservative management of scoliosis (guidelines). Scoliosis. 2006;1:5.

    PubMed Central  Google Scholar 

  61. Bafus BT, Chiravuri D, van der Velde ME, et al. Severe hypotension associated with the prone position in a child with scoliosis and pectus excavatum undergoing posterior spinal fusion. J Spinal Disord Tech. 2008;21(6):451–4.

    PubMed  Google Scholar 

  62. Chung JH, Park HJ, Kim KT. Scoliosis after pectus excavatum correction: does it improve or worsen? Eur J Cardio-Thorac Surg. 2017;52(1):76–82.

    Google Scholar 

  63. Tauchi R, Kawakami N, Tsuji T, et al. Evaluation of thoracic factors after scoliosis surgery in patients with both scoliosis and pectus excavatum. Eur Spine J. 2018;27(2):381–7.

    PubMed  Google Scholar 

  64. Meng Y, Lin T, Shao W, et al. Acquired scoliosis following Nuss procedure for pectus excavatum. Medicine (Baltimore). 2019. https://doi.org/10.1097/MD.0000000000013855.

    Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Eleftherios T. Beltsios.

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Beltsios, E.T., Mitsos, S.L. & Panagiotopoulos, N.T. Pectus excavatum and scoliosis: a review about the patient’s surgical management. Gen Thorac Cardiovasc Surg 68, 1225–1233 (2020). https://doi.org/10.1007/s11748-020-01496-y

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