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The thorax
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
The sternum is depressed, with a dish-shaped deformity of the anterior portions of the ribs on one or both sides. It is never a cause of respiratory problems. It can be repaired to improve its cosmetic appearance either as an open procedure (the Ravitch procedure) which involves resecting the affected costal cartilages and mobilising the sternum, or as a minimally invasive technique, the Nuss procedure. A metal bar is paced behind the sternum to hold this central panel in its new position and has to be removed after a period of time (Figure55.32).
Chest wall deformities
Published in Brice Antao, S Irish Michael, Anthony Lander, S Rothenberg MD Steven, Succeeding in Paediatric Surgery Examinations, 2017
Michael J Goretsky, Robert Obermeyer
Patients who present with worsening of their pectus excavatum and symptoms such as exercise intolerance are good candidates for the Nuss procedure. Recommended routine workup of these patients workupincludes: chest CT to determine the Haller index and anatomical information; pulmonary function tests to determine baseline lung function and any other underlying lung condition such as reactive airway disease; cardiac consultation to interpret data from the ECG and echocardiogram, which are required to assess for any rhythm abnormalities and valvular or aortic-root abnormalities. Nickel allergy has been found in only about 2.2% of patients undergoing the Nuss procedure. The surgeon must always inquire about any metal allergies or atopy. Metal allergies may present with a rash near nickel-containing metal belt buckles and irritation from nickel-containing jewellery. If a nickel allergy is suspected a TRUE skin test (Allerderm, Phoenix, AZ) must be performed preoperatively. If the patient is found to be allergic to either nickel or cobalt then a titanium bar will be required, since the stainless steel bar has both of these elements. Given the increased recognition of this condition older patients are starting to come forward seeking repair. Any pectus excavatum patient who presents with uncharacteristic cardiac symptoms should be sent for cardiac consultation prior to the typical preoperative workup.
Pectus deformities
Published in Larry R. Kaiser, Sarah K. Thompson, Glyn G. Jamieson, Operative Thoracic Surgery, 2017
At the present time, the Ravitch procedure should be reserved for adult patients who have a very rigid chest wall and severe defect for whom the Nuss procedure is considered inappropriate or too risky. Indications may include patients who have had a failed Ravitch procedure or those who have undergone a sternotomy. However, variants of the Nuss technique, such the one reported by Hans Pilegaard suggesting a more anterior approach in adults with severe pectus excavatum, allow the minimally invasive approach to be performed in nearly every patient.
REVIEW OF THE INTERNATIONAL LITERATURE
Published in American Journal of Clinical Hypnosis, 2018
The authors present a study on the uses of self-hypnosis training to help patients with severe postoperative pain. All patients in this study had been diagnosed with pectus excavatum, which is a rare condition affecting one in 300 to 500 people overall, albeit with a higher incidence rate in males. Patients with pectus excavatum have a malformation of their chest and rib area that causes their chest to develop a “caved-in” appearance. This malformation of the chest area can be corrected with a surgery known as the Nuss procedure, although this procedure is sometimes associated with severe postoperative pain. The authors trained 24 adolescents, who were about to undergo the Nuss procedure, in self-hypnosis training for analgesia to see if the patients might cope better with their pain than a control group which did not receive training in self-hypnosis. The patients who received training in self-hypnosis reported lower mean and maximum pain intensity scores. These patients also used less morphine equivalents per hour over time compared to the patients who did not receive training in self-hypnosis. The authors also reported that the patients who received self-hypnosis training had shorter overall lengths of stay in the hospital compared with the patients in the control group.
Bone-cartilage proportion in deformed ribs of male pectus excavatum patients
Published in Journal of Plastic Surgery and Hand Surgery, 2019
Tomohisa Nagasao, Niyazi Aizezi, Masahiko Noguchi, Tadaaki Morotomi, Hiroo Kudo, Tetsukuni Kogure
In the Nuss procedure, the concave part of the thorax is forcibly elevated and metal plates are placed underneath the elevated part to maintain its position. The concave part consists of ribs, costal cartilages and the sternum. Among these anatomical structures, only costal cartilages can be bent with force; the bony part of a rib does not change its shape. Hence, the proportion of cartilage in the bone-cartilage complex can influence the outcomes of the Nuss procedure. When the deformed part of the chest consists only of cartilage, the deformity can be optimally corrected with the Nuss procedure (Figure 1(A)). On the other hand, when the deformed part includes bone, complete correction cannot be achieved, since the bone parts (asterisk in Figure 1(B)) remain uncorrected.