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Pectus Excavatum:

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Ivan Schewitz

on 22 July 2015

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Transcript of Pectus Excavatum:

Results
Pectus Excavatum:
To Nuss or not to Nuss.

Treatment
Nuss technique.
Ivan Schewitz
Cardiothoracic Surgeon
At age 8 years his pediatrician told mother not to be concerned because it would be resolved by the time he finished puberty

THE NUSS PROCEDURE
Facts
Incidence: 1 / 400 – 1 / 1000
Male / Female: 4-6 / 1

85% evident in the first year of life
Increase at puberty
40% family history
More frequent in Marfan´s syndrome

Symptoms
Exercise intolerance
Lack of endurance
Shortness of breath
Chest pain with exercise
Chest pain without exercise
Body issues. Psychological

Haller index
“A thought, even a possibility, can shatter and transform us.” ― Friedrich Nietzsche

Z.D. Aged 16


Described by Haller JPS 22:904-908, 1987


Transverse diameter divided by antero-posterior diameter (Haller )
Estimate length of Pectus
Cardiac compression/displacement
Lung compression/liver compression
Scoliosis
Sternal torsion/costal flaring
Asymmetry/abnormal ossification

Radiological Evaluation CT Scan Haller Index

In the 19th century treatment consisted of “fresh air,
breathing exercises, aerobic activities and sternal
pressure.”

We must dare to think 'unthinkable' thoughts. We must learn to explore all the options and possibilities that confront us in a complex and rapidly changing world. We must learn to welcome and not to fear the voices of dissent. We must dare to think about 'unthinkable things' because when things become unthinkable, thinking stops and action becomes mindless.
~ James William Fulbright Quotes

HISTORICAL PERSPECTIVE 1940-50

We must dare to think 'unthinkable' thoughts. We must learn to explore all the options and possibilities that confront us in a complex and rapidly changing world. We must learn to welcome and not to fear the voices of dissent. We must dare to think about 'unthinkable things' because when things become unthinkable, thinking stops and action becomes mindless.
~ James William Fulbright Quotes

Costochondral incision or resection, sternal osteotomy AND EXTERNAL TRACTION
Sauerbruch (1931);

HISTORICAL PERSPECTIVE 1920-30

Costochondral incision or resection, sternal osteotomy AND EXTERNAL TRACTION
Sauerbruch (1931);

HISTORICAL PERSPECTIVE 1920-30

To raise new questions, new possibilities, to regard old problems from a new angle, requires creative imagination and marks real advance in science.Albert Einstein
 

Donald Nuss,
M.B., Ch.B.(UCT). MD.
Orthopedic surgeons are able to correct skeletal anomalies such as club foot and scoliosis with serial casting and braces.
Orthodontic surgeons use braces and “retainers” to re-align the teeth.

The Nuss Procedure
In 1998, Nuss et al published their 10-year experience with a minimally invasive technique that required no cartilage incision, no resection, and no sternal osteotomy, but instead, relied on internal bracing made possible by the flexibility and malleability of the costal cartilages.


Chairman, Pediatric Surgery
Vice President for Surgical Affairs
Emeritus Professor of Clinical Surgery
Eastern Virginia Medical School
Background
Medical School: University of Cape Town, South Africa
Residency:
Edendale Hospital, Natal, South Africa
Mayo Clinic
Fellowship: 
Mayo Graduate School of Medicine
Red Cross War Memorial Children's Hospital
Board Certifications
American Board of Surgery
Honors & Awards Dr. Nuss has won national acclaim for his development of a new surgical technique for correction of pectus excavatum. 
Under his guidance, this "minimally invasive" procedure has been refined and modified for more than fifteen years.


Without leaps of imagination, or dreaming, we lose the excitement of possibilities.
Dreaming, after all, is a form of planning.
Gloria Steinem 



Nuss D.,  Kelly R.E., Jr,  Croitoru D.P.,  Katz M.E.,  J Pediatr (1998) 33 : pp 545-552.  

Our thoughts and imagination are the
only real limits to our possibilities.
Orison Swett Marden
M.M. Ravitch in Pediatric Surgery, Fourth Edition, 1986
Nuss technique
Nuss technique
Nuss technique
Nuss technique
Nuss technique
Nuss technique
Nuss technique
“Our thoughts and imagination are the only real limits to our possibilities.”
Orison Swett Marden
 
“Probable impossibilities are to be preferred to improbable possibilities.”
Aristotle

Nuss Technique
Indications for Pectus Repair
Documentation of progression of the deformity with associated symptoms.
A Haller CT index greater than 3.2 showing cardiac compression and or displacement.
Pulmonary function studies that indicate restrictive or obstructive airway disease.
Cardiology: documenting cardiac compression or displacement, mitral valve prolapse, arrhythmias, murmurs etc.
Previous failed Ravitch or minimally invasive procedure.
Suicidal symptoms with above criteria.

The need for repair include 2 or more of the following criteria.
Complications
Dreaded Complications
Cardiac injury
Intra-pericardial bar with adhesions.
Previous cardiac surgery.
Severe deformities.

Comparison to Ravitch
We must dare to think 'unthinkable' thoughts. We must learn to explore all the options and possibilities that confront us in a complex and rapidly changing world. We must learn to welcome and not to fear the voices of dissent. We must dare to think about 'unthinkable things' because when things become unthinkable, thinking stops and action becomes mindless.
~ James William Fulbright Quotes

Patients
To raise new questions, new possibilities, to regard old problems from a new angle requires creative imagination and marks real advance in science.
Albert Einstein

Napoleon Hill
The possibilities of creative effort connected with the subconscious mind are stupendous and imponderable. They inspire one with awe.

It always seems impossible until its done.Nelson Mandela
Rotation – reoperation
Stabilizer - pain
Stabilizer palpable
Pleural effusion
Bleeding – RIMA/LIMA
Occlusion of IMA
Deep infection
Pneumonia
Pneumothorax

“The power of imagination makes us infinite.”
~John Muir~

Haller index

Diagnosis

History
Clinical examination
Static and exercise lung functions
CT-scanning (Haller index . >3)
Echocardiography

JUST LOOK AT THE PATIENT.

Advantages of the Nuss
No anterior incision
No need to raise the pectoralis muscle
No need to resect cartilage or rib
No need to do osteotomy
Shorter operation time
Minimal blood loss
No destabilization of the chest wall

Robert H. Schuller
Let your imagination release your imprisoned possibilities.

Incision

Comparison Ravitch-Nuss

Robert Browning
Our aspirations are our possibilities.

Pectus Excavatum
Deviation of the heart into the left chest
Compression of the right ventricle with exercise.

Elevate the sternum.
Two bars.

Sternal hook
Finger elevation
Sternal crane
Disadvantage of Ravitch
In 1990, Pena drew attention to the danger of asphyxiating chondrodystropy in young children and proved his hypothesis in an experimental study on baby rabbits.
“It appears necessary to develop alternative techniques that avoid the removal of costal cartilages and to re-evaluate the optimal age for repair of these malformations.”



Martinez D, Juame J, Stein T, Pena A: The Effect of Costal Cartilage Resection on Chest Wall Development. Pediatric Surgery International 1990;5:170-173
062.02_1.mp4
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