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REPAIR OF PECTUS DEFORMITIES WITH THE NUSS AND ABRAMSON TECHNIQUES

REPAIR OF PECTUS DEFORMITIES WITH THE NUSS AND ABRAMSON TECHNIQUES. Mustafa Yüksel, Korkut Bostancı, Aslı Gül Akgül , Rıza Serdar Evman , Barkın Eldem , Mehmet Hakan Özalper Marmara University Faculty of Medicine , Department of Thoracic Surgery.

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REPAIR OF PECTUS DEFORMITIES WITH THE NUSS AND ABRAMSON TECHNIQUES

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  1. REPAIR OF PECTUS DEFORMITIES WITH THE NUSS AND ABRAMSON TECHNIQUES Mustafa Yüksel, Korkut Bostancı, Aslı Gül Akgül, Rıza Serdar Evman, Barkın Eldem, Mehmet Hakan Özalper Marmara UniversityFaculty of Medicine, Department of ThoracicSurgery

  2. Pectusexcavatum(PE) & pectuscarinatum(PC) themostcommoncongenitalchestwalldeformities • No objectivecardiovascular / respiratoryproblems in most of thepatients • Cosmetic / psycho-socialproblemsareprominent • Themostcommonindicationforsurgicalrepair is cosmeticdisfigurement

  3. SurgicalTechniques • Classicaltechniquefortherepair of PE & PC • Ravitchsternoplasty & modifications • Minimallyinvasivetechniques • Nussprocedurefor PE • Abramsonprocedurefor PC

  4. NussTechnique

  5. NussProcedure – PE Correction 1 • Thoracoscopy-assistedintervention • Bestresults in symmetricdeformities, alsosatisfying in asymmetricones • Satisfyingresultseven in adults • Earlyreturntofullactivity

  6. NussProcedure – PE Correction 2 • Remodeling of theanteriorchestwallbyemploying a retrosternal metal bar • Smallerincisions on lateralchestwall • No cartilageresections • Minimal bloodloss • Shorteroperation time

  7. NussProcedure – PeroperativeProtocol 1 • Patient in supine position • Both arms hung up – 90o • Single-lumen endotracheal tube • Modeling the template (on route) • Bilateral incisions • Modeling the bar / bars

  8. NussProcedure – PeroperativeProtocol 2 • Thoracoscopic guidence, CO2 insuflation (mediastinal shifting, cardiac rhythm / end tidal CO2follow-up) • Retrosternal tunnel using introducer (from right to left) • Implanting the bar, rotation, fixation (stabilizersecured on the muscle using 1 PDS suture) • Air evacuation (using 16Ch suction catheter)

  9. NussProcedure(MS, 16y-M, PE, 2B)

  10. NussProcedure – PostoperativeFollow-up 1 • PA / lateral chest X-rays (pneumothorax, position of bar) • Pain control (epidural / intravenous PCA) • Ventilation physiotherapy • Discharge on postoperative 5th day (oral analgesics)

  11. NussProcedure – PostoperativeFollow-up 2 • Posture correction • Early return to regular activities (active sports not before the postoperative 30th day) • Patient feels the bar up to the 6th month • Bar kept in position at least for 2 years (2 – 4 yrs) • Bar removal under general anesthesia

  12. NussProcedure – Complications 1 • Pneumothorax • Pleural effusion • Wound infection / cellulitis / seroma • Cutaneous adherence on the bar • Dislocation / rotation • Metal allergy • Insufficient correction

  13. Wound infection (AG, 19y-M, PE, 2B)

  14. Cutaneous adherence on the bar (DG, 13y-M, PC, 1B)

  15. Bar dislocation(EC, 24y-M, PE, 2B)

  16. Insufficient correction (HA, 16y-M, PE, 1B)

  17. NussProcedure – Complications 2 Other reported complications • Haematoma • Pericarditis • Cardiac perforations • Horner syndrome • Plexus brachialis injury

  18. Plexus brachialis injury(DG, 13y-M, PC, 1B)

  19. AbramsonProcedure

  20. AbramsonProcedure – PC Correction • Minimallyinvazivetechnique A modifiedNussprocedureforthecorrection of PC • No needforthoracoscopicguidence • Implanting a metal bar in thepresternalregionforremodeling of thechest • Cosmeticresultsaresatisfying

  21. AbramsonProcedure – PeroperativeProtocol Positioning, entubation – like Nuss procedure Modeling the template and the bar Bilateral incisions Presternal tunnel (using a chest tube with a trocar) Fixation of the stabilizers around the ribs (using steel wire) Implanting the bar, rotation, fixation

  22. AbramsonProcedure(BY, 15y-M, PC, 1B)

  23. AbramsonProcedure • Postoperative follow up – like Nuss procedure • Complications - like Nuss procedure Rate of skin problems is higher (seroma, adherence, hyperpigmentation) Massaging the skin covering the implanted bar

  24. OurNuss & AbramsonExperience • August 2005 – April 2008 (33 months) • 40 patientswithpectusdeformity: • 37 PE Nussprocedure • 3 PC Abramsonprocedure • 35 male • 5 female • 7 – 27 years of age (mean 16.1)

  25. OurNuss & AbramsonExperience • 26 cases had symmetric deformity • 14 cases had asymmetric deformity • Concomitant pathologies • Scoliosis in 12 cases • Cardiac pathologies in 5 cases (PDA, MVR, AVR, TVR) • Polydactyly in 2 cases (on feet) (rachitism, mental retardation, bilateral inguinal hernia, recurrent pneumothorax, thalassemia minor)

  26. OurNuss & AbramsonExperience • Familyhistory in 3 cases (siblings PE 1, cousins PE 1, uncle PE + cousin PC 1) • Number of barsimplanted • 23 cases – 1 bar • 15 cases – 2 bars • 2 cases – 3 bars • Duration 20 – 180 mins (mean 80)

  27. OurNuss & AbramsonExperience • Other interventions • Nuss after Ravitch sternoplasty in 2 cases • Nuss + apical wedge resection in 1 case • Nuss + osteotomy in 1 case • Pain control • 10 cases – epidural PCA • 30 cases – intravenous PCA

  28. OurNuss & AbramsonExperience • Complications (perioperative) • Pneumothorax in 4 cases(2 unilateral, 2 bilateral) • Pleural effusion in 3 cases • Intercostal artery bleeding in 1 case • Sinusaltachycardiain1 case • Paralytic ileus in 1 case • Respiratory arrest in 2 cases (due to high dose epidural analgesia)

  29. OurNuss & AbramsonExperience • Complications (late) • Wound infections in 4 cases • Displacement in 2 cases (1 stabilizers, 1 bars) • Adherence of the skin on the bar in 2 cases • Plexus brachialis injury in 1 case • Duration of hospital stay 3 – 15 days (mean 5.4)

  30. OurNuss & AbramsonExperience • Early bar removal • 1 PE – intractable pain – 15th day • 1 PC – intractable pain – 5th month (None of the other bars have been removed yet) • Mortality – 0 • Quality of Life Surveys - % 92 satisfied

  31. OurNuss & AbramsonExperience (preoperative) (postoperative) (GM, 14y-M, PE, 2B)

  32. OurNuss & AbramsonExperience (preoperative) (postoperative ) (OÖ, 19y-M, PE, 3B)

  33. OurNuss & AbramsonExperience (preoperative) (postoperative) (BY, 15y-M, PC, 1B) (thorax CT)

  34. OurNuss & AbramsonExperience (preoperative) (postoperative) (İKŞ, 20y-M, PE, 1B)

  35. Both the Nuss and the Abramson procedures can be implemented with satisfactory results and few complications. These two minimally invasive procedures should be the preferred techniques for the repair of pectus deformities for the short operating time, low morbidity and high levels of patient satisfaction.

  36. Thanks…

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