Publications by authors named "Yvonne L J Vissers"

54 Publications

Translation, cultural adaptation and linguistic validation of the pectus excavatum evaluation questionnaire.

J Thorac Dis 2022 Jul;14(7):2556-2564

Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands.

Background: Pectus excavatum often imposes significant burden on the patients' quality of life. However, despite the known biopsychosocial effects, the deformity remains underappreciated. Patient reported outcome measures can be used to measure and appreciate results from a patient's perspective. The pectus excavatum evaluation questionnaire (PEEQ) is the most employed disease specific instrument to measure patient-reported outcome measures (PROMs). A translation and linguistic validation of this questionnaire is presented for its use in the Dutch pediatric pectus excavatum population. By providing an insight in our translation process, we want to encourage other researchers to perform translations to other languages to make the questionnaire available to clinicians and researchers worldwide.

Methods: The 22-item PEEQ was translated and adapted according to the leading guidelines for the translation of patient reported outcome measures. Conceptual equivalence and cultural adaptation were emphasized.

Results: One forward translation was produced through reconciliation of two forward translations. Back translation resulted in 15 identical items, as well as 6 literal, and 1 conceptual discrepancy. The latter was expected as during the forward translation a more culturally appropriate translation was chosen. Ten patients were involved during the cognitive debriefing process, following which one item was revised and the final Dutch version was established.

Conclusions: We provide a culturally appropriate and linguistically validated Dutch version of the PEEQ.
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http://dx.doi.org/10.21037/jtd-22-252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9344429PMC
July 2022

Predicting Aesthetic Outcome of the Nuss Procedure in Patients with Pectus Excavatum.

Semin Thorac Cardiovasc Surg 2022 Jun 17. Epub 2022 Jun 17.

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands. Electronic address:

Patients suffering from pectus excavatum often experience psychosocial distress due to perceived anomalies in their physical appearance. The ability to visually inform patients about their expected aesthetic outcome after surgical correction is still lacking. This study aims to develop an automatic, patient-specific model to predict aesthetic outcome after the Nuss procedure. Patients prospectively received preoperative and postoperative 3-dimensional optical surface scanning of their chest during the Nuss procedure. A prediction model was composed based on nonlinear least squares data-fitting, regression methods and a 2-dimensional Gaussian function with adjustable amplitude, variance, rotation, skewness, and kurtosis components. Morphological features of pectus excavatum were extracted from preoperative images using a previously developed surface analysis tool to generate a patient-specific model. Prediction accuracy was evaluated through cross-validation, utilizing the mean root squared deviation and maximum positive and negative deviations as performance measures. The prediction model was evaluated on 30 (90% male) prospectively imaged patients. The model achieved an average root mean squared deviation of 6.3 ± 2.0 mm, with average maximum positive and negative deviations of 12.7 ± 6.1 and -10.2 ± 5.7 mm, respectively, between the predicted and actual postoperative aesthetic result. Our developed 2-dimensional Gaussian model based on 3-dimensional optical surface images is a clinically promising tool to predict postsurgical aesthetic outcome in patients with pectus excavatum. Prediction of the aesthetic outcome after the Nuss procedure potentially improves information provision and expectation management among patients. Further research should assess whether increasing the sample size may reduce deviations and improve performance.
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http://dx.doi.org/10.1053/j.semtcvs.2022.06.007DOI Listing
June 2022

VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases.

Gen Thorac Cardiovasc Surg 2022 Jun 3. Epub 2022 Jun 3.

Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands.

Objectives: Early surgical stabilization of flail chest has been shown to improve chest wall stability and diminish respiratory complications. The addition of video‑assisted thoracoscopic surgery (VATS) can diagnose and manage intrathoracic injuries and evacuate hemothorax. This study analyzed the outcome of our 7-year experience with VATS-assisted surgical stabilization of rib fractures (SSRF) for flail chest.

Methods: From January 2013 to December 2019, all trauma patients undergoing VATS-assisted SSRF for flail chest were included. Patient characteristics and complications during 1-year follow-up were reported.

Results: VATS‑assisted SSRF for flail chest was performed in 105 patients. Median age was 65 years (range 21-92). Median injury severity score was 16 (range 9-49). Hemothorax was evacuated with VATS in 80 patients (median volume 200 ml, range 25-2500). In 3 patients entrapped lung was freed from the fracture site and in 2 patients a diaphragm rupture was repaired. Median postoperative ICU admission was 2 days (range 1-41). Thirty-two patients (30%) had a post‑operative complication during admission and six patients (6%) a complication within 1 year. In-hospital mortality rate was 1%. Six patients (6%) died after discharge, due to causes unrelated to the original injury.

Conclusions: Addition of VATS to SSRF for flail chest seems helpful to diagnose and manage intrathoracic injuries and adequately evacuate hemothorax. The majority of complications are low grade and occur during admission. Further prospective research needs to be conducted to identify potential risk factors for complications and better selection for addition of VATS to improve care in the future.
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http://dx.doi.org/10.1007/s11748-022-01830-6DOI Listing
June 2022

Influence of the sentinel node outcome analysed by one-step nucleic acid amplification on the risk for postmastectomy radiation therapy and the scheduling of immediate breast reconstruction.

J Surg Oncol 2022 Sep 9;126(3):443-449. Epub 2022 May 9.

Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands.

Background: In patients with cT1-T3N0 breast cancer, postmastectomy radiation therapy (PMRT) is considered a contraindication for immediate breast reconstruction (IBR) due to a high risk of complications. The sentinel node biopsy (SNB) is an important determinant for PMRT. In this study, we evaluated the impact of SNB outcome on the planning of IBR after mastectomy.

Methods: Data of patients undergoing mastectomy and SNB in Zuyderland Medical Centre between 2016 and 2019 were retrospectively analysed. Perioperative factors influencing the planning of IBR and SNB results assessed by the intraoperative one-step nucleic acid amplification (OSNA) were registered.

Results: Of 397 patients, 169 opted for IBR. One hundred and seven IBRs were performed: 101 tissue expanders, 5 deep inferior epigastric perforator flaps and 1 latissimus dorsi flap.  Eighteen patients (18/107) had macrometastases in the SNB, in six of them IBR was cancelled due to the indication for PMRT (33%). In the other 12 patients IBR was executed as planned.  A delayed reconstruction was performed in 59 patients.

Conclusion: In breast cancer patients undergoing mastectomy with macrometastases in the SNB, IBR was postponed in 33% due to risk on PMRT. To predict this risk, we advise to acknowledge the SNB outcome by using OSNA before proceeding to IBR.
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http://dx.doi.org/10.1002/jso.26916DOI Listing
September 2022

A No-Chest-Drain Policy After Video-assisted Thoracoscopic Surgery Wedge Resection in Selected Patients: Our 12-Year Experience.

Ann Thorac Surg 2022 Apr 30. Epub 2022 Apr 30.

Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, Netherlands. Electronic address:

Background: Postoperative pleural drainage omission after video-assisted thoracoscopic surgery (VATS) for wedge resections may facilitate faster recovery. This retrospective cohort study presents our 12-year experience with omitting thoracic drainage in patients who underwent a VATS wedge resection, aiming to assess its safety and efficacy.

Methods: Records from consecutive patients who underwent a VATS wedge resection at our hospital between February 2008 and October 2020 were retrospectively reviewed and assessed for eligibility. Patient and surgical characteristics as well as postoperative data were collected and compared between patients who received a chest drain (CD) or received no chest drain (NCD) after surgery. Univariable and multivariable analyses were performed to determine whether drain placement was associated with complications (primary outcome), and major complications requiring pleural drainage or length of hospital stay (secondary outcomes).

Results: Data of 348 patients were analyzed. The drainless group (n = 98) and drain group (n = 237) were significantly different in the following baseline and surgical characteristics: sex, pulmonary function, interstitial lung disease, final pathology, number of wedges, and surgical approach. No significant differences were detected in postoperative complications (NCD 8.2%, CD 14.8%; P = .10), major complications (NCD 5.1%, CD 5.1%; P > .99), or complications requiring pleural drainage (NCD 5.1%, CD 3.8%; P = .56). The drainless group did show a significantly shorter hospitalization (NCD 2 ± 2, CD 3 ± 2 days; P < .001). Multivariable analyses revealed that drain placement was not significantly correlated with postoperative complications. In contrast, prolonged hospitalization was significantly influenced by drain placement.

Conclusions: Our findings suggest that a no-chest-drain policy after VATS wedge resections can safely fast-track rehabilitation for selected patients.
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http://dx.doi.org/10.1016/j.athoracsur.2022.04.030DOI Listing
April 2022

Delayed presentation of manubriosternal dislocation after thoracolumbar spondylodesis in a polytrauma patient - a case report.

Acta Chir Belg 2022 Apr 8:1-4. Epub 2022 Apr 8.

Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

Background: Manubriosternal dislocations are a rare entity and frequently associated with thoracic spine fractures and, in minority of cases, with cervical or thoracolumbar fractures.

Methods: Our case represents a 38-year-old male who fell from a height resulting in multiple fractures, amongst others of the first lumbar vertebra. At primary survey and computed tomography scan no manubriosternal injury was apparent. After posterior stabilization of the thoracolumbar vertebrae a manubriosternal dislocation was identified and stabilized using plate-and-screw fixation.

Results: Clinical findings of a manubriosternal dislocation are not always obvious, allowing them to be missed at initial assessment.

Conclusions: Manubriosternal dislocations can be missed at the initial investigation, even on cross-sectional imaging, and only become visible after spine stabilization because of the tight relationship between sternum and vertebrae in the thoracic cage. There is no unanimity in literature for surgical treatment of manubriosternal dislocations, although plate fixation is generally considered a safe and effective treatment option.
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http://dx.doi.org/10.1080/00015458.2022.2061120DOI Listing
April 2022

Negative pressure wound therapy for massive subcutaneous emphysema: a systematic review and case series.

J Thorac Dis 2022 Jan;14(1):43-53

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands.

Background: Massive subcutaneous emphysema can cause considerable morbidity with respiratory distress. To resolve this emphysema in short-term, negative pressure wound therapy could be applied as added treatment modality. However, its use is sparsely reported, and a variety of techniques are being described. This study provides a systematic review of the available literature on the effectiveness of negative pressure wound therapy as treatment for massive subcutaneous emphysema. In addition, our institutional experience is reported through a case-series.

Methods: The PubMed, Embase and Cochrane Library were systematically searched for publications on the use of negative pressure wound therapy for subcutaneous emphysema following thoracic surgery, trauma or spontaneous pneumothorax. Moreover, patients treated at our institution between 2019 and 2021 were retrospectively identified and analyzed.

Results: The systematic review provided 10 articles presenting 23 cases. Studies demonstrated considerable heterogeneity regarding the location of incision, creation of prepectoral pocket, and surgical safety margin. Also closed incision negative pressure wound therapy and PICO device were discussed. Despite the apparent heterogeneity, all techniques provided favorable outcomes. No complications, reinterventions or recurrences were documented. Furthermore, retrospective data of 11 patients treated at our clinic demonstrated an immediate response to negative pressure wound therapy and a full remission of the subcutaneous emphysema at the end of negative pressure wound therapy. No recurrence requiring intervention or complications were observed.

Conclusions: The findings of this study suggest that negative pressure wound therapy, despite the varying techniques employed, is associated with an immediate regression of subcutaneous emphysema and full remission at the end of therapy. Given the relatively low sample size, no technique of choice could be identified. However, in general, negative pressure wound therapy appears to provide fast regression of subcutaneous emphysema and release of symptoms in all cases.
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http://dx.doi.org/10.21037/jtd-21-1483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8828515PMC
January 2022

Risk of Pneumothorax Requiring Pleural Drainage after Drainless VATS Pulmonary Wedge Resection: A Systematic Review and Meta-Analysis.

Innovations (Phila) 2022 Jan-Feb;17(1):14-24

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

Objective: Omitting pleural drainage after video-assisted thoracic surgery (VATS) for pulmonary wedge resections has been shown to be a safe approach to enhance recovery. However, major concerns remain regarding the risk of postoperative pneumothoraces requiring surgical interventions. Therefore, our objective was to provide conclusive evidence whether chest tube omission after VATS wedge resection is safe and does not increase the risk of pneumothoraces requiring pleural drainage.

Methods: Five scientific databases were searched. Studies comparing patients with (CT group) and without chest tube drainage (NCT group) after VATS wedge resection were evaluated. Outcomes included radiographically diagnosed pneumothoraces and pneumothoraces requiring pleural drainage, postoperative complications, hospitalization, and pain scores.

Results: Overall, 9 studies (3 randomized controlled trials) were included ( = 928). Meta-analysis showed significantly more radiographically diagnosed pneumothoraces in the NCT group (risk ratio [RR] = 2.58, 95% confidence interval [CI]: 1.56 to 4.29,  < 0.001;  = 0%). However, no significant differences were found in postoperative pneumothoraces requiring pleural drainage (RR = 1.72, 95% CI: 0.63 to 4.74,  = 0.29; = 0%) or complications (RR = 0.77, 95% CI: 0.39 to 1.52,  = 0.46;  = 0%). Furthermore, the NCT group showed significantly shorter hospitalization (mean difference = -1.26, 95% CI: -1.56 to -0.95,  < 0.001) with high heterogeneity ( = 58%,  = 0.02), and lower pain scores on postoperative day 1 (standard mean difference [SMD] = -0.98, 95% CI: -1.71 to -0.25,  = 0.009;  = 92%) and postoperative day 2 (SMD = -1.28, 95% CI: -2.55 to -0.01,  = 0.05;  = 96%) compared with the CT group.

Conclusions: VATS wedge resection without routine chest tube placement is suggested as a safe and less invasive approach in selected patients that does not increase the risk of a pneumothorax requiring pleural drainage.
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http://dx.doi.org/10.1177/15569845221074431DOI Listing
March 2022

Outcomes after hybrid minimally invasive treatment of Boerhaave syndrome: a single-institution experience.

Acta Chir Belg 2022 Jan 19:1-6. Epub 2022 Jan 19.

Department of Surgery, Zuyderland Medical Center, Heerlen, Sittard, The Netherlands.

Background: Spontaneous esophageal perforation or Boerhaave syndrome is a life-threatening emergency, associated with significant morbidity and mortality. In this retrospective series we describe our single-center experience with a hybrid minimally invasive treatment approach for the treatment of Boerhaave syndrome.

Methods: Clinical data of all patients who presented with spontaneous esophageal rupture between January 2009 and December 2019 were analyzed. All patients underwent esophageal endoscopic stenting to seal the perforation and debridement of the contaminated mediastinal and pleural cavity through video-assisted thoracoscopic surgery (VATS). Primary outcome measure was defined as in-hospital death and 30-day mortality.

Results: Twelve patients were included with a median age of 63 years (interquartile range [IQR] 51-74 years) of whom 58% ( = 7) were male. The median Pittsburg perforation severity score was 6.5 (IQR 6-9). Endoscopic reintervention was required in 8 patients (67%), primarily due to stent dislocation. In addition, 5 patients (42%) required re-VATS due to empyema formation. Thirty-day mortality and in-hospital mortality were respectively 17% ( = 2) and 25% ( = 3).

Conclusion: Endoscopic stenting in combination with thoracoscopic debridement is an effective and safe minimally invasive hybrid approach for the treatment of Boerhaave syndrome. This is depicted by the relatively low mortality rates, even among patients with high perforation severity scores. The relatively low mortality rates may be attributed to the combined approach of rapidly sealing the defect and decontamination of the thorax. Future studies should aim to corroborate this evidence which is limited by its sample size and retrospective nature.
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http://dx.doi.org/10.1080/00015458.2022.2029035DOI Listing
January 2022

Expert consensus on resection of chest wall tumors and chest wall reconstruction.

Transl Lung Cancer Res 2021 Nov;10(11):4057-4083

Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China.

Chest wall tumors are a relatively uncommon disease in clinical practice. Most of the published studies about chest wall tumors are usually single-center retrospective studies, involving few patients. Therefore, evidences regarding clinical conclusions about chest wall tumors are lacking, and some controversial issues have still to be agreed upon. In January 2019, 73 experts in thoracic surgery, plastic surgery, science, and engineering jointly released the Chinese Expert Consensus on Chest Wall Tumor Resection and Chest Wall Reconstruction (2018 edition). After that, numerous experts put forward new perspectives on some academic issues in this version of the consensus, pointing out the necessity to further discuss the points of contention. Thus, we conducted a survey through the administration of a questionnaire among 85 experts in the world. Consensus has been reached on some major points as follows. (I) Wide excision should be performed for desmoid tumor (DT) of chest wall. After excluding the distant metastasis by multi-disciplinary team, solitary sternal plasmacytoma can be treated with extensive resection and adjuvant radiotherapy. (II) Wide excision with above 2 cm margin distance should be attempted to obtain R0 resection margin for chest wall tumor unless the tumor involves vital organs or structures, including the great vessels, heart, trachea, joints, and spine. (III) For patients with chest wall tumors undergoing unplanned excision (UE) for the first time, it is necessary to carry out wide excision as soon as possible within 1-3 months following the previous surgery. (IV) Current Tumor Node Metastasis staging criteria (American Joint Committee on Cancer) of bone tumor and soft tissue sarcoma are not suitable for chest wall sarcomas. (V) It is necessary to use rigid implants for chest wall reconstruction once the maximum diameter of the chest wall defect exceeds 5 cm in adults and adolescents. (VI) For non-small cell lung cancer (NSCLC) invading the chest wall, wide excision with neoadjuvant and/or adjuvant therapy are recommended for patients with stage TNM. As clear guidelines are lacking, these consensus statements on controversial issues on chest wall tumors and resection could possibly serve as further guidance in clinical practice during the upcoming years.
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http://dx.doi.org/10.21037/tlcr-21-935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8674598PMC
November 2021

Minimally invasive repair of pectus carinatum by the Abramson method: A systematic review.

J Pediatr Surg 2021 Dec 5. Epub 2021 Dec 5.

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands. Electronic address:

Background: The aim of this review is to provide an overview of the outcomes after minimally invasive pectus cartinatum repair (MIRPC) by the Abramson method to determine its effectiveness.

Methods: The PubMed and Embase databases were systematically searched. Data concerning subjective postoperative esthetic outcomes after initial surgery and bar removal were extracted. In addition, data on recurrence, complications, operative times, blood loss, post-operative pain, length of hospital stay, planned time to bar removal and reasons for early bar removal were extracted. The postoperative esthetic result, was selected as primary outcome since the primary indication for repair in pectus carinatum is of cosmetic nature.

Results: Six cohort studies were included based on eligibility criteria, enrolling a total of 396 patients. Qualitative synthesis showed excellent to satisfactory esthetic results in nearly all patients after correctional bar placement (99.5%, n = 183/184). A high satisfaction rate of 91.0% (n = 190/209) was found in patients after bar removal. Recurrence rates were low with an incidence of 3.0% (n = 5/168). The cumulative postoperative complication rate was 26.5% (n = 105/396), of whom 25% required surgical re-intervention. There were no cases of mortality.

Conclusions: Minimally invasive repair of pectus carinatum through the Abramson method is effective and safe. Its efficacy is demonstrated by the excellent to satisfactory esthetic results in 99.5% and 91.0% of patients after respectively correctional bar placement and implant removal. Future studies should aim to compare different treatment options for pectus carinatum in order to elucidate the approach of choice for different patient groups.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.11.028DOI Listing
December 2021

Editorial commentary: a journey towards least invasive thoracic surgery?

Transl Lung Cancer Res 2021 Oct;10(10):4027-4028

Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

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http://dx.doi.org/10.21037/tlcr-21-766DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8577972PMC
October 2021

Video-Assisted Thoracoscopic Surgical Rib Fixation for Costochondral Separation Injury.

Innovations (Phila) 2021 Nov-Dec;16(6):568-570. Epub 2021 Nov 20.

Department of Surgery, Division of General Thoracic Surgery, 3802Zuyderland Medical Center, Heerlen, The Netherlands.

Costochondral separation is a rare phenomenon following blunt thoracic trauma that can also be associated with secondary injuries. We present a case with complete costochondral separation of the right second rib with concomitant mediastinal compression. Definitive treatment was provided through video-assisted thoracoscopic surgical plate osteosynthesis.
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http://dx.doi.org/10.1177/15569845211049245DOI Listing
December 2021

Development of Prediction Models for Cardiac Compression in Pectus Excavatum Based on Three-Dimensional Surface Images.

Semin Thorac Cardiovasc Surg 2021 Nov 13. Epub 2021 Nov 13.

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands. Electronic address:

In pectus excavatum, three-dimensional (3D) surface imaging provides an accurate and radiation-free alternative to computed tomography (CT) to determine severity. Yet, it does not allow for cardiac evaluation since 3D imaging solely captures the chest wall surface. The objective was to develop a 3D image-based prediction model for cardiac compression in patients evaluated for pectus excavatum. A prospective cohort study was conducted including consecutive patients referred for pectus excavatum who received a thoracic CT. Additionally, 3D images were acquired. The external pectus depth, its length, craniocaudal position, cranial slope, asymmetry, anteroposterior distance and chest width were calculated from 3D images. Together with baseline patient characteristics they were submitted to forward multivariable logistic regression to identify predictors for cardiac compression. Cardiac compression on CT was used as reference. The model's performance was depicted by the area under the receiver operating characteristic (AUROC) curve. Internal validation was performed using bootstrapping. Sixty-one patients were included of whom 41 had cardiac compression on CT. A combination of the 3D image derived external pectus depth and external anteroposterior distance was identified as predictive for cardiac compression, yielding an AUROC of 0.935 (95% confidence interval [CI]: 0.878-0.992) with an optimism of 0.006. In a second model for males alone, solely the external pectus depth was identified as predictor, yielding an AUROC of 0.947 (95% CI: 0.892-1.000) with an optimism of 0.0002. We have developed two 3D image-based prediction models for cardiac compression in patients evaluated for pectus excavatum which provide an outstanding discriminatory performance between the presence and absence of cardiac compression with negligible optimism.
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http://dx.doi.org/10.1053/j.semtcvs.2021.11.006DOI Listing
November 2021

Case report: ventricular fibrillation and cardiac arrest provoked by forward bending in adolescent with severe pectus excavatum.

Eur Heart J Case Rep 2021 Oct 25;5(10):ytab373. Epub 2021 Oct 25.

Department of Surgery, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands.

Background: Life-threatening arrhythmias have been reported in patients with severe pectus excavatum in absence of other cardiac abnormalities. Literature is scarce regarding diagnosis, cause and management of this problem, particularly regarding the question as to whether the placement of an implantable cardioverter-defibrillator (ICD) is necessary.

Case Summary: A 19-year-old male patient with severe pectus excavatum was scheduled for elective surgical correction. During forward bending for epidural catheter placement, syncope and ventricular fibrillation (VF) occurred resulting in cardiac arrest. After successful cardiopulmonary resuscitation, extensive analysis was performed and showed no cause for VF other than cardiac compression (particularly of the left atrium, right atrium, and ventricle to a lesser degree) due to severe pectus excavatum. Postponed correction by modified Ravitch was performed without ICD placement, with an uneventful post-operative recovery. Eighteen months after surgery, the patient remains well. Upon specific request, he did remember dizzy spells when tying shoelaces. He always considered this unremarkable.

Discussion: In severe pectus excavatum with cardiac compression, forward bending can decrease central venous return and cardiac output, causing hypotension, arrhythmia, and cardiac arrest. In absence of structural or electric abnormalities, cardiac compression by severe pectus excavatum was considered a reversible cause of VF and ICD placement unnecessary. Patients with cardiac compression due to severe pectus excavatum may report pre-existing postural symptoms upon specific request. When these postural symptoms are present, extreme and prolonged forward bending postures should be avoided.
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http://dx.doi.org/10.1093/ehjcr/ytab373DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8564689PMC
October 2021

Sternal elevation by the crane technique during pectus excavatum repair: A quantitative analysis.

JTCVS Tech 2021 Oct 17;9:167-175. Epub 2021 Jul 17.

Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

Introduction: The crane technique is used to facilitate sternal elevation to provide safe mediastinal passage during the Nuss procedure. The aim was to objectively quantitate the elevation of the crane by 3-dimensional chest images acquired during the Nuss procedure.

Methods: A prospective cohort study was conducted. Patients undergoing the Nuss procedure were eligible. Sternal elevation was achieved by the crane technique providing a simultaneous lift of the anterior chest wall and reduction of the pectus excavatum depth. Both effects were evaluated. Three-dimensional surface images were acquired before incision, following sternal lift, and after bar implantation and quantitatively compared. Reduction of the external pectus excavatum depth was expressed as a percentage.

Results: Thirty patients were included. Ninety percent were male, with a median age of 15.5 years (interquartile range [IQR], 14.5-17.4), Haller index of 3.56 (IQR, 3.09-4.65), and external pectus depth of 18 mm (IQR, 11-23). Sternal elevation by the crane provided a median 78% (IQR, 63-100) reduction of the deformity, corresponding with a residual depth of 3 mm (IQR, 0-7). The percentual reduction diminished with increasing depth of the sternal depression (correlation, -0.86). Besides reducing the deformity, the crane caused an elevation of the anterior chest over a large surface area with a maximum lift of 26 mm (IQR, 19-32).

Conclusions: The crane is an effective sternal elevation technique, providing 78% reduction of the sternal depression, although its effect lessens with increasing depth. In addition, it produces an elevation of the anterior chest over a large surface area.
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http://dx.doi.org/10.1016/j.xjtc.2021.05.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8501226PMC
October 2021

Surgical mediastinal lymph node staging for non-small-cell lung carcinoma.

Transl Lung Cancer Res 2021 Aug;10(8):3645-3658

Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

Background: The current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which lymph nodes are resected instead of biopsied is video-assisted mediastinoscopic lymphadenectomy (VAMLA) that is suggested to be superior in detecting N2 disease. Yet, evidence is conflicting and furthermore limited by sample size. The objective was to compare mediastinal staging through VAMLA and video-assisted mediastinoscopy.

Methods: A single-center cohort study was conducted. All consecutive patients that underwent surgical mediastinal staging of non-small-cell lung carcinoma by VAMLA (2011 to 2018) were compared to historic video-assisted mediastinoscopy controls (2007 to 2011). Patients with negative surgical mediastinal staging underwent subsequent anatomical resection with systematic regional lymphadenectomy. Primary outcome was the sensitivity and negative predictive value for detecting N2 disease.

Results: Two-hundred-sixty-nine video-assisted mediastinoscopic lymphadenectomies and 118 video-assisted mediastinoscopies were performed. The prevalence of N2 disease was 20% and 26% respectively in the VAMLA and video-assisted mediastinoscopy group, while the rate of unforeseen pN2 resulting from lymph node dissection during anatomical resection was 4% and 11%, respectively. Invasive staging using VAMLA demonstrated superior sensitivity of 0.82 and a negative predictive value of 0.96 when compared to video-assisted mediastinoscopy (0.62 and 0.89, respectively), offering a 64% decrease in risk of unforeseen pN2 following anatomical resection. However, VAMLA is also associated with a 75% risk increase on complications (P=0.36).

Conclusions: We conclude that performing invasive mediastinal lymph node assessment for staging of non-small-cell lung carcinoma, VAMLA should be the preferred technique with superior sensitivity and negative predictive value in detecting N2 disease. Though, VAMLA is also associated with an increased risk of complications.
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http://dx.doi.org/10.21037/tlcr-21-364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8435384PMC
August 2021

Suture Anchor Repair of Pectoralis Major Muscle Dehiscence After Modified Ravitch.

Innovations (Phila) 2021 Sep-Oct;16(5):485-487. Epub 2021 Aug 23.

3802 Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

During repair of pectus excavatum by the modified Ravitch procedure, the major pectoral muscles are detached from their sternal insertion to obtain adequate surgical exposure. Following repair, the muscles are approximated in midline and reinserted through scarring. Dehiscence of the major pectoral muscles after the modified Ravitch procedure is a rare phenomenon, not previously reported in literature. We report on 2 cases and describe an effective treatment method using sternal suture anchors with good long-term results.
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http://dx.doi.org/10.1177/15569845211034523DOI Listing
November 2021

Three-dimensional Surface Imaging for Clinical Decision Making in Pectus Excavatum.

Semin Thorac Cardiovasc Surg 2021 Aug 8. Epub 2021 Aug 8.

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands. Electronic address:

To evaluate pectus excavatum, 3-dimensional surface imaging is a promising radiation-free alternative to computed tomography and plain radiographs. Given that 3-dimensional images concern the external surface, the conventional Haller index, and correction index are not applicable as these are based on internal diameters. Therefore, external equivalents have been introduced for 3-dimensional images. However, cut-off values to help determine surgical candidacy using external indices are lacking. A prospective cohort study was conducted. Consecutive patients referred for suspected pectus excavatum received a computed tomography (≥18 years) or plain radiographs (<18 years). The external Haller index and external correction index were calculated from additionally acquired 3-dimensional images. Cut-off values for the 3-dimensional image derived indices were obtained by receiver-operating characteristic curve analyses, using a conventional Haller index ≥3.25, and computed tomography derived correction index ≥28.0% as indicative for surgery. Sixty-one and 63 patients were included in the computed tomography and radiograph group, respectively. To determine potential surgical candidacy, receiver-operating characteristic analyses found an optimum cut-off of ≥1.83 for the external Haller index in both the computed tomography and radiograph group with a positive predictive value between 0.90 and 0.97 and a negative predictive value between 0.72 and 0.81. The optimal cut-off for the external correction index was ≥15.2% with a positive predictive value of 0.86 and negative predictive value of 0.93. The 3-dimensional image derived external Haller index and external correction index are accurate radiation-free alternatives to facilitate surgical decision-making among patients suspected of pectus excavatum with values of ≥1.83 and ≥15.2% indicative for surgery.
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http://dx.doi.org/10.1053/j.semtcvs.2021.08.002DOI Listing
August 2021

Visual diagnosis of pectus excavatum: An inter-observer and intra-observer agreement analysis.

J Pediatr Surg 2022 Mar 11;57(3):526-531. Epub 2021 Jun 11.

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, the Netherlands.

Background/purpose: Among patients suspected of pectus excavatum, visual examination is a key aspect of diagnosis and, moreover, guides work-up and treatment strategy. This study evaluated the inter-observer and intra-observer agreement of visual examination and diagnosis of pectus excavatum among experts.

Methods: Three-dimensional surface images of consecutive patients suspected of pectus excavatum were reviewed in a multi-center setting. Interactive three-dimensional images were evaluated for the presence of pectus excavatum, asymmetry, flaring, depth of deformity, cranial onset, overall severity and morphological subtype through a questionnaire. Observers were blinded to all clinical patient information, completing the questionnaire twice per subject. Agreement was analyzed by kappa statistics.

Results: Fifty-eight subjects with a median age of 15.5 years (interquartile range: 14.1-18.2) were evaluated by 5 (cardio)thoracic surgeons. Pectus excavatum was visually diagnosed in 55% to 95% of cases by different surgeons, revealing considerable inter-observer differences (kappa: 0.50; 95%-confidence interval [CI]: 0.41-0.58). All other items demonstrated inter-observer kappa's of 0.25-0.37. Intra-observer analyses evaluating the presence of pectus excavatum demonstrated a kappa of 0.81 (95%-CI: 0.72-0.91), while all other items showed intra-observer kappa's of 0.36-0.68.

Conclusions: Visual examination and diagnosis of pectus excavatum yields considerable inter-observer and intra-observer disagreements. As this variation in judgement could impact work-up and treatment strategy, objective standardization is urged.

Levels Of Evidence: III.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.06.003DOI Listing
March 2022

Safety and feasibility of rigid fixation by SternaLock Blu plates during the modified Ravitch procedure: a pilot study.

J Thorac Dis 2021 May;13(5):2952-2958

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

Background: Patients with anterior chest wall deformities unsuitable for minimally invasive repair are commonly treated by the modified Ravitch procedure. Although rigid plate fixation of the sternal osteotomy has previously shown to facilitate adequate sternal union, its use is troubled by an implant removal rate of up to 23% due to local complaints or complications associated with bulky plates. In contrast, the use of thinner and therefore biomechanically weaker plates may result in a higher incidence of non- or mal-union. In this pilot study, we evaluate the feasibility, efficacy and safety of rigid sternal fixation by thin pre-shaped anatomical locking plates during the modified Ravitch procedure.

Methods: Between June 2018 and December 2019, all consecutive patients who underwent anterior chest wall deformity repair by the modified Ravitch procedure in our tertiary referral centre were included. Data was collected retrospectively. All pectus types were included. The sternal osteotomy was fixated using thin SternaLock Blu plates. Patients were followed for at least one year.

Results: Nine patients were included. The group consisted of six male and three female patients, with a median age of 20 years [interquartile range (IQR), 16-35 years]. Median duration of follow-up was 25 months (IQR, 16-28 months). No intraoperative complications occurred. No patients presented with symptomatic non- or mal-union. Plate removal was performed in one patient for atypical pain without relief. No other postoperative complications occurred.

Conclusions: Based on these pilot results, thin SternaLock Blu plates are deemed to be safe and effective in providing adequate rigid fixation of the sternal osteotomy during the modified Ravitch procedure. Compared to literature, the need for plate removal within 25 months after surgery was reduced.
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http://dx.doi.org/10.21037/jtd-21-284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182503PMC
May 2021

The Automatic Quantification of Morphological Features of Pectus Excavatum Based on Three-Dimensional Images.

Semin Thorac Cardiovasc Surg 2022 5;34(2):772-781. Epub 2021 Jun 5.

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands. Electronic address:

Visual examination and quantification of severity are essential for clinical decision making in patients with pectus excavatum. Yet, visual assessment is prone to inter- and intra-observer variability and current quantitative methods are inadequate. This study aims to develop and evaluate a novel, automatic and non-invasive method to objectively quantify pectus excavatum morphology based on three-dimensional images. Key steps of the automatic analysis are normalization of image orientation, slicing, and computation of the morphological features encompassing pectus depth, width, length, volume, position, steepness, flaring, asymmetry and mean cross-sectional area. A digital phantom mimicking a patient with pectus excavatum was used to verify the analysis method. Prospective three-dimensional imaging and subsequent surface analysis in patients with pectus excavatum was performed to assess clinical feasibility. Verification of the developed analysis tool demonstrated 100% reproducibility of all morphological feature values. Calculated parameters compared to the predetermined phantom dimensions were accurate for all but four features. The pectus width, length, volume and steepness showed an error of 4 mm (4%), 2 mm (2%), 12 mL (5%) and 1 degree (3%), respectively. Prospective imaging of 52 patients (88% males) demonstrated the feasibility of the developed tool to quantify morphological features of pectus excavatum in the clinical setting. Mean duration to calculate all features in one patient was 7.6 seconds. We have developed and presented a non-invasive pectus excavatum surface analysis tool, that is feasible to automatically quantify morphological features based on three-dimensional images with promising accuracy and reproducibility.
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http://dx.doi.org/10.1053/j.semtcvs.2021.05.018DOI Listing
June 2022

A case series: xiphoidectomy for xiphodynia, a rare thoracic wall disorder.

J Thorac Dis 2021 Apr;13(4):2216-2223

Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands.

Background: Xiphodynia is a rare musculoskeletal disorder characterized by pain at the lower anterior chest or epigastric region. Treatment options include oral analgesics, local injection with analgesic or laser therapy. Yet, these often provide only short-term symptom relieve. A definite reduction in pain sensation might be achieved by performing a xiphoidectomy, though studies on its safety and efficacy are scarce. In the current single-centre study the outcomes of xiphoidectomy for xiphodynia are retrospectively assessed.

Methods: All patients undergoing xiphoidectomy for xiphodynia between April 2013 and February 2020 at Zuyderland Medical Centre, Heerlen, the Netherlands, were included in this case series. Pain scores using the Numeric Rating Scale were assessed preoperatively and postoperatively and submitted to the Wilcoxon signed rank test. A clinically significant improvement was defined as a 2-point decrease in Numeric Rating Scale score. In addition, surgical outcomes, including complications and duration of surgery were extracted from the patient records.

Results: A total of 19 patients underwent xiphoidectomy for xiphodynia. The follow-up ranged from 1 to 83 months. Seventeen out of 19 patients showed a clinically relevant improvement in Numeric Rating Scale pain scores where the overall pain scores also revealed a statistically significant decrease from 8 (interquartile range, 7-8) to 0 (interquartile range, 0-0; P<0.001) after surgery. Median procedure time was 29 minutes (interquartile range, 24-38 minutes) and no postoperative complications occurred.

Conclusions: Xiphoidectomy for xiphodynia is a safe and effective surgical procedure with good outcomes on pain relief. Though, future comparative studies are urged to elucidate its value among other treatment options.
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http://dx.doi.org/10.21037/jtd-20-3396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107569PMC
April 2021

Minimally invasive repair of pectus excavatum by the Nuss procedure: The learning curve.

J Thorac Cardiovasc Surg 2022 Mar 10;163(3):828-837.e4. Epub 2020 Dec 10.

Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

Objectives: To define the learning process of minimally invasive repair of pectus excavatum by the Nuss procedure through assessment of consecutive procedural metrics.

Methods: A single-center retrospective observational cohort study was conducted of all consecutive Nuss procedures performed by individual surgeons without previous experience between June 2006 and December 2018. Surgeons were proctored during their initial 10 procedures. The learning process after the proctoring period was evaluated using nonrisk-adjusted cumulative sum (ie, observed minus expected) failure charts of complications. An acceptable and unacceptable complication rate of 10% and 20% were used. Logarithmic trend lines were used to assess over-time performance regarding operation time.

Results: Two-hundred twenty-two consecutive Nuss procedures by 3 general thoracic surgeons were evaluated. Cumulative sum charts showed an average performance from the first procedure after being proctored onward for all surgeons, whereas surgeon B demonstrated a statistically significant complication rate equal to or less than 10% after 59 cases. Post-hoc sensitivity analyses using a stricter acceptable and unacceptable complication rate of 6% and 12% also showed an average performance for all surgeons. Although, the median time between consecutive procedures ranged from 7 to 35 days, no frequency-outcome relationship was observed. In addition, surgeons required the same average operation time throughout their entire experience.

Conclusions: After a 10-procedure proctoring period, repair of pectus excavatum by the Nuss procedure is a safe procedure to adopt and perform without a typical (complication based) learning curve while performing at least 1 procedure per 35 days.
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http://dx.doi.org/10.1016/j.jtcvs.2020.11.154DOI Listing
March 2022

Nuss Procedure for Pectus Excavatum: A Comparison of Complications Between Young and Adult Patients.

Ann Thorac Surg 2021 09 9;112(3):905-911. Epub 2020 Nov 9.

Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands.

Background: The Nuss procedure is the gold standard surgical treatment for pectus excavatum in young patients. Its use in adults has also been described, although it may be associated with increased postoperative morbidity resulting from higher chest wall rigidity. This study aimed to examine the risk of complications after the Nuss procedure in adult patients compared with young patients with pectus excavatum.

Methods: This single-center retrospective cohort study evaluated all patients who underwent the Nuss procedure between 2006 and 2018. Patients were stratified by age as young (≤24 years old) and adult (>24 years old). The primary end point was the occurrence of perioperative or postoperative complications, subdivided into major (Clavien-Dindo class III or higher) and minor (less severe than Clavien-Dindo class III). Between-group differences were analyzed using the Mann-Whitney U and the χ test with post hoc analysis.

Results: A total of 327 participants were included, 272 in the young group (median age, 16 years; interquartile range [IQR], 15 to 18 years; range, 11 to 24 years) and 55 in the adult group (median age, 32 years; IQR, 27 to 38 years; range, 25 to 47 years). The median Haller index was similar between groups (young, 3.7; IQR, 3.2 to 4.4 vs adult,3.6; IQR, 3.0 to 4.3; P = .44). The median follow-up was 34 and 36 months, respectively. The incidence of major complications was comparable between young and adult participants (P = .43). Minor complications occurred more often among adults (young, 4% vs adult, 11%; P = .002). Chronic postoperative pain was the only minor complication with a significant difference in incidence (young, 1% vs adult, 7%; P = .008).

Conclusions: The Nuss procedure is a safe surgical treatment for pectus excavatum in both young and adult patients. The risk of major complications is comparable. However, adults more often have chronic pain.
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http://dx.doi.org/10.1016/j.athoracsur.2020.10.017DOI Listing
September 2021

Three-Dimensional Imaging of the Chest Wall: A Comparison Between Three Different Imaging Systems.

J Surg Res 2021 03 27;259:332-341. Epub 2020 Oct 27.

Department of Thoracic Surgery, Zuyderland Medical Centre, Heerlen, the Netherlands. Electronic address:

Background: Three-dimensional (3D) imaging is being used progressively to create models of patients with anterior chest wall deformities. Resulting models are used for clinical decision-making, surgical planning, and analysis. However, given the broad range of 3D imaging systems available and the fact that planning and analysis techniques are often only validated for a single system, it is important to analyze potential intrasystem and intersystem differences. The objective of this study was to investigate the accuracy and reproducibility of three commercially available 3D imaging systems that are used to obtain images of the anterior chest wall.

Methods: Among 15 healthy volunteers, 3D images of the anterior chest wall were acquired twice per imaging device. Reproducibility was determined by comparison of consecutive images acquired per device while the true accuracy was calculated by comparison of 3D image derived and calipered anthropometric measurements. A maximum difference of 1.00 mm. was considered clinically acceptable.

Results: All devices demonstrated statistically comparable (P = 0.21) reproducibility with a mean absolute difference of 0.59 mm. (SD: 1.05), 0.54 mm. (SD: 2.08), and 0.48 mm. (SD: 0.60) for the 3dMD, EinScan Pro 2X Plus, and Artec Leo, respectively. The true accuracy was, respectively, 0.89 mm. (SD: 0.66), 1.27 mm. (SD: 0.94), and 0.81 mm. (SD: 0.71) for the 3dMD, EinScan, and Artec device and did not statistically differ (P = 0.085).

Conclusions: Three-dimensional imaging of the anterior chest wall utilizing the 3dMD and Artec Leo is feasible with comparable reproducibility and accuracy, whereas the EinScan Pro 2X Plus is reproducible but not clinically accurate.
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http://dx.doi.org/10.1016/j.jss.2020.09.027DOI Listing
March 2021

The learning curve of video-assisted mediastinoscopic lymphadenectomy for staging of non-small-cell lung carcinoma.

Interact Cardiovasc Thorac Surg 2020 10;31(4):527-535

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, Netherlands.

Objectives: The objective of this study was to define the learning process of video-assisted mediastinoscopic lymphadenectomy (VAMLA) by the assessment of consecutive procedural metrics.

Methods: We conducted a single-centre retrospective observational study of all consecutive VAMLAs performed between 2011 and 2018 for the staging of non-small-cell lung carcinoma. Learning curves were assessed using non-risk adjusted cumulative observed minus expected (CUSUM) failure charts of complications. Boundary lines were defined by the acceptable and unacceptable complication rates of 4.5% and 15.0%. The Kruskal-Wallis test with post hoc analysis was used to assess trends in operation time and blood loss.

Results: Two-hundred-thirty-six unique VAMLAs by 4 surgeons performing their first procedures were evaluated. CUSUM charts of surgeons A and B showed a typical learning curve with an initial incline, followed by a turning point towards lower complications rates after 16-17 cases, whereas surgeons C and D showed an average performance. The median time between consecutive VAMLAs was shorter for surgeons A and B (13.0 vs 28.5-38.0 days for surgeons C and D). Overcoming the learning curve, complication rates of surgeons A and B decreased from 19% to 3% and from 18% to 5%, respectively. Operation time and blood loss showed a significant improvement after, respectively, 81-100 and 61-80 procedures compared to the first 20 procedures.

Conclusions: VAMLA is a safe procedure to adopt and perform with acceptable complication rates from the first operation onward, regardless of the caseload. To overcome its learning curve, 16-17 cases are required, preferably at least 1 per 2 weeks.
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http://dx.doi.org/10.1093/icvts/ivaa146DOI Listing
October 2020

Intercostal nerve cryoablation versus thoracic epidural for postoperative analgesia following pectus excavatum repair: a systematic review and meta-analysis.

Interact Cardiovasc Thorac Surg 2020 10;31(4):486-498

Department of Thoracic Surgery, Zuyderland Medical Centre, Heerlen, Netherlands.

Objectives: Minimally invasive pectus excavatum repair via the Nuss procedure is associated with significant postoperative pain that is considered as the dominant factor affecting the duration of hospitalization. Postoperative pain after the Nuss procedures is commonly controlled by thoracic epidural analgesia. Recently, intercostal nerve cryoablation has been proposed as an alternative method with long-acting pain control and shortened hospitalization. The subsequent objective was to systematically review the outcomes of intercostal nerve cryoablation in comparison to thoracic epidural after the Nuss procedure.

Methods: Six scientific databases were searched. Data concerning the length of hospital stay, operative time and postoperative opioid usage were extracted. If possible, data were submitted to meta-analysis using the mean of differences, random-effects model with inverse variance method and I2 test for heterogeneity.

Results: Four observational and 1 randomized study were included, enrolling a total of 196 patients. Meta-analyses demonstrated a significantly shortened length of hospital stay [mean difference -2.91 days; 95% confidence interval (CI) -3.68 to -2.15; P < 0.001] and increased operative time (mean difference 40.91 min; 95% CI 14.42-67.40; P < 0.001) for cryoablation. Both analyses demonstrated significant heterogeneity (both I2 = 91%; P < 0.001). Qualitative analysis demonstrated the amount of postoperative opioid usage to be significantly lower for cryoablation in 3 out of 4 reporting studies.

Conclusions: Intercostal nerve cryoablation during the Nuss procedure may be an attractive alternative to thoracic epidural analgesia, resulting in shortened hospitalization. However, given the low quality and heterogeneity of studies, more randomized controlled trials are needed.
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http://dx.doi.org/10.1093/icvts/ivaa151DOI Listing
October 2020

Minimally Invasive Approach to Esophageal Perforation after Endoscopic Ultrasound-Guided Fine-Needle Aspiration: A Report of 2 Cases.

Korean J Thorac Cardiovasc Surg 2020 Oct;53(5):313-316

Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands.

Esophageal perforation after endoscopic ultrasound-guided fine-needle aspiration for mediastinal staging is a rare but severe complication. We report 2 cases of patients with esophageal perforation who were treated using video-assisted thoracoscopic surgery in combination with esophageal stenting. Through these cases, the feasibility of minimally invasive thoracic surgery was evaluated.
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http://dx.doi.org/10.5090/kjtcs.19.064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7553825PMC
October 2020

Does the use of locking plates or mesh and wires influence the risk of symptomatic non-union of the sternal osteotomy after modified Ravitch?

J Thorac Dis 2020 Jul;12(7):3631-3639

Department of General and Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

Background: Patients with pectus excavatum which is unsuitable for minimally invasive repair are usually treated by modified Ravitch procedure. For fixation of the sternal osteotomy, mesh and wires are mostly used. To decrease non-union risk, we introduced a technique with double locking plate fixation of the osteotomy and compared this to fixation using mesh and wires.

Methods: Patients undergoing a modified Ravitch procedure for pectus excavatum between 2006 and 2016 were included. From 2006 to 2012, the sternum was fixated with mesh and wires. From 2012 to 2016, locking compression plates (LCP) were used. Baseline parameters, symptomatic non-union and total number of complications were retrospectively compared. Statistical analysis was performed using Mann-Whitney or Fisher's exact test. Data are presented as means +/- SD.

Results: Forty-four patients were included. In 18 patients, the sternum was fixed with mesh and wires, in 26 patients with LCP. Mean follow-up was 35 months in the mesh and 30 months in the LCP group, P=0.71. Haller index was similar in both groups (mesh 3.8±1.3 LCP 3.9±1.1, P=0.81). Symptomatic non-union occurred in 17% (n=3) in the mesh group and did not occur after LCP, P=0.062. Total number of complications was 33% (n=6) in the mesh group and 15% (n=4) after LCP, P=0.27.

Conclusions: After modified Ravitch procedure, union of the sternal osteotomy is challenging. In this retrospective cohort study, a lower incidence of symptomatic non-union was observed after fixation of the sternum with LCPs, with a trend towards statistical significance.
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http://dx.doi.org/10.21037/jtd-20-527DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7399391PMC
July 2020
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