DOI: 10.1510/icvts.2008.184580 2008;

2008;7:1084-1088; originally published online Sep 4,Interact CardioVasc Thorac SurgB. Rebeis

Rodrigo R. Brigato, José R.M. Campos, Fabio B. Jatene, Luiz F.P. Moreira and Eduardo : evaluation of Nuss technique by objective methodsPectus excavatum

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Interactive CardioVascular and Thoracic Surgery 7 (2008) 1084–1088

� 2008 Published by European Association for Cardio-Thoracic Surgery

Institutional report - Thoracic general

Pectus excavatum: evaluation of Nuss technique byobjective methods�

Rodrigo R. Brigato*, Jose R.M. Campos, Fabio B. Jatene, Luiz F.P. Moreira, Eduardo B. Rebeis

Department of Cardiopneumology, Hospital of Clinics, University of Sao Paulo (USP) Medical School, Sao Paulo, Brazil

Received 27 May 2008; received in revised form 18 August 2008; accepted 18 August 2008

Abstract

Pectus excavatum (PEX) is the most frequent congenital deformity of the anterior chest wall. Few studies have classified the degree ofanatomical distortion in an objective manner. Our objective was to present two new clinical and original methods for evaluation of PEXdeformity developed in our service (chest cyrtometry and anthropometric index) that are simple and easily applicable in the office. Twentypatients with PEX (submitted to the technique of Nuss) and forty normal chest patients were studied: all patients were evaluated by thesame objective methods. Our results suggest that the objective clinical methods are more sensitive or precise than the radiological onesby measuring the deformity in a direct manner external to the chest.� 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Thoracic wall; Thoracic surgery; Video-assisted; Funnel chest

1. Introduction

Among the defects related to abnormal growth of skeletalstructures, Pectus excavatum (PEX) is the most frequentdeformity. It occurs in one of every 400 liveborns w1x andis three times more frequent among males than femalesw2x. There is a positive family history in up to 37% of thecases.

The more marked depression of the sternum is frequentlyclose to the xiphoid appendix. In more severe cases thereis an important dislocation of the heart, most of the timesto the left hemithorax, and a significant reduction ofthoracic volume w3, 4x.

Psychological factors are highly relevant and cause impor-tant social retraction, especially during adolescence, lead-ing the patients not to expose themselves in public, toavoid sports activities, relationships and contact with col-leagues w5–7x.

Few studies have classified the degree of anatomicaldistortion in an objective manner in order to permit thequantitation of the depression of the anterior chest wall,the comparison of groups and the evaluation of postopera-tive results w8x. In general, these patients have beenevaluated in a subjective manner during clinical inspectionw9, 10x.

� The authors thank the National Council of Technological and ScientificDevelopment (CNPq) of the Ministry of Science and Technology, BrazilFederal Government for support with this study.

*Corresponding author. Rua Onze de Agosto, 798 apto 81, Campos ElıseosRibeirao Preto-SP, 14085-030 Brazil. Tel.yfax: q55-16-32342590.

E-mail address: rrbrigato@hotmail.com (R.R. Brigato).

The simple physical examination of the patients permitsthe doctor to measure the chest circumference with ametric tape. In anthropometry, the correct term used tospecify the section of the body contour measured with ametric tape in the chest region is chest cyrtometry (Fig.1).

Another reproducible and easily applicable method calledanthropometric index was developed in our service for PEXw11x. During physical examination, the patient is evaluatedin a horizontal dorsal decubitus position on a flat table andduring deep inspiration. Two clinical measurements aremade: A and B. The anthropometric index is defined asmeasurement B divided by measurement A (Fig. 2).

The methods for PEX evaluation by complementary imag-ing exams are widely known. The inferior vertebral indexw12x is defined as the quotient of the vertebral sagittaldiameter and the chest sagittal diameter from the posteriorportion of the vertebral body to the posterior portion ofthe sternum, with both diameters being measured in theregion of greatest deformity or of the distal third of thesternum (Fig. 3). The Haller index w13x is based on com-puted tomography of the chest and is defined as thequotient between the maximum laterolateral distance andthe minimum anteroposterior distance from the anteriorportion of the vertebral body to the posterior surface ofthe sternum (Fig. 4).

It is generally accepted that the treatment of severe ormarked PEX should be surgical w14x. The current emphasisis on the operative technique of Nuss that uses a metal barfor sternum positioning and is minimally invasive w15x.

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Fig. 1. Chest cyrtometry: region of the distal third of the sternum or at thesite of greatest deformity with the patient in the orthostatic position andinspiring deeply in front view (above) and transverse explanatory view withmetal bar in position (below).

Fig. 2. A: Maximum anteroposterior measurement in the region of greatestdeformity or of the distal third of the sternum (above, left) and close upview (above, right). B: Greatest depth of the defect, with the highest pointof the anterior costal wall and the lowest point of the pre-sternal region atthe site of greatest deformity being used as reference (below, left) and closeup view (below, right).

Fig. 3. Lateral chest radiography in order to obtain inferior vertebral indexmeasurements: BCyAC.

2. Materials and methods

The study protocol was approved by the Ethics Committeeof the Hospital of Clinics, University of Sao Paulo and awritten informed consent was obtained from allparticipants.

A prospective study was conducted from December 2001to December 2005 at our hospital. Twenty patients withPEX and 40 patients with a chest considered to be morpho-logically normal (control group) were studied.

The sample consisted of white subjects of both genderswith a body mass index (BMI) of -25, who were found tohave a normal chest or PEX upon physical examination.

This was an observational, randomized non-blind study.Twenty patients with PEX were treated by the same surgicalteam by the technique of Nuss and the postoperative resultscompared with the control group. The measurements wereperformed by someone else on the surgical team. Thepatients with PEX were examined on two occasions, i.e. onthe day of surgery and two years after metal bar removal.Morphologically normal patients were evaluated only onthe day when they accepted to participate in the study.

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Fig. 4. Correlation between anthropometric index and Haller index. Anthro-pometric indexsByA; Haller indexsA (Haller)yC (Haller).

Table 1Patients with PEX treated by Nuss procedure

Patient Weight Height BMI Age Gender(kg) (m) (kgym )2 (years)

1 53 1.74 17.5 13 M2 20.8 1.16 15.5 5 M3 62 1.77 19.8 19 M4 58.5 1.75 19.1 14 M5 58 1.6 22.6 14 M6 70.5 1.71 24.1 35 M7 47 1.7 16.3 14 F8 63 1.75 20.6 20 M9 54 1.75 17.6 19 M

10 43 1.58 17.2 16 F11 62 1.77 19.8 21 M12 48 1.61 18.5 19 F13 59 1.77 18.8 16 F14 70 1.9 19.4 30 M15 60 1.82 18.1 18 M16 55 1.85 16 20 M17 49 1.72 16.6 18 F18 56 1.81 17.1 23 M19 70 1.76 22.6 16 M20 58 1.95 15.3 17 M

The inclusion criteria for patients with PEX were: physicalexamination revealing a depression of the central portionof the anterior chest wall in relation to the adjacent costalcage, dissatisfaction with a defect of the anterior chestwall regardless of the comments of the examiner, age from5–40 years, BMI-25 kgym , white race. The inclusion cri-2

teria for normal patients were: absence of a depression orprotrusion of the anterior chest wall in relation to thecostal cage upon physical examination, and no recent chestradiography or computed tomography (performed duringhospitalization) due to another type of clinical interven-tion, age between 5 and 40 years, and BMI-25 kgym .2

All the 60 patients were evaluated by physical examin-ation in order to determine chest cyrtometry and anthro-pometric index. A lateral chest radiography was obtainedto calculate the inferior vertebral index and the patientswere submitted to computed tomography of the chest inorder to obtain the Haller index. The measurements forclinical and radiologic evaluation were made at the site ofgreatest deformity in patients with PEX and in the distalthird of the sternum for morphologically normal patients.

The 20 patients with PEX were submitted to preoperativeexams such as blood count and coagulogram and to radio-logic exams (radiography and chest tomography). All oper-ated patients were treated by the same surgical team. Forthe control of postoperative pain opiate analgesics wereapplied through an epidural catheter and non-hormonalanti-inflammatory agents were administered orally orparenterally.

Statistical analysis: the Shapiro–Wilk normality test wasused for sample distribution. The pre- and postoperativeresults were compared by the Kruskal–Wallis test. The pre-and postoperative results were compared to the controlgroup also by the Kruskal–Wallis test. The GraphPad Prism4.00 and Origin 7.5 programs were used for the statisticalcalculations. The level of significance was set at 95%, i.e.,P-0.05.

3. Results

No mortality occurred among the patients studied. Com-plications in the group operated by the technique of Nuss

were as follows: two cases of intense chest pain during thefirst postoperative day due to an epidural catheter of inade-quate function (then these patients received a higher doseof intravenous analgesic), one case of subcutaneous hema-toma on the right with spontaneous remission, and onecase of re-operation with a combined technique and resec-tion of dysmorphic costal cartilages. The patients weredischarged from the hospital four to nine days after surgery(mean: 5.6 days). Physical characteristics of our patientsare presented at Tables 1 and 2.

The comparison of preoperative data with the patientswith the morphologically normal chest patients accordingto the four indices studied (chest cyrtometry, anthropo-metric index, Haller index and inferior vertebral index)yielded the following respective results: P-0.001 – P-0.01– P-0.001 – P-0.001 (Table 3).The pre- and postoperative comparison of the Nuss tech-

nique according to the same four indices studied yieldedthe following respective results for the technique of Nuss:P-0.001 – P-0.001 – P-0.001 – P-0.0001.

Finally, postoperative comparison with the morphological-ly normal chest patients according to the same four indicesstudied yielded the following respective results for thepatients submitted to the Nuss technique: P)0.05 –P)0.05 – P)0.05 – P-0.05. Therefore, there was nosignificant difference obtained by three indices (weobtained significative difference only by inferior vertebralindex comparison) for Nuss technique.

4. Discussion

We emphasize the need to use objective measurements.In addition to two radiologic methods, we used forms ofclinical evaluation (chest cyrtometry and anthropometricindex) that are objective, simple and easily applicable inthe office, permitting the diagnosis and follow-up of thesepatients independently of any type of complementaryexam. Our objective was to evaluate PEX by means of

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Table 2Normal patients (control group)

Patient Weight Height BMI Age Gender(kg) (m) (kgym )2 (years)

1 53 1.66 19.23 25 M2 56 1.67 20.07 32 M3 57 1.65 20.93 31 M4 52 1.65 19.10 32 F5 59 1.70 20.41 21 M6 59 1.60 23.04 35 F7 58 1.66 21.04 30 M8 59 1.55 24.55 17 F9 54 1.78 17.04 16 M

10 54 1.62 20.57 17 F11 58 1.83 17.31 20 M12 75 1.75 24.48 35 M13 65.5 1.62 24.57 33 M14 63 1.79 19.66 18 M15 39 1.52 16.88 30 F16 57 1.66 20.68 18 F17 70 1.76 22.59 32 M18 69 1.85 20.16 16 M19 67 1.66 24.31 33 M20 69.5 1.79 21.69 16 M21 46 1.53 19.65 15 M22 64 1.70 22.14 36 M23 68 1.71 23.25 21 M24 48.5 1.63 18.25 22 M25 52.5 1.72 17.74 17 M26 43.6 1.55 18.4 26 M27 40 1.52 17.31 15 M28 73 1.71 24.96 23 M29 53 1.75 17.30 17 M30 53 1.57 21.50 22 M31 67 1.65 24.6 23 F32 50 1.65 18.4 26 F33 28 1.35 15.6 8 M34 29 1.26 18.3 7 F35 64 1.92 17.4 25 M36 55 1.6 21.5 32 M37 54 1.68 19.1 18 M38 48 1.51 21 12 M39 75 1.78 23.7 17 M40 65 1.67 23.3 19 M

Fig. 5. Pre- (left) and postoperative (right) views. Nuss technique change thechest conformation: (bqc))a.

Table 3Median values

Min. P25 Median P75 Max.

Cyrtometry Normal patients 60 82 86 90 94.5Nuss Pre-op. 58 75 79.5 83 87.5

Postop. 63.5 85 87 91 96Antropometric Normal patients 0.01 0.02 0.03 0.03 0.12index Nuss Pre-op. 0.13 0.16 0.18 0.21 0.49

Postop. 0.00 0.01 0.01 0.02 0.07Haller index Normal patients 1.75 1.91 2.14 2.29 3.00

Nuss Pre-op. 2.2 3.24 3.70 4.66 5.30Postop. 1.32 2.06 2.22 2.39 2.79

Inferior Normal patients 0.02 0.19 0.21 0.22 0.26vertebral index Nuss Pre-op. 0.25 0.29 0.31 0.35 0.40

Postop. 0.18 0.22 0.23 0.25 0.27

radiologic (Haller index and inferior vertebral index) andanthropometric measurements for comparison of theresults.

The patients at our hospital come from all regions of ourcountry with a mixed Brazilian population. Therefore, we

just included in this study white patients in order to avoidrace bias (variable thoracic shape related to race) instatistical analysis.

About the four indices used, the anthropometric indexand the inferior vertebral index use only anteroposteriorexternal and internal chest measurements, respectively.The inferior vertebral index, like the anthropometricindex, only measures distances on the anteroposterior axis;however, while the anthropometric index measures thechest externally, the inferior vertebral index uses a radiol-ogic method to analyze this same axis inside the chest.Thus, the anthropometric index evaluates the visible andexternal deformity, while the inferior vertebral index eval-uates the deformity internally to the chest.

The fact that the anthropometric index and the inferiorvertebral index evaluate the same axis with differentresults suggests that the anthropometric index is moresensitive or precise than the inferior vertebral index bymeasuring the deformity in a direct manner external to thechest.

The Nuss technique changes the chest conformation (Fig.5) modifying the laterolateral diameter. Thus, the resultsobtained with these four indices agree with the peculiarcharacteristics of this technique.

We propose the use of chest cyrtometry and anthropo-metric index as methods for the objective evaluation ofpatients with PEX because of: a) the simplicity of themeasurements and of the calculation of the index; b) theirhigh correlation with indices already widely employed inclinical practice; c) their high accuracy for the diagnosisof PEX.

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DOI: 10.1510/icvts.2008.184580 2008;

2008;7:1084-1088; originally published online Sep 4,Interact CardioVasc Thorac SurgB. Rebeis

Rodrigo R. Brigato, José R.M. Campos, Fabio B. Jatene, Luiz F.P. Moreira and Eduardo : evaluation of Nuss technique by objective methodsPectus excavatum

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