- Email: [email protected]
Surgical Repair of Pectus Excavatum
Ann Thorac Surg 2016;102:1762–7
techniques, esophagectomy remains 1 of the most demanding surgical procedures, and it is associated with a significant rate of morbidity and mortality. Esophageal anastomotic leak remains 1 of the most devastating complications after total gastrectomy or esophagectomy, with a reported incidence that reaches 6% and 35%, respectively, for upper anastomosis [2, 3]. In this study, the authors presented a numerous and homogeneous series of patients who underwent surgical procedures for cancer. However, it would have been interesting to divide the patient series into subgroups according to the precise tumor site, because leakage rates do have different incidence rates, different symptoms, and different therapeutic approaches. Moreover, it is not clear from the article in which kinds of leaks the stent is appropriate and successfully therapeutic. In addition, it would be interesting to know the total number of patients with esophageal-gastric cancer who were treated by the center to better evaluate the real anastomotic leakage rate. In the period from 2003 to 2012, the same authors reported in a previous study an anastomotic leakage rate after total gastrectomy of 14% [4], which seems too high in comparison with reports in the literature. Thus we think that it is very important to successfully heal the leak, but it is also important to know the causes that lead to such a high leakage rate, because postsurgical morbidity seems to affect patient survival, as shown by Markar and colleagues [5]. In fact Markar and colleagues [5] demonstrated that postoperative esophageal-gastric leaks were strongly correlated with survival and local recurrence. Luigina Graziosi, MD, PhD Elisabetta Marino, MD Annibale Donini, MD General and Emergency Surgical Department University of Perugia Santa Maria della Misericordia Hospital Via Dottori, 06132 Perugia, Italy email: [email protected]
1. Licht E, Markowitz AJ, Bains MS, et al. Endoscopic management of esophageal anastomotic leaks after surgery for malignant disease. Ann Thorac Surg 2016;101:301–4. 2. Kim SH, Son SY, Park YS, Ahn SH. Park do J, Kim HH. Risk factors for anastomotic leakage: a retrospective cohort study in a single gastric surgical unit. J Gastric Cancer 2015;15:167–75. 3. Rutegård M, Lagergren P, Rouvelas I, Lagergren J. Intrathoracic anastomotic leakage and mortality after esophageal cancer resection: a population-based study. Ann Surg Oncol 2012;19:99–103. 4. Selby LV, Vertosick EA, Sjoberg DD, et al, FREGAT (French Eso-Gastric Tumors) working group, FRENCH (F ed eration de Recherche EN CHirurgie), and AFC (Association Franc¸aise de Chirurgie). Morbidity after total gastrectomy: analysis of 238 patients. J Am Coll Surg 2015;220:863–71. 5. Markar S, Gronnier C, Duhamel A, et al. The impact of severe anastomotic leak on long-term survival and cancer recurrence after surgical resection for esophageal malignancy. Ann Surg 2015;262:972–80.
Reply To the Editor: We would like to thank Graziosi and colleagues [1] for their insightful commentary on our article [2], as well as their
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
1763
perspective on the often-complicated management of cancer patients with anastomotic leaks. Regarding the subdivision of patients, 40 patients (82%) were treated for esophageal adenocarcinoma, and 42 patients (86%) underwent Ivor-Lewis esophagectomy, resulting in a relatively homogenous study population. The decision to refer patients for endoscopic management was made at the discretion of the primary surgeon, often because the leak failed to heal or it was judged unlikely to heal with conservative management that included nil per os and parenteral nutrition. The ultimate determination of whether the leak was amenable to stent placement was made by the treating endoscopist at the time of the procedure. We agree that clarifying the factors that predispose patients to develop anastomotic leaks, as well as identifying the patients who are most likely to benefit from endoscopic management, are crucial avenues of further research. Eugene Licht, MD Mark Schattner, MD Memorial Sloan Kettering Cancer Center 1275 York Ave New York, NY 10065 email: [email protected]
References 1. Graziosi L, Marino E, Donini A. Stents placement in the management of esophageal leaks (letter). Ann Thorac Surg 2016;102:1762–3. 2. Licht E, Markowitz AJ, Bains MS, et al. Endoscopic management of esophageal anastomotic leaks after surgery for malignant disease. Ann Thorac Surg 2016;101:301–4.
Surgical Repair of Pectus Excavatum To the Editor: We read the article on surgical treatment of recurrent pectus deformities by Luu and colleagues [1] with interest. Recurrent pectus excavatum constitutes a major problem for both the surgical approach and the patient’s psychology. As mentioned in the article, the Nuss procedure is a perfect correction of symmetric pectus excavatum. In our clinic, the Ravitch procedure was performed in 46 patients who had pectus excavatum [2]. In 3 of them reccurence was seen. One of these patients had Marfan’s syndrome. We use three-dimensional imaging of the chest wall prepared from computed tomography of the thorax to evaluate the sternal position and cartilage defects in our patients. Thus, we are able to plan the incision level for inserting the Nuss bar. With this procedure, patient satisfaction and success rate has never been 100%. Also, the surgeon should be very careful while performing a repeated Nuss procedure. Sometimes a third incision should be performed from the xiphoid region for releasing and opening a cleavage for the bar. This maneuver was performed in our patient with Marfan’s syndrome, and the risk of postoperative adverse events was reduced. In our clinic we have performed the Nuss procedure since 2011. A total of 61 patients with pectus excavatum had a pectus bar inserted successfully, and none showed relapse. An important point to mention is that contrary to the view of Luu and colleagues [1] that “In adults who have a severe pectus excavatum with a pectus index greater than 4.0 and an asymmetric defect or calcified costal cartilages, a Nuss procedure should not be performed because of a high
0003-4975/$36.00
MISCELLANEOUS
References
CORRESPONDENCE
1764
CORRESPONDENCE
reccurence rate and complications” we are of the opinion that most patients with a Haller index of 6 can be succesfully operated on with the Nuss procedure, which is superior to open surgical techniques in every respect. Murat Oncel, MD Guven Sadi Sunam, MD Huseyin Yildiran, MD Department of Thoracic Surgery Selcuk University Medical Faculty Alaeddin Keykubat Kamp€ us€ u 42000 Konya, Turkey email: [email protected]
References 1. Luu TD, Kogon BE, Force SD, Mansour KA, Miller DL. Surgery for recurrent pectus deformities. Ann Thorac Surg 2009;88:1627–31. 2. Oncel M, Tezcan B, Akyol KG, Dereli Y, Sunam GS. Clinical experience of repair of pectus excavatum and carinatum deformities. Cardiovasc J Afr 2013;24:318–21.
MISCELLANEOUS
Reply To the Editor: Pectus excavatum repair in adults has traditionally been performed through an open approach using a modified Ravitch repair, with excellent long-term results [1]. A minimally invasive approach, the Nuss procedure, was introduced in 1998 for pectus repair in children [2]. The Nuss procedure has been used in adult patients with pectus excavatum, with conflicting results related to an increase in bar dislodgement, significant pain, less than perfect cosmetic results, and increased recurrence after bar removal. Therefore controversy exists about which technique is most appropriate for adults with primary and recurrent pectus deformities. In 2009, we published a series of 41 adult patients who underwent operative treatment for primary and recurrent pectus deformities within the Emory Healthcare System from 1999 through 2006; 13 cases (32%) were reoperations, and the median patient age was 26 years (range, 16–46 years). Eight patients (62%) had undergone a Nuss procedure with a pectus index (PI) greater than 4.0 and an asymmetrical defect. Bar removal was at a median of 18 months (range, 14–36 months) after placement. Because of those poor results, we suggested that when adults have a PI greater than 4.0 and an asymmetrical defect, they are at a greater risk of recurrence after a Nuss procedure and should undergo an open modified Ravitch repair [3]. In their Letter to the Editor, Oncel and colleagues [4] noted that our recommendation that patients with a PI greater than 4.0, an asymmetrical defect, and calcified costal cartilages should not undergo a Nuss procedure for correction of pectus excavatum is contrary to their practice of successful Nuss procedures, in which “most patients with a pectus index of 6.0” and is superior to open surgical techniques in every aspect. Oncel and colleagues [4] referenced an article from their institution published in 2013 [5]. That series of 77 patients with pectus deformities was from 2004 through 2011 and they underwent repair with an open Ravitch procedure and a K-wire for posterior sternal support. The mean age of their patients was 17 years (range, 10–22 years), and 52% of them were younger than 17 years of age. Follow-up was by telephone only (at 3–36 months) and was available in only 81% of patients; results were good or excellent. The recurrence rate was 4.8%. Oncel and colleagues [4] stated Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2016;102:1762–7
that they have been performing the Nuss procedure since 2011: 61 patients, more than likely a similarly aged population as their first series, underwent successful bar placement for pectus excavatum and none has shown relapse. These data have not been vetted by peer review or published. Our series covered a period that was early in the expansion of the Nuss procedure for adults, which was associated with a significant recurrence rate requiring reoperation. The patients of Oncel and colleagues [4] encompass mainly a pediatric population and young adults, which are best suited for the Nuss procedure. In our series, the majority of patients were adults and ranged in age from 16 to 46 years; this population is at higher risk of recurrence with a minimally invasive procedure. More series exist today in adults with successful repair using the Nuss procedure, with the majority being performed in select centers of excellence for both pediatric and adult patients with pectus excavatum. In the older patients, partial cartilage removal or wedge sternal osteotomy is still required to free a rigid chest cavity and has been incorporated into a modified Nuss procedure [6]. We still favor an open approach for those adult patients who have combined severe PI greater than 5.0, an asymmetrical defect (>45% tilt), and calcified costal cartilages. In our institution, a 3-dimensional reconstructive computed tomographic scan of the chest has become the standard radiologic modality to plan primary or redo pectus repair in adults. I would like to thank Oncel and colleagues [4] for their comments and results, but the majority of their patients were children or young adults, which is not the case in our previous series or in our current practice of adults with pectus deformities. Daniel L. Miller, MD WellStar Health System 61 Whitcher St Marietta, GA 30060 email: [email protected]
References 1. Mansour KA, Thourani VH, Odessey EA, et al. Thirty-year experience with repair of pectus deformities in adults. Ann Thorac Surg 2003;76:391–5. 2. Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545–52. 3. Luu TD, Kogon BE, Force SD, Mansour KA, Miller DL. Surgery for recurrent pectus deformities. Ann Thorac Surg 2009;88:1627–31. 4. Oncel M, Sunam GS, Yildiran H. Surgical repair of pectus excavatum (letter). Ann Thorac Surg 2016;102:1763–4. 5. Oncel M, Tezcan B, Akyol KG, Dereeli Y, Sunam GS. Clinical experience of repair of pectus excavatum and carinatum deformities. Cardiovasc J Afr 2013;24:318–21. 6. Jaroszewski DE, Ewais MM, Chao CJ, et al. Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (30 years). Ann Thorac Surg 2016;102: 993–1003.
Which Variables Should be Considered as Confounders of p38-Mitogen Activated Protein Kinase Activation Measurements? To the Editor: We read with interest the article by Bao and colleagues [1] in which it was suggested that both p38-mitogen activated protein kinase (MAPK) activation and reactive oxygen species were more 0003-4975/$36.00
techniques, esophagectomy remains 1 of the most demanding surgical procedures, and it is associated with a significant rate of morbidity and mortality. Esophageal anastomotic leak remains 1 of the most devastating complications after total gastrectomy or esophagectomy, with a reported incidence that reaches 6% and 35%, respectively, for upper anastomosis [2, 3]. In this study, the authors presented a numerous and homogeneous series of patients who underwent surgical procedures for cancer. However, it would have been interesting to divide the patient series into subgroups according to the precise tumor site, because leakage rates do have different incidence rates, different symptoms, and different therapeutic approaches. Moreover, it is not clear from the article in which kinds of leaks the stent is appropriate and successfully therapeutic. In addition, it would be interesting to know the total number of patients with esophageal-gastric cancer who were treated by the center to better evaluate the real anastomotic leakage rate. In the period from 2003 to 2012, the same authors reported in a previous study an anastomotic leakage rate after total gastrectomy of 14% [4], which seems too high in comparison with reports in the literature. Thus we think that it is very important to successfully heal the leak, but it is also important to know the causes that lead to such a high leakage rate, because postsurgical morbidity seems to affect patient survival, as shown by Markar and colleagues [5]. In fact Markar and colleagues [5] demonstrated that postoperative esophageal-gastric leaks were strongly correlated with survival and local recurrence. Luigina Graziosi, MD, PhD Elisabetta Marino, MD Annibale Donini, MD General and Emergency Surgical Department University of Perugia Santa Maria della Misericordia Hospital Via Dottori, 06132 Perugia, Italy email: [email protected]
1. Licht E, Markowitz AJ, Bains MS, et al. Endoscopic management of esophageal anastomotic leaks after surgery for malignant disease. Ann Thorac Surg 2016;101:301–4. 2. Kim SH, Son SY, Park YS, Ahn SH. Park do J, Kim HH. Risk factors for anastomotic leakage: a retrospective cohort study in a single gastric surgical unit. J Gastric Cancer 2015;15:167–75. 3. Rutegård M, Lagergren P, Rouvelas I, Lagergren J. Intrathoracic anastomotic leakage and mortality after esophageal cancer resection: a population-based study. Ann Surg Oncol 2012;19:99–103. 4. Selby LV, Vertosick EA, Sjoberg DD, et al, FREGAT (French Eso-Gastric Tumors) working group, FRENCH (F ed eration de Recherche EN CHirurgie), and AFC (Association Franc¸aise de Chirurgie). Morbidity after total gastrectomy: analysis of 238 patients. J Am Coll Surg 2015;220:863–71. 5. Markar S, Gronnier C, Duhamel A, et al. The impact of severe anastomotic leak on long-term survival and cancer recurrence after surgical resection for esophageal malignancy. Ann Surg 2015;262:972–80.
Reply To the Editor: We would like to thank Graziosi and colleagues [1] for their insightful commentary on our article [2], as well as their
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
1763
perspective on the often-complicated management of cancer patients with anastomotic leaks. Regarding the subdivision of patients, 40 patients (82%) were treated for esophageal adenocarcinoma, and 42 patients (86%) underwent Ivor-Lewis esophagectomy, resulting in a relatively homogenous study population. The decision to refer patients for endoscopic management was made at the discretion of the primary surgeon, often because the leak failed to heal or it was judged unlikely to heal with conservative management that included nil per os and parenteral nutrition. The ultimate determination of whether the leak was amenable to stent placement was made by the treating endoscopist at the time of the procedure. We agree that clarifying the factors that predispose patients to develop anastomotic leaks, as well as identifying the patients who are most likely to benefit from endoscopic management, are crucial avenues of further research. Eugene Licht, MD Mark Schattner, MD Memorial Sloan Kettering Cancer Center 1275 York Ave New York, NY 10065 email: [email protected]
References 1. Graziosi L, Marino E, Donini A. Stents placement in the management of esophageal leaks (letter). Ann Thorac Surg 2016;102:1762–3. 2. Licht E, Markowitz AJ, Bains MS, et al. Endoscopic management of esophageal anastomotic leaks after surgery for malignant disease. Ann Thorac Surg 2016;101:301–4.
Surgical Repair of Pectus Excavatum To the Editor: We read the article on surgical treatment of recurrent pectus deformities by Luu and colleagues [1] with interest. Recurrent pectus excavatum constitutes a major problem for both the surgical approach and the patient’s psychology. As mentioned in the article, the Nuss procedure is a perfect correction of symmetric pectus excavatum. In our clinic, the Ravitch procedure was performed in 46 patients who had pectus excavatum [2]. In 3 of them reccurence was seen. One of these patients had Marfan’s syndrome. We use three-dimensional imaging of the chest wall prepared from computed tomography of the thorax to evaluate the sternal position and cartilage defects in our patients. Thus, we are able to plan the incision level for inserting the Nuss bar. With this procedure, patient satisfaction and success rate has never been 100%. Also, the surgeon should be very careful while performing a repeated Nuss procedure. Sometimes a third incision should be performed from the xiphoid region for releasing and opening a cleavage for the bar. This maneuver was performed in our patient with Marfan’s syndrome, and the risk of postoperative adverse events was reduced. In our clinic we have performed the Nuss procedure since 2011. A total of 61 patients with pectus excavatum had a pectus bar inserted successfully, and none showed relapse. An important point to mention is that contrary to the view of Luu and colleagues [1] that “In adults who have a severe pectus excavatum with a pectus index greater than 4.0 and an asymmetric defect or calcified costal cartilages, a Nuss procedure should not be performed because of a high
0003-4975/$36.00
MISCELLANEOUS
References
CORRESPONDENCE
1764
CORRESPONDENCE
reccurence rate and complications” we are of the opinion that most patients with a Haller index of 6 can be succesfully operated on with the Nuss procedure, which is superior to open surgical techniques in every respect. Murat Oncel, MD Guven Sadi Sunam, MD Huseyin Yildiran, MD Department of Thoracic Surgery Selcuk University Medical Faculty Alaeddin Keykubat Kamp€ us€ u 42000 Konya, Turkey email: [email protected]
References 1. Luu TD, Kogon BE, Force SD, Mansour KA, Miller DL. Surgery for recurrent pectus deformities. Ann Thorac Surg 2009;88:1627–31. 2. Oncel M, Tezcan B, Akyol KG, Dereli Y, Sunam GS. Clinical experience of repair of pectus excavatum and carinatum deformities. Cardiovasc J Afr 2013;24:318–21.
MISCELLANEOUS
Reply To the Editor: Pectus excavatum repair in adults has traditionally been performed through an open approach using a modified Ravitch repair, with excellent long-term results [1]. A minimally invasive approach, the Nuss procedure, was introduced in 1998 for pectus repair in children [2]. The Nuss procedure has been used in adult patients with pectus excavatum, with conflicting results related to an increase in bar dislodgement, significant pain, less than perfect cosmetic results, and increased recurrence after bar removal. Therefore controversy exists about which technique is most appropriate for adults with primary and recurrent pectus deformities. In 2009, we published a series of 41 adult patients who underwent operative treatment for primary and recurrent pectus deformities within the Emory Healthcare System from 1999 through 2006; 13 cases (32%) were reoperations, and the median patient age was 26 years (range, 16–46 years). Eight patients (62%) had undergone a Nuss procedure with a pectus index (PI) greater than 4.0 and an asymmetrical defect. Bar removal was at a median of 18 months (range, 14–36 months) after placement. Because of those poor results, we suggested that when adults have a PI greater than 4.0 and an asymmetrical defect, they are at a greater risk of recurrence after a Nuss procedure and should undergo an open modified Ravitch repair [3]. In their Letter to the Editor, Oncel and colleagues [4] noted that our recommendation that patients with a PI greater than 4.0, an asymmetrical defect, and calcified costal cartilages should not undergo a Nuss procedure for correction of pectus excavatum is contrary to their practice of successful Nuss procedures, in which “most patients with a pectus index of 6.0” and is superior to open surgical techniques in every aspect. Oncel and colleagues [4] referenced an article from their institution published in 2013 [5]. That series of 77 patients with pectus deformities was from 2004 through 2011 and they underwent repair with an open Ravitch procedure and a K-wire for posterior sternal support. The mean age of their patients was 17 years (range, 10–22 years), and 52% of them were younger than 17 years of age. Follow-up was by telephone only (at 3–36 months) and was available in only 81% of patients; results were good or excellent. The recurrence rate was 4.8%. Oncel and colleagues [4] stated Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2016;102:1762–7
that they have been performing the Nuss procedure since 2011: 61 patients, more than likely a similarly aged population as their first series, underwent successful bar placement for pectus excavatum and none has shown relapse. These data have not been vetted by peer review or published. Our series covered a period that was early in the expansion of the Nuss procedure for adults, which was associated with a significant recurrence rate requiring reoperation. The patients of Oncel and colleagues [4] encompass mainly a pediatric population and young adults, which are best suited for the Nuss procedure. In our series, the majority of patients were adults and ranged in age from 16 to 46 years; this population is at higher risk of recurrence with a minimally invasive procedure. More series exist today in adults with successful repair using the Nuss procedure, with the majority being performed in select centers of excellence for both pediatric and adult patients with pectus excavatum. In the older patients, partial cartilage removal or wedge sternal osteotomy is still required to free a rigid chest cavity and has been incorporated into a modified Nuss procedure [6]. We still favor an open approach for those adult patients who have combined severe PI greater than 5.0, an asymmetrical defect (>45% tilt), and calcified costal cartilages. In our institution, a 3-dimensional reconstructive computed tomographic scan of the chest has become the standard radiologic modality to plan primary or redo pectus repair in adults. I would like to thank Oncel and colleagues [4] for their comments and results, but the majority of their patients were children or young adults, which is not the case in our previous series or in our current practice of adults with pectus deformities. Daniel L. Miller, MD WellStar Health System 61 Whitcher St Marietta, GA 30060 email: [email protected]
References 1. Mansour KA, Thourani VH, Odessey EA, et al. Thirty-year experience with repair of pectus deformities in adults. Ann Thorac Surg 2003;76:391–5. 2. Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545–52. 3. Luu TD, Kogon BE, Force SD, Mansour KA, Miller DL. Surgery for recurrent pectus deformities. Ann Thorac Surg 2009;88:1627–31. 4. Oncel M, Sunam GS, Yildiran H. Surgical repair of pectus excavatum (letter). Ann Thorac Surg 2016;102:1763–4. 5. Oncel M, Tezcan B, Akyol KG, Dereeli Y, Sunam GS. Clinical experience of repair of pectus excavatum and carinatum deformities. Cardiovasc J Afr 2013;24:318–21. 6. Jaroszewski DE, Ewais MM, Chao CJ, et al. Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (30 years). Ann Thorac Surg 2016;102: 993–1003.
Which Variables Should be Considered as Confounders of p38-Mitogen Activated Protein Kinase Activation Measurements? To the Editor: We read with interest the article by Bao and colleagues [1] in which it was suggested that both p38-mitogen activated protein kinase (MAPK) activation and reactive oxygen species were more 0003-4975/$36.00