Relevance. Pectus Excavatum (PE) is the most common developmental defect of the
chest, manifested by a depression of the sternum and ribs, accompanied by varying degrees
of functional and organic disturbances in the circulatory and respiratory systems, as well as
severe psychological issues. This defect is recorded with a frequency of 0.1–0.8% in the
population. Conservative treatment using vacuum bell therapy (VBT) does not have
standardized approaches regarding the timing of vacuum bell application, overall duration of
treatment, level of negative pressure, and indications for conversion to surgical correction.
After the Nuss procedure, there are often registered residual or secondary deformities of
the chest, high frequency of postoperative complications; chronic postoperative chest pain
remains a significant problem.
Thus, the lack of clear criteria for determining the appropriateness of conservative
therapy for PE and evidence-based protocols for its implementation, high risks of surgical
treatment, lack of systematized approaches to customizing the Nuss procedure for correcting
various anatomical types of PE, the presence of secondary and residual chest deformities,
and the lack of justified criteria for selecting the number and sizes of corrective bars, as well
as the chronicity of postoperative pain syndrome, remain unresolved issues and underline
the relevance of the chosen research topic.
Purpose. To improve treatment outcomes for children with PE by establishing clear
indications for conservative and surgical treatment, optimizing conservative treatment,
differentiation of minimally invasive correction of PE (MIRPE) and individual fixation
device selection.
Research Objectives:
8
1. To analyze the effectiveness of VBT of PE; study outcomes of its application as a
preoperative preparation; develop a prediction method for the conservative treatment
effectiveness and determining the optimal timing for surgical correction conversion.
2. To study the deflection and reliability coefficient of the corrective titanium bar as a
solid metal arch with rigidly fixed ends and to formulate approaches to the rational selection
of their sizes and quantities.
3. To develop a system of methods for Nuss procedure complication prevention
4. Based on the supplemented PE classification by Park, develop Nuss procedure
options for each anatomical deformity type.
The object of the Study - Children with PE.
Subject of the Study: Minimally invasive PE surgical treatment; mathematical modeling
of safety factors and deflection levels of the corrective bar in different age categories;
indications for conservative and surgical treatment.
A single-center retrospective cohort study was conducted based on the examination and
treatment results analysis of 261 patients with PE who underwent conservative therapy and
surgical correction, among them 163 patients were treated conservatively, and 110
surgically (12 of those after ineffective conservative treatment). The treatment was
conducted at the KNP "Zhytomyr Regional Children's Clinical Hospital" of the Zhytomyr
Regional Council from 2018 to 2023.
A search in scientometric databases for the query "Nuss procedure," "vacuum bell
therapy," and "pectus excavatum" revealed 1432 sources, of which 5 meta-analyses from 12,
which were most relevant to the research aim were selected.
To predict unsatisfactory outcomes and ensure timely cessation of VBT with transition
to surgical correction, a comparison of treatment effectiveness was conducted between
groups with positive and negative outcomes at 4 and 6 moths intervals. Conservative PE
treatment was effective in cases of grade I - 41 cases (93.18%), grade II - 77 cases
(74.76%), grade III - 11 patients (68.75%).
It was found that after six months of therapy, the effectiveness of conservative treatment
should be predicted to determine further treatment strategy. Continued VBT is indicated if
9
the chest elevation reaches 16.03±1.7 mm for ages 5-8 years, 17.03±1.5 mm for ages 9-12
years, 13.29±1.3 mm for ages 13-16 years, and 8.7±1.2 mm for ages over 17 years,
otherwise conversion to surgical correction is required. Among patients with ineffective
conservative treatment, surgical intervention was indicated in 31 cases. In these patients, the
area of deformity entry and PE degree reduced in most cases; thus, 12 (66.67%) surgeries
were performed using a single corrective bar. Pain assessment using the NPRS was
conducted at the next day, 4-5 days, one month, and three months post-surgery. It was
established that pain intensity one day after surgery was 28.52%-22.76% lower in patients
with prior VBT compared to those without one. By the 4th-5th day, pain levels were
20.26%-18.4% lower, depending on the degree of PE.
