Modification of the Abramson procedure for minimally invasive repair of pectus carinatum: introduction of a pectus carinatum compression system.

Pectus carinatum is characterized by a protruding sternum. This deformity can be surgically corrected through the minimally invasive Abramson technique. In this procedure, a presternal metal correctional bar, secured to rib-attached stabilizers, is implanted to redress the sternum to a neutral position. To anticipate the intended position of the sternum, manual compression is applied over the sternal deformity. We describe a modified version of the Abramson procedure, encompassing a table-mounted PectusAssist™ System which generates a constant mechanical compression over the protruding sternum. The PectusAssist™ System, most importantly, eliminates the necessity of manually applying repetitive pressure on the deformity, and therefore maintains a more stable sternal position. This will ensure accuracy of the template used to bend the bar into its desired configuration. The modification we propose also simplifies presternal tunnel creation as the two bilateral retromuscular tunnels, that need to be connected presternally, are potentially better aligned due to a more stable and reduced position of the sternum. The PectusAssist™ System makes the procedure less labor intensive and reduces variability without interfering with the safety of the procedure. Therefore, we advise standard use of the PectusAssist™ System during minimally invasive repair of pectus carinatum by the Abramson procedure.

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

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.

Signet ring cells in esophageal and gastroesophageal junction carcinomas have a more aggressive biological behavior.

OBJECTIVE: To clarify the biologic behavior of esophageal signet ring cell (SRC) carcinomas of the esophagus and gastroesophageal junction (GEJ). To evaluate the accuracy of pretreatment biopsies in diagnosing true SRC carcinoma. BACKGROUND: In contrast with gastric cancer, little is known about the biologic behavior and prognosis of SRC. METHODS: All adenocarcinomas (ADC) of the esophagus and GEJ-patients undergoing primary resection between 1990 and 2009 were included (n = 920). Specimens containing SRCs (n = 114) were classified according to World Health Organization criteria (>50% SRC or <50% SRC). RESULTS: Thirty-two patients showed more than 50% SRC and 71 patients showed less than 50% SRC. Overall cancer-specific 5-year survival was worse for SRC (22.4%, P < 0.0001) and for SRC > 50% (13.6%, P = 0.0001) compared with ADC. Complete resection was achieved in 86.5% of patients (n = 697) in ADC, 69.5% (n = 57) in SRC < 50%, and 78.1% (n = 25) in SRC > 50% (vs ADC, respectively, P < 0.0001 and P = 0.1801). In 379 pN + R0 patients, the median number of positive lymph nodes was comparable between ADC and SRC < 50% (4 vs 5, P = 0.207) or SRC > 50% (4 vs 8, P = 0.077). Compared with ADC, SRC > 50% showed more pN3's (30% vs 61%, P = 0.006), higher recurrence (56% vs 42% for ADC, P = 0.003), and local-regional recurrences (29% vs 16%, P = 0.002). Pretreatment biopsies were unreliable to define the presence of SRC > 50% (sensitivity = 56.3%, positive predictive value = 43.9%). CONCLUSIONS: SRCs are aggressive neoplasms associated with poorer prognosis than other ADCs after primary esophagectomy. Because our data suggest that pretreatment biopsies failed to reliably define presence of SRC > 50%, presence of SRCs in pretreatment biopsies seems to be of no use to define treatment strategy or prognosis.