Pectus excavatum is the most common thoracic RECONSTRUCTIVE

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Pectus excavatum is the most common thoracic RECONSTRUCTIVE"

Transcription

1 RECONSTRUCTIVE Correction of Pectus Excavatum by Custom-Made Silicone Implants: Contribution of Computer-Aided Design Reconstruction. A 20-Year Experience and 401 Cases Jean-Pierre Chavoin, M.D. Jean-Louis Grolleau, M.D. Benjamin Moreno Jérémie Brunello, M.D. Aymeric André, M.D. Marcel Dahan, M.D. Ignacio Garrido, M.D., Ph.D. Benoit Chaput, M.D. Toulouse, France Background: In the absence of demonstrable functional impairment, pectus excavatum is merely a congenital deformity, albeit with a marked psychological impact. Many patients do not wish to undergo thoracic remodeling operations, which are invasive and do not clearly result in respiratory or cardiac improvement. Methods: From 1993 to 2015, the authors designed 401 custom-made silicone implants to treat funnel chests. Before 2007, implants were made from plaster chest molds. Beginning in 2007, three-dimensional reconstructions were made from computed tomographic scans by computer-aided design. The authors prospectively recorded all assessments and follow-up data since Preoperative and postoperative photographs of two random groups of 50 patients were analyzed, in a blinded manner, by two surgeons independently. Intraoperative and postoperative complications, clinical outcomes, patient satisfaction, and quality of life were evaluated. Results: One infection and three hematomas were recorded. Periprosthetic seroma was evident in all cases. Patients rated the cosmetic outcomes of computer-aided design implants significantly higher than those of the earlier implants made using plaster molds (p = 0.030). Malformations were better corrected in the computer-aided design group (86 percent) than in the plaster group (72 percent) (p = 0.038). Patient satisfaction was higher in the former group (p = 0.011). Medical Outcomes Study 36-Item Short-Form Health Survey scores revealed significant improvements, both socially and emotionally. Conclusions: Correction of pectus excavatum using a computer-aided design silicone implant fulfils aesthetic and psychological demands. The technique is simple and reliable and yields high-quality results. In the medium term, the approach may render invasive techniques obsolete. These operations remain risky and of doubtful functional utility. (Plast. Reconstr. Surg. 137: 860e, 2016.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. Pectus excavatum is the most common thoracic deformity. The incidence thereof is one in 300 to one in 1000 births, and the sex ratio ranges from 3:1 to 5:1. 1,2 In the absence of any cardiac or respiratory impairment, the condition is a mere morphologic deformation, but has a strong psychological impact. 3,4 The question of whether functional impairment can be present From the Service de Chirurgie Plastique et Reconstructrice, CHU Toulouse Rangueil; and the Service de Chirurgie Thoracique, CHU Toulouse Larrey. Received for publication June 27, 2015; accepted December 17, Copyright 2016 by the American Society of Plastic Surgeons DOI: /PRS remains controversial 5,6 ; some thoracic and pediatric surgeons perform remodeling thoracic procedures, such as the Nuss or Ravitch operation, Disclosure: The authors have no financial interest in any of the products or devices mentioned in this article. Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal s Web site (www. PRSJournal.com). 860e

2 Volume 137, Number 5 Silicone Implant for Pectus Excavatum with interesting results Recently developed fat transfer techniques are of great assistance in minor cases, providing a significant improvement to patients, but in most deformations, the limits of this treatment are quickly reached. 11 Treatment of chest wall deformities remains challenging. Over 20 years, we have developed a minimally invasive technique; we place permanent custom-made implants made of a silicone elastomer. Initially (1993 to 2007), we manufactured prostheses using plaster molds of the thorax, 12 and later (2007 to 2015) with computer-aided design using three-dimensional computed tomographic data. 1,2 To the best of our knowledge, no study has yet explored long-term satisfaction, quality of life, or cosmetic results in such patients. We do so in this article, comparing patients given earlier (plaster group) and recent prostheses (computer-aided design group) with long-term evaluation. Patient demographics and symptoms are discussed, and the surgical technique is described. We report on patient self-evaluation and blinded surgical assessment. We evaluated satisfaction and quality of life using the questionnaire of Del Frari and Schwabegger 7 and the Medical Outcomes Study 36-Item Short-Form Health Survey. PATIENTS AND METHODS We include all (n = 401) patients with pectus excavatum treated in our plastic and reconstructive surgery unit (in Toulouse, France) from January of 1993 to April of All patients were adults, and all surgery was performed by the senior surgeon (J.P.C). No patients, even those with deep deformations, had any clinically relevant disorders (average Haller index, 4.79 ± 2.33). This was confirmed by preoperative testing of ventilatory function. We confirmed the absence of comorbidities and researched associated malformations by clinical examination (e.g., Marfan or Poland syndrome). The intrathoracic Haller index defined as the ratio of the transverse diameter (horizontal distance of the inside of the ribcage) and the anteroposterior diameter (shortest distance between the vertebrae and sternum) served as a useful and informative measure of the severity of the condition. All possible thoracic reconstruction techniques were explained to each patient both orally and in writing. The study followed the ethical tenets of the Strengthening the Reporting of Observational Studies in Epidemiology statement 13 and was approved by the Institutional Review Board of Toulouse University Hospital (Toulouse, Rangueil, France) in 1992; all patients gave oral and written consent. From 1993 to 2007, we used plaster molds of the thorax to make silicone implants (n = 61). From 2007, we used preoperative threedimensional volume-rendered computed tomographic scans to design implants (n = 340). All clinical characteristics, surgical details, technical efficacies of remodeling, and immediate and late postoperative complications were recorded (n = 401). Patients were categorized according to the classification of Chin, 14 as follows: type 1, the deformation is important but remains symmetric and localized to the sternum; type 2, the deformation is less profound but more diffuse, with large symmetric angulation of the costal cartilages; and type 3, the deformation is unilateral and asymmetric. We randomly formed groups of 50 patients treated by means of either approach. In consultation, these patients scored their postoperative appearances in a questionnaire of cosmetic evaluation as proposed by Del Frari and Schwabegger: Excellent, good, or failed. 7 Cosmetic appearance was assessed on photographs with blinded evaluation by two surgeons (B.C. and J.B.) not involved in the treatment of pectus excavatum and the postoperative appearance was graded as very good, good, reasonable, or bad according to the score used by Goretsky et al. 15 Patients also completed the questionnaire of satisfaction according to the postoperative appearance questionnaire proposed by Davis and Weinstein and the general QOL questionnaire MOS-SF Statistical Analysis Categorical variables are expressed as proportions and were compared using the Pearson chisquare test. Continuous variables are expressed as means with ranges (minimum to maximum) and were compared using t test. A two-sided value of p < 0.05 was considered to indicate statistical significance. All statistical analyses were performed using BiostaTGV software (Jussieu, France). Manufacture of Custom Implants by Means of Computer-Aided Design Several steps are required 3 : Obtain a computed tomographic scan with 1-mm sections. A computer scientist reconstructs the missing space between: 861e

3 Plastic and Reconstructive Surgery May 2016 The deep plane, termed the surgical plane (the rib cage, the intercostal spaces, and the sternum), which is reconstructed very accurately. The superficial plane, termed the anatomical plane, which seeks (when necessary) to correct virtually symmetrical deformations, and position female breasts. The company AnatomikModeling (SAS, Toulouse, France) performs the computer modeling. Prototyping: A virtual image is subjected to three-dimensional prototyping to make a polymer form. First, the implant prototype is performed by three-dimensional computerized numerical control mills. Second, each implant is made from the prototype (Perouse-plastie and Sebbin, Boissy l Aillerie, France) using a silicone elastomer (NuSil 4801 or 4811; NuSil Technology, Carpinteria, Calif.) by molding. The implant is semirigid and tear resistant. Next, the implant is gas-sterilized. Such implants are very durable. The average cost to this stage is $1800 to $2000. Ultimately, the implant is sterilized in our hospital some days before surgery. Surgical Technique Under general anesthesia, the patient is placed supine, with the arms along the thorax. We routinely prescribe intraoperative prophylactic antibiotics (2 g of intravenous cefazolin injected when we start the operation). The prototype is placed on the thorax to check positioning of the centerline. We trace the perimeter of the implant, thus defining the limits of prosthesis placement. A vertical presternal incision of 6 to 8 cm is made in the center of the deformation. Dissection continues until the sternal plane is attained. We remove the medial fibers of the pectoralis major muscle. Such submuscular detachment continues to the limits of the line on the chest skin. Submuscular placement of the prosthesis edges renders the implant undetectable both visually and to the touch. In the caudal region, dissection of the anterior fascia of the rectus abdominis muscles, although premuscular, allows the lower edge of the prosthesis to be concealed but prohibits vertical slippage. Also, the lower pole of the prosthesis is split with a scalpel, for 2 to 3 cm, to permit overlap with the intermuscular septum of the rectus abdominis muscles. This optimally stabilizes the implant, eliminating any risk of secondary displacement or rotation (Fig. 1). The semirigid consistency of the implant facilitates the bending and insertion thereof using a minimally invasive approach. These implants are easily foldable but not deformable, and are incompressible. In the factory, the midline of the surface plane of the prosthesis is marked by a line, which is used to correct any positional error and ensure the absence of rotation. Closure features three steps: deep (muscle or fascial for medial suturing of pectoral fibers); subcutaneous closure with reversed points; and skin closure by means of continuous intradermal suturing using absorbable thread. We do not place a suction drain; instead, we place a medial compressive dressing with a pressure garment. The dressing is not changed the 862e Fig. 1. Surgical procedure of computer-aided design implant with a Chin type 1 pectus excavatum. The flexibility of the implant allows its insertion by a small incision (7 cm).

4 Volume 137, Number 5 Silicone Implant for Pectus Excavatum Fig. 3. Schematic depiction of the implant in a male patient in its final position. full-text article on PRSJournal.com or, for Ovid users, at Fig. 2. Suture of the pectoralis muscles in the midline before skin closure. first week. At 8 to 15 days, during the first consultation, seroma puncture in the sitting position is performed. Most patients return to work after 2 to 3 weeks. The pressure garment is kept for 1 month. In general, the interruption of sports activity for 3 months is recommended. After this period, any physical or sporting restrictions are discontinued, they are no longer required (Figs. 2 and 3). (See Video, Supplemental Digital Content 1, which shows implant design by three-dimensional reconstruction and complete surgical procedure, available in the Related Videos section of the RESULTS We have treated 401 patients consecutively over a period of 20 years (1993 to 2015). The sex ratio was Mean patient age was 27 years (range, 14.9 to 55.5 years) in the plaster group (n = 61) and 26.9 years (range, 14.3 to 62.3 years) in the computer-aided design group (n = 340) (p = 0.763). The Chin type 1 malformation was the most common in both groups. Patient demographics and preoperative characteristics are listed in Table 1. The mean operative time was less than 1 hour: 59.7 minutes (range, 35 to 99 minutes) and 49.2 minutes (range, 32 to 78 minutes) for the plaster and computer-aided design groups, respectively. Patients were followed every year in consultation. The mean follow-up period was 97.9 months (range, 57.9 to months) for the plaster group and 45.4 months (range, 27.3 to 82.5 months) for the computer-aided design group. Intraoperative and hospital stay data are summarized in Table 2. Overall, complications were very rare. We encountered one late infection (7 years postoperatively), three hematomas, and two instances of postoperative wound dehiscence. All hematomas 863e

5 Plastic and Reconstructive Surgery May 2016 Video. Supplemental Digital Content 1, which shows implant design by three-dimensional reconstruction and complete surgical procedure, is available in the Related Videos section of the full-text article on PRS- Journal.com or, for Ovid users, at Table 1. Patient Demographics and Preoperative Characteristics Plaster Group (%) CAD Group (%) No. of patients Period Age, yr 0.763* Mean Range Sex <0.001 Male 49 (80.3) 187 (55) Female 12 (19.7) 153 (45) Chin classification <0.001 type 1 48 (78.7) 169 (49.7) 2 9 (14.8) 57 (16.8) 3 4 (6.5) 114 (33.5) Connective tissue disorders Marfan syndrome 1 4 CAD, computer-aided design *Calculated by t test. Calculated by Pearson χ 2 test with overall comparison. were attributable to bleeding of the internal mammary perforator, injured during pectoral muscle dissection, and required reintervention. The infection was the only complication rendering prosthesis replacement essential. Wound dehiscence was managed by reintervention (suture repair). All patients developed postoperative seroma completely managed by two or three transcutaneous punctures. No implant became displaced or exhibited capsular contracture. We never noticed rupture of the prosthesis. The long-term aesthetic results were judged good to excellent by the patients (Table 3). On p Table 2. Intraoperative Variables and Hospital Stay and Follow-Up Data Plaster Group CAD Group No. of patients Operative time, min <0.001* Mean Range Length of hospital stay, 0.104* days Mean Range Follow-up, mo <0.001* Mean Range CAD, computer-aided design. *Calculated by t test. Table 3. Long-Term Results on Self-Evaluation Plaster Group (%) self-assessment, computer-aided design reconstruction was shown to afford cosmetic results significantly better than those achieved with plaster (p = 0.030). However, in both groups, almost half p CAD Group (%) p No. of patients Results 0.030* Excellent 12 (24) 19 (38) G ood 33 (66) 31 (62) Failed 5 (10) 0 (0) Do you feel the 1* prosthesis? No 28 (56) 27 (54) Yes 22 (44) 23 (46) CAD, computer-aided design. *Calculated by Fisher s exact test with overall comparison. 864e

6 Volume 137, Number 5 Silicone Implant for Pectus Excavatum Table 4. Long-Term Clinical Evaluation Concerning Appearance of the Corrected Deformity Evaluated by Two Blinded Surgeons Plaster Group (%) CAD Group (%) p No. of patients Deformity correction 0.038* Very good (deformity or prosthesis invisible) 15 (30) 28 (56) Good (prosthesis or deformity not visible from the front) 21 (42) 15 (30) Reasonable (visible deformity or prosthesis in the frontosagittal plane, not visible through a tight T-shirt) 12 (24) 5 (10) Bad (visible through a tight T-shirt) 2 (4) 2 (4) CAD, computer-aided design. *Calculated by Fisher s exact test with overall comparison. of the patients stated that they were aware of the prosthesis during physical effort or intense sporting activity. Blinded evaluation by two surgeons of the extent of deformity correction revealed the utility and significant advantage for the reconstruction by computer-aided design; 86 percent of reconstructions were graded good or very good, compared with 72 percent of those of the plaster group (p = 0.038) (Table 4). Figures 4 through 8 present patients with results scored good to very good. In terms of satisfaction, 80 percent of patients who underwent reconstruction with the aid of computer-aided design were satisfied or very satisfied (score, 4 and 5) compared to 50 percent of patients in the plaster group (p = 0.011) (Table 5). Quality of life assessed by the Medical Outcomes Study 36-Item Short-Form Health Survey Fig. 4. Correction of the thoracic deformity corrects malposition and breast asymmetries (above and center). Breast implants can be placed, usually in a second step (below). (Table 6) revealed significant improvement in social functioning of both the plaster (p = 0.049) and computer-aided design groups (p = 0.024). In the latter group, role emotional also improved significantly (p = 0.025). Pain (bodily pain) associated with the prosthesis was significant in both groups. All patients described discomfort during intense sporting activities, but without any pain quantifiable on a visual analogue scale. Most other Medical Outcomes Study 36-Item Short- Form Health Survey items improved after placement of the prosthesis, but statistical significance was not attained. DISCUSSION The extent of functional impairment associated with pectus excavatum remains highly controversial. Indeed, the recent meta-analyses of Malek et al. and Gunteroth and Spiers on the pulmonary and cardiac consequences of the condition reveal that evidence bearing on any improvements in such conditions after thoracic surgery to correct malformations is lacking. 5,6 In fact, such operations are cumbersome, and most patients (both adolescents and adults) seek only aesthetic and psychological relief. 1,12 Thus, we developed a reconstruction procedure prioritizing the cosmetic need. External suction systems have not been very successful, 17,18 and fat tissue transfers (which can yield excellent results) require discrete shaping. 11,19 Our technique is minimally invasive, easy, rapid, and associated with very low morbidity. In general, our surgical procedure takes less than 1 hour and the hospital stay is less than 5 days. Initially, hospital stay was 4.7 days on average to achieve a seroma puncture before patient discharge; we now have gradually reduced this time to 3 days. All patients obtained satisfactory or very satisfactory aesthetic results. The mean patient ages in the computer-aided design and plaster groups were 26.9 and 27 years, respectively, reflecting the fact that a large part of 865e

7 Plastic and Reconstructive Surgery May 2016 Fig. 5. (Above, left) Preoperative front of the pectus excavatum of a 23-year-old woman (Chin type 1). (Above, right) Perioperative view. The silicone implant is placed on the skin before incision. (Below) Postoperative results at 6 months after correction with computer-aided design silicone implant. The scar is very inconspicuous. pectus excavatum is not corrected in childhood. Psychological difficulties often develop in adolescence or adulthood (sometimes late adulthood), motivating consultations. Such patients are frequently seen for the first time as adults, and often request surgery that is rapid, not disabling, and not associated with prolonged effects on work and sport. Our initial procedure (external plaster molding) yielded good results, but (sometimes) barely detectable imperfections in contour or volume were evident. This was attributable to interposition of soft tissues such as breasts in female patients, or well-developed muscles in male patients in efforts to camouflage the deformation, sometimes asymmetrically. These tissues varied in both thickness and location, compromising plaster molding. Also, when the skin was thin, the implant was more likely to be visible or detectable by touch. Computer-aided design with three-dimensional reconstruction renders prosthesis design perfect; the thoracic deformation (medial or lateral) is minutely charted, with or without default inclusion of muscles. Remodeling thoracic operations such the Nuss and Ravitch procedures often yield quite satisfactory cosmetic results, but these are rather major interventions (even the minimally invasive versions). 7 Moreover, these procedures seem to not improve cardiopulmonary plane function, unlike what has been claimed. Many serious complications have been reported, including cardiac perforation, pleural effusion, 26 erosion of the pulmonary vessels, 27,28 occlusion of the inferior vena cava, 29,30 superior mesenteric artery syndrome, 31 various infections, 20,32 and bar migration, the most frequent complication (almost 10 percent of all patients). 8,33 36 Custom-made silicone implants are complex to model, and expensive; few surgeons use such prostheses. Very few relevant articles have appeared, with relatively small patient numbers The study of Johnson is the only one available in the literature using computed tomographic scans to design 866e

8 Volume 137, Number 5 Silicone Implant for Pectus Excavatum Fig. 6. (Above) Preoperative frontal and oblique views of a 19-year-old woman with asymmetric pectus excavatum (Chin type 3). (Below) Postoperative results at 2 years after correction with computer-aided design silicone implant. The prosthesis has fully corrected the breast strabism and the pseudoasymmetry. Fig. 7. Three-dimensional modeling from computed tomographic scan before surgical procedure to design the custom-made prosthesis with accuracy. prostheses. 43 Indeed, Johnson used computed tomographic scans to design custom silicone prostheses to correct pectus excavatum. In this study, the three patients enjoyed excellent results. 43 In 2001, Nordquist et al. were the first to report on pectus excavatum repair using silicone implants in a large 37 series of patients. Almost 80 percent reported improvements in appearance 867e

9 Plastic and Reconstructive Surgery May 2016 Fig. 8. (Above) Preoperative frontal and oblique views of a severe asymmetric pectus excavatum of a 19-year-old man (Chin type 3 with left deformation). (Below) Postoperative results at 6 months after correction with computer-aided design silicone implant. Table 5. Long-Term Clinical Evaluation Concerning Appearance of the Corrected Deformity Plaster Group (%) CAD Group (%) Score p No. of patients Deformity correction 0.011* I am completely satisfied with my repair 8 (16) 14 (28) 5 I am very pleased with my repair, and notice considerable improvement 17 (34) 26 (52) 4 The repair is just okay 19 (38) 10 (20) 3 I am somewhat disappointed with the result; it doesn t look that great 3 (6) 0 (0) 2 I am very disappointed and dissatisfied with the result 3 (6) 0 (0) 1 CAD, computer-aided design. *Calculated by Fisher s exact test with overall comparison. and well-being. 37 The same year, Wechselberger et al. also reported on a series of 20 patients, 90 percent of whom enjoyed good to excellent outcomes and 10 percent of whom had acceptable results. 38 In 2005, Margulis et al. reported excellent corrections in a small series of seven patients. 39 More recently, in 2009, Snel reported that 83 percent of 16 patients were satisfied, and 69 percent considered their aesthetic outcomes to be good to excellent. 40 However, none of these authors used computer-aided design using threedimensional computed tomographic data. Computer-aided design three-dimensional modeling is ideally suited not only to treat asymmetric chests (a significant concern with external plaster molding) but also to manage 868e

10 Volume 137, Number 5 Silicone Implant for Pectus Excavatum Table 6. Medical Outcomes Study 36-Item Short-Form Health Survey* MOS-SF36 Subscale Plaster Group (mean ± SD) CAD Group (mean ± SD Preoperatively Postoperatively p Preoperatively Postoperatively p Physical functioning 96.7 ± ± ± ± Role physical 84.4 ± ± ± ± Bodily pain 89.4 ± ± ± ± General health 76.9 ± ± ± ± Vitality 70.5 ± ± ± ± Social functioning 75.4 ± ± ± ± Role emotional 76 ± ± ± ± Mental health ± ± ± ± MOS-SF36, Medical Outcomes Study 36-Item Short-Form Health Survey; CAD, computer-aided design. *Plaster group, n = 50; CAD group, n = 50. Calculated by Pearson χ 2 test. pectus excavatum in female patients. The implant restores the anterior thoracic wall and repositions distorted breasts to the orthotopic position, with restoration of breast projection. Moreover, we earlier showed that chest correction resolves 85 percent of breast strabism or pseudoasymmetry; most patients no longer require a breast prosthesis or other device. 4 Indeed, many asymmetries are relative, being induced by an asymmetric pectus excavatum. These will be corrected without any need for a breast prosthesis in a large portion of the patients. 4 Nonetheless, using a retrosternal steel bar, Schwabegger et al. showed very good results with breast strabism and funnel chest correcting simultaneously the funnel chest and the strabism of the breast without surgery on the breast itself. 9 In terms of complications, we experienced only three hematomas and a single infection. The hematomas required reoperations, and the infection necessitated removal of the prosthesis and antibiotic treatment. The infection rate was thus very low. Seroma formation in the early postoperative period was the most frequently observed minor complication, as also reported by Wechselberger et al. in 65 percent of patients. 38 Seroma was detected clinically in every case. In our series, the retromuscular dissection plane of the pectoral muscle explains why seroma developed; unlike the cited authors, we did not place the prosthesis subcutaneously. Nonetheless, the submuscular placement appears to be a good solution to limit implant exposure. In the first years, we used suction drain. Nonetheless, after removing the drain, seroma occurs systematically, so we chose to stop their use. We believe that drain use does not limit seroma formation in this specific indication. The seroma required two or three punctures during the first postoperative months but always resorbed. At 3 months, no patient evidenced residual seroma. Patients should be told to expect a seroma, and punctures should be made by a surgeon to avoid any risk of infection. No periprosthetic capsular contracture formed around the implants in the long term. Unlike breast implants filled with soft silicone gel, the silicone elastomer implants are semirigid, and we thus assume that they neither retract nor contract. In the absence of fracture, rupture, or degradation, the prostheses endure for life. Although psychological and cosmetic considerations remain the principal indications for pectus excavatum repair, few studies have explored patient satisfaction and the aesthetic results, and do not include any work involving computeraided design to create silicone implants. 7,9,44 In terms of cosmetic assessment, both the patients and the surgeons consider that the outcomes are good to excellent, being significantly better in the computer-aided design group than in the plaster group. In terms of satisfaction, 80 percent of patients who underwent reconstruction by means of computer-aided design were satisfied or very satisfied (score, 4 and 5), reflecting principally the cosmetic results. No specific scale evaluating the effect of pectus excavatum on quality of life exists, and we thus used the Medical Outcomes Study 36-Item Short-Form Health Survey, one of the most widely used and internationally validated scales. Significant improvements in social and emotional functioning were evident in the computer-aided design group; the patients had functioned rather poorly before surgery. Other parameters including general and mental health and role physical also improved, but the betweengroup differences were not significant. The reported pain associated with implant placement was highlighted on the Medical Outcomes Study 36-Item Short-Form Health Survey (bodily pain). We have not encountered this complaint before, and the literature is silent on the topic. Patients reported that they could feel the 869e

11 Plastic and Reconstructive Surgery May 2016 prostheses during certain intense sporting activities, as may also be the case for breast implants, for example. We believe that the medium- and longterm pain associated with remodeling thoracic surgery is greatly underestimated or not evaluated in the various publications, and it is thus difficult to compare such patients with those of our series. It should also be noted that, in retrospective studies, pain reports are often unreliable. The feel of the prosthesis during physical effort was described more as discomfort than pain. No patient has ever requested removal of a prosthesis. We will seek to reduce the discomfort in our future work. To the best of our knowledge, this is the largest series yet reported in the literature of pectus excavatum corrections using custom silicone implants made with the aid of computer-aided design. Also, we present long-term follow-up, showing stability of the implants and the results. Ideally, a future study should compare patient satisfaction and cosmetic results between those treated by means of remodeling thoracic surgery and computer-aided design aided prosthetic reconstruction. If the differences are not significant, and the functional symptomatologies do not differ, custom-made implants may become increasingly attractive. All of our demographic and surgical data were collected prospectively, but the cosmetic self-evaluation and quality-of-life assessment were retrospective in nature, with the limitations inherent in retrospectivity. CONCLUSIONS We managed pectus excavatum patients on a strictly cosmetic basis. Custom implants designed using three-dimensional computed tomographic data afforded good to excellent cosmetic results in most patients, who were generally satisfied and enjoyed an improved quality of life. The inevitable seroma poses few risks. Both remodeling thoracic operations and silicone implants correct pectus excavatum, affording significant cosmetic improvements with good patient satisfaction and quality-of-life improvement. Thus, we suggest that the simplest and least invasive procedure should be preferred; the risk of complications is low and morbidity is much reduced. Benoit Chaput, M.D. Plastic and Reconstructive Surgery Unit CHU Rangueil 1, Avenue Jean Poulhès Toulouse, France REFERENCES 1. Chavoin JP. Chirurgie plastique et reconstructrice des parois et des confins. Paris: Masson; Hong JY, Suh SW, Park HJ, Kim YH, Park JH, Park SY. Correlations of adolescent idiopathic scoliosis and pectus excavatum. J Pediatr Orthop. 2011;31: Chavoin JP, André A, Bozonnet E, et al. Mammary implant selection or chest implants fabrication with computer help (in French). Ann Chir Plast Esthet. 2010;55: Ho Quoc C, Chaput B, Garrido I, André A, Grolleau JL, Chavoin JP. Management of breast asymmetry associated with primary funnel chest (in French). Ann Chir Plast Esthet. 2013;58: Malek MH, Berger DE, Marelich WD, Coburn JW, Beck TW, Housh TJ. Pulmonary function following surgical repair of pectus excavatum: A meta-analysis. Eur J Cardiothorac Surg. 2006;30: Guntheroth WG, Spiers PS. Cardiac function before and after surgery for pectus excavatum. Am J Cardiol. 2007;99: Del Frari B, Schwabegger AH. Clinical results and patient satisfaction after pectus excavatum repair using the MIRPE and MOVARPE technique in adults: 10-year experience. Plast Reconstr Surg. 2013;132: Kelly RE, Goretsky MJ, Obermeyer R, et al. Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg. 2010;252: Schwabegger AH, Del Frari B, Pierer G. Aesthetic improvement of the female breast in funnel chest deformity by surgical repair of the thoracic wall: Indication or lifestyle surgery? Plast Reconstr Surg. 2012;130:245e 253e. 10. Pilegaard HK. Nuss technique in pectus excavatum: A mono-institutional experience. J Thorac Dis. 2015;7(Suppl 2):S172 S Ho Quoc C, Delaporte T, Meruta A, La Marca S, Toussoun G, Delay E. Breast asymmetry and pectus excavatum improvement with fat grafting. Aesthet Surg J. 2013;33: Chavoin JP, Dahan M, Grolleau JL, et al. Funnel chest: Filling technique with deep custom made implant (in French). Ann Chir Plast Esthet. 2003;48: Equator Network. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. Available at: Accessed May 1, Chin EF. Surgery of funnel chest and congenital sternal prominence. Br J Surg. 1957;44: Goretsky MJ, Kelly RE Jr, Croitoru D, Nuss D. Chest wall anomalies: Pectus excavatum and pectus carinatum. Adolesc Med Clin. 2004;15: Davis JT, Weinstein S. Repair of the pectus deformity: Results of the Ravitch approach in the current era. Ann Thorac Surg. 2004;78: Schier F, Bahr M, Klobe E. The vacuum chest wall lifter: An innovative, nonsurgical addition to the management of pectus excavatum. J Pediatr Surg. 2005;40: Haecker FM. The vacuum bell for conservative treatment of pectus excavatum: The Basel experience. Pediatr Surg Int. 2011;27: Pereira LH, Sterodimas A. Free fat transplantation for the aesthetic correction of mild pectus excavatum. Aesthetic Plast Surg. 2008;32: Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: Case reports. J Pediatr Surg. 2001;36: e

12 Volume 137, Number 5 Silicone Implant for Pectus Excavatum 21. Johnson WR, Fedor D, Singhal S. A novel approach to eliminate cardiac perforation in the Nuss procedure. Ann Thorac Surg. 2013;95: Schaarschmidt K, Lempe M, Schlesinger F, Jaeschke U, Park W, Polleichtner S. Lessons learned from lethal cardiac injury by Nuss repair of pectus excavatum in a 16-year-old. Ann Thorac Surg. 2013;95: Bouchard S, Hong AR, Gilchrist BF, Kuenzler KA. Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum. Semin Pediatr Surg. 2009;18: Becmeur F, Ferreira CG, Haecker FM, Schneider A, Lacreuse I. Pectus excavatum repair according to Nuss: Is it safe to place a retrosternal bar by a transpleural approach, under thoracoscopic vision? J Laparoendosc Adv Surg Tech A 2011;21: Darlong LM. Pectus tunneloscopy: Making Nuss procedure for pectus excavatum safe. Interact Cardiovasc Thorac Surg. 2013;17: Cheng YL, Lin CT, Wang HB, Chang H. Pleural effusion complicating after Nuss procedure for pectus excavatum. Ann Thorac Cardiovasc Surg. 2014;20: Leonhardt J, Kübler JF, Feiter J, Ure BM, Petersen C. Complications of the minimally invasive repair of pectus excavatum. J Pediatr Surg. 2005;40:e7 e Adam LA, Meehan JJ. Erosion of the Nuss bar into the internal mammary artery 4 months after minimally invasive repair of pectus excavatum. J Pediatr Surg. 2008;43: Nath DS, Wells WJ, Reemtsen BL. Mechanical occlusion of the inferior vena cava: An unusual complication after repair of pectus excavatum using the Nuss procedure. Ann Thorac Surg. 2008;85: Ballouhey Q, Léobon B, Trinchéro JF, Baunin C, Galinier P, Sales de Gauzy J. Mechanical occlusion of the inferior vena cava: An early complication after repair of pectus excavatum using the Nuss procedure. J Pediatr Surg. 2012;47:e1 e Ricca RL, Kasten J, Javid PJ. Superior mesenteric artery syndrome after minimally invasive correction of pectus excavatum: Impact of post-operative weight loss. J Pediatr Surg. 2012;47: Calkins CM, Shew SB, Sharp RJ, et al. Management of postoperative infections after the minimally invasive pectus excavatum repair. J Pediatr Surg. 2005;40: ; discussion Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: Review of 251 cases. J Pediatr Surg. 2000;35: ; discussion Park HJ, Kim KS, Lee S, Jeon HW. A next-generation pectus excavatum repair technique: New devices make a difference. Ann Thorac Surg. 2015;99: Fallon SC, Slater BJ, Nuchtern JG, et al. Complications related to the Nuss procedure: Minimizing risk with operative technique. J Pediatr Surg. 2013;48: Giacomo TD, Diso D, Francioni F, Anile M, Venuta F. Minimally invasive pectus excavatum repair: Migration of bar and ossification. Asian Cardiovasc Thorac Ann. 2013;21: Nordquist J, Svensson H, Johnsson M. Silastic implant for reconstruction of pectus excavatum: An update. Scand J Plast Reconstr Surg Hand Surg. 2001;35: Wechselberger G, Ohlbauer M, Haslinger J, Schoeller T, Bauer T, Piza-Katzer H. Silicone implant correction of pectus excavatum. Ann Plast Surg. 2001;47: Margulis A, Sela M, Neuman R, Buller-Sharon A. Reconstruction of pectus excavatum with silicone implants. J Plast Reconstr Aesthet Surg. 2006;59: Snel BJ, Spronk CA, Werker PM, van der Lei B. Pectus excavatum reconstruction with silicone implants: Long-term results and a review of the English-language literature. Ann Plast Surg. 2009;62: Saour S, Shaaban H, McPhail J, McArthur P. Customised silicone prostheses for the reconstruction of chest wall defects: Technique of manufacture and final outcome. J Plast Reconstr Aesthet Surg. 2008;61: Mishra A, Kain N, Constantinides J, McPhail J, Iqbal A. Customised chest wall implant to correct pectus excavatum and bilateral breast reconstruction with muscle-sparing latissimus dorsi (MS-LD) flap in a single stage. J Plast Reconstr Aesthet Surg. 2011;64:e132 e Johnson PE. Refining silicone implant correction of pectus excavatum through computed tomography. Plast Reconstr Surg. 1996;97: Nasr A, Fecteau A, Wales PW. Comparison of the Nuss and the Ravitch procedure for pectus excavatum repair: A metaanalysis. J Pediatr Surg. 2010;45: e

Pectus Excavatum (Funnel Chest) Dr Hasan Nugud Consultant Paediatric Surgeon

Pectus Excavatum (Funnel Chest) Dr Hasan Nugud Consultant Paediatric Surgeon Pectus Excavatum (Funnel Chest) Dr Hasan Nugud Consultant Paediatric Surgeon Pectus excavatum Pectus excavatum (PE) is an abnormal development of the rib cage where the breastbone (sternum) caves in,

More information

PECTUS DEFORMITY REPAIR

PECTUS DEFORMITY REPAIR COVERAGE DETERMINATION GUIDELINE PECTUS DEFORMITY REPAIR Guideline Number: CDG.015.01 Effective Date: October 1, 2013 Table of Contents COVERAGE RATIONALE... DEFINITIONS. APPLICABLE CODES... REFERENCES...

More information

The sandwich technique for repair of pectus carinatum and excavatum/carinatum complex

The sandwich technique for repair of pectus carinatum and excavatum/carinatum complex Featured rticle The sandwich technique for repair of pectus carinatum and excavatum/carinatum complex Hyung Joo Park, Kyung Soo Kim Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary s Hospital,

More information

PECTUS DEFORMITY REPAIR

PECTUS DEFORMITY REPAIR PECTUS DEFORMITY REPAIR Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and

More information

In 1998 a minimally invasive repair of pectus excavatum

In 1998 a minimally invasive repair of pectus excavatum Routine Use of Minimally Invasive Surgery for Pectus Excavatum in Adults Hans K. Pilegaard, MD, and Peter B. Licht, MD, PhD Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby Aarhus;

More information

Pectus excavatum repair from a plastic surgeon s perspective

Pectus excavatum repair from a plastic surgeon s perspective Perspective Pectus excavatum repair from a plastic surgeon s perspective nton H. Schwabegger Clinical Department of Plastic, Reconstructive and esthetic Surgery, Medical University of Innsbruck, Innsbruck,

More information

Breast Reconstruction in the U.S.

Breast Reconstruction in the U.S. The State of Antibiotic Use in Implant Based Breast Reconstruction Robert D. Foster, MD Professor of Surgery Division of Plastic and Reconstructive Surgery UCSF Breast Reconstruction in the U.S. Each year

More information

Surgical Correction of Chest Wall Deformities

Surgical Correction of Chest Wall Deformities Last Review Date: October 13, 2017 Number: MG.MM.SU.65aC Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth

More information

Pectus excavatum and breast asymmetry: correction with breast augmentation

Pectus excavatum and breast asymmetry: correction with breast augmentation Original Article Pectus excavatum and breast asymmetry: correction with breast augmentation Pectus excavatum e assimetrias mamárias: correção com mamoplastia de aumento PAULO ROBERTO DA SILVA MENDES 1

More information

Gastric Dilatation-Volvulus

Gastric Dilatation-Volvulus Gastric Dilatation-Volvulus The term "ACVS Diplomate" refers to a veterinarian who has been board certified in veterinary surgery. Only veterinarians who have successfully completed the certification requirements

More information

Use And Misuse Of Antibiotics In Neurosurgery

Use And Misuse Of Antibiotics In Neurosurgery Use And Misuse Of Antibiotics In Neurosurgery CSF infection in the United States after neurosurgery from 1992 to 2003 0.86% to 2.32% * *National Nosocomial Infections Surveillance System: National Nosocomial

More information

Paraesophageal Hernia. Matthew Hartwig, MD

Paraesophageal Hernia. Matthew Hartwig, MD Paraesophageal Hernia Matthew Hartwig, MD Disclosure Slide Consultant for Mallincrodkt and Quark Pharmaceuticals Case Presentation: Patient PH 82 y/o woman with HTN, PVD, BrCa 10 year history of dysphagia,

More information

Salvage of Infected Breast Implants

Salvage of Infected Breast Implants Salvage of Infected Breast Implants Original Article Joon Ho Song 1, Young Seok Kim 1, Bok Ki Jung 1, Dong Won Lee 2, Seung Yong Song 2, Tai Suk Roh 1, Dae Hyun Lew 2 1 Department of Plastic and Reconstructive

More information

The Effect of Perioperative Use of Prophylactic Antibiotics on Surgical Wound Infection

The Effect of Perioperative Use of Prophylactic Antibiotics on Surgical Wound Infection THE IRAQI POSTGRADUATE MEDICAL JOURNAL PROPHYLACTIC ANTIBIOTICS ON SURGICAL WOUND INFECTION The Effect of Perioperative Use of Prophylactic Antibiotics on Surgical Wound Infection Ahmed Hamid Jasim*, Nabeel

More information

Morphometeric analysis of infraorbital foramen in north indian skulls

Morphometeric analysis of infraorbital foramen in north indian skulls Original article: Morphometeric analysis of infraorbital foramen in north indian skulls Tilak Raj, Anshu Mishra, Parmatma Mishra Department of Anatomy, Integral Institute of Medical Science and Research,

More information

2018 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Process

2018 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Process Quality ID #464 (NQF 0657): Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use National Quality Strategy Domain: Effective Clinical Care 2018 OPTIONS FOR INDIVIDUAL MEASURES:

More information

Canine Total Hip Replacement

Canine Total Hip Replacement Canine Total Hip Replacement Many factors enter into the decision to have a total hip replacement performed on your pet. You may have questions about the procedure. The answers to the most commonly asked

More information

General Practice Service Willows Information Sheets. Neutering of dogs

General Practice Service Willows Information Sheets. Neutering of dogs General Practice Service Willows Information Sheets Neutering of dogs Male dogs Why castrate a male dog? Entire male dogs can have a tendency to roam and look for bitches on heat. This increases the risk

More information

The Choice. V e r s a t i l i t y. S t r e n g t h. F l e x i b i l i t y. of surgeons for half a century

The Choice. V e r s a t i l i t y. S t r e n g t h. F l e x i b i l i t y. of surgeons for half a century The Choice of surgeons for half a century V e r s a t i l i t y S t r e n g t h F l e x i b i l i t y S t o p b l e e d i n g f a s t w i t h t h r e e p r o v e n p e r f o r m e r s SURGICEL Absorbable

More information

Mesenteric adenitis - MDTC evaluation in an Emergency Service

Mesenteric adenitis - MDTC evaluation in an Emergency Service Mesenteric adenitis - MDTC evaluation in an Emergency Service Poster No.: C-1885 Congress: ECR 2012 Type: Authors: Keywords: DOI: Educational Exhibit A. A. S. M. D. Santos, C. A. P. Fontes, M. H. Santos,

More information

UNIVERSITY OF PITTSBURGH Institutional Animal Care and Use Committee

UNIVERSITY OF PITTSBURGH Institutional Animal Care and Use Committee UNIVERSITY OF PITTSBURGH Institutional Animal Care and Use Committee Policy: Surgical Guidelines EFFECTIVE ISSUE DATE: 2/21/2005 REVISION DATE(s): 2/14/15; 3/19/2018 SCOPE To describe guidelines and considerations

More information

Antimicrobial Stewardship Strategy: Intravenous to oral conversion

Antimicrobial Stewardship Strategy: Intravenous to oral conversion Antimicrobial Stewardship Strategy: Intravenous to oral conversion Promoting the use of oral antimicrobial agents instead of intravenous administration when clinically indicated. Description This is an

More information

Institute of Surgical Research

Institute of Surgical Research Institute of Surgical Research Surgical techniques A5 Practical Module. A1. MODUL - Asepsis and the surgeon A2. MODUL Surgical instrumentation A3. MODUL Operations A4. MODUL Bleedings A5. MODUL sterile

More information

Pierre-Louis Toutain, Ecole Nationale Vétérinaire National veterinary School of Toulouse, France Wuhan 12/10/2015

Pierre-Louis Toutain, Ecole Nationale Vétérinaire National veterinary School of Toulouse, France Wuhan 12/10/2015 Antimicrobial susceptibility testing for amoxicillin in pigs: the setting of the PK/PD cutoff value using population kinetic and Monte Carlo Simulation Pierre-Louis Toutain, Ecole Nationale Vétérinaire

More information

PIGEON DISCRIMINATION OF PAINTINGS 1

PIGEON DISCRIMINATION OF PAINTINGS 1 PIGEON DISCRIMINATION OF PAINTINGS 1 Pigeon Discrimination of Paintings by Image Sharpness ANONYMOUS Psychology and 20th Century Literature August 8th, 2016 PIGEON DISCRIMINATION OF PAINTINGS 2 Pigeon

More information

Identification methods for spayed and neutered feral cats

Identification methods for spayed and neutered feral cats Identification methods for spayed and neutered feral cats 1. Introduction In Switzerland and many other countries, the suffering of cats is immeasurable. Hundreds of thousands of homeless cats live on

More information

Dr Indran Balakrishnan Chair, Antimicrobial Stewardship Committee Royal Free London NHS Foundation Trust

Dr Indran Balakrishnan Chair, Antimicrobial Stewardship Committee Royal Free London NHS Foundation Trust Dr Indran Balakrishnan Chair, Antimicrobial Stewardship Committee Royal Free London NHS Foundation Trust (Scottish Intercollegiate Guidelines Network, 2014, National Healthcare Safety Network, 2012) BUT

More information

The surgical site infection risk in developing countries. Yves BUISSON Société de Pathologie Exotique

The surgical site infection risk in developing countries. Yves BUISSON Société de Pathologie Exotique The surgical site infection risk in developing countries Yves BUISSON Société de Pathologie Exotique Surgical site infections Health-care-associated infections occurring within 30 days after surgery, or

More information

Measure Information Form

Measure Information Form Release Notes: Measure Information Form Version 2.0 **NQF-ENDORSED VOUNTRY CONSENSUS STNDRDS FOR HOSPIT CRE** Measure Information Form Measure Set: Surgical Care Improvement Project (SCIP) Set Measure

More information

Prophylactic antibiotics for insertion of peritoneal dialysis catheter

Prophylactic antibiotics for insertion of peritoneal dialysis catheter Prophylactic antibiotics for insertion of peritoneal dialysis catheter Date written: October 2010 Final submission: September 2012 Author: Maha Yehia GUIDELINES a. Intravenous antibiotic prophylaxis should

More information

Surgical Site Infection (SSI) Prevention: The Latest, Greatest and Unanswered Questions

Surgical Site Infection (SSI) Prevention: The Latest, Greatest and Unanswered Questions Surgical Site Infection (SSI) Prevention: The Latest, Greatest and Unanswered Questions Keith S. Kaye, MD, MPH Corporate Vice President of Quality and Patient Safety Corporate Medical Director, Infection

More information

Measure Information Form

Measure Information Form Release Notes: Measure Information Form Version 2.0 **NQF-NDORSD VOUNTRY CONSNSUS STNDRDS FOR HOSPIT CR** Measure Information Form Measure Set: Surgical Care Improvement Project (SCIP) Set Measure ID #:

More information

PROTOCOL FOR ANIMAL USE AND CARE

PROTOCOL FOR ANIMAL USE AND CARE PROTOCOL FOR ANIMAL USE AND CARE Score 1: Score 2: Total: 1. Contacts Primary Investigator Alternate contact Name Sandra Weisker Name Email sweisker@ucdavis.edu Email Dept Animal Science Dept Telephone

More information

UPEI / AVC Guidelines for Categories of Invasiveness and Rest Periods for Teaching Animals

UPEI / AVC Guidelines for Categories of Invasiveness and Rest Periods for Teaching Animals UPEI / AVC Guidelines for Categories of Invasiveness and Rest Periods for Teaching Animals Created: 1996 Revised: April 2011 Background The UPEI Animal Care Committee (ACC) recognizes that animals can

More information

"Serpent" Sign, "Double Arch" Sign and "Air-Bubble"Sign in a case of Ruptured Hydatid Cyst-A Case Report

Serpent Sign, Double Arch Sign and Air-BubbleSign in a case of Ruptured Hydatid Cyst-A Case Report Article ID: WMC004602 ISSN 2046-1690 "Serpent" Sign, "Double Arch" Sign and "Air-Bubble"Sign in a case of Ruptured Hydatid Cyst-A Case Report Peer review status: No Corresponding Author: Dr. Dipti Gothi,

More information

Responders as percent of overall members in each category: Practice: Adult 490 (49% of 1009 members) 57 (54% of 106 members)

Responders as percent of overall members in each category: Practice: Adult 490 (49% of 1009 members) 57 (54% of 106 members) Infectious Diseases Society of America Emerging Infections Network 6/2/10 Report for Query: Perioperative Staphylococcus aureus Screening and Decolonization Overall response rate: 674/1339 (50.3%) physicians

More information

Treatment Duration for Uncomplicated Community-Acquired Pneumonia: The Evidence in Support of 5 Days

Treatment Duration for Uncomplicated Community-Acquired Pneumonia: The Evidence in Support of 5 Days Treatment Duration for Uncomplicated Community-Acquired Pneumonia: The Evidence in Support of 5 Days Executive Summary National consensus guidelines created jointly by the Infectious Diseases Society of

More information

GUIDELINE FOR ANTIMICROBIAL USE IN THE ORTHOPAEDIC AND TRAUMA DEPARTMENT

GUIDELINE FOR ANTIMICROBIAL USE IN THE ORTHOPAEDIC AND TRAUMA DEPARTMENT GUIDELINE FOR ANTIMICROBIAL USE IN THE ORTHOPAEDIC AND TRAUMA DEPARTMENT Written by: Dr Ken. N. Agwuh, Consultant Microbiologist Mr Roger Helm, Consultant Orthopaedic Surgeon Mr T Kumar, Consultant Orthopaedic

More information

Neutering Rabbits. Ness Exotic Wellness Center 1007 Maple Ave Lisle, IL

Neutering Rabbits. Ness Exotic Wellness Center 1007 Maple Ave Lisle, IL Neutering Rabbits Ness Exotic Wellness Center 1007 Maple Ave Lisle, IL 60532 630-737-1281 The word "neuter" refers to the removal of the reproductive organs of either a male or a female of a species, although

More information

Anesthesia Check-off Form

Anesthesia Check-off Form Anesthesia Check-off Form 5231 SW 91st Drive Gainesville, FL 32608 (352) 377-6003 The doctors and staff at Haile Plantation Animal Clinic would like to offer the most advanced medical care and services

More information

TECHNICAL BULLETIN Claude Toudic Broiler Specialist June 2006

TECHNICAL BULLETIN Claude Toudic Broiler Specialist June 2006 Evaluating uniformity in broilers factors affecting variation During a technical visit to a broiler farm the topic of uniformity is generally assessed visually and subjectively, as to do the job properly

More information

Infective complications according to duration of antibiotic treatment in acute abdomen

Infective complications according to duration of antibiotic treatment in acute abdomen International Journal of Infectious Diseases (2004) 8, 155 162 Infective complications according to duration of antibiotic treatment in acute abdomen Ana L.M. Gleisner*, Rodrigo Argenta, Marcelo Pimentel,

More information

WHO Surgical Site Infection Prevention Guidelines. Web Appendix 4

WHO Surgical Site Infection Prevention Guidelines. Web Appendix 4 WHO Surgical Site Infection Prevention Guidelines Web Appendix 4 Summary of a systematic review on screening for extended spectrum betalactamase and the impact on surgical antibiotic prophylaxis 1. Introduction

More information

Prevention of Perioperative Surgical Infections

Prevention of Perioperative Surgical Infections Prevention of Perioperative Surgical Infections Michael A. West, MD, PhD, FACS Department of Surgery University California San Francisco San Francisco, CA, USA Surgical Site Infections (SSI) 2-5% of operated

More information

UvA-DARE (Digital Academic Repository) Topics in plastic surgery of the breast Lapid, O. Link to publication

UvA-DARE (Digital Academic Repository) Topics in plastic surgery of the breast Lapid, O. Link to publication UvA-DARE (Digital Academic Repository) Topics in plastic surgery of the breast Lapid, O. Link to publication Citation for published version (APA): Lapid, O. (20). Topics in plastic surgery of the breast

More information

PREVENTION OF SURGICAL SITE INFECTION

PREVENTION OF SURGICAL SITE INFECTION PREVENTION OF SURGICAL SITE INFECTION Montreal, March 29 2011 Chantal Bellerose P. Dt., BScHN, M.Sc. Adm Claude Laflamme MD, FRCPC, MHSC(c) Sandra Savery BScN, M.Sc.Adm Disclosure Financial disclosure:

More information

POLICIES. Austin Peay State University. Animals on Campus

POLICIES. Austin Peay State University. Animals on Campus Page 1 Austin Peay State University Animals on Campus POLICIES Issued: (Date President approves policy) Responsible Vice President for Student Affairs and General Official: Counsel Office of Student Affairs

More information

DISCLAIMER: ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.

DISCLAIMER: ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics. DISCLAIMER: Video will be taken at this clinic and potentially used in Project ECHO promotional materials. By attending this clinic, you consent to have your photo taken and allow Project ECHO to use this

More information

Prescribers, trained nurses and pharmacists.

Prescribers, trained nurses and pharmacists. Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Author: Contact Name and Job Title Directorate & Speciality Date of submission June 2015 Explicit definition of

More information

Non-Clinical Benefits of Evidence-Based Veterinary Medicine

Non-Clinical Benefits of Evidence-Based Veterinary Medicine Non-Clinical Benefits of Evidence-Based Veterinary Medicine A Knowledge Summary by Sarah Hauser BSc (Hons) MPA MPP 1* Elizabeth L. Jackson BAg (Hons) MBA PhD SFHEA 1 1 Royal Veterinary College, 4 Royal

More information

Minimally invasive repair of pectus excavatum (the Nuss procedure) in Poland and worldwide a summary of 25 years of history

Minimally invasive repair of pectus excavatum (the Nuss procedure) in Poland and worldwide a summary of 25 years of history DOI: 10.5114/kitp.2013.34304 Minimally invasive repair of pectus excavatum (the Nuss procedure) in Poland and worldwide a summary of 25 years of history Adam J. Białas, Bogumiła Kempińska-Mirosławska Department

More information

Veterinary Assistant Course Curriculum

Veterinary Assistant Course Curriculum Semester 1 (32 Hours) Course Prefix & No. VAC100 Course Title: Intro to Veterinary Assistant Course None 5 (5 1-hr classes) Introduction to role of the Veterinary Assistant, client education & communication,

More information

Antimicrobial Stewardship Strategy:

Antimicrobial Stewardship Strategy: Antimicrobial Stewardship Strategy: Prospective audit with intervention and feedback Formal assessment of antimicrobial therapy by trained individuals, who make recommendations to the prescribing service

More information

LANAnC64 - SQA Unit Code HA8F 04 Carry out the implantation of a microchip in an animal

LANAnC64 - SQA Unit Code HA8F 04 Carry out the implantation of a microchip in an animal LANAnC64 - SQA Unit Code HA8F 04 Carry out the implantation of a microchip in an animal Overview This standard covers carrying out the implantation of a microchip in an animal. It includes preparation,

More information

Surgery of pulmonary hydatid cystthe Barrett technique

Surgery of pulmonary hydatid cystthe Barrett technique Surgery of pulmonary hydatid cystthe Barrett technique IVAN LICHTER Department of Surgery, University of Otago Medical School, Dunedin, New Zealand Thorax (1972), 27, 529. A number of methods have been

More information

SHC Surgical Antimicrobial Prophylaxis Guidelines

SHC Surgical Antimicrobial Prophylaxis Guidelines SHC Surgical Antimicrobial Prophylaxis Guidelines I. Purpose/Background This document is based upon the 2013 consensus guidelines from American Society of Health-System Pharmacists (ASHP), the Infectious

More information

IEEE Std 592 Test Program using Current Cable Accessories and Installation Practices

IEEE Std 592 Test Program using Current Cable Accessories and Installation Practices IEEE Std 592 Test Program using Current Cable Accessories and Installation Practices Thomas J. Parker GTRC 1 Notice a. The material contained herein is, to our knowledge, accurate and reliable at the date

More information

Dry Eye Keratoconjunctivitis sicca (KCS)

Dry Eye Keratoconjunctivitis sicca (KCS) House Paws Home Veterinary Care (651) 283-7216 housepawsmn@gmail.com Dry Eye Keratoconjunctivitis sicca (KCS) Our veterinarian has diagnosed your dog with keratoconjunctivitis sicca (KCS), more simply

More information

UW-Green Bay Emotional Support Animal Policy (University Housing) OP

UW-Green Bay Emotional Support Animal Policy (University Housing) OP Amended by: Vice-Chancellor-Student Affairs Date: Eric Arneson, Vice-Chancellor Approved by Cabinet August 2, 2016 Amended February 27, 2017 UW-Green Bay Emotional Support Animal Policy (University Housing)

More information

Why Do Dog Breeds with Genetic Disorders Suddenly Get Hot?

Why Do Dog Breeds with Genetic Disorders Suddenly Get Hot? The Animal Studies Repository From the SelectedWorks of Harold Herzog, Ph.D. February 24, 2017 Why Do Dog Breeds with Genetic Disorders Suddenly Get Hot? Harold Herzog, Western Carolina University Available

More information

THE VERTEBRAL HEART SCORE (VHS) measurement has

THE VERTEBRAL HEART SCORE (VHS) measurement has VERTEBRAL HEART SCORES IN EIGHT DOG BREEDS K. JEPSEN-GRANT, R.E.POLLARD, L.R.JOHNSON The vertebral heart score (VHS) measurement is commonly used to provide a more objective measurement of cardiomegaly

More information

Animal Care Best Management Practices

Animal Care Best Management Practices 2013 Animal Care Best Management Practices NTF published its first guidelines on the care of turkeys in 1990 and has continued to update its members with new information ever since. To do this, NTF has

More information

Appropriate Antibiotic Administration in Elective Surgical Procedures: Still Missing the Message

Appropriate Antibiotic Administration in Elective Surgical Procedures: Still Missing the Message Original Article Appropriate Antibiotic Administration in Elective Surgical Procedures: Still Missing the Message Yunus A. Gul, Lim Chong Hong and Subhita Prasannan, Department of General Surgery, University

More information

WHO Guideline for Management of Possible Serious Bacterial Infection (PSBI) in neonates and young infants where referral is not feasible

WHO Guideline for Management of Possible Serious Bacterial Infection (PSBI) in neonates and young infants where referral is not feasible WHO Guideline for Management of Possible Serious Bacterial Infection (PSBI) in neonates and young infants where referral is not feasible Department of Maternal, Newborn, Child & Adolescent Health Newborn

More information

PACKAGE LEAFLET: INFORMATION FOR THE USER. GENTAMICIN VISION 3 mg/g eye ointment Gentamicin

PACKAGE LEAFLET: INFORMATION FOR THE USER. GENTAMICIN VISION 3 mg/g eye ointment Gentamicin PACKAGE LEAFLET: INFORMATION FOR THE USER GENTAMICIN VISION 3 mg/g eye ointment Gentamicin Read all of this leaflet carefully before you start using this medicine. - Keep this leaflet. You may need to

More information

CHRONIC NON-HEALING STUMP GRANULOMA ON A DOCKTED TAIL OF A DOBERMAN PINTURE

CHRONIC NON-HEALING STUMP GRANULOMA ON A DOCKTED TAIL OF A DOBERMAN PINTURE CHRONIC NON-HEALING STUMP GRANULOMA ON A DOCKTED TAIL OF A DOBERMAN PINTURE PRESENTATION & HISTORY One-year-old Female Neutered Doberman Pincher weighing 32kg presented with a chronic non-healing wound

More information

LABORATORY EXERCISE 7: CLADISTICS I

LABORATORY EXERCISE 7: CLADISTICS I Biology 4415/5415 Evolution LABORATORY EXERCISE 7: CLADISTICS I Take a group of organisms. Let s use five: a lungfish, a frog, a crocodile, a flamingo, and a human. How to reconstruct their relationships?

More information

FINAL DECISION AND SECTION 43 STATEMENT TO THE VETERINARY COUNCIL BY THE COMPLAINTS ASSESSMENT COMMITTEE Dr B. CAC (Complaint by Mr A)

FINAL DECISION AND SECTION 43 STATEMENT TO THE VETERINARY COUNCIL BY THE COMPLAINTS ASSESSMENT COMMITTEE Dr B. CAC (Complaint by Mr A) FINAL DECISION AND SECTION 43 STATEMENT TO THE VETERINARY COUNCIL BY THE COMPLAINTS ASSESSMENT COMMITTEE Dr B CAC2-12-06 (Complaint by Mr A) Mr A Dr B C Ms D E Complainant Veterinarian complained against

More information

European Regional Verification Commission for Measles and Rubella Elimination (RVC) TERMS OF REFERENCE. 6 December 2011

European Regional Verification Commission for Measles and Rubella Elimination (RVC) TERMS OF REFERENCE. 6 December 2011 European Regional Verification Commission for Measles and Rubella Elimination (RVC) TERMS OF REFERENCE 6 December 2011 Address requests about publications of the WHO Regional Office for Europe to: Publications

More information

Surgical Antibiotic Prophylaxis: What Happens When SCIP Skips the Evidence Base?

Surgical Antibiotic Prophylaxis: What Happens When SCIP Skips the Evidence Base? Surgical Antibiotic Prophylaxis: What Happens When SCIP Skips the Evidence Base? NOTIFICATIONS CHART Institute, LLC is an approved provider of continuing nursing education by the Pennsylvania State Nurses

More information

NSIP EBV Notebook June 20, 2011 Number 2 David Notter Department of Animal and Poultry Sciences Virginia Tech

NSIP EBV Notebook June 20, 2011 Number 2 David Notter Department of Animal and Poultry Sciences Virginia Tech NSIP EBV Notebook June 20, 2011 Number 2 David Notter Department of Animal and Poultry Sciences Virginia Tech New Traits for NSIP Polypay Genetic Evaluations Introduction NSIP recently completed reassessment

More information

Pre-operative Instructions

Pre-operative Instructions Pre-operative Instructions Please read the following instructions carefully, as any animal that does not meet the outlined physical parameters for surgery (over/underweight, undisclosed medical conditions,

More information

Executive Summary: A Point Prevalence Survey of Antimicrobial Use: Benchmarking and Patterns of Use to Support Antimicrobial Stewardship Efforts

Executive Summary: A Point Prevalence Survey of Antimicrobial Use: Benchmarking and Patterns of Use to Support Antimicrobial Stewardship Efforts Executive Summary: A Point Prevalence Survey of Antimicrobial Use: Benchmarking and Patterns of Use to Support Antimicrobial Stewardship Efforts Investigational Team: Diane Brideau-Laughlin BSc(Pharm),

More information

Developed by Kathy Wonderly RN, MSEd,CPHQ Developed: October 2009 Most recently updated: December 2014

Developed by Kathy Wonderly RN, MSEd,CPHQ Developed: October 2009 Most recently updated: December 2014 Developed by Kathy Wonderly RN, MSEd,CPHQ Developed: October 2009 Most recently updated: December 2014 The Center for Medicare and Medicaid (CMS) is moving away from collecting data on the process of care

More information

Measure #21 (NQF 0268): Perioperative Care: Selection of Prophylactic Antibiotic First OR Second Generation Cephalosporin

Measure #21 (NQF 0268): Perioperative Care: Selection of Prophylactic Antibiotic First OR Second Generation Cephalosporin Measure #21 (NQF 0268): Perioperative Care: Selection of Prophylactic Antibiotic First OR Second Generation Cephalosporin 2013 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION: Percentage

More information

Post-operative surgical wound infection

Post-operative surgical wound infection Med. J. Malaysia Vol. 45 No. 4 December 1990 Post-operative surgical wound infection Yasmin Abu Hanifah, MBBS, MSc. (London) Lecturer Department of Medical Microbiology, Faculty of Medicine, University

More information

S aureus infections: outpatient treatment. Dirk Vogelaers Dept of Infectious Diseases University Hospital Gent Belgium

S aureus infections: outpatient treatment. Dirk Vogelaers Dept of Infectious Diseases University Hospital Gent Belgium S aureus infections: outpatient treatment Dirk Vogelaers Dept of Infectious Diseases University Hospital Gent Belgium Intern Med J. 2005 Feb;36(2):142-3 Intern Med J. 2005 Feb;36(2):142-3 Treatment of

More information

DRAFT. Code of Practice for the Care of Dogs in New Brunswick. The New Brunswick Society for the Prevention of Cruelty to Animals.

DRAFT. Code of Practice for the Care of Dogs in New Brunswick. The New Brunswick Society for the Prevention of Cruelty to Animals. DRAFT Code of Practice for the Care of Dogs in New Brunswick The New Brunswick Society for the Prevention of Cruelty to Animals Published 2015 (Note: The New Brunswick SPCA invites comments from the public

More information

Acinetobacter baumannii mediastinitis after cardiopulmonary bypass: case report and literature review

Acinetobacter baumannii mediastinitis after cardiopulmonary bypass: case report and literature review University of Wollongong Research Online Faculty of Science, Medicine and Health - Papers Faculty of Science, Medicine and Health 2008 Acinetobacter baumannii mediastinitis after cardiopulmonary bypass:

More information

Health and Welfare of Resreach Animals. Richard E. Brown Psychology Department Dalhousie University Halifax, Nova Scotia Canada B3H 4J1

Health and Welfare of Resreach Animals. Richard E. Brown Psychology Department Dalhousie University Halifax, Nova Scotia Canada B3H 4J1 Health and Welfare of Resreach Animals Richard E. Brown Psychology Department Dalhousie University Halifax, Nova Scotia Canada B3H 4J1 What is Animal Welfare? Concern for the well-being of research animals

More information

McHenry Western Lake County EMS System Mandatory CE for Paramedics, EMT-B and PHRN s Active Shooter Bag Online CE 2016

McHenry Western Lake County EMS System Mandatory CE for Paramedics, EMT-B and PHRN s Active Shooter Bag Online CE 2016 McHenry Western Lake County EMS System Mandatory CE for Paramedics, EMT-B and PHRN s Active Shooter Bag Online CE 2016 This Continuing Education will look at the new Active Shooter Bag contents. Remember,

More information

Critical appraisal Randomised controlled trial questions

Critical appraisal Randomised controlled trial questions Critical appraisal Randomised controlled trial questions Korpivaara, M., Laapas, K., Huhtinen, M., Schoning, B., Overall, K. (2017) Dexmedetomidine oromucosal gel for noise-associated acute anxiety and

More information

PHYSIOLOGIC AND GENETIC STUDIES OF CROOKED KEELS IN CHICKENS

PHYSIOLOGIC AND GENETIC STUDIES OF CROOKED KEELS IN CHICKENS PHYSIOLOGIC AND GENETIC STUDIES OF CROOKED KEELS IN CHICKENS SUMMARY 1. In most instances, birds developing crooked keels will do so before maturity. Most of the keel deformities appear between the 6-

More information

MANAGEMENT STRATEGIES FOR ORTHOPEDIC IMPLANT-ASSOCIATED INFECTIONS. 5-6 March 2018 Berlin Germany. Endorsed by:

MANAGEMENT STRATEGIES FOR ORTHOPEDIC IMPLANT-ASSOCIATED INFECTIONS. 5-6 March 2018 Berlin Germany. Endorsed by: MANAGEMENT STRATEGIES FOR ORTHOPEDIC IMPLANT-ASSOCIATED INFECTIONS 5-6 March 2018 Berlin Germany Endorsed by: Dear colleagues, It is our great pleasure to invite you to the first workshops on orthopedic

More information

Are Dogs That Are Fed from a Raised Bowl at an Increased Risk of Gastric Dilation Volvulus Compared with Floor-Fed Dogs?

Are Dogs That Are Fed from a Raised Bowl at an Increased Risk of Gastric Dilation Volvulus Compared with Floor-Fed Dogs? Are Dogs That Are Fed from a Raised Bowl at an Increased Risk of Gastric Dilation Volvulus Compared with Floor-Fed Dogs? A Knowledge Summary by Louise Buckley PhD RVN 1* 1 Harper Adams University, Edgmond,

More information

SUPER TRAINER EZT SERIES

SUPER TRAINER EZT SERIES TM SUPER TRAINER EZT SERIES Electronic Dog Trainer Owner s Manual EZT 1000 EZT 1002 EZT 1003 EZT 2000 EZT 2002 EZT 2003 EZT 3000 EZT 3002 D.T. SYSTEMS, INC. Congratulations and Thank you for purchasing

More information

Dog Evaluation Book PROJECT AGREEMENT

Dog Evaluation Book PROJECT AGREEMENT Dog Evaluation Book PROJECT AGREEMENT I (the 4-H member) will be responsible for the primary care of my animal project. I will keep accurate records throughout the project year and agree to finish this

More information

Barbara French, Vice Chancellor, Strategic Communications & University Relations, University of California, San Francisco

Barbara French, Vice Chancellor, Strategic Communications & University Relations, University of California, San Francisco November 27, 2012 UCSF Statement on Its Animal Care and Research Program: Barbara French, Vice Chancellor, Strategic Communications & University Relations, University of California, San Francisco The University

More information

ADULT CLIENT APPLICATION AND MEDICAL HISTORY LOVING ANGEL SERVICE DOGS, INC. PLEASE PRINT CLEARLY

ADULT CLIENT APPLICATION AND MEDICAL HISTORY LOVING ANGEL SERVICE DOGS, INC. PLEASE PRINT CLEARLY ADULT CLIENT APPLICATION AND MEDICAL HISTORY PLEASE PRINT CLEARLY GENERAL First Name Last Name Street Address City State Zip Home Phone Cell Phone (Including Area Code) E-Mail Date of birth (mm/dd/yyyy)

More information

1 SUPERFICIAL SURGICAL-SITE INFECTIONS COLORECTAL

1 SUPERFICIAL SURGICAL-SITE INFECTIONS COLORECTAL 1 SUPERFICIAL SURGICAL-SITE INFECTIONS COLORECTAL Pathway 1 COLORECTAL * Diverting Stoma * No diversion For 2 weeks 1. CBC SUPER- FICIAL INCISIONAL + Wound vacuum Discharge to Home Out patient follow up

More information

Chapter 13 First Year Student Recruitment Survey

Chapter 13 First Year Student Recruitment Survey Chapter 13 First Year Student Recruitment Survey Table of Contents Introduction...... 3 Methodology.........4 Overall Findings from First Year Student Recruitment Survey.. 7 Respondent Profile......11

More information

Necrotizing Soft Tissue Infections: Emerging Bacterial Resistance

Necrotizing Soft Tissue Infections: Emerging Bacterial Resistance Necrotizing Soft Tissue Infections: Emerging Bacterial Resistance Eileen M. Bulger, MD Professor of Surgery Harborview Medical Center University of Washington Objectives Review definition & diagnostic

More information

Indication for laser acupuncture, body and ear acupuncture treatment

Indication for laser acupuncture, body and ear acupuncture treatment 108 Indication for laser acupuncture, body and ear acupuncture treatment Orthopedics 1. Back pain 2. Tying up 3. Acute lameness, distortion and contusion 4. Acute and chronic laminitis 5. Acute and chronic

More information

Methicillin-resistant Staphylococcus aureus infection in a cardiac surgical unit

Methicillin-resistant Staphylococcus aureus infection in a cardiac surgical unit Methicillin-resistant Staphylococcus aureus infection in a cardiac surgical unit Michel Carrier, MD a Richard Marchand, MD b,c Pierre Auger, MD b,c Yves Hébert, MD a Michel Pellerin, MD a Louis P. Perrault,

More information

COLLEGE OF VETERINARY MEDICINE

COLLEGE OF VETERINARY MEDICINE Title: A randomized, masked, placebo controlled field study to determine efficacy and safety of Paccal Vet in dogs with non resectable (or unresected) mammary carcinoma of stage III-V 1. Why is the study

More information