Research and Publications

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In the years since Dr. Donald Nuss developed the groundbreaking, minimally invasive surgery to correct pectus excavatum, CHKD has performed more than 1,800 surgeries to correct the condition, far more than any other center.

Because of the number of patients treated and the data gathered, CHKD has also become a worldwide center for pectus research.

Below you'll find some of the articles published by CHKD-affiliated surgeons, geneticists and radiologists, often in collaboration with resident physicians and researchers affiliated with Eastern Virginia Medical School, CHKD’s academic partner.

February 2014

Journal of Pediatric Surgery
High rates of metal allergy amongst Nuss procedure patients dictate broader pre-operative testing
CHKD-affiliated authors: Bhairav Shah, Amy Cohee, Cynthia Kelly, Frazier Frantz, Robert E. Kelly, Marcia A. Kuhn, Michele Lombardo, Robert Obermeyer, Michael J. Goretsky

A previous study from our group estimated that as few as 2.2% of pectus excavatum patients suffered from allergy to the implanted metal bar. We sought to assess recent changes in incidence of metal allergy and identify the benefit of metal allergy testing prior to surgery.

June 2013

American College of Surgeons
Multicenter Study of Pectus Excavatum, Final Report: Complications, Static/Exercise Pulmonary Function, and Anatomic Outcomes
CHKD-affiliated authors: Robert E. Kelly, Karen Mitchell, Donald Nuss, Michael Goretsky, Traci Bagley, Amy Quinn, Alan Moskowitz

A multicenter study of pectus excavatum was described previously. This report presents our final results.

February 2013

Journal of Pediatric Surgery
Staged management of pectus carinatum
CHKD-affiliated authors: Robert E. Kelly, Frazier Frantz

The aim was to report the treatment of pectus carinatum with a novel argentine brace and operation.

December 2012

Arch Bronconeumol
Dysmorphology of Chest Wall Deformities: Frequently Distribution of Subtypes of Typical Pectus Excavatum and Rare Subtypes
CHKD-affiliated author: Robert E. Kelly

More than 40 percent of patients with pectus excavatum have a family history of chest deformity. However, no studies of the frequency of the different phenotypes of pectus excavatum have been published.

August 2012

Journal of Pediatric Genetics
Advancing our understanding of the inheritance and transmission of pectus excavatum
CHKD-affiliated author: Lisa Horth, Michael W. Stacey, Virginia K. Proud, Kara Segna, Chelsea Rutherford, Donald Nuss and Robert E. Kelly

Pectus excavatum is the most common congenital chest wall abnormality expressed in children, yet its inheritance is poorly understood. Here we present the first comprehensive assessment of the inheritance of this disorder. After evaluating 48 pedigrees and 56 clinical traits of probands and family members, we find strong evidence of autosomal recessive, genetic control for this disorder.

June 2012

Surgical Clinics of North America, Volume 92, Issue 3 (June 2012)
Chest Wall Deformities in Pediatric Surgery in Surgical Clinics of North America
CHKD-affiliated author: Dr. Michael J. Goretsky, Dr. Robert J. Obermeyer

Chest wall deformities can be divided into 2 main categories, congenital and acquired. Congenital chest wall deformities may present any time between birth and early adolescence. Acquired chest wall deformities typically follow prior chest surgery or a posterolateral diaphragmatic hernia repair (Bochdalek). The most common chest wall deformities are congenital pectus excavatum (88%) and pectus carinatum (5%). This article addresses the etiology, pathophysiology, clinical evaluation, diagnosis, and management of these deformities.

January 2012

Journal of Pediatrics, Volume 47, Issue 1 (January 2012)
Optoelectronic plethysmography demonstrates abrogation of regional chest wall motion dysfunction in patients with pectus excavatum after Nuss repair.
CHKD-affiliated authors: Dr. Michael J. Goretsky, Dr. Robert E. Kelly, Jr., Dr. Robert J. Obermeyer, Dr. Donald Nuss

We previously demonstrated that patients with pectus excavatum (PE) have significantly decreased chest wall motion at the pectus defect compared with the rest of the chest vs unaffected individuals and use abdominal respiratory contributions to compensate for decreased upper chest wall motion. We hypothesize that PE repair will reverse chest wall motion dysfunction.

August 2011

Journal of Pediatrics, Volume 159, Issue 2 ( August 2011)
Increasing severity of pectus excavatum is associated with reduced pulmonary function.
CHKD-affiliated authors: Dr. Michael J. Goretsky, Dr. Robert E. Kelly, Jr., Dr. Donald Nuss

Surgical planners are used to achieve the optimal outcome for a surgery, especially in procedures where a positive aesthetic outcome is the primary goal, such as the Nuss procedure which is a minimally invasive surgery for correcting pectus excavatum (PE)--a congenital chest wall deformity. Although this procedure is routinely performed, the outcome depends mostly on the correct placement of the bar. It would be beneficial if a surgeon had a chance to practice and review possible strategies for placement of the corrective bar and the associated appearance of the chest. Therefore, we propose a strategy for the development and validation of a Nuss procedure surgical trainer and planner.

June 2011

Journal of Pediatric Surgery, Volume 46, Issue 6 (June 2011)
One hundred patients with recurrent pectus excavatum repaired via the minimally invasive Nuss technique--effective in most regardless of initial operative approach.
CHKD-affiliated authors: Dr. Robert E. Kelly, Jr., Dr. Donald Nuss, Dr. Michael J. Goretsky, Dr. M. Ann Kuhn, Dr. Robert J. Obermeyer

Controversy exists as to the best operative approach to use in patients with failed pectus excavatum (PE) repair. We examined our institutional experience with redo minimally invasive PE repair along with the unique issues related to each technique. We conducted an institutional review board-approved review of a prospectively gathered database of all patients who underwent minimally invasive repair of PE. The minimally invasive NUS technique is safe and effective for the correction of recurrent PE. Patients with prior NUS repair can have extensive pleural adhesions necessitating decortication during secondary repair. Patients with a previous RAV repair may have acquired thoracic chondrodystrophy that may require a greater number of pectus bars to be placed at secondary repair and greater risk for complications. We have a greater than 95% success rate regardless of initial repair technique.

Journal of Pediatric Surgery, Volume 46, Issue 6 (June 2011)
Regional chest wall motion dysfunction in patients with pectus excavatum demonstrated via optoelectronic plethysmography.
CHKD-affiliated authors: Dr. Michael J. Goretsky, Dr. M. Ann Kuhn Dr. Robert E. Kelly, Jr., Dr. Donald Nuss, Dr. Robert Obermeyer

Paradoxical chest wall motion is recognized clinically in pectus excavatum (PE). We report chest wall volume and motion differences between PE patients and unaffected individuals.

2011

Studies In Health Technology And Informatics, Volume 163 (2011)
A design for simulating and validating the nuss procedure for the minimally invasive correction of pectus excavatum.
CHKD-affiliated authors: Dr. Michael J. Goretsky, Dr. Robert E. Kelly, Jr., Dr. Frazier W. Frantz

Surgical planners are used to achieve the optimal outcome for a surgery, especially in procedures where a positive aesthetic outcome is the primary goal, such as the Nuss procedure which is a minimally invasive surgery for correcting pectus excavatum (PE)-a congenital chest wall deformity. Although this procedure is routinely performed, the outcome depends mostly on the correct placement of the bar. It would be beneficial if a surgeon had a chance to practice and review possible strategies for placement of the corrective bar and the associated appearance of the chest. Therefore, we propose a strategy for the development and validation of a Nuss procedure surgical trainer and planner.

December 2010

Annals of Surgery, Volume 252, Issue 6
Twenty-one Years of experience with Minimally Invasive Repair of Pectus Excavatum by the Nuss Procedure in 1215 Patients.
CHKD-affiliated authors: Robert Kelly, Michael Goretsky, Robert Obermeyer, M. Ann Kuhn, Richard Redlinger, Donald Nuss

CHKD surgeons have performed minimally invasive surgery on 1,215 patients to correct pectus excavatum since 1987, when the technique was pioneered by surgeon Donald Nuss. This article focuses on refinements developed over the last two decades that have increased both its safety and success.

November 2010

Clinical Genetics, Volume 78, Issue 5
Variable Number of Tandem Repeat Polymorphisms (VNTR’s) in the ACAN Gene Associated with Pectus Excavatum.
CHKD-affiliated authors – Michael Stacey, Robert Kelly, M. Ann Kuhn, Michael Goretsky, Virginia Proud

In an ongoing effort to determine a genetic cause of pectus excavatum, researchers looked for defects in a gene that helps build the cellular scaffolding of human cartilage. Although no correlation was found between the gene and pectus excavatum using the technique the researchers employed, researchers are continuing to look for a genetic causes of pectus excavatum, which often runs in families.

January 2010

Journal of Pediatric Surgery, Volume 45, Issue 1
Minimally Invasive Repair of Pectus Excavatum in Patients with Marfan Syndrome and Marfanoid Features.
CHKD-affiliated authors – Richard Redlinger, Gregory Rushing, Robert Kelly, Robert Obermeyer, Michael Goretsky

The presence of a pectus excavatum requiring surgical repair is a major skeletal feature of Marfan syndrome, a rare disorder of connective tissue that strengthens the body's structures. This research reviewed surgical records of patients with Marfan syndrome or Marfanioid features and determined that such patients tend to have more severe pectus excavatum requiring multiple bars for chest repair. The review also documents that the minimally invasive procedure is safe and effective despite the severity of the defect.

Annals of Surgery (Accepted) (no month listed)

Twenty-one Years of experience with Minimally Invasive Repair of Pectus Excavatum by the Nuss Procedure in 1215 Patients

Authors – Robert E. Kelly, Jr., M.D., Michael J. Goretsky, M.D., Robert Obermeyer, M.D., M. Ann Kuhn, M.D., Richard Redlinger M.D., Tina S. Haney R.N, M.S.N., Alan Moskowitz, M. Stat., Donald Nuss, M.B., Ch.B.

Clinical Genetics (Accepted) (no month listed)

Variable Number of Tandem Repeat Polymorphisms (VNTR’s) in the ACAN Gene Associated with Pectus Excavatum.

Authors – Stacey M, Neumann SA, Dooley A, Segna K, Kelly Jr RE, Kuhn MA, Goretsky MJ, Fecteau AH, Pastor A, Proud V.

December 2008

Pediatrics, Volume 22, Issue 6
The Surgical Repair of Pectus Excavatum Markedly Improves Body Image and Perceived Ability for Physical Activity; Multicenter Study
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky, Karen Mitchell, Amy Quinn

Patients who have had pectus excavatum correct often report an improved body image and ability to exercise, including some who have excelled in competitive sports. While those cases are anecdotal, this study documented the improved body image and decreased problems exercising with research conducted at 11 North American hospitals.

September 2008

Advances in Pediatrics, Volume 55, issue 1
Minimally Invasive Surgical Correction of Chest Wall Deformities in Children
CHKD-affiliated authors: Donald Nuss, Robert Kelly

This study discusses the entire pectus surgery process including evaluation, surgical correction and long-term outcomes.

August 2008

Seminars in Pediatric Surgery, Volume 17, Issue 3
Chest Wall Deformities

In recognition of their critical roles in developing cutting-edge treatment of chest wall deformities such as pectus carinatum and pectus excavatum, the journal Seminars in Pediatric Surgery tapped CHKD Surgeons Dr. Donald Nuss and Dr. Robert Kelly to edit an August, 2008, issue focusing on surgery to correct the anomalies. Nuss and Kelly recruited surgeons to author the articles and edited the entire journal. They also wrote a preface and two articles,  Pectus Excavatum: Historical Background, Clinical Picture, Preoperative Evaluation and Criteria for Operation by Kelly and Minimally Invasive Surgical Repair of Pectus Excavatum by Nuss.

September 2007

Contemporary Surgery, Volume 63, Issue 9
Our approach: MIS repair of pectus excavatum

This manuscript describes the experience in 939 patients over a twenty year time frame — showing a good to excellent long term outcome in 96% of the patients.

August 2007

Journal of American College of Surgeons: Volume 205, Issue 2
Prospective Multicenter Study of Surgical Correction of Pectus Excavatum: Design, Perioperative Complications, Pain, and Baseline Pulmonary Function Facilitated by Internet-Based Data Collection
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky and nurse Traci Bagley

Given widespread adoption of the Nuss procedure, researchers thought it would be valuable to examine and compare the results of pectus correction at various centers around the nation. They compared results in 327 patients treated at 11 centers in North America. Of those patients, 284 underwent the Nuss procedure and 43 had the open surgery that was the previous standard of care. While the small number who had the older procedure made meaningful comparisons between the two groups impossible, the case review confirmed that pectus patients overall showed depressed lung function before the surgery and that the surgical techniques developed by Nuss were safe and effective.

July 2007

The Japanese Journal of Thoracic and Cardiovascular Surgery
Recent experiences with minimally invasive pectus excavatum repair “Nuss procedure”
CHKD-affiliated authors: Donald Nuss

With the Nuss procedure becoming more common in Japan, the Japanese Journal of Thoracic and Cardiovascular Surgery published an article by Dr. Nuss on techniques and outcomes in 688 cases.

October 2006

Journal of Pediatric Surgery, Volume 41, Issue 10
Family study of the inheritance of pectus excavatum
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky, Virginia Proud and Karen Mitchell

CHKD clinicians reviewed 34 cases of pectus excavatum and confirmed anecdotal observations that many cases appear to have a genetic basis. They also observed other disorders – and Ehlers Danlos syndrome – that often occur along with pectus excavatum, as well as benign physical traits such as long arms and legs and high-arched palates.

September 2006

Journal of Pediatric Surgery: Volume 41, Issue 9
Classification of the dysmorphology of pectus excavatum
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky, geneticist Virginia Proud and nurse Karen Mitchell

CHKD researches, surgeons and nurses examined the case files and clinical findings in 64 pectus patients to gather epidemiological information such as the incidence in males and females, the age the problem presented itself and the different forms of the condition, including the length, shape and the location of the depressed portion of the chest.

August 2006

Journal of Pediatric Surgery: Volume 40, Issue 8
Pectus excavatum in a 112-year autopsy series: anatomic findings and the effect on survival
CHKD-affiliated authors: Robert Kelly

Researchers based at CHKD performed a computer-assisted examination of 50,496 autopsies conducted at Johns Hopkins Hospital over a 112-year period and found evidence of pectus excavatum in 62 patients. Although a subset of pectus patients who lived beyond 56 years of age tended to outlive matched counterparts, pectus patients overall tended to die younger.

July 2006

Journal of Pediatric Surgery: Volume 41, Issue 7
Reliability of a standardized protocol to calculate cross-sectional chest area and severity indices to evaluate pectus excavatum
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky

Surgeons must evaluate all patients with pectus excavatum to determine if the case is serious enough to warrant surgery. In this paper, surgeons demonstrate that a protocol developed at CHKD to evaluate prospective pectus patients is as useful as a standard evaluation regimen used by surgeons at other hospitals.

January 2005

Journal of Pediatric Surgery, Volume 40, Issue 1
Impact of pectus excavatum on pulmonary function before and after repair with the Nuss procedure
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky

While post-operative pectus patients have reported increases in exercise tolerance, no laboratory study confirmed improved physical capabilities in patients who have undergone the Nuss procedure. This study uses pulmonary function tests to document increased lung function in patients after pectus surgery.

October 2004

Adolescent Medicine Clinics, Volume 15, Issue 3
Chest wall anomalies: pectus excavatum and pectus carinatum
CHKD-affiliated authors: Donald Nuss, Robert Kelly and Michael Goretsky

Nuss and CHKD surgeons discuss the formation of chest wall deformities such as pectus excavatum and pectus carinatum, offering additional evidence that the pectus excavatum is more than a cosmetic anomaly.

June 2003

Pediatric Surgery, Volume 38, Issue 6
A pilot study of the impact of surgical repair on disease-specific quality of life among patients with pectus excavatum
CHKD-affiliated authors: Donald Nuss, Robert Kelly and Michael Goretsky

To address a common perception that pectus excavatum was largely a cosmetic problem, a team of surgeons and researchers interviewed 22 patients and their parents before and after surgery and documented reports of increased exercise tolerance, decreased shortness of breath and fewer incidents in which patients reported feeling tired, sad, frustrated or isolated.

May 2002

Journal of Pediatric Surgery, Volume 37, Issue 3
Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky

During the course of treating hundreds of patients using the new surgical technique, Nuss and fellow surgeons developed number of modifications. This article reviews technical changes developed from 1998 to 2002.

January 2002

Cirugia Pediátrica, Enero 2002, Volume 15 (1) (Publication of the Spanish Society of Pediatric Surgeons)
Reparación mínimamente invasiva del pectus excavatum (“Minimally invasion repair of pectus excavatum”)
CHKD-affiliated authors: Donald Nuss

With the Nuss procedure growing popular around the world, the Spanish Society of Pediatric Surgery published and translated an article by Nuss on the new technique.

May 2001

Pediatric Radiology, Volume 31, Number 6
Radiologic considerations in patients undergoing the Nuss procedure for correction of pectus excavatum.
CHKD-affiliated authors: Donald Nuss

Correction of pectus excavatum using the Nuss technique involves not just the surgeon but a complete medical team, including the radiologists who evaluate the severity of the cases and also the extent of the correction. In this study, Nuss and CHKD radiologists present techniques they’ve developed to evaluate the surgical, pulmonary and cardiac functions of patients before and after surgery.

February 2000

Journal of Pediatric Surgery: Volume 35, Issue 2
Outcome analysis of minimally invasive repair of pectus excavatum: Review of 251 cases
CHKD-affiliated authors: Donald Nuss

By 2000, the minimally invasive surgical techniques for pectus excavatum developed by Dr. Donald Nuss had grown increasingly common, but no published studies had documented the outcomes with a large number of patients. In this study, Nuss and a team of surgeons from around the nation analyzed the outcomes in 251 cases.

Book Chapters

2008

“Pectus Deformities” in Fundamentals of Pediatric Surgery, Springer (In Press).
CHKD-affiliated authors: Ann Kuhn, Donald Nuss

“Minimally Invasive Surgical Correction of Chest Wall Deformities in Children (Nuss Procedure)” in Advances in Pediatrics, Vol 55, Elsevier.
CHKD-affiliated authors: Robert Kelly and Donald Nuss

“Thoracic Wall Deformities” in Thoracic Wall deformities – Diagnosis and Therapy, Springer.
CHKD-affiliated authors: Ann Kuhn, Donald Nuss

“Complications of Pectus Excavatum and Carinatum Repair” in Reoperative Pediatric Surgery, Humana Press.
CHKD-affiliated authors: Donald Nuss, Robert Kelly

“The Minimally Invasive Pectus Excavatum Repair (Nuss Procedure)” in Atlas of Pediatric Laparoscopy and Thorascopy, Saunders/Elsevier.
CHKD-affiliated authors: Donald Nuss, Robert Kelly

2007

“Chest Wall Deformities” in Pediatric Surgery: Diagnosis and Management, Springer.
CHKD-affiliated authors: Robert Kelly, Donald Nuss

“Complications of Thoracic Surgery” in Complications in Pediatric Surgery, Informa Healthcare USA.
CHKD-affiliated authors: Robert Kelly, Ann Kuhn

2006

“Pectus Excavatum” in Paediatric Thoracic Surgery, Springer.
CHKD-affiliated authors: Robert Kelly, Donald Nuss

"Chest Wall Deformities” in Pediatric Surgery and Urology Long-Term Outcomes (2nd ed.), Cambridge.
CHKD-affiliated authors: Donald Nuss, Robert Kelly

"The Nuss procedure for pectus excavatum” in Pediatric Surgery (6th ed.), Mosby Elsevier.
CHKD-affiliated authors: Donald Nuss, Robert Kelly

"Surgical treatment of chest wall deformities in children” in Operative Pediatric Surgery (6th ed), Hodder Arnold.
CHKD-affiliated authors: Michael Goretsky

2005

"Chest wall deformities” in Ashcraft’s Pediatric Surgery (4th ed.), Elsevier Saunders.
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky

Results and Outcomes

Patients undergoing surgery are monitored on an ongoing basis through our database in order to provide information on early results as well as on long-term outcomes.

For more information about pectus excavatum research at CHKD, contact Amy Quinn at 866-279-6430.

(757) 668-7703