Research and Publications

In the years since Dr. Donald Nuss developed a groundbreaking minimally invasive surgery to correct pectus excavatum – a deformity that causes the chest to collapse inward creating an indentation -- Children’s Hospital of The King’s Daughters has performed well over 1,000 surgeries for the condition, far more than any center. Because of the number of patients treated and the data gathered, CHKD has also become a worldwide center for pectus research.

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

Note: Click on the highlighted link to read the abstract.

February 2013

Journal of Pediatric Surgery
Staged management of pectus carinatum
CHKD-affiliated author: Dr. Robert Kelly, Dr. 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: Frequency Distribution of Subtypes of Typical Pectus Excavatum and Rare Subtypes.
CHKD-affiliated author: Dr. Robert Kelly

 More than forty 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.
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.
CHKD-affiliated authors: Dr. Michael J. Goretsky, Dr. Robert E. Kelly, Jr., Dr. Robert J. Obermeyer, Dr. Donald Nuss

August 2011


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

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.
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.
CHKD-affiliated authors: Dr. Robert E. Kelly, Jr., Dr. Donald Nuss, Dr. Michael J. Goretsky, Dr. M. Ann Kuhn, Dr. Robert J. Obermeyer

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

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.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.
CHKD-affiliated authors: Dr. Michael J. Goretsky, Dr. Robert E. Kelly, Jr., Dr. Frazier W. Frantz

December 2010


Annals of Surgery, Volume 252, Issue 6 (December 2010)
Twenty-one Years of experience with Minimally Invasive Repair of Pectus Excavatum by the Nuss Procedure in 1215 Patients.
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.
CHKD-affiliated authors: Robert Kelly, Michael Goretsky, Robert Obermeyer, M. Ann Kuhn, Richard Redlinger, Donald Nuss.

November 2010


Clinical Genetics, Volume 78, Issue 5 (November 2010).
Variable Number of Tandem Repeat Polymorphisms (VNTR’s) in the ACAN Gene Associated with Pectus Excavatum.
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.
CHKD-affiliated authors – Michael Stacey, Robert Kelly, M. Ann Kuhn, Michael Goretsky, Virginia Proud

January 2010


Journal of Pediatric Surgery, Volume 45, Issue 1 (January 2010)
Minimally Invasive Repair of Pectus Excavatum in Patients with Marfan Syndrome and Marfanoid Features.
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.
CHKD-affiliated authors – Richard Redlinger, Gregory Rushing, Robert Kelly, Robert Obermeyer, Michael Goretsky.

Annals of Surgery (Accepted) (no month listed as of yet)
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 as of yet)
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 (December 2008)
The Surgical Repair of Pectus Excavatum Markedly Improves Body Image and Perceived Ability for Physical Activity; Multicenter Study
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.
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky, Karen Mitchell, Amy Quinn

September 2008

Advances in Pediatrics, Volume 55, issue 1 (September 2008)
Minimally Invasive Surgical Correction of Chest Wall Deformities in Children
This study discusses the entire pectus surgery process including evaluation, surgical correction and long-term outcomes.
CHKD-affiliated authors: Donald Nuss, Robert Kelly

August 2008

Seminars in Pediatric Surgery, Volume 17, Issue 3. (August 2008)
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 (September 2007)
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 (August 2007)
Prospective Multicenter Study of Surgical Correction of Pectus Excavatum: Design, Perioperative Complications, Pain, and Baseline Pulmonary Function Facilitated by Internet-Based Data Collection
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.
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky and nurse Traci Bagley

July 2007

The Japanese Journal of Thoracic and Cardiovascular Surgery (July 2007):
Recent experiences with minimally invasive pectus excavatum repair “Nuss procedure”
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.
CHKD-affiliated authors: Donald Nuss

October 2006

Journal of Pediatric Surgery, Volume 41, Issue 10 (October 2006)
Family study of the inheritance of pectus excavatum
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.
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky, Virginia Proud and Karen Mitchell.

September 2006

Journal of Pediatric Surgery: Volume 41, Issue 9 (September 2006)
Classification of the dysmorphology of pectus excavatum
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.
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky, geneticist Virginia Proud and nurse Karen Mitchell.

August 2006

Journal of Pediatric Surgery: Volume 40, Issue 8 (August 2005)
Pectus excavatum in a 112-year autopsy series: anatomic findings and the effect on survival
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.
CHKD-affiliated authors: Robert Kelly

July 2006

Journal of Pediatric Surgery: Volume 41, Issue 7 (July 2006)
Reliability of a standardized protocol to calculate cross-sectional chest area and severity indices to evaluate pectus excavatum
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.
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky

January 2005

Journal of Pediatric Surgery, Volume 40, Issue 1 (January 2005)
Impact of pectus excavatum on pulmonary function before and after repair with the Nuss procedure
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.
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky

October 2004

Adolescent Medicine Clinics, Volume 15, Issue 3 (October 2004)
Chest wall anomalies: pectus excavatum and pectus carinatum
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.
CHKD-affiliated authors: Donald Nuss, Robert Kelly and Michael Goretsky

June 2003

Pediatric Surgery, Volume 38, Issue 6 (June 2003)
A pilot study of the impact of surgical repair on disease-specific quality of life among patients with pectus excavatum
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.
CHKD-affiliated authors: Donald Nuss, Robert Kelly and Michael Goretsky

May 2002

Journal of Pediatric Surgery, Volume 37, Issue 3 (March 2002)
Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients
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.
CHKD-affiliated authors: Donald Nuss, Robert Kelly, Michael Goretsky

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”)
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.
CHKD-affiliated authors: Donald Nuss

January 2001

Pediatric Radiology, Volume 31, Number 6 / May, 2001
Radiologic considerations in patients undergoing the Nuss procedure for correction of pectus excavatum.
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.
CHKD-affiliated authors: Donald Nuss

February 2000

Journal of Pediatric Surgery: Volume 35, Issue 2 (February 2000)
Outcome analysis of minimally invasive repair of pectus excavatum: Review of 251 cases
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.
CHKD-affiliated authors: Donald Nuss

Book Chapters

2009


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.