Academic Publications by CHKD Surgeons

Pectus Excavatum

Most Recent Articles

Seminars Pediatric Surgery (2023)
The past, present and future of ACS NSQIP-Pediatric: Evolution from a quality registry to a comparative quality performance platform.
CHKD Authors: Goretsky MJ

Conclusion: While a mature program, NSQIP-Pediatric remains dynamic and responsive to meet the needs of the surgical community. Future directions include introduction of variables and analyses to address patient-centered care and healthcare equity.

Annals of Surgery (2023)
Incidence and Relative Burden of Surgical Site Infections in Children Undergoing Non-Emergent Surger: Implications for Performance Benchmarking and Prioritization of Prevention Efforts
CHKD Authors: Goretsky MJ

Conclusions: A small number of procedures account for a disproportionate burden of SSIs in pediatric surgery. The results of this analysis can be used as a prioritization framework for refocusing SSI prevention efforts where they are needed most. 

Journal of Pediatric Surgery (2023)
Procedure-level Misutilization of Antimicrobial Prophylaxis in Pediatric Surgery: Implications for Improved Stewardship and More Effective Infection Prevention
CHKD Authors: Goretsky MJ

Conclusion: A relatively small number of procedures account for a disproportionate burden of antibiotic misutilization in pediatric surgery.

Journal of Thoracic Disease (2023)
Pectus repair after prior sternotomy: clinical practice review and practice recommendations based on a 2,200-patient database

CHKD Authors: Obermeyer RJ

Conclusions: Since the introduction of the MIRPE procedure by Dr. Nuss in 1998, the procedure has become the standard for repair of PE. In rare cases, patients with a history of prior sternotomy may present for repair and are at the highest risk of iatrogenic injury due to retrosternal post-surgical adhesions. With appropriate preparation and safe practices including the recommendations as listed above, surgical outcomes can be optimized for this patient population.

JAMA Surgery (2022)
Correlation Between Postoperative Antimicrobial Prophylaxis use and Surgical site Infection Children Undergoing Nonemergent Surgery
CHKD Authors: Goretsky MJ

Conclusions: Use of postoperative surgical antimicrobial prophylaxis was not correlated with SSI rates at the hospital level after adjusting for differences in procedure mix and patient characteristics.

Annals of Surgery (2022) 
Recent modifications of the Nuss procedure – The pursuit of safety during the minimally invasive repair of pectus excavatum
CHKD authors: D Nuss, R J Obermeyer, R E Kelly Jr, M M McGuire, D S Duke, M A Kuhn 

Conclusion: “A standardized Nuss procedure was performed by multiple surgeons in 1034 patients with good overall safety and results in primary repairs. Vacuum bell treatment is useful.”

Journal of Pediatric Surgery (2021)
Selective use of sternal elevation before substernal dissection in more than 2000 Nuss repairs at a single institution 

CHKD authors: R J Obermeyer, M J Goretsky, R E Kelly Jr, M M McGuire, M A Kuhn, D S Duke

Conclusion: “Selective use of sternal elevation before substernal dissection during the Nuss procedure is safe but may not prevent cardiac injuries in patients with previous sternotomy. Infection rates were not increased with SE.”


Seminars in Pediatric Surgery (2018)
The physiologic impact of pectus excavatum repair 

CHKD authors: R J Obermeyer

Summary: "The adverse physiologic effects of pectus excavatum and subsequent resolution following correction remain a controversy due to inconsistencies between patient reports and studies. It is not uncommon for pediatric surgeons to operate on adult patients, so this review helps provide an understanding of the physiological impact of repair on pediatric and adult patients separately."

Seminars in Pediatric Surgery (2018)
Outcomes, quality of life, and long-term results after pectus repair from around the globe 

CHKD authors: R E Kelly Jr

Summary: "Since the introduction of the Nuss procedure in 1997, its use around the world has produced robust evidence that supports its safety and efficacy and has led to the development of a methodology to measure the psychosocial and physical benefits of the procedure."

European Journal of Pediatric Surgery (2018)
Cardiopulmonary Function in Thoracic Wall Deformites: What Do We Really Know?
CHKD authors: R J Obermeyer

Abstract: Patients with pectus excavatum (PE) frequently present with complaints of exercise intolerance and cardiopulmonary symptoms. There continues to be controversy regarding the physiologic benefits of repair. The aim of this review is to summarize and discuss recent data regarding the cardiopulmonary effects of PE deformity and the evidence for improvement obtained after surgical repair including (1) a greater efficiency of breathing (chest wall mechanics), (2) improvement in pulmonary restrictive deficits, (3) an increase in cardiac chamber size and output, with improved cardiac strain and strain rate, and (4) improvement in exercise capacity.

Journal of Pediatric Surgery (2018)
Multivariate Analysis of Risk Factors for Nuss Bar Infections: A Single Center Study
CHKD Authors: R J Obermeyer, Kelly RE Jr, Ann Kuhn M, Frantz FW, MM McGuire

Conclusion: Following primary Nuss repair, the rate of deep bar infection increased with the use of perioperative clindamycin rather than cefazolin. The rate of superficial infection increased when perioperative antibiotic infusion was completed more than 60min prior to incision and with the use of peri-incisional subcutaneous catheters. Further studies are needed to better understand these findings.

European Journal of Pediatric Surgery (2018)
Modifications and further development of the original Nuss procedure: blessing or curse? 
CHKD authors: R E Kelly Jr

Summary: "Since the introduction of the Nuss procedure in 1997, there have been several procedural modifications after its adoption and use in medical centers worldwide. The confirmed safety and efficacy of the procedure has led it to become a standard treatment and allows it to adapt to new circumstances."

European Journal of Cardiothoracic Surgery (2017)
Pectus excavatum repair after sternotomy: the Chest Wall International Group experience with substernal Nuss bars 
CHKD authors: R J Obermeyer, R E Kelly Jr

Conclusion: “Over a broad range of institutions, substernal Nuss bars were used in PE repair for patients with a history of sternotomy for cardiac surgery. Several technique modifications were reported and may have facilitated repair. Cardiac injury occurred in 7% of cases, and appropriate resources should be available in the event of complications. Prophylactic resternotomy was reported at a minority of centres.”

Annals of Cardiothoracic Surgery (2016)
Pectus excavatum from a pediatric surgeon’s perspective 
CHKD authors: D Nuss, R J Obermeyer, R E Kelly Jr

Summary: "Pectus excavatum cases are less often noticed (22%) in the first decade of life and instead are more commonly discovered during puberty when rapid progression is seen. Surgical correction is recommended early on due to the patient’s young age and thus ability to progress through puberty with the bar in place."

Annals of Cardiothoracic Surgery (2016)
Nuss bar procedure: past, present and future

CHKD authors: D Nuss, R J Obermeyer, R E Kelly Jr

Summary: "The original method of repair for pectus excavatum involved an open procedure and then evolved to other techniques which were still invasive and led to unsatisfactory outcomes. In 1987, Nuss developed a minimally invasive technique which quickly gained acceptance and led to an influx of new patients. Since then, new instruments were developed, and various medical options were added to fit the needs of this procedure specifically."

Operative Techniques in Thoracic and Cardiovascular Surgery (2014)
The minimally invasive repair of pectus excavatum 
CHKD authors: D Nuss, R E Kelly

Conclusion: “The minimally invasive repair of pectus excavatum is highly successful when carried out by surgeons in a center dedicated to the management of chest wall malformations.” 

Journal of the American College of Surgeons (2013)
Multicenter Study of Pectus Excavatum, Final Report: Complications, Static/Exercise Pulmonary Function, and Anatomic Outcomes  
CHKD authors: R E Kelly Jr, D Nuss, M J Goretsky

Summary: "There is significant improvement in lung function at rest after surgical correction of pectus excavatum. Operative correction significantly reduces CT index and markedly improves the shape of the entire chest and can be performed safely in a variety of centers."

Basic Techniques in Pediatric Surgery (2013)
Minimally invasive repair of a pectus excavatum 
CHKD authors: Frantz FW, Nuss D

Summary: "The minimally invasive repair of pectus excavatum is indicated for patients with a severe deformity and associated psychological impairment. Certain inclusion criteria help determine patient diagnosis."

Operative Pediatric Surgery 2nd Edition (2013)
Surgical treatment of chest wall deformities in children 
CHKD authors: M J Goretsky, D Nuss

Summary: "Pectus excavatum is the most common chest wall deformity in infants, children, and adolescents and has a genetic predisposition with patients who have a family history of chest deformities in 37% of cases. The pectus excavatum depression is created by two components and may be symmetric or asymmetric."

Operative Pediatric Surgery 2nd Edition (2013)
Pectus Excavatum 

CHKD authors: M J Goretsky, Frantz F

Summary: Unavailable

Journal of Pediatric Surgery (2012)
Optoelectronic plethysmography demonstrates abrogation of regional chest wall motion dysfunction in patients with pectus excavatum after Nuss repair  
CHKD authors: R E Kelly Jr, D Nuss, M J Goretsky, M A Kuhn, R J Obermeyer

Conclusion: “Optoelectronic plethysmography kinematic analysis demonstrates that chest wall remodeling during Nuss repair results in increased thoracic volume. Chest wall motion dysfunction at the pectus defect is reversed after Nuss repair. Abdominal respiratory contributions are also markedly decreased. These findings may help to explain why patients with PE report an improvement in endurance after the Nuss procedure.”

Journal of Pediatric Surgery (2011)
One hundred patients with recurrent pectus excavatum repaired via the minimally invasive Nuss technique-effective in most regardless of initial operative approach 
CHKD authors: R E Kelly Jr, D Nuss, M A Kuhn, R J Obermeyer, M J Goretsky

Summary: “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.”

Fundamentals of Pediatric Surgery (2011)
Pectus Deformities 
CHKD authors: M A Kuhn, D Nuss

Summary: “Pectus excavatum is the most common (90%) congenital chest wall deformity, occurring in between 1 and 3 in 1,000 individuals. In addition to poor body image, many patients with pectus excavatum describe symptoms of poor exercise tolerance and shortness of breath, presumably due to compression or displacement of the heart and lungs. The minimally invasive approach to the correction of pectus excavatum has been proven to be safe, effective, and durable.”

Current Opinion in Pediatrics (2011)
Indications and guidelines for pectus excavatum repair  
CHKD authors: Frantz FW

Summary: “The findings presented in this review provide objective evidence of the cardiorespiratory impairment associated with severe pectus excavatum. Clinical identification of affected patients should prompt timely work-up and referral for pectus excavatum repair if inclusion criteria are met. Regular follow-up through pubertal growth is recommended.”

Congenital Thoracic Wall Deformities (2011)
Thoracic wall deformities

Contributing CHKD Authors: Kuhn MA, Nuss, D

Summary: The minimally invasive procedure provides good to excellent correction of pectus excavatum in over 90% of patients with no rib resection, no sternal osteotomy, minimal blood loss, and rapid return to normal activity. Studies have shown marked improvement in the patient’s body image and have also shown slight improvement in pulmonary function [20]. The 1,101 patients managed at our institution have had excellent long term results and low morbidity.

Journal of Pediatric Surgery (2011)
Regional chest wall motion dysfunction in patients with pectus excavatum demonstrated via optoelectronic plethysmography
CHKD authors: R E Kelly Jr, D Nuss, M J Goretsky, M A Kuhn, R J Obermeyer

Summary: "Optoelectronic plethysmography kinematic analysis allows for quantification of focal chest wall motion dysfunction. Patients with pectus excavatum (PE) demonstrate significantly decreased chest wall motion at the area of the defect and increased abdominal contributions to respiration compared with controls. This finding may help to explain exertional symptoms of easy fatigability or shortness of breath in PE."

Studies in Health Technology and Informatics (2011)
A Design for Simulating and Validating the Nuss Procedure for the Minimally Invasive Correction of Pectus Excavatum 
CHKD authors: R E Kelly Jr, M J Goretsky, D Nuss, Frantz, FW

Summary: “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.”


Annals of Surgery (2010)
Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients  
CHKD Authors: Nuss D, M J Goretsky, Kelly RE Jr, M A Kuhn, R J Obermeyer

Conclusion: "The minimally invasive repair of pectus excavatum has been performed safely and effectively in 1215 patients with a 95.8% good to excellent anatomic result in the primary repairs at our institution." 

Journal of Pediatric Surgery (2010)
Minimally Invasive Repair of Pectus Excavatum in Patients with Marfan Syndrome and Marfanoid Features 

CHKD authors: R E Kelly Jr, D Nuss, R J Obermeyer, M J Goretsky, M A Kuhn

Summary: "Minimally invasive pectus excavatum (PE) repair is safe in patients with Marfan syndrome or marfanoid features with equally good results. Patients with Marfan syndrome have clinically more severe PE requiring multiple bars for chest repair and may have slightly higher wound infection rates. Patients are satisfied with minimally invasive repair despite a phenotypically more severe chest wall defect."

Thoracic Surgery Clinics (2010)
Indications and technique of Nuss procedure for pectus excavatum
CHKD authors: D Nuss, R E Kelly Jr

Summary: "As a result of the modifications made to the minimally invasive pectus excavatum procedure, there has been an increased number of patients seeking surgical correction. This article discusses clinical features, reviews the preoperative considerations, and outlines the steps involved in the repair."

Ashcraft’s Pediatric Surgery 5th Edition (2010)
Congenital chest wall deformities 

CHKD authors: Nuss D, Kelly RE

Summary: “Presents practical guidance on treating a range of surgical problems in infants, children, and adolescents. This title offers coverage of hot topics including the increased use of minimally invasive surgery (MIS) for pediatric patients, urology, bariatric surgery in adolescents, and evidence-based treatments and outcomes in children.”

Seminars in Pediatric Surgery (2008)
Pectus Excavatum: Historical background, clinical picture, preoperative evaluation and criteria for operation

CHKD authors: R E Kelly Jr

Conclusion: "Pectus excavatum, present at birth or during the teenage growth spurt, includes symptoms such as shortness of breath or chest pain. Careful evaluation is required to determine the most effective course of treatment."

Pediatrics (2008)
Surgical Repair of Pectus Excavatum Markedly Improves Body Image and Perceived Ability for Physical Activity: Multicenter Study 
CHKD authors: R E Kelly Jr, D Nuss, M J Goretsky, K Mitchell

Conclusion: “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.”

Seminars in Pediatric Surgery (2008)
Minimally invasive surgical repair of pectus excavatum  
CHKD Authors: D Nuss

Conclusion: "Over the last 20 years, this minimally invasive repair has become widely accepted and has grown to be more successful. With increased safety, patient satisfaction has increased, and long-term results show a 95% good to excellent outcome."

Advances in Pediatrics (2008)
Minimally Invasive Surgical Correction of Chest Wall deformities in children (Nuss Procedure)
CHKD Authors: D Nuss, R E Kelly Jr

Summary: "Following the repair of pectus excavatum, patients report increased exercise tolerance and ability to participate in competitive sports. Recent studies and surveys have confirmed improvements in pulmonary function tests, cardiac output, and patient satisfaction and quality of life."

Journal of Pediatric Surgery (2007)
Infectious complications after the Nuss repair in a series of 863 patients 
CHKD authors: M J Goretsky, R E Kelly Jr, D Nuss

Conclusion: “Infectious complications after Nuss repair are uncommon and occurred in 1.5% of our patients. Published rates of postoperative infection range from 1.0% to 6.8%. Superficial infections responded to antibiotics alone. Bar infection occurred in only 0.7% and required surgical drainage and long-term antibiotics. Only 3 of these (50% of bar infections and 0.34% overall) required early bar removal at 3 and 18 months because of recurring infections. Early bar removal should be a rare morbidity with the Nuss repair.”

Journal of Pediatric Surgery (2007)
When it is not an infection: metal allergy after the Nuss procedure for repair of pectus excavatum
CHKD authors: M J Goretsky, R E Kelly Jr, D Nuss

Conclusion: “Allergy symptoms often are misdiagnosed as infection, but require different treatment. If a history of metal allergy or atopy is suggested preoperatively, the patient should be tested for metal allergy, and if positive, a titanium bar used. Because the consequences of metal allergy may include the need to replace the bar, pediatric surgeons should be aware of this occurrence.”

Journal of the American College of Surgeons (2007)
Prospective Multicenter Study of Surgical Correction of Pectus Excavatum; Design, Perioperative Complications, Pain, and Baseline Pulmonary Function Facilitated by Internet-Based Data Collection 
CHKD authors: R E Kelly Jr, D Nuss, M J Goretsky

Summary: “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.”

Journal of Pediatric Surgery (2006)
Reliability of a standardized protocol to calculate cross-sectional chest area and severity indices to evaluate pectus excavatum

CHKD authors: D Nuss, R E Kelly Jr, M J Goretsky

Summary: "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.”

Journal of Pediatric Surgery (2005)
The minimally invasive Nuss technique for recurrent of failed pectus excavatum repair in 50 patients
CHKD authors: D Nuss, R E Kelly Jr, M J Goretsky

Conclusion: "Although failed or recurrent pectus excavatum repairs are technically more challenging, reoperative correction by the Nuss procedure has met with excellent success." 

The Japanese Journal of Thoracic and Cardiovascular Surgery (2005)
The evolution of the Nuss procedure 
CHKD authors: D Nuss

Summary: "The minimally invasive technique has evolved into an effective method of pectus excavatum repair. Modifications of the technique have reduced complications. Long-term results continue to be excellent."

Journal of Pediatric Surgery (2003)
A pilot study of the impact of surgical repair on disease-specific quality of life among patients with pectus excavatum 
CHKD authors: D Nuss, R E Kelly Jr, M J Goretsky

Summary: “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.”

European Journal of Pediatric Surgery (2002)
Review and Discussion of the Complications of Minimally Invasive Pectus Excavatum Repair
CHKD authors: D Nuss, R E Kelly Jr, M J Goretsky

Conclusion and Results: "Long-term outcome after bar removal showed an excellent result in 71%, good result in 21% and recurrence in 7.8%. The minimally invasive technique has a low complication rate with excellent long-term results.”

Journal of Pediatric Surgery (2002)
Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients
CHKD authors: R E Kelly Jr, Michael J Goretsky, D Nuss

Conclusion: “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.”  


Journal of Pediatric Surgery
A 10 Year Review of a Minimally Invasive Technique for the Correction of Pectus Excavatum
CHKD authors: D Nuss, R E Kelly Jr

Conclusion: “This minimally invasive technique, which requires neither cartilage incision nor resection, is effective. Since increasing the strength of the steel bar and inserting two bars where necessary, we have had excellent long-term results. The upper limits of age for this procedure require further evaluation.”

Pediatric Endosurgery & Innovative Techniques
Repair of Pectus Excavatum
CHKD authors: D Nuss, R E Kelly Jr

Conclusion: “In reviewing the history of the pectus excavatum surgery, it becomes clear that this new technique is a natural evolutionary step. The three procedures preceding this technique each lessened the degree of “invasiveness” of the operation.”

Vacuum Bell

Journal of Pediatric Surgery (2018)
Nonoperative management of pectus excavatum with vacuum bell therapy: a single center study 

CHKD authors: R J Obermeyer, R E Kelly Jr, M A Kuhn, M M McGuire

Conclusion: “Nonoperative management of pectus excavatum with vacuum bell therapy results in an excellent correction in a small percentage of patients. Variables predictive of an excellent outcome include age ≤ 11 years, chest wall depth ≤ 1.5 cm, chest wall flexibility, and vacuum bell use over 12 consecutive months.”

Society for Computer Simulation International (2016)
Investigating the fidelity of an improvement- assessment tool after one vacuum bell treatment session
CHKD authors: R J Obermeyer, R E Kelly Jr

Summary: "When considering either a surgical or conservative intervention, the severity of the condition and associated risk are evaluated in order to determine the future course of action. For pectus excavatum, an instrument for quantifying the improvements after the procedure has been developed using real patient data."


Experimental and Molecular Pathology (2019)
Abnormal response of costal chondrocytes to acidosis in patients with chest wall deformity
CHKD authors: R E Kelly Jr

Summary: "Understanding the properties of costal cartilage is a major confounder in predicting causes and outcomes of chest wall deformities."

Archivos de Bronconeumología (2013)
Dysmorphology of Chest Wall Deformities: Frequency Distribution of Subtypes of Typical Pectus Excavatum and Rare Subtypes 
CHKD authors: R E Kelly Jr, D Nuss

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

Micron, Volume 44 (2013)
Atomic force microscopy characterization of collagen ‘nanostraws’ in human costal cartilage
CHKD authors: R E Kelly Jr

Summary: "Costal cartilage is relatively understudied compared to load bearing cartilages, and deformities can result in the deformation of the chest wall, having a significant clinical impact. An observational study found significant differences in nanostraw elasticity and diameter which affects nano-fluid transport calculations. Therefore, the results are of importance to the scientific community."

Connective Tissue Research (2012)
Decorin expression, straw-like structure, and differentiation of human costal cartilage 
CHKD authors: R E Kelly Jr

Summary: "Abnormally grown costal cartilages are associated with the chest wall deformities of pectus excavatum and pectus carinatum. Due to a lack of understanding of the molecular biology of costal cartilage, a study was performed to analyze the structure of marginal human costal cartilage."

Journal of Pediatric Genetics (2012)
Advancing our understanding of the inheritance and transmission of pectus excavatum 
CHKD authors: D Nuss, R E Kelly Jr

Summary: “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.”

Clinical Genetics (2010)
Variable Number of Tandem Repeat Polymorphisms (VNTR’s) in the ACAN Gene Associated with Pectus Excavatum 
CHKD authors: R E Kelly Jr, D Nuss, M A Kuhn, M J Goretsky

Summary: “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.”

Journal of Pediatric Surgery (2006)
Classification of the dysmorphology of pectus excavatum 
CHKD authors: D Nuss, M J Goretsky, K Mitchell, R E Kelly Jr

Summary: “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.”

Journal of Pediatric Surgery (2006)
Family study of the inheritance of pectus excavatum 
CHKD authors: R E Kelly Jr, D Nuss, M J Goretsky, K Mitchell

Summary: “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.”

Journal of Pediatric Surgery (2005)
Pectus Excavatum in a 112 year autopsy series: anatomic findings and the effect on survival 
CHKD authors: R E Kelly Jr

Summary: “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.”

Pectus Carinatum

Journal of Pediatric Surgery (2021)
Ten-year experience with staged management of pectus carinatum: Results and lessons learned
CHKD authors: R J Obermeyer, M J Goretsky, M A Kuhn, M M McGuire, D S Duke, R E Kelly Jr

Conclusion: "A report was done over a 10+ year period concerning pectus carinatum management. Brace treatment for pectus carinatum (PC) can be guided by pressure of correction (POC), which fell by more than half in successfully treated patients. If POC does not fall, surgery should be considered. Open repair of PC is generally successful, while the Abramson operation has a significant rate of complications with the implants currently available in the U.S."

Bracing Therapy

Journal of Pediatric Surgery (2019)
Development and validation of the pectus carinatum body image quality of life (PeCBI-QOL) questionnaire 
CHKD authors: R J Obermeyer, M A Kuhn, M M McGuire, R E Kelly Jr

Summary: "While body image disturbances and quality of life in persons with pectus excavatum (PE) have been well documented, very little has been done to systematically measure and document the same in patients with pectus carinatum (PC). Because of this, a study was aimed to develop and validate an instrument to assess body image related quality of life in patients with PC and their parents."

Journal of Pediatric Surgery (2013)
Staged management of pectus carinatum
CHKD authors: R E Kelly Jr, Frantz, FW

Summary: "Staged treatment of pectus carinatum allows most teenagers to be managed non-operatively. If bracing does not work for the patient, minimally invasive surgical treatment is a viable option."

Body Image

Chest Wall Deformities - Springer Chapter 11 (2017)
Psychologic effects, body image, and pectus excavatum and carinatum
CHKD Authors: Kelly RE Jr, Lombardo ML 

Abstract: "The appearance of the chest is a major concern to patients with pectus excavatum and carinatum. Surgical and psychological disciplines merge in the field of body image as it relates to chest wall deformities. This chapter discusses the history of body image, the evolution of body image study in pectus excavatum, and results of such inquiry to demonstrate how repair influences body image and quality of life."

Mixed Chest Wall Deformities

Adolescent Medicine Clinics (2004)
Chest wall anomalies: pectus excavatum and pectus carinatum 
CHKD authors: M J Goretsky, R E Kelly Jr, D Nuss

Summary: “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.”


Transactions in Biomedical Engineering (2020)
Development and validation of a hybrid Nuss procedure surgical simulator and trainer
CHKD authors: R E Kelly Jr

Summary: "This work presents the development and validation of an interactive simulation training platform for the minimally invasive repair of pectus excavatum. A hybrid virtual/physical configuration of the trainer can efficiently and realistically reproduce the primary steps of the procedure." 

Korean Journal of Thoracic and Cardiovascular Surgery (2018)
Use of an optical scanning device to monitor the progress of noninvasive treatments for chest wall deformity: a pilot study 
CHKD authors: R E Kelly Jr, R J Obermeyer, M A Kuhn

Summary: "The option of non-surgical treatment of a chest wall deformity is done by vacuum bell or external brace and takes place over the span of several months. The lengthy monitoring process for this treatment method can discourage patients which can lead them to abandon the process. Optical scanning was used in a pilot study for both surgical and nonsurgical cases to assess treatment progress."

Journal of Medical and Surgical Research (2014)
Engineering collaborations in medical modeling and simulation  
CHKD authors: R E Kelly Jr

Summary: "Collaboration between medical/healthcare practitioners and engineering developers must exist to advance technology and procedures for improving the experience and outcome for the patient. Using Modeling & Simulation (M&S), the healthcare field may benefit through increased patient satisfaction and the promotion of better health outcomes."

Computer-Aided Design & Applications, Volume 10 (2012)
Evaluation of fatigue for a pectus bar removal surgical tool design for a safe clinical practice use setting 
CHKD authors: R J Obermeyer

Summary: "The Nuss procedure is a minimally invasive surgery which places a metal bar inside the chest cavity for approximately 2 years to correct pectus excavatum. Following the modification of the tools used to extract the bar, a determination needs to be made on whether the effects from repetitive loading will affect the performance of the tool over a long period of time."

Surgical Clinics of North America (2012)
Chest wall deformities in pediatric surgery 
CHKD authors: R J Obermeyer, M J Goretsky

Summary: "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, while acquired chest wall deformities typically follow prior chest surgery or a posterolateral diaphragmatic hernia repair. 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."

CAD Journal (2011)
Application of CAD analysis to update the design for a pectus excavatum bar extraction tool
CHKD authors: R J Obermeyer

Summary: "Motivated by issues reported by surgeons from CHKD regarding the optimized tool for pectus bar extraction, an iterative method of applying computer-aided design (CAD) tools, finite element analysis (FEA) software and manufacturing of conceptual models and metal prototypes to update initial designs of the tool was employed. By using this approach, reported issues were resolved and we were able to maintain advantages which make the tool superior to the commercial bar benders in terms of shortening surgery time which limits costs and reduces risk of infection."

Pediatric Surgery and Urology Long-Term Outcomes, 2nd Edition (2010)
Chest Wall Deformities
CHKD authors: D Nuss

Summary: "Out of the two categories of chest deformities, pectus excavatum is the most common with a frequency of 1 in 1000 individuals, compared to pectus carinatum. Abnormalities in which there is partial agenesis or failure of fusion are rare, and instead patients are more likely to lack breast tissue, pectoralis major or minor muscle, and ribs."

26th Southern Biomedical Engineering Conference (2010)
Development of an average chest shape for objective evaluation of the aesthetic outcome in the Nuss procedure planning process 
CHKD authors: R E Kelly Jr, M J Goretsky, D Nuss

Summary: "The Nuss procedure is a minimally invasive surgery for correcting pectus excavatum and has proven to have a high rate of success and satisfactory aesthetic outcomes. The procedure’s success depends on the correct placement of the bar, so it is recommended that a surgical planner be used to ensure the optimal outcome."

Bar Removal

Journal of Laparoendoscopic & Advanced Surgical Techniques (2018)
Bleeding at removal of Nuss bar: rare but sometimes significant  
CHKD authors: M J Goretsky, R J Obermeyer

Summary: "Hemorrhage during Nuss bar removal is an uncommon but feared complication that can be life threatening if not controlled rapidly. This study aims to identify the incidence and sources of large volume hemorrhage, discuss successful management strategies, and provide patient care recommendations.”

32nd Annual International Conference of the IEEE EMBS (2010)
Optimized surgical tool for pectus bar extraction
CHKD authors: R J Obermeyer

Summary: "Surgeons have reported that the current tools available for bar removal during a Ness procedure do not provide optimal functionality. Therefore, it is proposed that there be an improved tool design, and that it is then evaluated and analyzed to create a final design."


Seminars in Pediatric Surgery (2018)
Complications associated with the minimally invasive repair of pectus excavatum 
CHKD authors: M J Goretsky, M M McGuire

Abstract: “Complications related to pediatric surgical procedures are always a major concern for surgeons and their patients, and as with all surgery, especially pectus surgery, complications can be life-threatening. The purpose of this article is to discuss early and late complications of pectus excavatum surgery and potential preventive strategies to minimize them.”

Journal of Pediatric Surgery (2018)
Life-threatening complications and mortality of minimally invasive pectus surgery 
CHKD authors: R E Kelly Jr, D Nuss

Summary: "Published reports support the safety and efficacy of the minimally invasive repair of pectus excavatum; however, major adverse outcomes are underreported. Although major complications with this procedure are very rare, awareness of the risk and mortality of life-threatening complications is essential. These preventable events can be avoided with proper training, mentoring, and the use of sternal elevation techniques."

Complications in Pediatric Surgery (2008)
Cardiopulmonary complications of thoracic surgery 
CHKD authors: R E Kelly, M A Kuhn

Summary: "Preoperative efforts are important to the prevention of complications during surgery. Atelectasis are discouraged and it is advised that medications are utilized under the direction of a pulmonary specialist. Additionally, encouragement from family members is helpful for patients to feel that they are contributing to their recovery."


Journal of Pediatric Surgery (2018)
Selective versus routine patch metal allergy testing to select bar material for the Nuss procedure in 932 patients over 10 years 
CHKD authors: R J Obermeyer, R E Kelly Jr, M A Kuhn, M M McGuire

Summary: "Stainless steel bar allergies occur at a low incidence with either routine or selective patch metal allergy testing. This testing is advisable in females and patients with a personal or family history of metal sensitivity. It is important to note that a negative preoperative patch metal allergy test does not preclude the possibility of a postoperative stainless-steel bar allergy."

Journal of Pediatric Surgery (2014)
High rates of metal allergy amongst Nuss procedure patients dictate broader pre-operative testing 
CHKD authors: R J Obermeyer, R E Kelly, M A Kuhn, M J Goretsky

Conclusion: “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.”

Journal of Pediatric Surgery (2013)
Development of metal allergy after Nuss procedure for repair of pectus excavatum despite preoperative negative skin test
CHKD authors: M J Goretsky, R E Kelly, R J Obermeyer

Summary: "Because the Nuss procedure uses a metal bar for the correction of a chest wall deformity, metal allergy testing is completed prior to the operation. The report describes the testing process for one patient who had no history of drug allergies nor contact dermatitis but experienced a local infection several weeks after the Nuss procedure."


Journal of Pediatric Surgery (2016)
Risk factors and management of Nuss bar infections in 1717 patients over 25 years
CHKD authors: R J Obermeyer, M J Goretsky, M A Kuhn, R E Kelly Jr

Conclusion: “An increase in postoperative infections after Nuss procedures led us to seek risks and review management. We report potential risk factors and make inferences for prevention of infections.”


Annals of Cardiothoracic Surgery (2016)
Diminished pulmonary function in pectus excavatum: from denying the problem to finding the mechanism
CHKD Authors: R E Kelly Jr, D Nuss, R J Obermeyer

Conclusion: “Pectus excavatum is accompanied in most patients by diminished static pulmonary function. Correction by Nuss procedure results in improvement in chest wall motion; this improvement in the thoracic bellows action is accompanied by improvement in pulmonary function testing.”

Journal of Pediatric Surgery (2011)
Increasing Severity of Pectus Excavatum is Associated with Reduced Pulmonary Function
CHKD authors: D Nuss, M J Goretsky, R E Kelly Jr

Conclusion: “Among patients presenting for surgical repair of pectus excavatum, those with more severe deformities have a much higher likelihood of decreased pulmonary function with a restrictive pulmonary pattern.”

Journal of Pediatric Surgery (2005)
Impact of pectus excavatum on pulmonary function before and after repair with the Nuss procedure
CHKD authors: R E Kelly Jr, M J Goretsky, D Nuss

Summary: “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.”