Correction of Pectus Excavatum by Custom-Made Silicone Implants: Contribution of Computer-Aided Design Reconstruction. A 20-Year Experience and 401 Cases
Bibliographic record
Abstract
Sir: In their recent article, Chavoin et al. advocate for the correction of pectus excavatum by using silicone implants.1 We congratulate the authors for their impressive cosmetic results obtained in a large series of adult patients, mainly with the use of custom implants constructed by means of computer-aided design. However, this article raises several issues. First, to justify an exclusively cosmetic approach, they claim the absence of demonstrable functional impairment in pectus excavatum patients and the doubtful functional utility of chest wall remodeling surgery (i.e., Nuss- and Ravitch-type procedures). These assertions are based on meta-analyses of Malek et al. and Guntheroth et al., published in 2006 and 2007, respectively.1 Although we partially agree with these assertions concerning respiratory function supported by the meta-analysis of Malek et al., Chavoin et al. fail to refer to numerous relevant works published afterward in the field, demonstrating evidence of normalized cardiovascular function after pectus excavatum repair. Notably, our prospective study conducted in 70 pectus excavatum adult patients (to our knowledge, the largest series in the literature) thoroughly assessed cardiopulmonary function before and at 1-year follow-up after Ravitch-type repair.2 Lung function tests at rest were within the normal range as usual, whereas maximal oxygen uptake (peak Vo2) was significantly impaired (77 percent of the predicted value). Evaluation of physical activity following surgery was unchanged compared with preoperative exercise habits. At 1-year follow-up, the pectus excavatum repair was associated with minor changes in lung function tests at rest and, in contrast, a statistically significant increase in maximal oxygen uptake. Postoperative increase of oxygen pulse (a surrogate of heart stroke volume) at maximal exercise suggested that aerobic capacity improvement was the result of better cardiovascular adaptation at maximal workload. In addition, in a second series of 20 adult patients, we reported that inspiratory muscle strength was significantly impaired before operation and that normalization of the thoracic cage by the Ravitch-type repair could restore adequate capacity of the inspiratory muscle system (mainly the diaphragm) to generate negative pulmonary pressure during ventilation (the so-called respiratory pump) that is essential to enhance venous return, heart filling, cardiac output and, consequently, aerobic capability.3 Thus, objective improvements of physical activity are experienced by adult patients following the pectus excavatum correction, mainly in trained athletes.2 Second, the authors claim that remodeling thoracic interventions such as the Nuss and Ravitch procedures “are rather major interventions” and that “[m]any serious complications have been reported.” However, all severe complications listed by the authors have been specifically observed only following the Nuss procedure, and we agree that this potential high-risk procedure should be discarded in the setting of pectus excavatum correction.4 In contrast, no such severe complications have been encountered following the Ravitch-type repair that fulfills the criteria of safety and reliability.5 Finally, Chavoin et al., by routinely performing basic lung function tests at rest before surgery, underestimate the impact of pectus excavatum on cardiopulmonary function, and neglect the well-known negative long-term consequences of such anomalies after which a purely cosmetic procedure would have been applied. DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this communication. Alain Wurtz, M.D., Ph.D.Julien De Wolf, M.D.Cardiac and Thoracic Surgery DivisionLille University Teaching HospitalCHU LilleLille, France Emmanuel Brian, M.D.Thoracic DepartmentInstitut Mutualiste MontsourisParis, France Lotfi Benhamed, M.D.Thoracic and Vascular Surgery DivisionValenciennes HospitalValenciennes, France Massimo Conti, M.D.Department of Thoracic SurgeryIUCPQ-ULQuebec City, Quebec, Canada Remi Neviere, M.D., Ph.D.Department of Pulmonary Function TestsLille University Teaching HospitalCHU LilleLille, France
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.002 | 0.000 |
| Bibliometrics | 0.001 | 0.000 |
| Science and technology studies | 0.000 | 0.001 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".