EUPSA webinar " Controversies in Pectus Excavatum repair Short bar vs intermediate/long bar"

Good afternoon. Uh, good morning, um, everybody, wherever, um, you logged on. Um, I have the privilege, uh, to share and share this, uh, webinar, uh, actually alone because I was Zani, our co-chair, um, I had to rush to the OR, um, but, uh, we will manage without him, then later on, he, he joins us. So, uh, we have two very promising Permanent speakers of the uh field tonight with us, uh, Professor Frank Martin Hecker from Basel and St. Gallen and Hans Pilligaard from Aarhus, Denmark. Um, so we will start with uh Professor Hacker. Um, he has several affiliations, actu actually, he's currently working as an attending surgeon at the Departments of Pediatric Surgery in In St. Gallen and Basel. For years, he has uh a special interest in the treatment of uh chest wall deformities, studied medicine in Tubingen, Germany, and after his surgical training in tubing in Baden Baden, he became consultant and later, in 2014, professor of pediatric Surgery at the University of Basel. And 15 years ago, in 2007, Professor Hacker has started a specialized outpatient clinic for chest wall deformities in these institutions, and he's mentoring actually the world's largest series of pectus excavating patients treated conservatively using the vacuum valve. In 2018, he took an interesting step in his career by serving for two years as a consultant pediatric surgeon in Dubai at the American Hospital in Dubai, and served um and started actually a new practice program in the Emirates. Apart from chest wall diseases, Professor Hacker has an, an interest in urology, and since 2018, he's a Fellow of the European Association of Pediatric Urology. So coming back to the practice, um, topic, Professor Hacker is a founding member of the Chessball International Group, um, a member of its executive Committee. He was president of that society from 2018 to 2021. So Professor Hacker, dear, my dear Frank Martin, it's a great honor, um, to have you with us this afternoon, and we are curious to, uh, listen to your presentation. Well, Martin, thank you very much. Thank you for the kind introduction. Thank you for giving me the opportunity to talk about our experience with uh surgical repair of pectus excavatum and, uh, I'm more than happy that you already mentioned, uh, I think I'm pretty well known for conservative treatment of pectus excavatum, so I'm happy to talk, uh, today now about surgical repair. And the topic of our, uh, talk is uh short bar versus intermediate or long bar. So just to introduce, uh, I never had a greater serious experience with short bar. Uh, it's not why we were not convinced to use this, it's just we don't have so many patients that we can do so many different techniques. Uh, I have nothing to disclose, no conflict of interest with any implant company. So, preparing for this talk, of course, you have to go back to the history and the history when you're talking about minimally invasive repair is this fundamental publication paper, it's now more than 20 years old from Donald Nuss and his group. And still today, the interesting thing for me is that when they published the paper, they talked about their 10 years experience. So that means they started with the Pectus program and the Pus repair in the late 80s and they published their experience in the late 90s. And I think the majority of you know this figure, this graph, and all, all pectosurgeons who do pectosurgery may be aware that this graph is not completely showing all details. But I went back, so in preparing this talk, I thought, OK, I have to go back to the roots and look what type of bar, what length of bar Donald Musk presented in his original publication. And you see two interesting figures from this paper, I think, uh, interesting figures in my, in my personal experience because you see, it's, it, it's something like an intermediate or a long bar, but it's also interesting that even in this very early publication, they demonstrated the technique of some type of bridge fixation and I will come back to this later on. The second step, preparing this talk, I thought, OK, I'm going back. What is our experience when we started? I think we've been one of the first surgeons in Switzerland, uh, starting with the pectus repair now more than 20 years ago, and after 2 years, we published our first experience with the 1st 35 patients, uh, who underwent surgery in Basel at this time. And there were 3 or 4 major complications. The number 1 is the bar displacement, of course, and when you're thinking about which type of bar you should apply, which type, which length of bar, I think bar displacement is an important aspect. Hematothorax, pneumothorax, and re-operation in, in, in uh in connection with the bar displacement. And of course in our first experience, we had all these horrible cases and I think everybody who is honest with his own figures, with his own data would agree that we all make mistakes, but mistakes are to improve our experience and to avoid, not to repeat the mistakes. So you see just a couple of our first patients on the left side. The bar displacement in the horizontal plane, what we call also shifting, so the bar left the stabilizer in the middle, a pneumothorax vonne Marfan syndrome patient and on the right side, the bar slipping or bar shifting downwards. So today, If we are talking about the NUS procedure and I'm, I'm wondering all the time, at least at every civic meeting, you see different talks about surgical repair and you see completely different images, completely different, uh, type of implants, and I will show you. So I think for the majority, the standard is 1 pectus spar with 1 stabilizer. Some people apply 2 pectus spars with 2 stabilizers. And depending on the patient's age, some people also apply free Pusspars, sometimes with or without stabilizer. And that's the topic of Hans, just to mention the complete, so about the short bar, but if you continue, sometimes you see a situa situation like this, so that it's a multiple bar placement and it's not the multiple bar placement, also the so-called crossbar technique, and you see, that's one of the advantages to use uh intermediate or long bar. If you want to connect and fix these bars with a bridge technique, I, in my personal experience, the patient will feel more comfortable if you have an intermediate bar, not ending here, but on the lateral aspect, and you can connect these bars with a bridge technique, and that will increase the stability and decrease the risk of secondary displacement. Coming back to the original publication from Donald Nuss, I think a very important aspect is age of patients at the time of surgery. You see on the left side, that's the figure from his 1998 publication, and you see that the majority of patients who underwent Pectus repair within this 10-year period were under the age of 10. And 10 years later, you see as a significant age shift to puberty, and during puberty, you will have a different growth situation than in pediatric patients and in contrast to adult patients, and that's for my personal aspect, a very important aspect if you're considering short bar or intermediate bar. You have to keep in mind when they keep an eye on the patient's growth, and there is one aspect I took this slide from Donald Nass. It's, he, he mentioned two stabilizers should not be used in growing patients because they will cause an hourglass effect. And in my personal experience, the first couple of patients I showed you before, we had in 2 or 3 patients using the lumbar um implant, we had this hourglass effect. If, if you do the surgery at the age of 14 or 15, And these patients are in the middle of their pubertal growth spurt, you may have the risk of the hourglass effect either with two lateral stabilizers or only with the long bar. Bar selection, again, I have no conflict of interest, so I will show you just a couple of uh convenient and um popular implants. I think many of you know the implant of biomed and there is a new design that's already available in the US market. They changed the system with the connection with the stabilizer and also adapted the screw system. Uh, on the right side, it's from Medexpert, it's from a German company, and also for this company, it's in my personal experience, it's uh better to use an intermediate or long bar, but I prefer the intermediate bar because you can put the stabilizer on the lateral aspect and the stabilizer will be fixed with a screw. I used a couple of times this implant from a French company and that's in my personal experience, also the intermediate type and you have a complete connection with some type of stabilizer and it's very good applicable, especially in very tiny female patients. And on the right side, you see the primate implant. It's from Doctor Park from, it's a very famous pecto surgeon from Korea who developed his own system including this bridge system. So bar selection and configuration, we prefer the intermediate length of the bar, and for that, you should have in the middle a tile bending, not too sharp. And for as a landmark to um select the appropriate size, you'd go in the middle, you have the frontal axilla line, you have the medium axilla line, and the tip of the bar should be in the middle, in this like this. So the bar has some stability. That decreases the risk of secondary displacement, and also you can on the lateral aspect, put your stabilizer. It's not on the frontal aspect, which is sometimes obvious seen, and it's also not on the completely lateral side where sometimes it's disturbing and movement of the upper extremity. What are the, from my personal experience, the most important aspects when you think about the bar, the type of bar and the length of bar, infection, I think there is no difference between the different ranks and just for, for completeness, if you think about infection, be aware that sometimes you may have also allergy. Um, horizontal shifting I already showed you, and of course, dislocation of the bar, bar flipping, that's what we are afraid of and what we should avoid. And when you're going back to the literature, this is a publication 15 years old when most of the European centers and all the US centers published the first experience. So 15 years ago, secondary bar dislocation was a very common phenomenon. If you see here in this table. 27%, even in the group of Dr. Nass, 10%, European multi-center study, 11%. Only Dr. Kark was below 10% and again to others with between 15 and 20%, and displacement means in the majority of patients, you have to do a redo surgery. So the recommendation is proper fixation, and you do these pericostal wires, you can do the wire around the bar and the rib, and you can do additional fixation between the bar and the stabilizer, and finally, you do a fixation of the stabilizer on the skin, and you will increase the stability if you select two separate ribs for fixation of the bar. But, however, you have to be aware that even in this situation, sometimes we have an image like this, and that means you have to do re-operation. So to avoid this, Doctor Park, and as I tried to show you also Donald Nusk in his first publication already mentioned by Doctor Park from Korea introduced the so-called bridge technique, and in my personal experience, the bridge technique for that, you should use the intermediate bar. I know you can also use it with short bars, but I prefer to use the uh intermediate bar length to bring the bridge on the lateral aspect. And if you do this, you can do different applications and depending on the shape and the degree of the deformity, it might be useful to uh to apply this crossbar technique or parallel bar technique or you can also combine crossbar for uh with parallel bar technique in uh patients with complex deformities. And as I've already shown you, sometimes you will have 3 bars, 4 bars. I've never seen a patient with 5 bars, but I've seen a couple of patients with 4 bars. Again, it's dependent on the patient's age and time of surgery. Bar selection and configuration, bending the bar, avoid excessive bending in the middle, and also uh avoid excessive bending at the ends because you have to be sure that the stabilizer will be slipped on the bar that you can fix the stabilizer with the bar with uh enough distance. One more, for my personal um experience, important argument to use the intermediate bar is the skin incision. If you have a short bar, of course, you will do the skin incision more in the frontal aspect. If you have a long bar, you will do it in the lateral aspect. And if you do it, if you have the intermediate bar, you do it in between the frontal and the middle axilla line. And I hope you agree that in this patient, you will see nearby no scar formation. So that's a very convenient and very comfortable technique to avoid severe scar formation, and in many of my patients, you don't see any major scar formation. So just to summarize, Patient's age at time of surgical repair is for me important for selection of the appropriate bar length, and of course, you have to have an opinion, idea whether you want to implant a single bar, two bar, or 3 bars, and whether you want to fix it with or without a bridge technique. And as shown with the slide before, skin incision, it's for me a good argument to use the intermediate lengths. Then they have, especially in female patients, they have nearby invisible scar formation. And I thank you very much for your attention and I'm wondering what Hans will tell us about the shortboard technique. Thank you. Yeah, thank you very much. Uh, I'm introducing the second speaker of this afternoon, which is Professor Hans Pilligaard. He does not need much of an introduction. He's one of the pioneers and giants in the field, graduated from Medical School of Odense University in 1977, graduated there, and then underwent cardiac and thoracic training. In specialization until 1993, he was appointed as a consultant for thoracic and cardiac surgery at Aarhus University Hospital. After retiring from this position in 2016, he remained assistant professor in surgery at that hospital and now works in a private hospital called Eleris Hamlet in Oto Ahus. He's also traveling around the world and teaching and helping other um surgeons with the NSC procedure. Professor Pilligaard has a vast experience in cardiothoracic surgery with unbelievable numbers like 1000 heart operations, over 5000 general thoracic procedures, 2000 corrections of pectus excavatum, and 250 repairs of pectus carinate. On the scientific side, he has authorized chapters in 15 books, contributed to over 100 chapters, and he has chaired a lot of societies, including the Danish Society of Thoracic Surgery, the Danish Surgical Lung Cancer Group, and he is a member of the chest wall Internet Interest Group, the CIVIC, where he's also, like Frank Martin on the executive Committee. And he has been president of that society, uh, between 2013 and 2015. So we have here in Leipzig the, the honor to have Hans Piliger also as a visiting professor for, uh, quite some good cases here in 2018, uh, which all went very smooth and had a speedy recovery and also speeded up our own Pus program, which we are, uh, very grateful for. So Hans, it's a great, um, to have you with us here tonight, and we are looking forward to your talk. That's right, yeah. What I will talk about is, uh, the position of the patient. I will be quite, uh, take it as a surgical point, how we do it, how we can make, in my mind, the best stable system, and uh how the bar should be shaped and in which position we should uh put them. What's that? It's like, so. Um, if you look from the, uh, original position of the, uh, scope, it was in the lower end, but I don't think that's the optimal part because uh there might be a risk of uh mag lesion to the diaphragm. And also, well, well, I'll show you in the next, um, slide that uh you don't have the same good view in my mind as if you put You are Let's go higher And also that the arm is above the head because then you can move. The scope from side to side. It's also very important that the patient is uh totally to the right, so you can go down with the scope and look uh at the anterior wall of the chest. Inside. So if you have the scope in the low position, you will see you have a lot of diaphragm. If you put it higher, you have a much better view. You have the diaphragm here. So I think that's the optimal uh position of the scope. When I started, I, of course, used the original technique with a long bar to stabilize us, but I was wondering why we needed such a long bar because uh It was going from the mid-axilla line to the other mid-axilar line. What we need is only In principle, a shot bar because it should um push the sternum in front. But such a short bar, it's not very stable, laterally. Um, What I've found out, uh, because, uh, I changed. So you can see I used the short bar. With one stabilizer in the beginning, also the suture surround the, the bar and the, the rib. But we found that with, with a short bar and if the ribs was quite horizontal, there was a risk that this end would drop into the chest. So, therefore, today, I use, you can say an omeric bar, which is longer on the side where you don't have the stabilizer. As you see here on an X-ray, and if you put the bar outside the chest, you can see we have a longer end opposite the stabilizer. But I will show you a little later, uh, at, uh. Uh, slide where you can see why I put the stabilizer here, because I think if you have the stabilizer on the lateral side and you have the turning point here, it will not stabilize very good. Another thing is, if you want a good stabilization is that you go in and out of the chest. Cavity medially to the highest point. Another thing is that the bending techniques. I prefer that you, you can may say bend, so you are correct. Because When you put the bar in the, in the chest, there will be some deepening, and I can illustrate it with these two pictures here. This is the bar I put in the patient. Because I used the same incision for two bars. I put this bar in first, and then I put another bar, and then I removed this bar, but it was looking so. So, therefore, I think it's very important when you bend the bar that you do overcorrect in some way. You also have to take into account asymmetry. If it's go to the left, you should put your stabilizer on the right side because there's a better plateau, a better ground for the stabilization. And if it's going to the right, you should put it on the left. And normally, I prefer to have it on the left. And the other thing that I talked about was this position of the stabilizer. As you see here, that's the original. You have the stabilizer laterally. You can turn the bar, because you have the turning point here. If you, instead of that, put the stabilizer medially, you can see it stabilized very, very good. So therefore you get a very, very good stabilization. And what I forgot to say before when I have that Aramidic bar. This side opposite the stabilizer is uh working like a hook, so if you retract that to the chest side and you put the stabilizers medially to the exit. You will have a very good lateral stabilization. And where should you put your body? You should always, or in most cases, support the deepest point. You mark where you have the possibilities of intercostal rooms. You put your scope in and you look for the deepest point, and you can follow the line of the scope, and to see if the point where you want to have the bar on the deepest point is OK, you can push your finger on the spot. On the chest wall, you can see and see if it's Goes in the direction of the deepest point, then it's OK. So, in those cases, you will see an hoisensal bar asom replaced with one stabilizer. Fixed to the bar with a steel wire, and I don't use any sutures at all because this situation is very stable because this longer leg. is doing that it can't move laterally. And another thing why this end should be a little bit longer is that over here, the stabilizer will be on two ribs, so therefore, you also need a longer uh end at this side. So you have it on two ribs. And this is a high and a low bar. I will be back in that. And what do we know about the number of bars? We can see that um As Frank Martin mentioned, uh, We don't, uh, put bars, uh, in, uh, patients below 11 years, but we think that the optimal basics believe, believe, uh between 11 and er and certain years. And our median age is about 16. And you can see if the patient is younger than 18 years, most of the patients only need one bar, but if it's older than 30 years, most of the patients need more than one bar. 80% need around um 2 and even 3 bars. And what I think is the big challenge of um of this procedure is when you have a very deep pectus. You can see here on the, OK, forgot to close the noise, but you can see. Paul David. It's growing. So if you try to get your introducer under here, you will probably be in risk of perforating the heart or making lesions to the heart. So what do we do when we have a deep excavation? We know we always need more than one bar. So, um, in my, uh, technique, I put the first bar higher than the deepest point, and often at the level of the nibbles. And then why do I start there? I put the first introducer up there. And when you elevate that part, you will also elevate the deepest point. So it's much, much easier to get under the deepest point. Another thing is when you have your channel up here, you might enlarge it down without problems. I will share it in a slide in a little later. The distance to go when you have made your tunnel is under the other side is very short. You can see when you have the scope, quite low. You can look to this area and then you only have 2, maybe 3 centimeters to, uh, to go um for doing the, the rest of the tunnel. Another thing is that it might be a good idea to use a harmonic scalpel if you don't have so much space. Um, you can cut into the mediastinum, and you can make your tunnel totally by cutting and dissecting. It's easier to work with than the introducer. So you do your whole tunnel work with the, with the harmonic scalpel. And then it's very easy to um So put uh your intro introducer in. You can see You can also see where you get out. And and put the first introducer in. Another thing is that you have to use a Optimal introducer, so you always are in contact with the backside of the chest wall with the chip. So you have the large one and the extra-large one, because I think the small one is too um It's, it's not rigid enough to, uh, to handle uh our patients with. Another thing you should avoid is stripping, because um when you come to the left side, there is a risk that you strip the intercostal muscle. The risk is not very uh big with the blacks introducer, because when the tip is through the skin, You can push because then you will just go above your rib, but if you use the extra large one. And you only have the chip through the skin, and you push, it will work like a routine, so you have some stripping. So therefore, it's a very good idea when you use the extra large, and you can even do it if you use a large one, put a steel wire in the eyelet, and elevate. And you can see here, what also is Um, So you have your assistant just to pull up and then you like pumping movements. You gradually elevate the sternum and you can push your introducer through the patient. Here was a patient, the first. Um, introducer, and you see that the deepest point now is elevated quite a lot. And why it's a good idea to start. More, uh, cranially, you can see here, that's a higher bar, Ella the high introducer, let it stay. Because the introducer is also more rigid than the, the bar, so it's very good to have the, the introducer and the patient. And you can see, you can just move and you can get a very big tunnel, so you don't have any risk of making uh lesions to the To the heart, and you can see here. When you, when I use a high bar, I prefer to make a small incision around the nibble because I want my stabilizer here in the midline, it's very difficult to get up from the side. So I just make a skin incision, split the muscle, so I make a pocket uh beneath the, the pectoral muscle, and you see here how it looks. A very small incision, you can hardly see it, and a small incision after. Another uh trick when you should put the stabilizer on is that Before you turn the bar, you put a steel wire around. Turn the bar And then you can use this steel wire to elevate the end, because sometimes it goes between two ribs and compresses the intercostal muscle. So, um, It might be a little bit difficult to get the stabilizer on, therefore, you can use your steel wire to uh elevate the end of the bar and then put the uh stabilizer on. And you can use uh Um, crossbark, I introduced that in 2015. If you have a very short and narrow, and it can also be used in other cases. I know that Doctor Park now is very pleased with that uh technique. Sometimes you have that the rip is just where you have the deepest point, so you can't get onto the deepest point, if you go just across, but then if you go. The intra. Intrigue, uh, just on uh the Intercostal space, uh, caudally for the rib and, uh, come out, exit just granually, you will just have your force just under the deepest point, so you have this construction, and then you should Be aware that if you have this direction, you should put your stabilizer on this size because here, you, this uh end of the bar is quite uh perpendicular to the ribs. If you do the other way, you should put your stabilizer here. Sometimes you need two parallel bars, and in some cases, this Part is elevated too much that's around the sea floor, then you can use the same exit on one side. Another thing is that it doesn't matter that you have the two stabilizers at the same side. It, it might be a good idea because sometimes the upper flap from the system we have now is a little bit too short, so there is a risk that it will turn between two ribs. So if you put this flap above the lower flap on this side, it works like a bridge. You can even use it if you have an excavation in the lower part with a very rare oblique bar. So you have a lot of possibilities. Thank you for your attention. Yeah, thank you very much, Hans. That was uh also a beautiful talk. Where, where is this, um, picture, the last picture? It's, uh, it's not from my window, but it's close to, I'm I'm not leaving to this lake, but, uh, if you sail this way to the right, I'm living, uh, about 2 kilometers from there, and I can see the, the next lake. We have a, a, a lot, a lot of lakes here in the area where, where I live. Beautiful. Beautiful. So please, uh, all the audience type in your, um, questions in the chat. Um, You may start now. I don't see any from the audience. Then maybe I'll, I'll go to you. Yes, can I start with a, with a question? You know, we do see a lot of patients as, as pediatric surgeons that are of course teenagers and come with, uh, pectus anomalies of any kind. Uh, but I have no experience, uh, in, uh, with, with adults, uh, and I've seen that in your, um, first, uh, one of the first, uh, slides you had, uh, picture of patients that are also over 30 years of age, and I'm wondering whether these patients had any symptoms or whether it was like something that uh Um, it was uh like clinical indication, um, but I'm also interested in the results because we always try to fix, uh, the issue when, uh, patients, as I said, are teenagers because they allegedly the, the, the rib cage is more pliable. What are the results in these ones that are actually, uh, older? I think they are quite good. Sorry, sorry to interrupt. Can you end your presentation because then we can all see each other again. Sorry. You can stop the sharing. I stopped yelling, OK. You know I'm asking this question because sometimes the parents ask whether they can wait uh until uh the, the child is um is not a minor anymore and later and then my, my uh comment is always that it's better when you do this kind of surgery when they are teenagers, when they are younger, but you were saying that the results are pretty good. Yeah. Uh, I can tell you, of course, I also prefer to do the patients when they are teenagers because they are so soft in the chest wall and uh it's not a problem to uh correct them. But um When we started to do the NOS procedure, it was in 2001. We haven't uh corrected any patients with the pictures before. I think maybe one or two in uh The, the period before. Uh I started in the department in '86 and uh I remember only one case, so we didn't have uh any experience with the, with the rabbits procedure, and we started with um With the NUS procedure. And of course, we knew from the beginning that it was only from teenagers. But then we gradually increased and could see that, OK, if they were 2025, no problem, 30, no problem, 35, no problem. But then they get 40, 45, 50. There might be, they are more rigid, but then you, um, of course, you, uh, use more bars. Uh, and I think with the technique, what I showed you about the pumping, so you gradually increase, um, you can say the pressure from behind of the sternum, you can do a, a proper job. Um, I can tell you that, uh, the oldest patient I had, had done was, uh, I was to a meeting in um Shangijin. And then they asked me to do some light surgery and uh said, we would do some add-ons. Yeah, no problems. They found a 64 year old previous GP and I was a little bit um Oh, afraid that we couldn't do it, but I said, OK, we can try. He had a lot of problems, uh, a lot of symptoms. And we put two bars in, he was quite deep. Um, before, he couldn't go more than maybe 100 150 m after he got several kilometers because the compression of the heart was removed. And even the, you can say the cosmetic result was quite good. But of course, uh, it's, it's, there's much more work uh with it, but I think that uh there's Of course, there might be some uh more complications, but when you get uh more uh experience about it. It, it's, it's not a problem, and if you think it's I think if you think it's too difficult to just use the introducers, you might use a crane technique. Uh, put a steel wire in the sternum or maybe uh put a kind of hook uh under the sternum and elevate with the crane. And I think you can do it, uh, because I think that a rabbits, uh, OK, it's, it's quite good, but, uh, when we look at the chest of the chest wall after. It's get more, more rigid. Even you produce new cartillates, you will see in a CT scan that it uh ossificates. So instead of having a, you can say uh acceptable uh uh um uh flexible chest wall, we will now have a, an unflexible chest wall because it's like a wall. So therefore, I think if we can, we should avoid to remove any cartilage. In the patients. And I have, I have, uh, uh, published, uh, several years ago, uh, a paper about, uh, addons more than 30 years, and, and at that time, I didn't find any uh more uh complications, um. And especially there was no problem with um flipping because I put my stabilizer where I do. OK, there's one question from the chat, um, maybe, uh, it goes to Frank Martin first because he's doing the, the vacuum valve treatment also. So one delegate is asking any criteria that You used to assign the patient for bar treatment, so, Oh Martin, when so sorry, to assign the patient for what for the NAS procedure for the bar treatment, I guess that's it, right? So what is your criteria? So, I, I, I, I, I would like just to comment or to, to add and confirm what Thomas already said. Um, if you do surgery, uh, the patient should not be too young. So, because also patient's compliance is in my personal experience very important for the postoperative course. And on the other side, we as pediatric surgeons are privileged in comparison to thoracic surgeons to see the patient at a comfortable age. So, and uh when we started, we, I, I tried to show you, we started in 2000 with the NAS procedure and we started 2.5 years later with the vacuum belt. And um I think many of us had the experience before we had the NAS procedure. We didn't see so many patients because the majority of patients, you had only the, the open repair, the ravage procedure, and uh it's, it's some like major surgery, you have a big scar, you have this cardiac resection, you know what will happen with these patients later on. So in my personal experience, we didn't have so many patients and when we started with the NAS procedure, that was the first you and then we started with the vacuum belt and the number of patients increased significantly and at that time, it was really difficult to assign which of, who of the patients will be appropriate for surgery and two of the patients will be more convenient with the vacuum belt. So now after a couple of years, we try to convince our general practitioners and pediatricians to refer the patients at an early age. So if you see the patient with a mild degree of Pus at the age of 6 or 7 years, you may consider them for a conservative vacobel treatment. And then it's important in my personal experience to follow up these patients because we know there is always a worsening of the condition during puberty. So, and if you, if you have a patient with a mild degree of Pus and he is uh successful with the vacuum belt treatment, you will just see them for. Every 2nd or 3rd year just for follow-up, but there are about 10 to 15% of patients in whom vacuum valve treatment will be not effective. Or you see a worsening or something like a recurrence during puberty. And the majority of these patients, they don't feel comfortable to restart with Waco Ebel treatment. And we also have to be aware the majority of these patients are male. 1415 year old boys and um we see it many times in our outpatient clinic that the mother is sitting on a chair and try to convince her son to please go on with the vacuum valve and you may avoid surgery, but the boys, they just tell you, forget it. Either I stop treatment or I will go ahead for surgery. So, so for, for, for me, it's, it's, there is only a small number of patients in whom you just separate between conservative or surgical. We see in the meantime, we see the majority of patients before puberty, and then we can demonstrate what would be a good option for conservative treatment and about 80, 85% are interested and they start. And about 10 to 15% of these patients, especially male patients, will not be successful, and the majority of them, you don't have to discuss to continue with surgery. They are interested, they want to have, uh, their chest wall fixed, and most, the majority of them are asking for surgery. OK, there's another question in the, in the chat. This is from Doctor Soulatankova from RIGA. Two questions in fact. One is, uh, are there differences in post-operative period in short versus long bar groups in score management, uh, uh, patient activization? And do you use the CO2 insufflation uh during the operation to improve uh inthoracic, uh, interthoracic space and visualization? So, so maybe I can, can just come in error, uh, so we use the CO2 when, when we started with the procedure, we, we had double lu in Europe and we had a lot of things and, and the preparation of the patient took nearby the same time as the, as the procedure. And then we, we stopped with the double loom. We just have a single loom and uh intubation and we use the CO2. And, and the number 2, I don't can compare um the difference between short bar and long bar. I just can compare between long bar and intermediate bar, and as I try to demonstrate. We feel much more comfortable with the intermediate bar because if the, if the patient is growing, it's not only the lungs, it's also in the deep zone and if you put the intermediate bar, you just place it in front of the chest wall, it will grow and will not have any hourglass effect. But maybe Hans can comment on, on that because you started with the long bar and you switched to the short bar. Hans, you're muted if you can. So, can you hear me now? Yeah. OK. Yes, I started with a long bar because I would cheat to the long bar. Uh, then I thought, why should it, as I told you, why should I use such a long bar. But then I found that a really short bar that was maybe too short. So you see now. My bar, where I have ended is, I think something like an intermediate bar too, because it's longer on the opposite side than uh it is on the side where you have the stabilizer. And I think, uh, uh, again, we'll change now when we have the possibility to put the stabilizer wherever we want because now we can put the stabilizer with a new system. I haven't tried it, but I saw it at the annual meeting now we had in Barcelona. You can uh put it in the front and even have a little longer bar. So I think I would like to use, you can say, an intermediate bar and make a small incision in front of the patient to put the stabilizer there. Another thing is that, um, as I told you that the old stabilizer, it was a Semitic one, and sometimes one of the flaps, uh, normally the upper one, and you can change it, whatever you want, but was too short, but now they have made, because I've asked for that, it in several years, an asymitic stabilizer with a, a longer flap on one side and a normal flap on the other side. So, I think that will minimize too the risk. That the upper flap could go between two ribs and the, the, um, the bars should flip. Uh, and with my system too, they can grow because You will never, never see a clock form, uh, because on one side it's shorter, uh, the length of the, the bar is shorter, and if they grow and get wider, it will, um, retract the parts of the side where they have a long leg. Um, what I think, uh, Concerning where, where you put your stabilizers, I think my uh technique gives less pain because we can see that 85% can leave the hospital on day two. After surgery, And I think that um might be because you have a more stable system. If you put your stabilizer on the lateral side, it's not so fixed, so there might be more movement when you uh uh Brief, but now, when you have the stabilizer medially, it's so fixed that it can't turn. So I think that's a, a very good idea too. Yeah, I agree from what your lessons, you told us, um, if you really put the stabilizer so medial that it can flip, that, that really worked. Now I got, I got another um question here. Uh, I think Martin um mentioned allergies. Can, could you both comment on how do you deal with the, the, the myth of nickel allergy and what experience you had? Do you test, uh, for allergies prior to the surgery and so on? I think I can start because Um, I put the normal steel bar in the patient even though they have nickel allergy. And um, why do I do that? Uh, the first, it was in the beginning of the, of our area, so, to do the NOS procedure, suddenly, the mother called us, uh, a couple of days before surgery on her son. Oh, we've forgotten to tell you that he has nickel allergy. And I was thinking, OK, my God, what do we do because we can't get a titanium bar uh with such a short, uh, time period. So I asked the dermatologist and he said, don't mention it because nickel allergy is, um, a contact allergy you should put on the skin. If you put it inside the, the body, there's no problem. So since that, I have never used a titanium bar. We are when I visited you because you had to. In Leipzig. So, um, I don't think it's a problem. And uh you can see we have done more than 2000 cases in Aarhus and uh I personally have maybe used about 2500, 3000 bars and, uh, it has not been a problem. So I don't think that the cases we have had of infection is caused by allergy. I think it's caused by other things and because when in the beginning, we had some very late infections uh after surgery, we only uh gave the patient one shot of antibiotic, and then we changed them uh. Gave them a 3 days of inservenously. And uh after that, of course, we will have infections so it is beyond surgery, but uh it's less than 1% so it's a very low rate. OK, thanks for sharing this, Martin. Uh, so, so we, we, fortunately we have, uh, 23 years, uh, never a case where, where we had to remove or, or revise the, the practice part due to allergy, but, uh, we take patient's history and in case if there is a positive, uh, patient's history or family history, we send the patient for a specific allergy testing. And I think in total, as far as I remember, we had uh 4 or 5 patients in, in whom we had to use the titanium. So we were not uh tough enough to um just to disregard this recommendation, uh, but it's in, in our experience, it's only a minority of patients in whom you have to have the titanium bulb. OK, we have, I think, the last question in the Q&A which is about the reservations regarding the use of MRI scan after the bar placement. Do you have any Reservations in using MRI scans? No. No, no, uh, I, I tell the patient they can go to the MRI scanner without problems. There might be like, uh, if you put them in the CT scanner, there might be some, uh, Uh, change things, but, uh, else it, uh, work, works very well. Perfect. I, I may just, uh, may, may add a, a funny history, um, uh, in, in Basel, one of our patients, it was the daughter of the security boss at the airport. And uh then he left the hospital and he checked all his uh 25 or 30 different security check points at the airport and the interesting thing was that about 40% of the machines indicated a foreign body but the remaining did not, so. So we provide for every patient the, the implant, um, card for that, but it was interesting for us to see that not every machine, uh, it's, um, searching for the same. That's scary. That's, uh, that's scary because 60%, almost 2/3, uh, did not detect it, so it's. But thanks, we have the same experience uh when we talk to the patients that, uh, a lot of them just go through the security without making any alarm. Interesting. It's different for hip replacements and although it depends of course what kind of material you use, but. Well, thank you very much for sharing your vast experience. I think that we are 5 minutes over the hour. Um, it was two great presentations and uh thank you very much for, for, for sharing your experience over so many years with so many patients. And I think this was the last webinar of 2022. Uh, so we're gonna see each other, uh, in, uh, 2023. So happy holidays to everyone and, uh, and happy New Year. Um, thanks Gaya for arranging this and thanks for, uh, to Professor Pil Pilligaard and, uh, Heckert for joining us and thanks Martin for co-sharing and sorry if I was late. I was in the OR. Yeah, and, um, thanks, everybody. Also from my side. I just put in the, the address of our YouTube channel in the chat. Please subscribe to this channel. There are over 1000 subscribers, uh, of the channel now. So, um, this, uh, edited webinar will be placed on that channel. So within the next year, I'm sure a lot of surgeons will, will watch it and, um, you can also track the, the further ongoing of what we did tonight. Thank you for the invitation. It was a great pleasure and thank you, Hans. Thank you. Great discussion. He was looking forward to seeing you in person at YSA next year. Yeah, thank you very much for me too. Merry Christmas and a happy New Year to everybody. Yes, thank you. Bye-bye. Bye-bye. Bye-bye. Diechvog von Neum Lieben istwglichber Einhogensweitereffenfernander Verliebenig und Werden Eitz. Dieer eine stanenneeler began danzig in Miloneenvonen teen sibden an Hertz eingehern beiner armer aum. Nounmunner desberter is ein Neuer menschbereit Diveld cannon Soeren. When. Aba mama i nicht. Edvard Reipo sent Alla babies were mit Animbotsvilageborn. Spina bifida und annoretale felungen senswei angeborn er rankungen die Houzna damn. Esko and uzachen ferne damn st by Kan Geben dassaggibnus ester doctor Selber daskanelliben is of Kopfgested eine Elosegeschichte von verstop von st in continent und problemenbaim stulgang. Dinmeisten elton mattesnitz a er muna baby devindxel Wenderskin rat undortus. 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