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[幻世子衍 <unrealyan-Re5JQEeQqe8AvxtiuMwx3w@public.gmane.org>]

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[INFO] Skipped '\noindent{\textit{Correspondence to:} Frank-Martin Haecker, 
MD, Professor of Pediatric Surgery. Chest Wall Unit at the Department of 
Pediatric Surgery, Children’s
  Hospital of Eastern Switzerland, Claudiusstrasse 6, CH-9006 St. Gallen, 
Switzerland. Email: frank-martin.haecker-kpaEHHRHYO5yDzI6CaY1VQ@public.gmane.org}' at main.tex line 140 
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[INFO] Skipped '\noindent{\textit{Comment on}: Scalise PN, Demehri FR. The 
management of pectus excavatum in pediatric patients: a narrative review. 
Transl Pediatr 2023;12:208-20.}' at main.tex line 142 column 149
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Pectus excavatum; pediatric patients; Nuss procedure; vacuum bell; 
cryoablation}' at main.tex line 145 column 95
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[INFO] Skipped '\noindent{Submitted Apr 26, 2023. Accepted for publication 
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[INFO] Skipped '\begin{multicols}{2}
      {
      \indent The majority of congenital chest wall deformities (CWD)
  affects the anterior chest wall. The most common anterior
  CWD is pectus excavatum (PE), followed by Pectus
  carinatum (PC). The incidence of PE is approximately
  1 in every 300–400 births, affecting male patients with
  an approx. 4:1 ratio (\cite{pmid36891368}). For the last 70 to 80 years, 
open
  surgical repair such as the Ravitch technique and its
  modifications (\cite{pmid35820596,pmid35455522}) was the preferred method 
to correct
  CWDs. An essential paradigm shift occurred with the
  inauguration of the minimally invasive repair of pectus
  excavatum (MIRPE) by Nuss (\cite{pmid35377161}). In contrast to open
  repair, MIRPE does not require cartilage or sternal
  resection. Flexibility and elasticity of the chest wall which
  are preserved applying MIRPE, were identified as relevant
  parameters for successful treatment of CWD. Furthermore,
  an increasing number of patients presented with thoracic
  chondrodystrophy as a long-term side effect after open
  surgical repair. As a consequence, the management of CWD
  including diagnostic work-up as well as conservative and
  surgical treatment options has made substantial progress
  during the past two decades. Today, treatment of CWD
  includes all age groups with pediatric, adolescent and adult
  patients, covered by a dedicated multidisciplinary team
  (in particular pediatric and thoracic surgeons) based in a
  specialized chest wall unit, what is the most important pillar
  of present time.
  The physiologic effects of CWD are still discussed
  controversially. There is an ongoing controversial debate
  concerning effects of MIRPE on exercise tolerance, lack
  of endurance, shortness of breath, cardiopulmonary
  function, body posture, etc. Even if the number of articles
  reporting on different aspects of CWD treatment went
  up from approximately 300 (1980 to 1989) to more than
  1,000 published papers (2012 to 2021), the controversial
  debate will continue (\cite{pmid34942673}). Information on new diagnostic
  and therapeutic modalities provided by online platforms
  and social media circulates not only among surgeons
  and paediatricians, but also rapidly among patients. Not
  only different surgical techniques, but also conservative
  treatment options are available. In almost the same manner,
  postoperative pain management is an important part of
  an effective and successful treatment protocol. Several
  modifications were introduced over the past years. For a
  long time, regional analgesia such as paravertebral nerve
  blocks or catheters, epidurals as well as patient-controlled
  analgesia (PCA) represented the preferred anesthesia
  method. Nowadays, cryoablation became a more and
  more applied alternative technique (\cite{pmid33853733,pmid32753276}). 
Cryoablation
  may be applied thoracoscopically during MIRPE (\cite{pmid31600804}), or as
  ultrasound guided percutaneous intercostal injection 
(\cite{pmid31199434}).
  After its introduction, MIRPE was well established
  in the first decade of this century and subsequently
  performed with increasing frequency worldwide. Today,
  MIRPE represents the worldwide used “gold-standard”
  for surgical repair of PE. Applying the technique in
  different age groups, the method experienced numerous
  modifications. Modifications include patient selection
  and indication, preoperative evaluation, as well as age
  at time of surgical repair. Positioning of the patient on
  the OR table, intubation (single lumen vs. double lumen
  tubus) were modified. Number, location and size of skin
  incisions, shape/size or number of bars and bar fixation as
  well as bar passage (intra vs. extrapleural placement) were
  modified (\cite{pmid29672193}). To reduce the risk of secondary bar
  displacement and/or to correct complex CWDs, placement
  of more than 1 bar including the so called cross-bar
  technique was introduced (\cite{pmid28822540}).

  Two fundamental techniques were introduced to reduce
  the risk of intraoperative cardiac injuries: routine unilateral
  and/or bilateral thoracoscopy (\cite{pmid25814003}), and routine sternal
  elevation (\cite{pmid18582824,pmid11877663}). Whereas in the initial 
publication by
  Nuss retrosternal dissection was described as “blunt” using
  a long-curved clamp without thoracoscopy (4), the same
  group reported their experience using routine thoracoscopy
  4 years later, achieving improved safety during mediastinal
  dissection (\cite{pmid10803339}). In particular the risk of cardiac 
perforation
  as the most severe complication could be decreased with
  the routine use of thoracoscopic guidance (\cite{pmid9574749}). Even
  more than 2 decades after its introduction there is no
  evidence-based data available concerning the protective
  effect of thoracoscopy on the true incidence of near fatal
  complications like cardiac injuries. However, the majority of
  articles and studies reporting on catastrophic complications
  were all published before 2011 (5). Furthermore, the
  widespread use of routine intraoperative sternal elevation
  must be considered as an additional effective measure
  to improve safety of MIRPE (13).

  Visualization across
  the mediastinum during retrosternal dissection may be
  compromised in severe defects. Notably in older adult PE
  patients, decreased flexibility and stiffness of the anterior
  chest wall as well as the corresponding force required
  to elevate the sternum may make retrosternal dissection
  difficult and sometimes nearby impossible. Applying routine
  sternal elevation during MIRPE, the safety of the procedure
  has improved clearly as there was no near-fatal and/or fatal
  incident reported anymore when the technique was applied
  intraoperatively (13).
  Evolution in the management of congenital CWD and
  modifications of newly introduced techniques have made
  significant progress over the past 2–3 decades, and as a
  consequence patients outcome improved substantially.
  The aim of the narrative review presented by Scalise and
  Demehri (\cite{pmid18582824}) is to outline current practice concerning
  diagnostic work-up, conservative and surgical treatment
  as well as management in general of pediatric PE patients.
  Since we may find numerous publications dealing with this
  topic, it is nearby impossible to review all the literature,
  covering all different age groups. In particular no
  randomized double-blind studies are available. Therefore,
  the quality of evidence regarding this topic remains
  relatively low with still many unexplored and unknown
  pathways. Different objective criteria were screened, verified
  and added to identify PE patients that would benefit from
  surgery. An increasing number of studies accentuating the
  cardiopulmonary consequences of PE. Notably, more than
  275 papers have been published in the last 10 years focusing
  on functional changes prior to and after surgical correction
  of PE. Due to different reasons (e.g., retrospective and/or
  small cohort studies), the results are still heterogenous and
  of low evidential quality (\cite{pmid18582824}). Based on this generally 
poor
  evidence, the controversial debate on the cardiopulmonary
  impact of PE and whether patients may benefit from
  surgical repair or not will continue as long as we may be
  able to provide double blind randomized studies. However,
  IRB approval for such a study has to be considered as
  difficult or nearby impossible. This is aggravated by the
  fact that PE is many times considered as an “only” esthetic
  disorder and in particular associated with body image
  disturbances. In contrast, among surgeons and confirmed
  by recently published studies it is clearly acknowledged
  that subjective improvement in exercise intolerance is
  often reported after MIRPE (\cite{pmid18582824}). Thus, despite above
  mentioned facts as well as current believes, reviews such as
  presented by Scalise and Demehri may help to bridge the
  lack of convincing high-quality evidence which remains a
  critical concern that could potentially interfere with future
  management of PE. As concluded by Scalise and Demehri
  in their narrative review, there is still a lack of international
  consensus guidelines concerning preoperative diagnostic
  work-up, conservative and surgical treatment as well as
  postoperative management. A recently published study
  by Janssen et al. reported on a consensus statement for
  perioperative care for PE based on a multi-round Delphi
  survey (\cite{pmid18582824}). Pectus surgeons all around the world are
  encouraged to draw up standardized consensus guidelines to
  establish a high-level algorithm for preoperative diagnostic
  protocol, indications for conservative and/or surgical
  treatment as well as postoperative management.
      }

     \amesection{Acknowledgments}

     Funding: None.

     \amesection{Footnot}

     \textit{Provenance and Peer Review:} This article was commissioned
  by the editorial office, Translational Pediatrics. The article
  did not undergo external peer review.

      \vspace{1ex}

      \textit{Conflicts of Interest: }The author has completed the ICMJE
      uniform disclosure form (available at \url{https://tp.amegroups.
      com/article/view/10.21037/tp-23-264/coif} ). The author has
      no conflicts of interest to declare.

      \vspace{2ex}

      \textit{Ethical Statement:} The author is accountable for all
  aspects of the work in ensuring that questions related
  to the accuracy or integrity of any part of the work are
  appropriately investigated and resolved.

      \vspace{2ex}

      \textit{Open Access Statement:} This is an Open Access article
  distributed in accordance with the Creative Commons
  Attribution-NonCommercial-NoDerivs 4.0 International
  License (CC BY-NC-ND 4.0), which permits the non-
  commercial replication and distribution of the article with
  the strict proviso that no changes or edits are made and the
  original work is properly cited (including links to both the
  formal publication through the relevant DOI and the license).
  See: 
\href{https://creativecommons.org/licenses/by-nc-nd/4.0}{https://creativecommons.org/licenses/by-nc-nd/4.0}

  Let's cite! Einstein's journal paper and Dirac's book \cite{dirac} are 
physics-related items.


      \titleformat{\section}
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      % 
\cite{pmid18582824,pmid10803339,pmid9574749,pmid35455522,pmid31600804,pmid29672193,pmid33853733,pmid34942673,pmid35820596,pmid25814003,pmid31199434,pmid32753276,pmid11877663,pmid28822540,pmid36891368,pmid35377161}

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      Cite this article as: Haecker FM. Evolution in the management of 
pectus excavatum in pediatric patients. Transl Pediatr 
2023;12(8):1450-1453. doi: 10.21037/tp-23-264

  \end{minipage}}

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<p>https://dx.doi.org/10.21037/tp-23-264</p>
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[INFO] Skipped '\noindent{\textit{Correspondence to:} Frank-Martin Haecker, 
MD, Professor of Pediatric Surgery. Chest Wall Unit at the Department of 
Pediatric Surgery, Children’s
  Hospital of Eastern Switzerland, Claudiusstrasse 6, CH-9006 St. Gallen, 
Switzerland. Email: frank-martin.haecker-kpaEHHRHYO5yDzI6CaY1VQ@public.gmane.org}' at main.tex line 140 
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management of pectus excavatum in pediatric patients: a narrative review. 
Transl Pediatr 2023;12:208-20.}' at main.tex line 142 column 149
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Pectus excavatum; pediatric patients; Nuss procedure; vacuum bell; 
cryoablation}' at main.tex line 145 column 95
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[INFO] Skipped '\noindent{Submitted Apr 26, 2023. Accepted for publication 
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[INFO] Skipped '\begin{multicols}{2}
      {
      \indent The majority of congenital chest wall deformities (CWD)
  affects the anterior chest wall. The most common anterior
  CWD is pectus excavatum (PE), followed by Pectus
  carinatum (PC). The incidence of PE is approximately
  1 in every 300–400 births, affecting male patients with
  an approx. 4:1 ratio (\cite{pmid36891368}). For the last 70 to 80 years, 
open
  surgical repair such as the Ravitch technique and its
  modifications (\cite{pmid35820596,pmid35455522}) was the preferred method 
to correct
  CWDs. An essential paradigm shift occurred with the
  inauguration of the minimally invasive repair of pectus
  excavatum (MIRPE) by Nuss (\cite{pmid35377161}). In contrast to open
  repair, MIRPE does not require cartilage or sternal
  resection. Flexibility and elasticity of the chest wall which
  are preserved applying MIRPE, were identified as relevant
  parameters for successful treatment of CWD. Furthermore,
  an increasing number of patients presented with thoracic
  chondrodystrophy as a long-term side effect after open
  surgical repair. As a consequence, the management of CWD
  including diagnostic work-up as well as conservative and
  surgical treatment options has made substantial progress
  during the past two decades. Today, treatment of CWD
  includes all age groups with pediatric, adolescent and adult
  patients, covered by a dedicated multidisciplinary team
  (in particular pediatric and thoracic surgeons) based in a
  specialized chest wall unit, what is the most important pillar
  of present time.
  The physiologic effects of CWD are still discussed
  controversially. There is an ongoing controversial debate
  concerning effects of MIRPE on exercise tolerance, lack
  of endurance, shortness of breath, cardiopulmonary
  function, body posture, etc. Even if the number of articles
  reporting on different aspects of CWD treatment went
  up from approximately 300 (1980 to 1989) to more than
  1,000 published papers (2012 to 2021), the controversial
  debate will continue (\cite{pmid34942673}). Information on new diagnostic
  and therapeutic modalities provided by online platforms
  and social media circulates not only among surgeons
  and paediatricians, but also rapidly among patients. Not
  only different surgical techniques, but also conservative
  treatment options are available. In almost the same manner,
  postoperative pain management is an important part of
  an effective and successful treatment protocol. Several
  modifications were introduced over the past years. For a
  long time, regional analgesia such as paravertebral nerve
  blocks or catheters, epidurals as well as patient-controlled
  analgesia (PCA) represented the preferred anesthesia
  method. Nowadays, cryoablation became a more and
  more applied alternative technique (\cite{pmid33853733,pmid32753276}). 
Cryoablation
  may be applied thoracoscopically during MIRPE (\cite{pmid31600804}), or as
  ultrasound guided percutaneous intercostal injection 
(\cite{pmid31199434}).
  After its introduction, MIRPE was well established
  in the first decade of this century and subsequently
  performed with increasing frequency worldwide. Today,
  MIRPE represents the worldwide used “gold-standard”
  for surgical repair of PE. Applying the technique in
  different age groups, the method experienced numerous
  modifications. Modifications include patient selection
  and indication, preoperative evaluation, as well as age
  at time of surgical repair. Positioning of the patient on
  the OR table, intubation (single lumen vs. double lumen
  tubus) were modified. Number, location and size of skin
  incisions, shape/size or number of bars and bar fixation as
  well as bar passage (intra vs. extrapleural placement) were
  modified (\cite{pmid29672193}). To reduce the risk of secondary bar
  displacement and/or to correct complex CWDs, placement
  of more than 1 bar including the so called cross-bar
  technique was introduced (\cite{pmid28822540}).

  Two fundamental techniques were introduced to reduce
  the risk of intraoperative cardiac injuries: routine unilateral
  and/or bilateral thoracoscopy (\cite{pmid25814003}), and routine sternal
  elevation (\cite{pmid18582824,pmid11877663}). Whereas in the initial 
publication by
  Nuss retrosternal dissection was described as “blunt” using
  a long-curved clamp without thoracoscopy (4), the same
  group reported their experience using routine thoracoscopy
  4 years later, achieving improved safety during mediastinal
  dissection (\cite{pmid10803339}). In particular the risk of cardiac 
perforation
  as the most severe complication could be decreased with
  the routine use of thoracoscopic guidance (\cite{pmid9574749}). Even
  more than 2 decades after its introduction there is no
  evidence-based data available concerning the protective
  effect of thoracoscopy on the true incidence of near fatal
  complications like cardiac injuries. However, the majority of
  articles and studies reporting on catastrophic complications
  were all published before 2011 (5). Furthermore, the
  widespread use of routine intraoperative sternal elevation
  must be considered as an additional effective measure
  to improve safety of MIRPE (13).

  Visualization across
  the mediastinum during retrosternal dissection may be
  compromised in severe defects. Notably in older adult PE
  patients, decreased flexibility and stiffness of the anterior
  chest wall as well as the corresponding force required
  to elevate the sternum may make retrosternal dissection
  difficult and sometimes nearby impossible. Applying routine
  sternal elevation during MIRPE, the safety of the procedure
  has improved clearly as there was no near-fatal and/or fatal
  incident reported anymore when the technique was applied
  intraoperatively (13).
  Evolution in the management of congenital CWD and
  modifications of newly introduced techniques have made
  significant progress over the past 2–3 decades, and as a
  consequence patients outcome improved substantially.
  The aim of the narrative review presented by Scalise and
  Demehri (\cite{pmid18582824}) is to outline current practice concerning
  diagnostic work-up, conservative and surgical treatment
  as well as management in general of pediatric PE patients.
  Since we may find numerous publications dealing with this
  topic, it is nearby impossible to review all the literature,
  covering all different age groups. In particular no
  randomized double-blind studies are available. Therefore,
  the quality of evidence regarding this topic remains
  relatively low with still many unexplored and unknown
  pathways. Different objective criteria were screened, verified
  and added to identify PE patients that would benefit from
  surgery. An increasing number of studies accentuating the
  cardiopulmonary consequences of PE. Notably, more than
  275 papers have been published in the last 10 years focusing
  on functional changes prior to and after surgical correction
  of PE. Due to different reasons (e.g., retrospective and/or
  small cohort studies), the results are still heterogenous and
  of low evidential quality (\cite{pmid18582824}). Based on this generally 
poor
  evidence, the controversial debate on the cardiopulmonary
  impact of PE and whether patients may benefit from
  surgical repair or not will continue as long as we may be
  able to provide double blind randomized studies. However,
  IRB approval for such a study has to be considered as
  difficult or nearby impossible. This is aggravated by the
  fact that PE is many times considered as an “only” esthetic
  disorder and in particular associated with body image
  disturbances. In contrast, among surgeons and confirmed
  by recently published studies it is clearly acknowledged
  that subjective improvement in exercise intolerance is
  often reported after MIRPE (\cite{pmid18582824}). Thus, despite above
  mentioned facts as well as current believes, reviews such as
  presented by Scalise and Demehri may help to bridge the
  lack of convincing high-quality evidence which remains a
  critical concern that could potentially interfere with future
  management of PE. As concluded by Scalise and Demehri
  in their narrative review, there is still a lack of international
  consensus guidelines concerning preoperative diagnostic
  work-up, conservative and surgical treatment as well as
  postoperative management. A recently published study
  by Janssen et al. reported on a consensus statement for
  perioperative care for PE based on a multi-round Delphi
  survey (\cite{pmid18582824}). Pectus surgeons all around the world are
  encouraged to draw up standardized consensus guidelines to
  establish a high-level algorithm for preoperative diagnostic
  protocol, indications for conservative and/or surgical
  treatment as well as postoperative management.
      }

     \amesection{Acknowledgments}

     Funding: None.

     \amesection{Footnot}

     \textit{Provenance and Peer Review:} This article was commissioned
  by the editorial office, Translational Pediatrics. The article
  did not undergo external peer review.

      \vspace{1ex}

      \textit{Conflicts of Interest: }The author has completed the ICMJE
      uniform disclosure form (available at \url{https://tp.amegroups.
      com/article/view/10.21037/tp-23-264/coif} ). The author has
      no conflicts of interest to declare.

      \vspace{2ex}

      \textit{Ethical Statement:} The author is accountable for all
  aspects of the work in ensuring that questions related
  to the accuracy or integrity of any part of the work are
  appropriately investigated and resolved.

      \vspace{2ex}

      \textit{Open Access Statement:} This is an Open Access article
  distributed in accordance with the Creative Commons
  Attribution-NonCommercial-NoDerivs 4.0 International
  License (CC BY-NC-ND 4.0), which permits the non-
  commercial replication and distribution of the article with
  the strict proviso that no changes or edits are made and the
  original work is properly cited (including links to both the
  formal publication through the relevant DOI and the license).
  See: 
\href{https://creativecommons.org/licenses/by-nc-nd/4.0}{https://creativecommons.org/licenses/by-nc-nd/4.0}

  Let's cite! Einstein's journal paper and Dirac's book \cite{dirac} are 
physics-related items.


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      % 
\cite{pmid18582824,pmid10803339,pmid9574749,pmid35455522,pmid31600804,pmid29672193,pmid33853733,pmid34942673,pmid35820596,pmid25814003,pmid31199434,pmid32753276,pmid11877663,pmid28822540,pmid36891368,pmid35377161}

      % 在文中插入引用信息
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      Cite this article as: Haecker FM. Evolution in the management of 
pectus excavatum in pediatric patients. Transl Pediatr 
2023;12(8):1450-1453. doi: 10.21037/tp-23-264

  \end{minipage}}

  \end{multicols}' at main.tex line 157 column 22
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<p>https://dx.doi.org/10.21037/tp-23-264</p>

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