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Ann Thorac Surg 2008;86:402-409. doi:10.1016/j.athoracsur.2008.04.038
© 2008 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Lorenz Bar Repair of Pectus Excavatum in the Adult Population: Should it be Done?

Vanessa A. Olbrecht, MDa, Meghan A. Arnold, MDb, Rosemary Nabaweesi, MPH, MBChBa, David C. Chang, PhD, MPHb, Kimberly H. McIltrot, CRNPa, Fizan Abdullah, MD, PhDa, Charles N. Paidas, MD, MBAc, Paul M. Colombani, MDa,*

a Division of Pediatric Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
b Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
c Division of Pediatric Surgery, University of South Florida, Tampa, Florida

Accepted for publication April 14, 2008.

* Address correspondence to Dr Colombani, Division of Pediatric Surgery, 600 N Wolfe St, Harvey 320, Baltimore, MD 21287-4618 (Email: pc{at}jhmi.edu).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
Background: Although extensive literature exists on the Lorenz bar repair of pectus excavatum (PE) in pediatric patients, few data examine this repair in adults or compare long-term outcomes in adults with the pediatric population. We identified the preoperative characteristics, postoperative complications, and outcomes of adult patients undergoing Lorenz bar repair of PE who had bar removal and compared these outcomes with a pediatric population undergoing the same procedure.

Methods: A retrospective review (1997 to 2006) of patients undergoing primary repair of PE with a Lorenz bar identified 107 individuals aged older than 18 and 137 patients aged 6 to 14, of whom 52 and 80 had their bar(s) removed, respectively. These latter patients were the focus of analysis. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes.

Results: The median (interquartile range, IQR) age and pectus index of adult patients (81% men) at the time of repair was 23 (18 to 30) years and 3.8 (3.5 to 4.3), respectively. In 2 adults (3.9%), PE recurred after bar removal, and 6 (11.6%) required surgical revision for bar displacement or upper sternal depression. These rates of complications were similar to those found in children undergoing Lorenz bar repair of PE at our institution.

Conclusions: Lorenz bar placement to correct PE in adults can be performed safely and effectively, with rates of bar displacement, sternal depression, recurrence, and reoperation that are not statistically different than those found in a younger pediatric population.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
Pectus excavatum (PE) is one of the most common congenital abnormalities and is thought to occur in approximately 1 in every 400 births. In many cases, PE is identified and repaired in childhood, but if left untreated, the defect becomes more pronounced over time and may dramatically increase in severity during the pubertal growth spurt [1].

Repair of the defect can be done with an open approach (Ravitch) or through a newer, minimally invasive technique, the Lorenz bar. In the Ravitch procedure, a large portion of the deformed costal cartilage is removed [2]. The Lorenz bar repair avoids resection of the costal cartilage or cutting of the sternum by using a steel bar inserted through small bilateral thoracic incisions. By inserting the bar and then flipping it, the surgeon can elevate the sternum without the use of anterior chest wall incisions and with the advantages of minimal blood loss and shorter operating times [3].

Nuss and colleagues [4] have argued that the optimal time to repair a pectus defect is between the ages of 6 and 14 years, when the chest is most pliable. These authors argue that older patients experience higher rates of bar displacement, longer recovery times, and a greater need to have 2 bars placed instead of 1 to achieve adequate correction of their pectus defect [4]. In part, the forces required to elevate the chest in an adult vs a pediatric patient is thought to play a role, with the force requirement in adults found to be much higher than that needed to elevate the sternum in a child [5].

Very little literature exists examining the use of the Lorenz bar repair to treat primary PE or secondary PE in adult patients after bar removal [6–10], and even fewer studies examine outcomes of adult patients compared with a younger pediatric population [11]. As a result, our goal was to identify the preoperative characteristics, postoperative complications, and outcomes after bar removal of adult patients undergoing Lorenz bar repair of PE and to compare operative variables and postoperative outcomes with a pediatric patient cohort repaired at our institution during the same time period. In addition, we sought to identify predictors of further surgical revision in our adult population.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 Acknowledgments
 References
 
A retrospective review was performed of all patients undergoing Lorenz bar repair of pectus excavatum at The Johns Hopkins Hospital from January 1997 to December 2006. Patients were excluded if they underwent repair related to acquired Jeune syndrome, thoracic dystrophy, or developed pectus excavatum after median sternotomy. We identified 359 patients who fit these criteria: 107 patients were 18 years or older at the time of first repair. Of those, 52 (48.6%) had had their bar(s) removed at the time of their last follow-up and were the focus of this study. An additional 80 patients between the ages of 6 and 14 years, who had their bar removed at the time of their last follow-up, were used as a comparison group. Subsequent follow-up was limited to 1 year after the time of last bar removal.

General endotracheal anesthesia was used in all cases, and no epidural catheters were placed. Consent was obtained for a modified Nuss procedure and possible cartilage resection/osteotomy if necessary. Additional maneuvers to gain sternal mobility were performed through the original incisions. The only indication for an open procedure was unsuccessful repair with the modified Nuss procedure. No patient required conversion to an open repair, and only 2 patients required sternal osteotomies.

At this institution, a modified Lorenz bar procedure is used. Although the bars are generally precurved before being placed beneath the sternum through bilateral inframammary incisions, modifications to the curvature of the bar are made without removing the bar from the patient's chest. In situ bar benders are used to conform the bar to the sidewalls of the chest, and lateral stabilizers are commonly used to anchor the bar. No. 6 sternal wire was used to further anchor the bar to the crossing ribs bilaterally. Routine use of thoracoscopic visualization is not used. All instrumentation below the sternum and chest wall was performed from the left to the right side, therefore moving away from the heart. A Lorenz bar (Biomet Microfixation, Jacksonville, FL) was used for all patient repairs.

Postoperative patients received intravenous patient-controlled analgesia using narcotics. Most patients were converted to oral narcotics and nonsteroidal antiinflammatory agents by day 3, and most patients were weaned off of oral narcotics as an outpatient over 2 to 4 weeks.

Patients could resume normal activities after 2 weeks and sports and manual labor after 6 weeks. Bars were left in place for 2 years and removed on an outpatient basis. After bar removal, most patients were able to resume full activity in 6 weeks, and most slowly resumed exercise. No complications occurred during the bar removal procedure.

Medical records, including electronic patient records, hospital charts, and pediatric surgery records were used to obtain patient histories, demographics, preoperative, operative, and postoperative data, and complications. The Institutional Review Board approved the study on January 18, 2007, and waived the need for patient consent.

Data were analyzed with Stata 9 statistical software (StataCorp LP, College Station, TX). Bivariate analysis was performed using Pearson's {chi}2 test or Fisher exact test with two-tailed p values for categoric data, the t test for normally distributed continuous data, and the nonparametric K-sample test of equal medians for nonnormally distributed continuous data. Descriptive statistics are presented as a mean ± standard deviation and median (interquartile range [IQR]) for normally and nonnormally distributed data, respectively. The IQR is the difference between the first and third quartiles of a nonnormally distributed data set. Follow-up free of recurrence was calculated using the Kaplan-Meier method. Statistical significance was defined as a probability of less than 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 Acknowledgments
 References
 
Our patient cohort consisted of 52 patients aged 18 and older who had a Lorenz bar repair of PE as their first procedure and whose bar(s) had been removed at the time of their last follow-up. These patients were a median age of 23.0 years (IQR, 18 to 30 years) at the time of surgery, and the male/female ratio was 21:5 (Table 1). Most patients were white, with no black patients and only 4 patients of Hispanic or other background. Three patients had Marfan syndrome, 1 had Ehlers-Danlos syndrome, and 2 had a nonspecific connective tissue disorder.


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  		Table 1 Demographic Variables and Preoperative Characteristics of Patients Undergoing Lorenz Bar Repair
 
The mean depth of the sternal defect was 4.0 ± 1.1 cm (range, 2 to 6 cm), with a median pectus index of 3.8 (IQR, 3.5 to 4.3). The pectus index was derived from computed tomography scan measurements and was calculated in the standard fashion by dividing the internal transverse distance of the thorax by the vertebral-sternal distance at the most depressed portion of the chest. A normal chest has an index of 2.5, and the higher the index, the more severe the deformity. Median patient follow-up was 2.5 years from the date of initial Lorenz bar repair.

Most patients were symptomatic at the time of repair, and many patients had more than one complaint (Table 1). Common signs and symptoms included dyspnea on exertion in 43 (82.7%), shortness of breath at rest in 8 (15.4%), cardiac arrhythmias or palpitations in 6 (11.4%), chest pain in 27 (51.9%); fatigue, decreased energy, or diminished exercise tolerance in 16 (30.8%); and electrocardiogram changes in 7 (13.5%). Concomitant mitral valve prolapse was present in 12 patients (23.1%), and the mean ejection fraction for patients who underwent echocardiogram before operation was 56.1 ± 7.3%.

The median operative time was 82 minutes (range, 32 to 247 minutes; Table 2). Estimated median blood loss was 20 mL (range, 10 to 300 mL). No patient required a blood transfusion during or after the procedure. The low rate of blood loss can be attributed to the small incisions equivalent to those used for tube thoracostomies used in this procedure. Most patients were surgically corrected with the use of 1 Lorenz bar, and a few (5.8%) required the use of 2 bars.


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  		Table 2 Intraoperative Variables and Characteristics of Hospital Stay
 
There were no intraoperative complications involving damage to surrounding structures or excessive bleeding, and no intraoperative deaths. No patients had died at the time of last follow-up. The median length of hospital stay was 3 days (IQR, 3 to 4 days), and no patient required admission to the intensive care unit.

The most common early postoperative complication was pneumothorax, but most were clinically insignificant and resolved on their own; only 2 patients required tube thoracostomy (Table 3). Other common complications included pleural effusion in 2 (3.9%) and pneumonia in 2 (3.9%). No patient experienced a symptomatic pleural effusion requiring external drainage. The most common late complication was prolonged pain, which occurred in almost half of the patients. In all patients, this pain was managed on an outpatient basis using a combination of narcotics, nonsteroidal antiinflammatory drugs, nerve blocks, or a combination of these agents.


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  		Table 3 Early and Late Postoperative Complications
 
Superficial site infection occurred in 11 patients (21.6%). This high rate of wound infection can be attributed to two factors: a nickel reaction/allergy and preoperative preparation of the surgical sites. A nickel allergy/reaction developed in a large number of patients after bar insertion. With regard to preoperative preparation, our institution has switched to using a chlorhexidine scrub, which has lowered the infection rate to about 2%. Three patients with infection required surgical revision, and 2 required early bar removal. The sterni in both of these patients remained elevated. Only 1 patient presented with pectus carinatum (PC) after bar repair.

Bars were removed on average about 2 years after placement (Table 4). Eight (15.4%) patients underwent early bar removal, defined as removal before 2 years.


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  		Table 4 Recurrence and Follow-Up Information
 
Most adults undergoing Lorenz bar repair of PE did not require further operative procedures. Only 2 patients (3.9%) experienced a recurrence after bar removal, and neither has required operative repair. Bar displacement requiring operative correction occurred in 4 patients (7.7%). Depression of the upper sternum requiring insertion of a second pectus bar to correct the defect developed in 2 patients (3.9%) (Table 3). One patient experienced bar displacement twice and required operative correction both times. The median time to reoperation was 48.5 days (IQR, 35 to 379 days; Table 4). The mean age at the time of reoperation was 30.5 ± 8.0 years. Costal cartilage was cut in two of the revisions, but cartilage was removed in neither, and sternal osteotomy was never required.

Postoperative complications after the second bar procedure were minimal: A clinically insignificant pneumothorax occurred in only 1 patient (16.7%), and pleural effusion occurred in 2 (33.3%). No hemorrhage occurred that required transfusion or reoperation. There was no pneumonia or respiratory distress. The mean length of stay after reoperation was 3.2 ± 0.8 days. Few late complications occurred. Only 1 patient experienced prolonged pain, which was managed as an outpatient, and no superficial surgical site infections developed. No silicone prostheses implants were required, and no PC developed.

Results after revision were excellent. After reoperation, no patient experienced a recurrence of PE nor depression of the upper sternum requiring insertion of a second bar (Table 4). Only 1 patient experienced another bar displacement after the revision. Freedom from further surgical revision was 93.5% ± 4.5% at 1, 5, and 11 months (Fig 1).


Figure 1
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  		Fig 1. Freedom from further surgical revision after bar removal.

 
Table 5 compares our adult population with a younger patient cohort undergoing Lorenz bar repair of PE at our institution during the same time period. The patients were statistically different in age, but did not differ in terms of sex, race, and depth of defect. The median operative times and length of stay did not differ between the two groups, but the adult patients had a higher estimated blood loss during the repair, and a few more patients required the placement of a second Lorenz bar to achieve adequate surgical correction of their chest wall deformity. Patient groups did not differ with respect to postoperative complications, including rates of bar displacement, recurrence, upper sternal depression, or reoperation. The median lengths of follow-up were similar between the two groups.


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  		Table 5 Comparison of Demographic Characteristics, Operative Variables, and Postoperative Outcomes Between Adults Undergoing Lorenz Bar Procedure and Pediatric Patients
 
Bivariate analysis showed that predictors of surgical revision after the Lorenz bar repair were bar displacement (p < 0.001) and early bar removal, defined as bar removal within 2 years of bar placement (p < 0.001).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 Acknowledgments
 References
 
Our goal was to identify the preoperative characteristics, postoperative complications, and outcomes of adult patients undergoing Lorenz bar repair of PE in a subset of patients who have been monitored long enough to have their bar(s) removed and to compare these outcomes to a pediatric population that has been determined in the literature to be of "ideal" age for bar repair. Extensive data exist about the use of the Ravitch repair in adult patients [12–16], but there is an increasing trend towards using the minimally invasive approach to repair these defects in an older population [3]. When such shifts occur, questions of safety and efficacy in specific patient populations need to be answered before the new minimally invasive approach can replace the use of the open procedure. Several studies have established the safety of the Lorenz bar repair in adults, but few have considered its efficacy in this population [4, 6–11, 17–21].

All of the studies that have addressed Ravitch repairs of adult PE patients have found that the repair does an adequate job in mitigating or eliminating preoperative symptoms, with a short hospital stay and relatively few postoperative complications [12–16]. However, operative times can often be long, especially in adult patients, usually more than 3 hours and even longer in adults presenting with recurrence [13, 16]. Protrusion of costal cartilage can also occur after operation, which often requires surgical resection to achieve an acceptable cosmetic outcome [12]. This complication is more common in young children but still occurs in the adult population.

Our patients had a hospital length of stay of 3 to 4 days, which was consistent with hospital stays after the Ravitch repair. In addition, operative times were substantially shorter and postoperative complications were similar. Recurrence after repair of PE using the Ravitch technique is reported in 2% to 16% of patients [12, 14, 16, 22]. In our series, 4.0% had mild recurrence (< 2.5 cm), and no patients had a severe recurrence (> 2.5 cm). This rate compares very favorably with these statistics, as does our 12.0% reoperation rate.

Previous studies have documented the feasibility of performing the Lorenz bar repair in adult patients, indicating that the procedure can be performed safely, with minimal blood loss, shorter operating times, and with relatively few postoperative complications [4, 6–11, 17–21]. Despite these promising early results, only three studies mention recurrence rates after bar removal, and all suffer from small sample sizes [6–8]. For that reason, our study was conducted to determine the technical feasibility of primary and secondary bar repair in an adult population, and describe the outcomes of these patients once all bars have been removed.

Our results indicate that adults whose defect is corrected with the Lorenz bar procedure do extremely well, with no intraoperative complications, short operative times, minimal blood loss, short hospital stays, and low rates of early and late postoperative complications. More important, few patients experienced a recurrence of their defect after bar removal, and most patients had not required further surgical procedures at the time of their last follow-up. Recurrences in our series were 1 patient with an initial 6-cm defect who had a recurrence of 1.5 cm, and a 2-cm defect that developed in another patient after bar removal. Both patients are asymptomatic, happy with their repairs, and are being observed.

When the adult population was compared with the pediatric cohort, rates of longer-term complications were equivalent between the two groups. The only differences were a higher median estimated blood loss and a requirement in some adult patients to have their defect corrected with more than one bar. Although the blood loss was statistically higher in adults, this is not clinically significant, and only a few adult patients required correction with 2 Lorenz bars. Some have argued that the ideal time to correct patients with the bar repair is between the ages of 6 and 14 years, but our results indicate that outcomes in adult patients rival those found in this younger patient population [4, 11].

Our data show that early displacement of the bar after Lorenz bar repair remains a significant problem, with most of these patients requiring reoperation. Our rate of bar displacement of 7.7%, however, compares favorably with the reported rate of bar displacement in the literature of 4.3% to 19% [4, 17, 23–27]. Nevertheless, the results of our surgical experience and bivariate analysis emphasize the importance of adequate surgical technique at the time of primary repair. In patients who required reoperation, however, all but one was successfully managed with a single repeat Lorenz bar procedure. Modification to the procedure (cutting cartilage) was only required in 2 patients. In addition, our results compare favorably with the two pediatric studies that address the use of this procedure to repair recurrent pectus excavatum [9, 10].

The retrospective nature of this study leads to some limitations when our data are analyzed. Because the surgical correction of PE is relatively rare and the Lorenz bar procedure has only been performed for a few years, only a small number of patients were included in our cohort. In addition, our follow-up time was limited because bar removal occurs 2 to 3 years after the initial procedure. We limited the amount of time of follow-up to 1 year after bar removal to include as many patients as possible. In future studies, we will address longer term follow-up as well as have a larger cohort of patients. Despite these limitations, our findings provide new insight into the outcomes of adults who have undergone the Lorenz bar repair of PE. Further studies will be undertaken to assess functional outcomes by using patient questionnaires and quality assessment tools as our follow-up time increases.

In conclusion, using the Lorenz bar technique to treat PE in adult patients is feasible and provides excellent longer-term results, with most patients being free from recurrence and further surgical revisions within the first year after bar removal. As surgeons become more adept with this procedure in adults, the technical aspects leading to complications can be minimized, thereby further enhancing the excellent outcomes experienced by adult patients.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
Acknowledgments
 References
 
DR DANIEL L. MILLER (Atlanta, GA): I'd like to lead off. Excellent presentation and series. I think it is kind of interesting. This is from the pediatric surgery department. Having these older patients on the pediatric wing must be very interesting. My question, I have several problems with this study. One, first of all, especially in your adult population, is in regards to pain: 52% of your patients were operated on for pain, and afterwards 47% continued to have pain. And that is a major issue in regards to this procedure, and could you address that, please?

DR OLBRECHT: Approximately one-half of patients complain of prolonged pain following the procedure. What we define as "prolonged pain" was pain that required the use of narcotics for a longer period of time compared with other patients. All of these patients were able to be managed on an outpatient basis and did not require hospital readmission. Following discharge, these patients were seen on an outpatient basis by Dr Colombani. I think he may be better able to provide insight into their long-term management.

DR MILLER: And also, too, you were very nice to give us the paper beforehand. There is no pulmonary function data and that is a number one criteria that we have to use to get these patients to have their surgical procedure cleared by insurance. And I think when people have chronic pain, a lot of times they will develop restrictive disease afterwards, which you were trying to correct.

DR OLBRECHT: In fact, we have collected preoperative pulmonary function testing data on all of our patients. Our goal in presenting this data, however, is to compare preoperative testing data to postoperative data. Because we are still in the process of collecting the postoperative data, we have not yet published this information. When looking at the preoperative data, all patients had a restrictive ventilatory defect at the time of surgery.

DR MILLER: And one last question. From the data from our institution, we found that when patients had a pectus index of greater than 4.1 and had asymmetric disease, they should not have a Nuss bar. And there is no mention here about the type of defect that they had. Could you comment on that?

DR OLBRECHT: We actually did not look specifically at the different types of symmetry vs asymmetry when we did our analysis.

DR MILLER: Okay. Thank you.

DR CARLOS SALDARRIAGA (Medellin, Colombia): Congratulations, nice presentation and nice paper. My first question is: Would you like to tell us about this surgical technique without video thoracoscopy? My second question is: did you have in your series patients with Marfan syndrome or Morquio disease?

DR OLBRECHT: Let me address your second question first. In this particular series, we had 3 patients with Marfan syndrome, and 2 patients with a nonspecific connective tissue disease. We didn't look at these patients separately because we actually have another series in which we only looked at patients with connective tissue disease and found the outcomes were no different when we compared those to patients without connective tissue disease. And in regard to your first question, I actually did not participate in any of the operative repairs, but Dr Colombani is standing at the microphone and I am sure would be happy to comment.

DR COLOMBANI: Well, three comments. One is that we kind of backed into this as pediatric surgeons, having started with a long series from Alex Haller. We had a number of adult patients who came back with recurrences. So actually, our first series of adult patients were actually patients who had recurrence after a Ravitch repair.

We do the procedure basically from left to right when you pass the Crawford aortic clamp. Using a very medial incision in the midclavicular line, you are looking at the pericardium when you insert through the small hole through the intercostal space. We then pass the Crawford clamp from left to right, so we are really going by the heart very quickly and safely. And so after using the scope a couple times, we just realized it was a needless expense for the patient. We have not had any serious injuries or any problems going from left to right.

The pain issue is a big issue, and I think the older the patient gets, the longer their pain lasts. So for our typical teenager or older school age kid, they will have pain for a couple of weeks and then they are pretty much pain free. Our adults, though, may have pain for a number of months, and occasionally longer. But virtually all of the adult patients are pain free after 4 to 6 months. But it does take longer. They do have to take nonsteroidals for a longer period of time.

There was one other question that was asked about pulmonary function tests. We can't get in the OR [operating room] without having objective and abnormal pulmonary function tests for the patients. All of these patients have pre-op PFTs. Virtually all of them had FVCs [forced vital capacities] of less than 80% of predicted to get into the operating room to begin with, and we are in the process of doing post-op comparison studies.

I think what we're finding is that the amount of restriction that we create is less, because we do very little dissection, I think the amount of restriction that we used to see with our Ravitch patients, that their forced vital capacity was unchanged from pre- to post-op. With the Nuss procedure, what we are seeing is that there is percentage increase in forced vital capacity in these patients after repair, which reflects how little scar tissue we create.

DR MILLER: And how about the asymmetric defect, any issues with that?

DR COLOMBANI: Yes. The deeper the defect, the more angulation we have, the less optimal the result is. So we can usually get the sternum to come up, but sometimes what will happen is that the left cartilages will come up a little bit higher, so there will be some residual asymmetry. In the teenagers, a lot of that asymmetry will resolve spontaneously over time as they finish their teenage growth. But in a few adult patients, after 2 years, and at the time of bar removal, I have resected some of those cartilages that were high on.

DR SCOTT J. SWANSON (New York, NY): I enjoyed the presentation as well. Are there any patients on which you would primarily do a Ravitch other than the deep asymmetric ones, and does the length of time you leave the bar in ever affect your decision of which repair to do?

DR COLOMBANI: Originally we left the bars in for 2 years, and then we had some recurrences, actually in our younger kids that had the bar out before their teenage growth, so then we went to 3 years. And then I realized that none of our adults recurred. We had two mild recurrences. Both patients were very happy with their result so we did not redo them. So we are back to 2 years for the patients.

What I tell all the patients is that when you go in the operating room, we will try and do the Nuss procedure, even if they have a very deep, 6-, 7-cm defect or rotation. But I tell them that we'll cut cartilages and maybe do a sternal osteotomy, if we have to, to get the sternum to come up into a neutral position.

And so we have not had to do a formal Ravitch in really anybody, and we are up to over 500 patients now. But we are prepared to do that, and the patients know that they'll come out of the operating room sometimes with 1 bar or 2 bars, and sometimes with cartilages cut or a sternal osteotomy in the extreme case.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
References
 
We would like to thank Dr Stephen C. Yang for his assistance in the creation of this project.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 

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