Thoracic outlet syndrome after the Nuss procedure for the correction of extreme pectus excavatum

Post-operative arrest following pectus excavatum repair: A case report with a systematic review of the published case reports

Key Clinical Message

Common complications after PE surgery include ventricular tachycardia, cardiac arrest, pneumothorax, and bar displacement. These can lead to severe outcomes, emphasizing the need for caution and meticulous post-operative monitoring. Patients and their families should be well-informed about potential risks during the consent process.

Abstract

The objective of this study was to raise awareness among medical staff and surgeons about potential complications, particularly rare and life-threatening ones, associated with pectus excavatum (PE) surgery. PE is the most common chest wall deformity, characterized by sternal depression. Patients primarily seek treatment for cosmetic concerns, but some also report exercise intolerance and shortness of breath. Although surgical repair is the standard treatment, the incidence and nature of severe complications remain unclear and underreported. This study presents a case of a lethal cardiac event following PE surgery and conducts a systematic review of published case reports. This study describes a case of a lethal complication of ventricular fibrillation and cardiac arrest following the Ravitch procedure for correction of PE in a 10-year-old boy. A systematic review of relevant cases of PE surgery complications was conducted. Of the 506 initial records retrieved, 93 case reports from 83 articles were identified over the 23 years. Among them, 72 patients were male, and 20 cases were female. The average age of patients was 19.2 ± 7.7 years (range: 5-53). Complications had occurred up to 37 years from the time of surgery, with most of the cases (22.5%) occurring during the operation. The most frequent complications included cardiothoracic issues and displacement of the implanted steel bar. In nine patients, complications led to fatal outcomes. Due to the possible risks of PE surgery, particularly in cosmetically motivated cases, surgeons must exercise extreme caution and remain vigilant for rare and potentially life-threatening complications.

Thoracic Outlet Syndrome after Minimally Invasive Repair of Pectus Excavatum in a 15-Year-Old Boy: A Case Report

Nuss procedure has become the treatment of choice in pectus excavatum mainly because of the excellent functional and cosmetic results. Despite the good results, several complications have been reported. The aim of this study is to describe a case of thoracic outlet syndrome (TOS) after Nuss procedure and review the management of such rare complication. A 15-year-old boy otherwise healthy was submitted to Nuss procedure, with no perioperative complications. Two-weeks later, the patient complained of right-hand paresthesia, progressive weakness of the right arm and coldness. After imaging and electromyography, TOS diagnosis was established. Removal of the bar was proposed but refused by the patient. Conservative management with rehabilitation exercising and nerve nourishing was initiated. At 7 months, the patient recovered arm and hand function. Abrupt structural changes of thoracic cavity with marked elevation of the upper chest induce nerve and vascular compression arousing a TOS and should be acknowledged as one potential complication of Nuss procedure. Conservative management can be an alternative treatment to bar removal, showing good results on functional recovery in early stages of compression.

Thoracic outlet syndrome (TOS): A case report of a rare complication after Nuss procedure for pectus excavatum

RATIONALE

The Nuss procedure has become a major alternative operation for patients with pectus excavatum (PE).

PATIENT CONCERNS

We report a case of 27-year-old man with PE who developed thoracic outlet syndrome (TOS) after the Nuss procedure. The patient showed clinical symptoms of brachial plexus compression.

DIAGNOSES

Further evaluation demonstrated a narrowed space between the first rib and the anterior scalene muscle and compressing the brachial plexus and vessels.

INTERVENTIONS

Nerve nourishing medicine and rehabilitation exercising were taken to restore the muscle strength.

OUTCOMES

Several months later, the clinical symptoms disappeared.

LESSONS

Medicine and rehabilitation exercising may benefit the functional recovery of impaired nerve in TOS in the early stage of TOS.

Successful Treatment of Persistent Pain After Pectus Excavatum Repair Using Paravertebral Nerve Radiofrequency Thermoablation

We present a case of a 25-year-old male patient suffering from severe prolonged pain after uneventful pectus excavatum repair that could be treated successfully by paravertebral nerve radiofrequency thermoablation. The patient was scheduled for a minimally invasive Nuss pectus excavatum repair. Surgical correction was performed under general anesthesia in combination with a thoracic peridural catheter. The immediate postoperative course was uneventful; however, the patient developed severe prolonged bilateral chest wall pain across segments T8 and T9. After failure of conservative treatment options, a specialized interventional anesthesiologist performed paravertebral nerve radiofrequency thermoablation of segment T9 bilaterally, after which the patient was pain free until scheduled removal of the pectus bar 3 years after placement.

Minimally invasive repair of pectus excavatum: analyzing contemporary practice in 50 ACS NSQIP-pediatric institutions

BACKGROUND

Minimally invasive repair of pectus excavatum (MIRPE) is a well-established procedure. However, morbidity rate varies widely among institutions, and the incidence of major complications remains unknown.

STUDY DESIGN

The American College of Surgeons 2012 National Surgical Quality Improvement Program-Pediatric (NSQIP-P) participant user file was utilized to identify patients who underwent MIRPE at 50 participant institutions. Outcomes of interest were overall 30-day morbidity, hospital readmission, and reoperation.

RESULTS

Chest wall repair designated MIRPE accounted for 0.6% (n = 264) of all surgical cases included in the NSQIP-P database in 2012. The median age at surgical repair was 15.2 years. Thoracoscopy was used in 83.7% of cases. No mediastinal injuries or perioperative blood transfusions were identified. The 30-day readmission rate was 3.8%. Three patients (1.1%) required re-operation due to the following complications: superficial site infection, bar displacement and pneumothorax. The overall morbidity was 3.8% with no incidences of mortality.

CONCLUSIONS

This analysis of a large prospective multicenter dataset demonstrates that major complications following MIRPE are uncommon in contemporary practice. Wound infection is the most common complication and the main cause of hospital readmission. Targeted quality improvement initiative should be focused on perioperative strategy to further reduce wound occurrences and hospital readmission.

A study about the costoclavicular space in patients with pectus excavatum

Background

The aim of the present study is to investigate the costoclavicular space in patients with pectus excavatum.

Materials and methods

Between April and November 2011, consecutive 50 patients with pectus excavatum and consecutive 50 patients without pectus excavatum were included into the present study. The costoclavicular measurements (the shortest distance, the crossing angle) were measured for the costoclavicular investigation.

Results

Firstly, there were no significant differences of the costoclavicular measurements in each and between symmetric and asymmetric subgroup, and in the overall, bilaterally. The shortest distance had a significant positive correlation with BMI (right p = 0.001, left p = 0.032) and a significant negative correlation with the crossing angle (right p = 0.013, left p = 0.001). Secondly, in the control group, the shortest distance had significant positive correlations with body weight and BMI (Body weight right p = 0.001, left p < 0.001; BMI right p = 0.001, left p < 0.001), and significant negative correlations with the crossing angles (right p = 0.002, left p < 0.001) and the sternal angle (right p = 0.032, left p = 0.017). Thirdly, the control group had the significant longer shortest distance than the pectus excavatum group (right p <0.001, left p <0.001). Fourthly, a decrease of the shortest distance (right p <0.001, left p <0.001), an increase of the crossing angle (right p < 0.001, left p < 0.001) and the sternal angle (p <0.001), and also a decrease of the Haller index (p <0.001) was found postoperatively.

Conclusion

Patients with pectus excavatum originally have narrower costoclavicular spaces than the normal control group, and the postoperative costoclavicular space are much narrower also.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-014-0189-2) contains supplementary material, which is available to authorized users.

Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume, single institution experience

BACKGROUND

The safety and efficacy of minimally invasive pectus excavatum repair have been demonstrated over the last twenty years. However, technical details and perioperative management strategies continue to be debated. The aim of the present study is to review a large single-institution experience with the modified Nuss procedure.

METHODS

A retrospective review was performed of patients who underwent primary pectus excavatum repair at a single tertiary hospital via a modified Nuss procedure that included: no thoracoscopy, retrosternal dissection achieved via a left-to-right thoracic approach, four-point stabilization of the bar, and no routine epidural analgesia. Data collected included demographics, preoperative symptoms, operative characteristics, hospital charges and postoperative outcomes.

RESULTS

A total of 336 pediatric patients were identified. No cardiac perforations occurred and the rate of pericarditis was 0.6%. Contemporary rates of bar displacement have fallen to 1.2%. Routine use of chlorhexidine scrub reduced superficial site infections to 0.7%. Two patients (0.6%) with severe recurrence required reoperation. Bars were removed after an average period of 31.7(SD 13.2) months, with satisfactory cosmetic and functional results in 94.9% of cases.

CONCLUSIONS

We report here a single-institution large volume experience, including modifications to the Nuss procedure that make the technique simpler and safer, improve results, and minimize hospital charges.

Vascular thoracic outlet syndrome developed after minimally invasive repair of pectus excavatum

The Nuss procedure is a minimally invasive surgical repair technique for pectus excavatum with fewer delayed complications compared to open procedures. We report the case of a 22-year-old man with deep pectus excavatum who developed vascular thoracic outlet syndrome after the Nuss procedure. Further evaluation demonstrated that the first rib was causing severe obstruction of the right subclavian artery. The patient showed clinical features of subclavian artery compression. A first rib resection, division of the anterior scalene muscle and fibrous bands provided complete relief of the complaints. The forced structural and spatial changes produced by the elevation of the depressed upper chest might have caused this complication. Vascular thoracic outlet syndrome should be kept in mind as a possible complication in patients who have undergone minimally invasive repair of pectus excavatum, and this complication can be treated by first rib resection.

Complex regional pain syndrome following the Nuss procedure for severe pectus excavatum

Complex regional pain syndrome (CRPS) is not an uncommon complication after surgery, but has never been reported after the Nuss procedure for repairing pectus excavatum. A 22-year-old man with pectus excavatum had type I CRPS that developed 2 weeks after the Nuss procedure. He complained of persistent pain, hyperalgesia, weakness, edema, and color and temperature changes on right upper extremity. Following intensive rehabilitation, the degree of pain, weakness and edema were ameliorated. He recovered 6 months after surgery and the pectus bars were removed uneventfully 3 years after the repair.

Development of supravalvular pulmonary artery stenosis following a Nuss procedure

We report a case of a 13-year old girl with pectus excavatum who had a Nuss procedure and two years later a new cardiac murmur appeared which on investigation was diagnosed as supravalvular pulmonary artery stenosis. Following removal of the Nuss bar the stenosis resolved.