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Roostaei G, Amini H, Abtahi H, Kazemizadeh H, Edalatifard M, Rahimi B, Asadi S, Khoshnam‐Rad N. Post-operative arrest following pectus excavatum repair: A case report with a systematic review of the published case reports. Clin Case Rep 2024; 12:e8650. [PMID: 38464576 PMCID: PMC10920322 DOI: 10.1002/ccr3.8650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024] Open
Abstract
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.
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Affiliation(s)
- Ghazal Roostaei
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hesam Amini
- Department of Thoracic Surgery, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hamidreza Abtahi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Hossein Kazemizadeh
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Maryam Edalatifard
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Besharat Rahimi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Sanaz Asadi
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Niloofar Khoshnam‐Rad
- Thoracic Research Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
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Deol PK, Hoover JD, Phillips JD. Use of Transesophageal Echocardiography for Enhanced Safety During Bar Removal Procedures After Minimally Invasive Repair of Pectus Excavatum. J Laparoendosc Adv Surg Tech A 2023; 33:1218-1222. [PMID: 37844062 DOI: 10.1089/lap.2022.0410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
Background: Minimally invasive repair of pectus excavatum involves placement of retrosternal support (Nuss) bars. Hardware removal has been rarely associated with life-threatening hemorrhage from the heart, aorta, internal mammary arteries, and/or lung. There is no accepted standard intraoperative monitoring technique used during removal. We hypothesized that the use of transesophageal echocardiography (TEE) during Nuss bar removal would enhance safety of the procedure and be cost-effective. Methods: IRB-approved retrospective review of patients who underwent Nuss bar removal with intraoperative TEE monitoring over a 4-year period, from March 2013 to May 2017, was completed. Bar removal procedures were performed supine, under general anesthesia. TEE images were monitored and any distortion of the cardiac silhouette, new pericardial effusion, and/or cardiac arrhythmias would be considered evidence of possible bar adherence, triggering possible conversion to sternotomy or thoracotomy. Results: In total, 87 consecutive patients, mean age of 20 years, were identified. Bars had been in place for a mean of 30 months. Average procedure time was 67 minutes. No patients experienced arrhythmias, cardiac injury, or significant hemorrhage during removal. TEE gave excellent visualization of the cardiac silhouette and pericardium in all cases. No patient required insertion of an arterial line, a postoperative chest X-ray, or overnight hospitalization. Patients were discharged from the recovery room an average of 89 minutes postprocedure. Conclusion: TEE offers a minimally invasive safe way to visualize the pericardium and its contents during Nuss bar removal. Significant cardiac/mediastinal injuries should be immediately visible. The use of TEE is cost-effective and allows safe discharge the day of surgery.
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Affiliation(s)
- Preeya K Deol
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - J David Hoover
- WakeMed Health and Hospitals, Pediatric Surgery, Raleigh, North Carolina, USA
| | - J Duncan Phillips
- WakeMed Health and Hospitals, Pediatric Surgery, Raleigh, North Carolina, USA
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Aly MR, Farina JM, Bostoros PM, Botros MM, Pulivarthi VS, Peterson MA, Lackey JJ, Jaroszewski DE. Risk Factors and Techniques for Safe Pectus Bar Removal in Adults After Modified Nuss Repair. Ann Thorac Surg 2023; 116:787-794. [PMID: 36549569 DOI: 10.1016/j.athoracsur.2022.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/26/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Nuss repair involves implants designed for removal after 2 to 3 years. Although rare, significant complications can occur with bar removal, and the incidence of these complications may be higher in adults. This study was performed to review complications and risk factors associated with bar removal and discuss strategies to improve operative safety. METHODS A retrospective study was performed including all patients after pectus excavatum repair who underwent Nuss implant removal at Mayo Clinic Arizona (Phoenix, AZ) from 2013 to 2022. RESULTS In total, 1555 bars were removed (683 patients; 71% men; median age, 34 years[(range, 15-71 years]). Of the removals, 12.45% of patients had bars placed at outside institutions. Major complications were rare, with bleeding most common (2.05%), followed by pneumothorax (0.88%), infection (0.59%), and effusions (0.44%). Most major bleeding (85.71%) occurred from the bar track during removal and was controlled by packing the track. One patient required subsequent hematoma evacuation and transfusion. Bleeding secondary to lung injury was also successfully controlled with packing. Bar removal in 1 patient with significantly displaced bars required sternotomy and cardiopulmonary bypass as a result of aortic injury. Risk factors identified for bleeding included sternal erosion (P < .001), bar migration (P < .001), higher number of bars (P = .037), and revision of a previous pectus repair (P = 0.001). Bar migration was additionally associated with major complications (P < .001). Older age, although a risk factor for overall complications (P = 0.001), was not a risk factor for bleeding. CONCLUSIONS Bar removal can be safely performed in most patients; however, significant complications, including bleeding, may occur. Identifying potential risk factors and being prepared for rescue maneuvers are critical to prevent catastrophic outcomes.
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Affiliation(s)
- Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Peter M Bostoros
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michael M Botros
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Venkata S Pulivarthi
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michelle A Peterson
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jesse J Lackey
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona.
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Beati F, Frediani S, Pardi V, Aloi I, Bertocchini A, Accinni A, Inserra A. Case report-Every thoracic surgeon's nightmare: cardiac and lung perforation during placement of Nuss bar for pectus excavatum. Front Pediatr 2023; 11:1241273. [PMID: 37744443 PMCID: PMC10513049 DOI: 10.3389/fped.2023.1241273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/14/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction The prevalence of life-threatening complications (LTCs) related to the minimally invasive repair of pectus excavatum (MIRPE) is unknown and underreported. The aim of this study is to contribute to the real prevalence of these rare but dramatic complications and show what went wrong in order to prevent it in the future. Case presentation A 15-year-old boy affected by pectus excavatum with severe asymmetric deformity of the chest wall was evaluated for elective corrective surgery. Preoperative computed tomography showed a Haller index of 5.7 and a correction index of 0.40. MIRPE was performed under right video-assisted thoracoscopy. Cardiac arrhythmias occurred after placement of the bar introducer. The introducer was removed, and massive bleeding was noted. Emergency Clamshell thoracotomy was performed, and cardiac surgeon was alerted immediately. A first pulmonary wound was found and controlled. Two cardiac lacerations were found: on the interventricular wall and on the right atrium. Under cardiopulmonary bypass, cardiac lacerations were sutured and other three pulmonary wounds were repaired. An urgent fasciotomy was performed for compartmental syndrome of the right lower art after femoral cannulation. Pulmonary distress occurred; the patient was admitted on ECMO (ExtraCorporeal Membrane Oxygenation) in intensive care unit. Right lower lobectomy was carried out on the fifth postoperative day due to massive pulmonary bleeding requiring temporary tracheostomy. The patient was discharged to rehabilitation after 3 months with no brain injuries, minor hearing loss, and tracheostomy. Conclusion We want to maintain the high alertness required for this procedure. Reporting these scaring complications contributes to the real prevalence of LTCs. We suggest the use of bilateral thoracoscopy and crane elevator in severe sternal defects. We also suggest to have a cardiac surgeon available in the hospital owing to cardiac perforation.
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Affiliation(s)
| | - Simone Frediani
- General and Thoracic Pediatric Surgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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Parrado RH, Notrica DM, Jaroszewski DE, McMahon LE. Surgical technique for Nuss bar exchange due to metal allergy. J Pediatr Surg 2023; 58:179-180. [PMID: 35973861 DOI: 10.1016/j.jpedsurg.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Raphael H Parrado
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016, USA; Division of Pediatric Surgery, Department of Surgery, Shawn Jenkin's Children's Hospital, Charleston, SC, USA.
| | - David M Notrica
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Division of Pediatric Surgery, Department of Surgery, Shawn Jenkin's Children's Hospital, Charleston, SC, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA
| | - Lisa E McMahon
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
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Gu H, Xu G, Liu T, Zhang S. The influence of 10-year Nuss bar placement on bar removal: a case report. J Cardiothorac Surg 2022; 17:271. [PMID: 36266715 PMCID: PMC9585857 DOI: 10.1186/s13019-022-02021-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 10/14/2022] [Indexed: 11/28/2022] Open
Abstract
Background The Nuss bar is commonly used for minimally invasive correction of pectus excavatum and is usually removed within 2–3 years. Here, we report a case of 10-year bar placement after the Nuss procedure accompanied by unique complications of thoracic malformation that have not been described before. The asymmetric pectus carinatum caused by bar displacement and significant rib periosteal hyperplasia is described for the first time. Case presentation A 23-year-old man was admitted to our hospital due to the main complaint of obvious chest discomfort when lifting heavy weights. The bar removal was seriously delayed due to his loss to follow-up. Chest asymmetry and distant heart sounds were found during a physical examination. A chest CT scan demonstrated that the right end of the lower bar originally fixed outside the ribs had shifted into the thoracic cavity, and the left costal cartilage was obviously protruding. Additionally, the displaced bars were separated from the sternum and tightly attached to the pericardium, resulting in abnormalities of the anterior mediastinum. These secondary thoracic deformities made the patient extremely prone to massive hemorrhage or multiple rib fractures when sliding the bars out. However, serious consequences were avoided due to reasonable adjustments to the usual bar removal procedures. Conclusion This case demonstrates a specific type of bar displacement caused by prolonged placement of the bars and highlights the importance of rigorous follow-up of patients after the Nuss procedure.
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Affiliation(s)
- Haihua Gu
- Department of Thoracic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88, Hangzhou, 310009, Zhejiang, People's Republic of China
| | - Guanxin Xu
- Department of Thoracic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88, Hangzhou, 310009, Zhejiang, People's Republic of China
| | - Tianshu Liu
- Department of Thoracic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88, Hangzhou, 310009, Zhejiang, People's Republic of China
| | - Sai Zhang
- Department of Thoracic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88, Hangzhou, 310009, Zhejiang, People's Republic of China.
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Elsayed HH, Ahmed TA, Hassaballa AS, Sharkawy HY. Does the Nuss procedure for treating pectus excavatum compromise the long term internal mammary artery flow? A systematic review. J Card Surg 2021; 36:2518-2523. [PMID: 34018244 DOI: 10.1111/jocs.15576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 03/03/2021] [Accepted: 04/08/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The Nuss procedure is the most common procedure used to treat patients with pectus excavatum. The effect of the Nuss bars on the long-term internal mammary artery flow (IMA) is not well studied. This could have an impact on patients requiring a coronary artery bypass grafting surgery after the Nuss procedure. We performed a systematic review to study the impact of the Nuss bars on the IMA long term flow. METHODS A Medline search from January 1990 to August 2020 was performed using [Nuss OR thoracoscopic pectus OR minimally invasive pectus] AND [Internal mammary OR Internal thoracic OR IMA OR ITA]. English language papers only were included. This trial was registered with PROSPERO under registration number CRD42021234010. RESULTS A total of 48 papers were identified using the reported search, of which three represented the best evidence to answer the clinical question. One study looked at the IMA flow via computed tomography (CT)-angiography on the 10th postoperative day after the Nuss procedure and found 15 out of 34 patients (44%) to have abnormal IMA blood flow but with no clinical consequences. Two studies looked at the IMA flow after removal of the Nuss-bar. The first study utilized CT-angiography on the 5th postoperative day after Nuss-bar removal and found four out of the six patients studied (67%) to have abnormal flow. The last study was composed of 19 patients and looked at IMA flow during the presence of the Nuss-bars and after its removal utilizing Doppler-angiography. It found 11 out of 19 patients (58%) to have abnormal blood flow with the bars in place. After removal of the bars, only two patients (10%) were found to have unilateral IMA obstructed flow. CONCLUSION In patients undergoing the Nuss procedure for management of pectus excavatum, the internal mammary artery flow is compromised in 44%-58% of patients with the bar in situ. When these patients are assessed 10 days following removal of the bar, some reversal of compromised IMA flow is evident. However, in up to 67% of patients, abnormal IMA flow remains. Further studies are required to determine whether this abnormal flow is permanent, which will require examining patients at longer follow-up intervals. Patients undergoing coronary artery bypass grafting who have a history of a Nuss procedure should receive preoperative IMA imaging.
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Affiliation(s)
- Hany H Elsayed
- Thoracic Surgery Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Taha A Ahmed
- Cardiothoracic Surgery Department, Ain Shams University, Cairo, Egypt
| | - Aly S Hassaballa
- Cardiothoracic Surgery Department, Ain Shams University, Cairo, Egypt
| | - Hazem Y Sharkawy
- Cardiothoracic Surgery Department, Ain Shams University, Cairo, Egypt
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Haecker FM, Hebra A, Ferro MM. Pectus bar removal - why, when, where and how. J Pediatr Surg 2021; 56:540-544. [PMID: 33228972 DOI: 10.1016/j.jpedsurg.2020.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Despite its less invasive nature, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. On the other hand, Pectus bar removal (PBR) is often considered a simple procedure and often scheduled in an outpatient setting. However, several studies report near-fatal complications not only during bar placement, but also during bar removal. The aim of our study was to clarify why a pectus bar should be removed, timing for removal, where PBR should be performed, and overall setup for safe removal. METHODS A comprehensive review was performed in accordance with PRISMA guidelines, searching for articles published since 1998 in English. "Pectus bar removal AND (near-fatal) complications" were the applied terms. Inclusion criteria were articles reporting on the focus of PBR after MIRPE. Eligible study designs included (retrospective) case study series, case report and reviews. Full-text articles in which the technique in general was described were omitted. RESULTS Recently published results of an online survey raised awareness about type and number of possible complications during PBR. Furthermore, our comprehensive literature review identified only a few, but serious complications during PBR. CONCLUSIONS PBR has a high safety profile but in rare cases may be associated with major complications such as life-threatening hemorrhage from various thoracic sources. This risk is higher in patients with a history of complex MIPRE. In an effort to decrease these complications we recommend bilateral opening of surgical incisions, unbending the bar and meticulous mobilization of the bar. To manage these complications if they occur, we recommend removal in a hospital setting with adequate resources and personal including cardiac surgeons. If the postoperative course is uneventful discharge on the same day is reasonable.
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Affiliation(s)
- Frank-Martin Haecker
- Department of Pediatric Surgery, American Hospital Dubai, Dubai, U.A.E; Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland.
| | - Andre Hebra
- Nemours Children's Hospital, Orlando, FL, USA
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Jawitz OK, Raman V, Thibault D, Yerokun B, Zwischenberger BA, Kosinski AS, Allen MS, Harpole DH. Complications after Ravitch versus Nuss repair of pectus excavatum: A Society of Thoracic Surgeons (STS) General Thoracic Surgery Database analysis. Surgery 2021; 169:1493-1499. [PMID: 33494946 DOI: 10.1016/j.surg.2020.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are conflicting reports in the literature comparing outcomes after open Ravitch and minimally invasive Nuss procedures for pectus excavatum repair, and there is relatively little data available comparing the outcomes of these procedures performed by thoracic surgeons. METHODS The 2010 to 2018 Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients age 12 or greater undergoing open or minimally invasive repair of pectus excavatum. Patients were stratified by operative approach. Multivariable logistic regression was performed with a composite outcome of 30-day complications. RESULTS A total of 1,767 patients met inclusion criteria, including 1,017 and 750 patients who underwent minimally invasive pectus repair and open repair, respectively. Open repair patients were more likely to be American Society of Anesthesiologists (ASA) class III or greater (24% vs 14%; P < .001), have a history of prior cardiothoracic surgery (26% vs 14%; P < .001), and require longer operations (median 268 vs 185 minutes; P < .001). Open repair patients were more likely to require greater than 6 days of hospitalization (18% vs 7%; P < .001), undergo transfusion (7% vs 2%; P < .001), and be readmitted (8% vs 5%; P = .004). After adjustment, open repair was not associated with an increased risk of a composite of postoperative complications (odds ratio 0.99, 95% confidence interval 0.67-1.46). This finding persisted after propensity score matching (odds ratio 1.11, 95% confidence interval 0.74-1.67). CONCLUSION Pectus excavatum repair procedure type was not associated with the risk of postoperative complications after adjustment. Further investigation is necessary to determine the impact of pectus excavatum repair type on recurrence and patient reported outcomes, including satisfaction, quality of life, and pain control.
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Affiliation(s)
- Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Babatunde Yerokun
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Brittany A Zwischenberger
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Mark S Allen
- Department of Thoracic Surgery, Mayo Clinic, Rochester, MN
| | - David H Harpole
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Toselli L, Bellía Munzón G, Martinez J, Vallee M, Sanjurjo D, Nazar Peirano M, Martínez-Ferro M. Safety-string: A handy maneuver to control pectus bar removal bleeding complications. J Pediatr Surg 2020; 55:1162-1164. [PMID: 32143902 DOI: 10.1016/j.jpedsurg.2020.01.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/10/2019] [Accepted: 01/29/2020] [Indexed: 11/19/2022]
Abstract
The pectus bar removal procedure is often considered a simple, straightforward surgery with a low incidence of complications. However, life-threatening bleeding complications have been reported requiring major measures for hemostatic control. Our objective is to share a simple maneuver that our group has systematically included in the bar removal procedure to facilitate bleeding control in case hemorrhage occurs.
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Affiliation(s)
- Luzia Toselli
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602, Capital Federal, Buenos Aires, Argentina, C1429AKL.
| | - Gastón Bellía Munzón
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602, Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Jorge Martinez
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602, Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Maxroxia Vallee
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602, Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Daniela Sanjurjo
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602, Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Maximiliano Nazar Peirano
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602, Capital Federal, Buenos Aires, Argentina, C1429AKL
| | - Marcelo Martínez-Ferro
- Fundación Hospitalaria Mother and Child Medical Center, Av. Crámer 4602, Capital Federal, Buenos Aires, Argentina, C1429AKL
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Ning J, Xie Y. A new type of forceps for stabilizer removal after NUSS procedure. J Pediatr Surg 2020; 55:1139-1141. [PMID: 31859044 DOI: 10.1016/j.jpedsurg.2019.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
This paper describes the design and application of a new type of forceps for stabilizer removal after NUSS procedure. The forceps are made up of two strips of streamline forceps, which is composed of forceps handle and forceps head. One forceps head was designed as "Y" shaped, with an "L" shaped convex teeth set on each tip. It protrudes a small cylinder on the end platform of the other forceps head. Compared to the traditional operation method, with utilization of the forceps for stabilizer removal, it is expected that the operation time will be shortened and the bleeding will be reduced. The clinical application showed a good value of using the forceps in stabilizer removal after NUSS procedure. LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Jinbo Ning
- 165, Xincheng Road, Department of Pediatric Surgery, Chongqing Three Gorges Central Hospital, Wanzhou District, Chongqing, China.
| | - Yimin Xie
- 165, Xincheng Road, Department of Pediatric Surgery, Chongqing Three Gorges Central Hospital, Wanzhou District, Chongqing, China.
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Hsieh MS, Tong SS, Wei BC, Chung CC, Cheng YL. Minimization of the complications associated with bar removal after the Nuss procedure in adults. J Cardiothorac Surg 2020; 15:65. [PMID: 32316997 PMCID: PMC7175579 DOI: 10.1186/s13019-020-01106-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pectus bar removal after Nuss repair is associated with the risk of major complications that are underreported. Of these, surgical bleeding is the main concern. Old age and placement of more than one bar are reported risk factors for pectus bar removal. In this study, we presented our experience regarding the modified skills required to minimize complications during bar removal, especially in adult patients. METHODS Consecutive patients who underwent pectus bar removal as the final stage of Nuss repair between August 2014 and December 2018 were included. The patients were positioned in the supine position. The bar(s) was (were) removed from the left side via the bilateral approach using the previous surgical scars after full dissection of the ends of the bar lateral to the hinge point and after straightening the right end of the bar. Bleeding was carefully checked after removal. An elastic bandage was wrapped around the chest after wound closure to prevent wound hematoma/seroma formation. RESULTS A total of 283 patients (260 male and 23 female), with a mean age of 22.8 ± 6.6 years at the time of the Nuss repair were included. The mean duration of pectus bar maintenance interval was 4.3 years (range: 1.9 to 9.8 years). A total of 200 patients (71%) had two bars. The mean estimated blood loss was 11.7 mL (range: 10 mL to 100 mL). Nine patients (3.1%) experienced complications, six had pneumothorax and three had wound hematoma. No major bleeding occurred. Adults and the use of more than one bar were not associated with a significantly higher rate of complications (P = 0.400 and P = 0.260, respectively). CONCLUSIONS Adult patients and removal of multiple bars were not risk factors for complications in our cohort. Skill in preventing intraoperative mediastinal traction, carefully controlling bleeding, and reducing the effect of dead space around the wounds could minimize the risk of bleeding complications. A multicentric study or case accumulation is needed to further evaluate the risk factors of removal pectus bar(s).
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Affiliation(s)
- Min-Shiau Hsieh
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian-Gao RD, Xindian District, New Taipei City, 23143, Taiwan
| | - Shao-Syuan Tong
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian-Gao RD, Xindian District, New Taipei City, 23143, Taiwan
| | - Bo-Chun Wei
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian-Gao RD, Xindian District, New Taipei City, 23143, Taiwan
| | - Cheng-Chin Chung
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian-Gao RD, Xindian District, New Taipei City, 23143, Taiwan
| | - Yeung-Leung Cheng
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian-Gao RD, Xindian District, New Taipei City, 23143, Taiwan. .,School of Medicine, Tzu Chi University, Hualien, Taiwan.
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13
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Kovács T, Pásztor G, Rieth A. Internal Mammary Artery Compression After Pectus Excavatum Repair Does Not Increase Risk of Hemorrhagic Complications in Pediatric Patients. Front Pediatr 2020; 8:619065. [PMID: 33469524 PMCID: PMC7813807 DOI: 10.3389/fped.2020.619065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/07/2020] [Indexed: 11/30/2022] Open
Abstract
Objectives: Minimal invasive repair of pectus excavatum (MIRPE) described by Nuss is the most popular correction nowadays of this deformity. During the introduction of the bars, they can hurt or compress the internal mammary arteries (IMA). The aim of this study was to observe the prevalence of IMA compression in children after MIRPE. Also, we examined if IMA obstruction increases the risk of complications at bar removal, and if these vascular changes are reversible. Materials and Methods: All patients operated on pectus excavatum in our tertiary pediatric surgical center between 2013 and 2019 were involved in the study. Data of age, sex, number of bars and characteristics of the deformity were examined. IMA flow was checked by Doppler ultrasound (DUS) after MIRPE and after bar removal, too. Results: Among 41 patients with mean age of 15.2 years there were 18 asymmetrical deformities, 23 sternal rotations. Mean pectus index was 4.01. After the Nuss procedure 7(9%) stenoses and 10(12%) occlusions of IMA were found on DUS. After bar removal 3 of 4 stenoses have resolved, but all examined occlusions (3/3) persisted. There were no complications during bar removals. Conclusion: IMA compression after MIRPE in children is uncommon, and is not influenced by severity of deformity. Obstruction of these vessels does not increase the risk of hemorrhagic complications at bar removal. Data of larger cohort are needed to determine reversibility of these changes.
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Affiliation(s)
- Tamás Kovács
- Unit of Pediatric Surgery, Department of Pediatrics, Albert Szent-Gyorgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Gyula Pásztor
- Department of Radiology, Albert Szent-Gyorgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Anna Rieth
- Unit of Pediatric Surgery, Department of Pediatrics, Albert Szent-Gyorgyi Clinical Center, University of Szeged, Szeged, Hungary
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14
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Notrica DM. The Nuss procedure for repair of pectus excavatum: 20 error traps and a culture of safety. Semin Pediatr Surg 2019; 28:172-177. [PMID: 31171153 DOI: 10.1053/j.sempedsurg.2019.04.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In 1998, Donald Nuss changed the way the world thought about the surgical repair of pectus excavatum. The new operation adheres to sound orthopedic fundaments, but has a significantly higher learning curve than other operations in pediatric surgery. Variations in pectus excavatum type, severity, symmetry and chest wall pliability bring challenges. This article will detail common error traps and ways to avoid them when performing the Nuss procedure. As recent publications have shown, an operation done more than 50,000 times across the world may bring to light infrequent but devastating outcomes that may be preventable. The critical view of safety for pectus repair is discussed, as are areas where a culture of safety could optimize results on a larger scale. We will review potential opportunities to improve outcomes by identifying error traps in the preoperative, intraoperative, and postoperative care of patients undergoing the Nuss procedure.
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Affiliation(s)
- David M Notrica
- Department of Surgery, Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, United States; Department of Surgery, Mayo Clinic College of Medicine and Science, 5757 East Mayo Boulevard, Phoenix AZ 85054, United States; Department of Child Health, University of Arizona College of Medicine Phoenix, 1919 East Thomas Road, Phoenix, AZ 85016, United States.
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15
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Goretsky MJ, McGuire MM. Complications associated with the minimally invasive repair of pectus excavatum. Semin Pediatr Surg 2018; 27:151-155. [PMID: 30078485 DOI: 10.1053/j.sempedsurg.2018.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The minimally invasive pectus excavatum repair (Nuss repair) is performed by pediatric general surgeons and pediatric and adult thoracic surgeons around the world. Complications related to pediatric surgical procedures are always a major concern for surgeons and their patients, and as with all surgery, especially pectus surgery, complications can be life-threatening. The purpose of this article is to discuss early and late complications of pectus excavatum surgery and potential preventive strategies to minimize them.
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Affiliation(s)
- Michael J Goretsky
- Children's Hospital of the Kings Daughters, Division of Pediatric General and Thoracic Surgery, 601 Children's Lane, Norfolk, VA 23507.
| | - Margaret M McGuire
- Children's Hospital of the Kings Daughters, Division of Pediatric General and Thoracic Surgery, 601 Children's Lane, Norfolk, VA 23507
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16
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Hebra A, Kelly RE, Ferro MM, Yüksel M, Campos JRM, Nuss D. Life-threatening complications and mortality of minimally invasive pectus surgery. J Pediatr Surg 2018; 53:728-732. [PMID: 28822540 DOI: 10.1016/j.jpedsurg.2017.07.020] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/28/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED The prevalence and type of life-threatening complications related to the minimally invasive repair of pectus excavatum (MIRPE) and bar removal are unknown and underreported. The purpose of this communication is to make surgeons aware of the risk of these life threatening complications as well as the modifications which have been developed to prevent them. METHODS Data related to life-threatening complications of Pectus Excavatum (PE) patients was obtained from four sources: 1. A survey of Chest Wall International Group (CWIG) surgeons who specialize in repairing congenital chest wall malformations, 2. Papers and case reports presented at CWIG meetings, 3. Review of medico-legal cases from the USA and 4. A systematic review of the literature related to major complications post MIRPE. RESULTS From 1998 to 2016, we identified 27 published cases and 32 unreported life-threatening complications including: cardiac perforation, hemothorax, major vessel injury, lung injury, liver injury, gastrointestinal problems, and diaphragm injury. There were seven cases of major complications with bar removal (reported and non-reported) with two lethal outcomes. Mortality data with bar placement surgery: Four published death cases and seven unpublished death cases. The overall incidence of minor & major complications post MIRPE has been reported in the literature to be 2-20%. The true incidence of life-threatening complications and mortality is not known as we do not know the overall number of procedures performed worldwide. However, based on data extrapolated from survey information, the pectus bar manufacturer in the USA, literature reports, and data presented at CWIG meetings as to the number of cases performed we estimated that approximately fifty thousand cases have been performed and that the incidence of life-threatening complications is less than 0.1% with many occurring during the learning curve. Analysis of the cases identified in our survey revealed that previous chest surgery, pectus severity and inexperience were noted to be significant risk factors for mortality. CONCLUSIONS Published reports support the safety and efficacy of MIRPE; however major adverse outcomes are underreported. Although major complications with MIRPE and pectus bar removal surgery are very rare, awareness of the risk and mortality of life-threatening complications is essential to ensure optimal safety. Factors such as operative technique, patient age, pectus severity and asymmetry, previous chest surgery, and the surgeon's experience play a role in the overall incidence of such events. These preventable events can be avoided with proper training, mentoring, and the use of sternal elevation techniques. TYPE OF STUDY Treatment Study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- André Hebra
- Nemours Children's Hospital, Orlando, FL, USA; Children's Hospital of the King's Daughters, Norfolk, VA, USA; Fundación Hospitalaria Children's Hospital, Buenos Aires, Argentina; University of Sao Paulo, Sao Paulo, SP, Brazil; Marmara University, Istanbul, Turkey.
| | - Robert E Kelly
- Nemours Children's Hospital, Orlando, FL, USA; Children's Hospital of the King's Daughters, Norfolk, VA, USA; Fundación Hospitalaria Children's Hospital, Buenos Aires, Argentina; University of Sao Paulo, Sao Paulo, SP, Brazil; Marmara University, Istanbul, Turkey
| | - Marcelo M Ferro
- Nemours Children's Hospital, Orlando, FL, USA; Children's Hospital of the King's Daughters, Norfolk, VA, USA; Fundación Hospitalaria Children's Hospital, Buenos Aires, Argentina; University of Sao Paulo, Sao Paulo, SP, Brazil; Marmara University, Istanbul, Turkey
| | - Mustafa Yüksel
- Nemours Children's Hospital, Orlando, FL, USA; Children's Hospital of the King's Daughters, Norfolk, VA, USA; Fundación Hospitalaria Children's Hospital, Buenos Aires, Argentina; University of Sao Paulo, Sao Paulo, SP, Brazil; Marmara University, Istanbul, Turkey
| | - Jose Ribas M Campos
- Nemours Children's Hospital, Orlando, FL, USA; Children's Hospital of the King's Daughters, Norfolk, VA, USA; Fundación Hospitalaria Children's Hospital, Buenos Aires, Argentina; University of Sao Paulo, Sao Paulo, SP, Brazil; Marmara University, Istanbul, Turkey
| | - Donald Nuss
- Nemours Children's Hospital, Orlando, FL, USA; Children's Hospital of the King's Daughters, Norfolk, VA, USA; Fundación Hospitalaria Children's Hospital, Buenos Aires, Argentina; University of Sao Paulo, Sao Paulo, SP, Brazil; Marmara University, Istanbul, Turkey
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17
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De Wolf J, Brian E, Wurtz A. Letter to the Editor. J Pediatr Surg 2018; 53:857-858. [PMID: 29366505 DOI: 10.1016/j.jpedsurg.2017.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 12/17/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Julien De Wolf
- CHU Lille, Department of Thoracic Surgery, F-59000 Lille, France
| | | | - Alain Wurtz
- CHU Lille, Department of Thoracic Surgery, F-59000 Lille, France.
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18
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Lung Middle Lobe Laceration Needing Lobectomy as Complication of Nuss Bar Removal. Case Rep Orthop 2018; 2018:8965641. [PMID: 29682380 PMCID: PMC5842718 DOI: 10.1155/2018/8965641] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/03/2018] [Accepted: 01/24/2018] [Indexed: 11/18/2022] Open
Abstract
Minimally invasive procedure for the treatment of pectus excavatum as described by Nuss has been used from 1987. The bar initially introduced blindly is now introduced under thoracoscopic control to increase safety of the procedure. It is usually removed two to three years after its insertion in a one-day procedure. Complications of the bar removal are rare but potentially serious. We report the case of a serious complication which occurred immediately after the Nuss bar removal. A 15-year-old boy underwent a Nuss procedure for a severe pectus excavatum without relevant complication. The bar has been removed two years after its insertion in a minimally invasive procedure. Unfortunately, he developed in the immediate postoperative period a hemopneumothorax due to a right middle lobe laceration which required a middle lobectomy by thoracotomy for hemostasis. Lesions of intrathoracic organs are a rare but potentially serious complication of the removal of the Nuss bar. We now propose to perform this procedure under thoracoscopic control to avoid it. In our experience, adhesions between the bar and the pleura are always present, and those with potential risk for bleeding or inducing intrathoracic organ lesions are suppressed prior to the bar removal.
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19
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Incerti F, Bertocchini A, Ghionzoli M, Messineo A. Ultrasound-Guided Bar Edge Labeling in the Perioperative Assessment of Nuss Bar Removal. J Laparoendosc Adv Surg Tech A 2017; 27:1326-1327. [PMID: 29087764 DOI: 10.1089/lap.2017.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Nuss bar removal after minimally invasive repair of pectus excavatum in patients where bar ends are not palpable, can be a challenging procedure for the surgeon; a blind dissection toward the bar edges may lead to intercostal vessels or deep intercostal muscle injuries. In this article, we describe a fast, repeatable, low-cost technique to detect bar edge and stabilizers. METHODS A perioperative scan is performed by means of a portable ultrasonograph a few minutes before the operation. The bar edge stabilizer is detected as a hyperechogenic image with a concentric crescent while the bar edge is detected as a hyperechogenic dashed line with net edges. The scan is performed, and the actual projection on the skin of the metal plaque bulk is then labeled on the patient's chest by an ink marker. CONCLUSIONS We believe that this method may improve morbidity, operative time, and consequently, hospitalization length and costs.
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Affiliation(s)
- Filippo Incerti
- Department of Pediatric Surgery, Children's Hospital A. Meyer , Florence, Italy
| | - Alessia Bertocchini
- Department of Pediatric Surgery, Children's Hospital A. Meyer , Florence, Italy
| | - Marco Ghionzoli
- Department of Pediatric Surgery, Children's Hospital A. Meyer , Florence, Italy
| | - Antonio Messineo
- Department of Pediatric Surgery, Children's Hospital A. Meyer , Florence, Italy
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20
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Bilgi Z, Ermerak NO, Çetinkaya Ç, Laçin T, Yüksel M. Risk of serious perioperative complications with removal of double bars following the Nuss procedure. Interact Cardiovasc Thorac Surg 2017; 24:257-259. [PMID: 27798060 DOI: 10.1093/icvts/ivw322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/25/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives The aim of this study is to present our experience with Nuss bar removal and evaluate potential risk factors. The Nuss procedure requires an operation to remove the bar 2-3 years after the initial correction. Although removal of the bar is generally believed to be safe, perioperative complications including major bleeding can occur. Methods All cases involving removal of the Nuss bar done since April 2007 were recorded in a prospective database. Data were collected on the amount of blood loss, the number of diagnostic interventions, operative management and postoperative course. Results Of a total of 246 (162 with single bars, 80 with double bars, 4 with triple bars) cases, 43 patients (17.5%) experienced perioperative complications. Five patients underwent secondary postoperative interventions; one patient required same-session emergency video-assisted thoracic surgery (VATS) due to major bleeding. Patients who had complications were significantly older than patients with no complications (20.5 ± 6.5 years vs 17.2 ± 5.9 years, P = 0.002). People having double bars removed were significantly more likely to have perioperative complications (12% vs 27%, P = 0.03) and complications requiring secondary interventions (n = 1 for a single bar, n = 5 for double bars, P = 0.01). Conclusions Major complications after removal of the Nuss bar occur with some frequency. Although the double-bar removals in our cohort were associated with major complications, the reasons are poorly understood. Immediate management of the complications may require multidisciplinary care. Multicentric pooling of cases is needed for better risk stratification.
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Affiliation(s)
- Zeynep Bilgi
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Nezih Onur Ermerak
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Çagatay Çetinkaya
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Tunç Laçin
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Mustafa Yüksel
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
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Park HJ, Kim KS. Pectus bar removal: surgical technique and strategy to avoid complications. J Vis Surg 2016; 2:60. [PMID: 29078488 DOI: 10.21037/jovs.2016.02.27] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 02/04/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pectus bar removal is the final stage of the procedure for minimally invasive repair of pectus excavatum. Based on our experience with one of the largest scale data, we would like to address the important issues in pectus bar removal, such as appropriate duration of bar maintenance, techniques for bar removal, and strategies to avoid complications. METHODS Between September 1999 and August 2015, we operated on 2,553 patients with pectus excavatum and carinatum using pectus bars for a minimally invasive approach. Among them, 1,821 patients (71.3%) underwent pectus bar removal as a final stage of pectus deformity repair, and their data were analyzed retrospectively to identify the outcomes and adverse effects of the pectus bar removal procedure. The mean age of the patients was 9.13 years (range, 16 months to 44 years) and the male to female ratio was 3.55. The study is approved by the Institutional Review Board (IRB), the ethical committee of Seoul St. Mary's Hospital. The IRB has exempted the informed consent from every patient in this study due to this is a retrospective chart review without revealing any patients' personal data. RESULTS Our technique involved straightening of the bar in a supine position. The overall mean duration of pectus bar maintenance was 2.57 years (range, 4 months to 14 years). The mean duration was 2.02 years (range, 4 months to 7 years) for children under 12 years, 2.99 years (range, 7 months to 9 years) for teenagers aged 12-20 years, and 3.53 years (range, 3 months to 14 years) for adults over 20 years. Forty-eight patients (2.6%) underwent bar removal more than 5 years after bar insertion and 58 patients (3.2%) underwent bar removal earlier than initially planned. The most common adverse reaction after bar removal was wound seroma including infection (43 patients, 2.36%). Recurrence after bar removal occurred in nine patients (0.49%), and seven of these required redo repair (0.38%). CONCLUSIONS Pectus bar removal is a safe and straightforward procedure with a low rate of complication.
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Affiliation(s)
- Hyung Joo Park
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Kyung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
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Fibla JJ, Molins L, Moradiellos J, Rodríguez P, Heras F, Canalis E, Bolufer S, Martínez P, Aragón J, Arroyo A, Pérez J, León P, Canela M. Experience with the Nuss technique for the treatment of Pectus Excavatum in Spanish Thoracic Surgery Departments. Cir Esp 2015; 94:38-43. [PMID: 26546550 DOI: 10.1016/j.ciresp.2015.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/18/2015] [Accepted: 08/07/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Although the Nuss technique revolutionized the surgical treatment of pectus excavatum, its use has not become widespread in our country. The aim of this study was to analyze the current use of this technique in a sample of Thoracic Surgery Departments in Spain. METHODS Observational rectrospective multicentric study analyzing the main epidemiological aspects and clinical results of ten years experience using the Nuss technique. RESULTS Between 2001 and 2010 a total of 149 patients were operated on (mean age 21.2 years), 74% male. Initial aesthetic results were excellent or good in 93.2%, mild in 4.1% and bad in 2.7%. After initial surgery there were complications in 45 patients (30.6%). The most frequent were wound seroma, bar displacement, stabilizer break, pneumothorax, haemothorax, wound infection, pneumonia, pericarditis and cardiac tamponade that required urgent bar removal. Postoperative pain appeared in all patients. In 3 cases (2%) it was so intense that it required bar removal. After a mean follow-up of 39.2 months, bar removal had been performed in 72 patients (49%), being difficult in 5 cases (7%). After a 1.6 year follow-up period good results persisted in 145 patients (98.7%). CONCLUSION Nuss technique in adults has had good results in Spanish Thoracic Surgery Departments, however its use has not been generalized. The risk of complications must be taken into account and its indication must be properly evaluated. The possibility of previous conservative treatment is being analyzed in several departments at present.
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Affiliation(s)
- Juan J Fibla
- Cirugía Torácica, Hospital Universitari Sagrat Cor, Barcelona, España.
| | - Laureano Molins
- Cirugía Torácica, Hospital Universitari Sagrat Cor, Barcelona, España; Cirugía Torácica, Hospital Clinic, Barcelona, España
| | - Javier Moradiellos
- Cirugía Torácica, Hospital Puerta de Hierro, Majadahonda (Madrid), España
| | - Pedro Rodríguez
- Cirugía Torácica, Hospital Insular de Las Palmas de Gran Canaria, Las Palmas, España
| | - Félix Heras
- Cirugía Torácica, Hospital Clínico Universitario, Valladolid, España
| | - Emili Canalis
- Cirugía Torácica, Hospital Universitari Joan XXIII, Tarragona, España
| | - Sergio Bolufer
- Cirugía Torácica, Hospital General Universitario de Alicante, Alicante, España
| | - Pablo Martínez
- Cirugía Torácica, Hospital Miguel Servet, Zaragoza, España
| | - Javier Aragón
- Cirugía Torácica, Hospital Universitario Central de Asturias, Oviedo, España
| | - Andrés Arroyo
- Cirugía Torácica, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Javier Pérez
- Cirugía Torácica, Hospital Germans Trias i Pujol, Badalona, España
| | - Pablo León
- Cirugía Torácica, Complejo Hospitalario Universitario, Albacete, España
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Wurtz A, Hysi I. The Nuss procedure: above all, do no harm. Ann Thorac Surg 2015; 99:1866. [PMID: 25952234 DOI: 10.1016/j.athoracsur.2014.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 10/29/2014] [Accepted: 11/18/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Alain Wurtz
- Clinique de Chirurgie Cardiaque et Thoracique, CHULille, F59037 Lille, France.
| | - Ilir Hysi
- Clinique de Chirurgie Cardiaque et Thoracique, CHULille, F59037 Lille, France
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