The minimally invasive Nuss technique for recurrent or failed pectus excavatum repair in 50 patients

Simultaneous pectus excavatum repair using sternal plate in a patient undergoing the Bentall procedure

Objective: Pectus excavatum is a deformity that occurs at the lower part of the sternum of the thorax, including the xiphoid process. Deformity generally causes cosmetic and psychosocial problems. Life-threatening conditions may ensue in patients with severe deformities. Ravitch surgery and Nuss's minimally invasive surgical procedures are the main procedures for correcting the pectus excavatum. A rare method of pectus excavatum is the stabilization of the sternum by using sternal plates. In this report, we present a case; successful pectus excavatum repair using the sternal plate simultaneously in a 48-year-old male patient who underwent Bentall operation due to ascending aortic aneurysm and aortic valve insufficiency. Case presentation: The patient was admitted with complaint of dyspnea. Examinations including clinical examinations, echocardiography, computed tomography  and pulmonary tests revealed pectus excavatum, with Haller index&qt;3.5,   reduced forced vital capacity 72% and ascending aorta aneurysm of 5.7 cm and moderate aortic valve regurgitation. The decision  to proceed with simultaneous aortic root and aortic valve replacement with pectus excavatum correction was taken. The operation were performed successfully under cardiopulmonary bypass without complications. Patient was discharged  on 9th postoperative day. Conclusion: In patients with pectus excavatum deformity who undergo cardiac surgery (in our case ascending aorta and aortic valve replacement) with median sternotomy, simultaneous sternal repair using a sternal plate is safe and preferable because it positively affects cardiac and pulmonary surgical outcomes. Therefore, we recommend simultaneous sternal plate application in patients with pectus excavatum who will have a cardiac operation.

Factors reducing psychological satisfaction after the Nuss procedure in pediatric patients

PURPOSE

We examined patient satisfaction with postoperative chest appearance after Nuss procedure and analyzed the factors for postoperative low satisfaction.

METHODS

We retrospectively reviewed data of 133 patients who underwent the Nuss procedure from 2000 to 2016. Their medical records, X-rays, and computed tomography scans were evaluated. Haller index and concave rate were used as objective indices of the deformity. The questionnaires were used to evaluate satisfaction with the chest appearance by a linear scale including five markers (1: dissatisfaction, 5: satisfaction). The patients were divided into two groups: the low satisfaction (score = 1, 2) and the high satisfaction (score = 3-5).

RESULTS

The median age during the Nuss procedure was 7.6 (interquartile range, 5.8-12.8) years. Out of 133, 65 patients replied, and the mean postoperative satisfaction score was 3.8 ± 0.2. Out of the 65 respondents, 16 patients (24.6%) were classified as low satisfaction group. Haller index and concave rate were significantly higher and the previous instances of chest operation history were more frequent in the low satisfaction group than in the high satisfaction group, although there was no significant intergroup difference in terms of the postoperative concave rate.

CONCLUSIONS

Severe deformity and previous chest operation history were considered to be factors for low satisfaction.

Heart recovery from a brain-dead donor with a history of Ravitch procedure for repair of pectus excavatum

BACKGROUND

We describe the successful heart transplantation of a brain-dead male donor with a remote history of pectus excavatum repair.

METHOD AND RESULTS

On computed tomography, the ascending aorta was in close proximity to metallic struts from the donor's sternal repair. Before harvesting the heart, visual and digital inspections revealed minimal space between the sternum and ascending aorta, complicated by severe adhesions in the lower sternum. After the pericardium was opened, the subsequent recovery of the heart was performed in a standard fashion. At one-year post-transplant, the recipient continues to have normal graft function.

CONCLUSIONS

Careful evaluation, intraoperative consideration, and coordination with other transplant teams were essential in the successful recovery of the heart during a time of organ shortages.

Co-existing obstructive sleep apnea reduces Nuss surgery efficacy in pectus excavatum

Nuss surgery is effective in correcting pectus excavatum (PE), with a recurrence rate of 1.2–27%. Re-do surgery is successful but still has a 6% failure rate. Patients with obstructive sleep apnea (OSA) experience repetitive PE-associated sternal depression during sleep. As the prevalence of OSA among PE patients is higher than the average, co-existing OSA in PE patients might negatively affect the efficacy of Nuss surgery. This study aimed to evaluate the impact of co-existing OSA on Nuss surgery in patients with PE. In total, 20 adult patients with PE only and 9 patients with PE and OSA were analyzed. Polysomnography was performed before Nuss surgery to evaluate OSA. Sternovertebral distance (SVD) and radiographic Haller index (RHI) were recorded before surgery and at 3, 6, and 24 months postoperatively. The results showed that percentage changes in SVD in patients with PE only at 3, 6, and 24 months postoperatively were significantly increased compared with those in the patients with PE and OSA (31.1% vs. 14.1% at 3 months; 37.5% vs. 21.4% at 6 months; 42.5% vs. 19.2% at 24 months). Meanwhile, percentage changes in RHI were significantly lower in patients with PE alone than in the patients with PE and OSA (-22.9% vs. -9.3% at 3 months; -27.9% vs. -18.7% at 6 months; -30.6% vs. -16.7% at 24 months). This study showed that co-existing OSA might reduce the efficacy of Nuss surgery for patients with PE. We recommend that patients with PE should be evaluated and treated for OSA before surgery to prevent surgical failure after bar removal.

A Modfied Nuss Procedure for Recurrent Pectus Excavatum of Adults

Background

Limited data exist for adults with recurrent pectus excavatum (PE) treated with minimally invasive surgical repair.

Methods

Between July 2008 and December 2020, forty-two adult patients with recurrent PE underwent a modified Nuss procedure with a newly designed bar in our center. A small vertical subxiphoid incision was used to separate severe adhesions when necessary. Multiple steel wires were sutured, and the rib space was narrowed to firmly fix the bar. The primary end point was Haller index change after operation. The secondary end points included length of stay after operation, short-term and long-term complications.

Results

The mean patient age was 22.02 ± 3.49 years. The mean Haller index was 4.59 ± 1.09. A subxiphoid incision was performed in 12 patients. Thirty-nine patients had one bar placed, and 3 patients required two bars. Sixteen patients had 3 or more wires fixation, and 4 patients needed to have their intercostal space narrowed. There was no perioperative death, and the mean hospitalization was 5.57 ± 2.47 days. The Haller index reduced to 3.03 ± 0.41 after the operation (t = 11.85, p < 0.001). During the follow-up, there were 3 patients who developed non-infective wound effusion; bar rotations occurred in 3 patients. Twenty patients had the bar removed, post-bar removal Haller index was significantly reduced compared to the preoperative Haller index (2.89 ± 0.37 vs. 4.72 ± 1.05, t = 8.96, p < 0.001).

Conclusions

The modified Nuss procedure with a new titanium alloy bar can achieve good results for adult patients with recurrent PE.

An Initial 5-Year Single-Center Experience of 365 Patients Undergoing the Video-Assisted Thoracoscopic Surgery for Nuss Procedure for Pectus Excavatum in Resource-Scare Setting

Background: Little is known about video-assisted thoracoscopic surgery in the Nuss procedure (VATS-NUSS) and its postoperative outcomes in the resource-scarce conditions in clinical practice such as Vietnam. Available evidence in the literature was mostly reported from large institutions in developed countries. Hence, this study was conducted to review our initial large single-center experience in the use of the VATS-NUSS for patients with pectus excavatum (PE) within 5 years.

Methods: Data from 365 consecutive PE patients between January 2015 and December 2019 who were surgically treated with VATS-NUSS were retrospectively analyzed.

Results: Of 365 patients, median age at operation was 15.61 ± 3.73 years (range = 5–27 years), most being child and adolescent. Three hundred nine patients (84.65%) were male. PE was commonly detected at puberty (n = 328, 89.9%). Postoperatively, early complications consisted of pneumothorax (n = 5, 1.37%), pleural bleeding/pleural fluid (n = 2, 0.55%), pleural hematoma (n = 1, 0.27%), pneumonia (n = 1, 0.27%), surgical wound infection (n = 1, 0.27%), incision fluid accumulation (n = 3, 0.82%), metal bar infection (n = 1, 0.27%), atelectasis (n = 3, 0.82%), and fever (n = 8, 2.19%). Late complications included surgical wound infection (n = 2, 0.55%), metal bar deviation (n = 5, 1.37%), metal bar allergy (n = 10, 2.74%), recurrent PE (n = 2, 0.55%), and persistent PE (n = 5, 1.37%). No deaths occurred. In 175 patients (47.95%) experiencing bar removal, mean operative time for bar removal was 34.09 ± 10.61 min, and the length of hospitalization following bar removal was 2.4 ± 1.34 days; the most frequent complication was pneumothorax (n = 19, 10.85%). One wound infection and one incision fluid accumulation happened following bar removal. Favorable midterm to long-term postoperative outcomes were achieved.

Conclusions: From the beginning of the Vietnamese surgeons' experience, VATS-NUSS application obtained favorable outcomes with minimizing the occurrence of serious intraoperative and postoperative complications. Current rare evidence enables to give a real picture in the application, modification, and development of VATS-NUSS in the countries having similar resource-scarce conditions.

Analysis of chest wall elevation after the Nuss procedure using 3D body scanning technique in patients with pectus excavatum

PURPOSE

For the evaluation of the chest wall deformity, we adopted a non-invasive 3D body scanning system. The objective of this study is to evaluate surgical effect on the whole thorax using 3D scanning technique before and after Nuss procedure.

METHODS

We performed 3D body scanning using Structure Sensor (Occipital Inc, USA) in 11 symmetric patients (average age 13 ± 3.2) under general anesthesia before and after Nuss procedure. Using the scanned data, the improved chest wall was analyzed using 3D-Rugle (Medic Engineering, Japan) imaging software. Preoperative and postoperative 3D data were super-imposed and a thoracic elevating distance in the line of the axial and sagittal section through the deepest point was calculated. Pre- and postoperative external sternal angle (ESA) were calculated from the scanned data.

RESULTS

Mean thoracic elevation distance at the deepest point was 38.6 ± 6.1 mm and it was 28.4 ± 5.1 mm and 19.4 ± 4.9 mm at 4 cm and 8 cm cranial side, respectively. Average ESA improved from 3.9 ± 1.6 degrees to 15.0 ± 1.1 degrees after the operation.

CONCLUSION

Chest depression was effectively elevated 39 mm at the deepest point after Nuss procedure. An indirect elevation effect by pectus bars was found on the wide area of the anterior chest.

Adult pectus excavatum repair: national outcomes of the Nuss and Ravitch procedures

Background

National data is limited on pectus excavatum, the most common chest wall deformity which is often repaired using the Ravitch and Nuss procedures. The purpose of the study was to describe demographics and outcomes of adult patients who underwent surgical repair of pectus excavatum via open and minimally invasive thoracoscopic methods.

Methods

A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2018 was performed, capturing patients 18 years or older with pectus excavatum as the postoperative diagnosis. Patients were placed into two groups of minimally invasive (Nuss) and open (Ravitch) repair procedure code. Baseline characteristics and postoperative outcomes were analyzed.

Results

A total of 168 adult patients were captured. Most of these patients were white (84.52%) male (69.64%) and 26 years old on average. Median operative time was longer in the open repair group [250 (IQR, 173-308) versus 122 (IQR, 94-160) minutes, P<0.0001]. Median length of stay was five days (IQR, 4-6) in the open group and three days (IQR, 2-4) in the minimally invasive group (P=0.2873).

Conclusions

Complications after repair of pectus excavatum occur at similar rates between open and minimally invasive repair. Though minimally invasive repair decreases operative time and may decrease length of stay, the decision of type of procedure depends upon clinical scenario and factors unique to the individual patient.

Surgical correction of recurrent pectus excavatum of an adult patient, case report, and review of literature

Purpose

The aim of this paper is to review the literature on recurrent pectus excavatum (PE) and present our surgical approach to a complex case of recurrent PE in an adult patient at a Mexican Hospital.

Methods

We present the case of an adult patient with severe and symptomatic PE, with history of a failed Nuss procedure 1 year previous our intervention, which consisted of a combination of both classic techniques, by performing an osteochondrectomy of affected cartilages and placing a titanium bar substernal and stabilizing coastal arches with secondary osteosynthesis system (Stratos ™ system, medXpert, Germany).

Results

Adequate correction of thoracic silhouette and both cardiac and respiratory disorders in the 1-year follow-up was achieved as indicated by the improvement of the patient's Haller index.

Conclusion

Successful surgical correction of pectus excavatum is achieved when the thoracic silhouette is restored, thus improving cardiopulmonary symptoms. As there are many different techniques available, the more minimally invasive ones are reserved for mild cases, but the treatment of complex cases as in our patient requires a combination of multiple techniques and reconstruction materials in order to achieve adequate correction of the thoracic deformity and reduce recurrence rate.

Clinical application of enhanced recovery after surgery (ERAS) in pectus excavatum patients following Nuss procedure

Background

Evaluate the effect of enhanced recovery after surgery (ERAS) protocol on postoperative recovery quality of pectus excavatum patients with Nuss procedure.

Methods

A retrospective study was performed on patients undergoing Nuss procedure from the Department of Thoracic Surgery of The Cancer Hospital of China Medical University between September 2016 and September 2019. Patients were divided into 2 groups by perioperative management: the traditional procedure group (T group) and the ERAS strategy group (E group). The outcome measures were postoperative drainage time, postoperative hospital time, and postoperative complications measured by the Clavien-Dindo method.

Results

Of the 168 patients from this time period, 148 met the inclusion criteria (75 in Group T and 73 in Group E). All operations involved in this study were completed successfully. There was no statistical difference between the 2 groups with respect to baseline demographics (P>0.05). In Group E, postoperative drainage time (2.53±0.72 vs. 3.45±2.07 days) and postoperative hospitalization time (4.96±1.48 vs. 7.71±7.78 days) were statistically significantly better than those in Group T (P<0.05). There was no difference in overall postoperative complications as measured by Clavien–Dindo score.

Conclusions

The measures of no indwelling urinary catheter (IDUC), laryngeal mask anesthesia, and indwelling tubule drainage can improve postoperative recovery quality of pectus excavatum patients following Nuss procedure.

Reoperative Pectus Repair Using Biomaterials

BACKGROUND

Reoperation after failed pectus repair, Open or Nuss, is complex. In the majority of patients, metal bars or plates are used. Recently, an absorbable bar (poly-L-lactide [PLA]) was introduced for rib fixation. This series is my experience of using this biomaterial for reoperative pectus surgery.

METHODS

We respectively reviewed the medical records of all patients who were referred to our institution for pectus abnormalities; 180 patients were evaluated, 62 patients (34%) underwent reoperation.

RESULTS

Sixty-two patients underwent reoperative Open repair. Median age was 38 years (range 18-, 72 years); 39 (63%) were men. Thirty-two patients had Open repair for recurrent pectus using posterior sternal support with PLA bars, and 30 patients with acquired restrictive thoracic dystrophy had expansion surgery with multiple PLA bars. Median hospital stay was 7 days (4-21 days). Postoperative complications occurred in 22 patients (35%); late complications in 10 patients (16%); all required reoperation for incisional or soft tissue issues. No patient required reoperation for a pectus or acquired restrictive thoracic dystrophy recurrence. Patient satisfaction was excellent in 85%, good in 8%, fair in 4%, and poor in 3%.

CONCLUSIONS

Reoperative pectus surgery is complex and requires a detailed preoperative evaluation and individualized plan for correction. Use of PLA absorbable bars for sternal support and chest cavity expansion provides a safe alternative. Soft tissue complications are common and reversible; early results are promising in these challenging patients.

Nuss procedure for patients with pectus excavatum with a history of intrathoracic surgery

BACKGROUND

The aim of this study was to demonstrate the feasibility and safety of the Nuss procedure for patients with pectus excavatum (PE) with a history of intrathoracic surgery.

PATIENTS

From April 2010 to December 2013, we performed 6 cases of PE repair in patients with a history of intrathoracic surgery. The causes of previous operations were congenital cystic adenomatoid malformation in 4 patients and congenital diaphragmatic hernia in 2. The patients' median age was 5 years (range, 4-9 years) and median preoperative pectus severity index was 4.63 (range, 3.42-10.03). Their intraoperative and postoperative courses were reviewed retrospectively.

RESULTS

The mean overall operation time was 127.5 ± 17.0 minutes, and the mean operation time for endoscopic pneumolysis was 28.8 ± 12.3 minutes. Intraoperative exploration for pleural adhesion revealed that the endoscopic approach in the previous operation was associated with low pleural adhesion, and the open thoracotomy or laparotomy approach was associated with low to high pleural adhesion. One patient developed a pneumothorax on the first postoperative day. All the other patients had uneventful postoperative courses. All the patients received bar removal 2-3 years after bar insertion. One patient developed atelectasis after bar removal. All the other patients had an uneventful postoperative course. The mean postoperative follow-up time after bar removal was 20.1 ± 14.7 months.

CONCLUSIONS

History of intrathoracic surgery seems not a contraindication for the Nuss procedure. However, perioperative complications should be carefully monitored in both the bar insertion and removal operations.

Complications associated with the minimally invasive repair of pectus excavatum

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.

Nuss procedure in the adult population for correction of pectus excavatum

Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.

Outcomes in adult pectus excavatum patients undergoing Nuss repair

Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.

Nuss procedure for repair of pectus excavatum after failed Ravitch procedure in adults: indications and caveats

BACKGROUND

Recurrence of pectus excavatum (PE) is not an uncommon problem after open repair using the Ravitch technique. The optimal approach for redo surgery is still under debate, especially in adults with less chest wall pliability. Aim of this study was to investigate the usefulness and efficacy of the minimally invasive Nuss technique for repair of recurrent PE after conventional open repair.

METHODS

We performed a retrospective multicentre review of 20 adult patients from University Hospital Bern (n=6) and the US Mayo Clinic (n=14) who underwent minimally invasive repair of recurrent PE after unsuccessful prior Ravitch procedure.

RESULTS

Mean patient age at primary open correction was 21 years, with recurrence being evident after a mean duration of 10.5 years (range, 0.25-47 years). Mean age at redo surgery using the Nuss technique was 31 years, with a mean Haller index of 4.7 before and 2.5 after final correction. Main reason for redo surgery was recurrent or persistent deformity (100%), followed by chest pain (75%) and exercise intolerance (75%). No major intraoperative or postoperative complications occurred and successful correction was possible in all patients.

CONCLUSIONS

Although the procedure itself is more challenging, the minimally invasive Nuss technique can be safely and successfully used for repair of recurrent PE after failed open surgery. In our series final results were good to excellent in the majority of patients without major complications or recurrence.

Revision of failed, recurrent or complicated pectus excavatum after Nuss, Ravitch or cardiac surgery

Pectus excavatum (PE) can recur after both open and minimally invasive repair of pectus excavatum (MIRPE) techniques. The cause of recurrence may differ based on the initial repair procedure performed. Recurrence risks for the open repair are due to factors which include incomplete previous repair, repair at too young of age, excessive dissection, early removal or lack of support structures, and incomplete healing of the chest wall. For patients presenting after failed or recurrent primary MIRPE repair, issues with support bars including placement, number, migration, and premature removal can all be associated with failure. Connective tissue disorders can complicate and increase recurrence risk in both types of PE repairs. Identifying the factors that contributed to the previous procedure's failure is critical for prevention of another recurrence. A combination of surgical techniques may be necessary to successfully repair some patients.

Contemporary management of recurrent pectus excavatum

BACKGROUND

Optimal management of recurrent pectus excavatum (PE) has not been established. Here, we review our institutional experience in managing recurrent PE to evaluate long-term outcomes and propose an anatomic classification of recurrences, and a decision-making algorithm.

METHODS

Clinical records of patients undergoing repair of recurrent PE (1996-2011) were reviewed. Univariate and multivariate logistic regression analyses were employed to examine patient characteristics as potential predictors for re-recurrence.

RESULTS

Eighty-five patients with recurrent PE were identified during the study period. The initial operation was a Ravitch procedure in 85% of cases. Revision procedures were most frequently Nuss repairs (N=73, 86%), with remaining cases managed via open approach. Overall cosmetic and functional results were satisfactory in 67 patients (91.8%) managed with Nuss and in 7 (58%) patients managed with other techniques. Seven (8%) patients required additional surgical revision. Multivariate analysis identified no statistically significant patient or procedural factors predictive of re-recurrence.

CONCLUSION

This study demonstrates that the Nuss procedure can be an effective intervention for recurrent pectus excavatum, regardless of the initial repair technique. However, open repair remains valuable when managing severe cases with abnormalities of the sternocostal junction and cartilage regrowth under the sternum.

Customized silicone implant for the correction of acquired and congenital chest wall deformities: A valuable option with pectus excavatum

BACKGROUND

Surgical remodeling and correction of congenital and acquired chest wall deformities (CWD) is undertaken many times for cosmesis. Although reportedly minimally invasive, commonly used Nuss procedure for correction of pectus excavatum (PE) is not without complications. Nuss procedure is also not suitable for complex deformities and Poland syndrome cases. Insertion of custom-made silicone implants for the reconstruction of defects has been adopted from adult plastic reconstructive surgery as primary repair of CWD or rescue procedure for recurrence of PE after recurrence or residual deformity.

METHODS

We present our experience with CWD reconstruction in children with customized silicone prosthesis made from a surgically implantable liquid silicone rubber (NuSil MED-4805, Ca).

RESULTS

Since 2006 we treated 26 patients with CWD: six were children (age <17years, median 14.6) with PE. Implants were custom made for each patient's chest. The implants were inserted under general anesthesia. Postoperatively all patients were fully satisfied with the cosmetic result and subjective patient satisfaction remained excellent at follow-up in all the children. Only one child developed postoperative complications (seroma).

CONCLUSIONS

Customized silicone implant for PE in the pediatric age is an alternative therapeutic method, as primary or rescue treatment, with equally good cosmetic outcome, fewer significant complications, less postoperative pain and a faster recovery.

Anesthesia and analgesia for pectus excavatum surgery

The technique of choice for surgical correction of pectus excavatum is the Nuss procedure, a minimally invasive technique in which rigid metal bars are placed transthoracically beneath the sternum and costal cartilages until permanent remodeling of the chest wall has occurred. Intraoperatively, anesthesia focuses on three areas: the potential for catastrophic blood loss caused by perforation of large capacitance vessels and the heart, the potential for malignant arrhythmias, and the consequences of bilateral iatrogenic pneumothoraces. Postoperatively, analgesia is institutionally dependent and controversial, based on usage and type of regional anesthesia. The necessity of multimodal analgesic techniques creates a common ground across different hospital systems.

Thoracoscopic repair of pectus excavatum using different bar stabilizers versus open repair

Objectives

To identify the preoperative characteristics and compare operative variables and postoperative outcomes in adult patients with pectus excavatum undergoing thoracoscopic repair using different bar stabilizers or open surgical repair.

Methods

31 patients were randomly divided into 3 groups: group A was 9 patients who underwent a modified Ravitch repair, group B was 11 patients who underwent video-assisted thoracoscopic repair using metal stabilizers, and group C was 11 patients who underwent video-assisted thoracoscopic repair using absorbable stabilizers. Preoperative, intraoperative, and postoperative variables and mortality were compared among groups.

Results

In all groups, preoperative variables were well-matched for age, sex, and Haller index. Operative time was significantly longer in group A. The postoperative length of hospital stay was significantly shorter in group A. Postoperative complications occurred in 7 (22.6%) patients, mostly in groups B and C. All patients were satisfied with the cosmetic result.

Conclusions

Repair of pectus excavatum in adult patients can be performed effectively either through an open surgical technique or thoracoscopy, with no intraoperative complications and excellent immediate results, but video-assisted thoracoscopic repair using metallic or absorbable bar stabilizers gives a better cosmetic result; however, absorbable bar stabilizers are more vulnerable and break more easily than metal stabilizers.

Pectus excavatum: a comparison of the Ravitch repair with the Nuss thoracoscopic technique with a standard metal bar or an absorbable bar

OBJECTIVE

Although pectus excavatum repair has evolved to a minimally invasive technique in prepubescent patients, the best approach in adults is less clearly understood. The aim of this study was to identify the preoperative characteristics, operative variables, and postoperative outcomes in adult patients with pectus excavatum undergoing thoracoscopic repair using different bar stabilizers compared with the open surgical repair.

METHODS

We conducted a prospective study between July 2009 and July 2012 in a single institution. Thirty-one patients (26 men and 5 women) aged 18 to 35 years were randomly assigned into three groups: group A, 9 patients underwent modified Ravitch repair; group B, 11 patients underwent video-assisted thoracoscopic repair using metal stabilizers; and group C, 11 patients underwent video-assisted thoracoscopic repair using absorbable stabilizers. Preoperative, intraoperative, and postoperative variables are compared between all groups.

RESULTS

In all groups, the preoperative variables were well matched for age, sex, and Haller index. Operative time was 2 hours longer in group A (P = 0.0001). There was no intraoperative complication. Length of hospital stay was 4 days shorter in group A. Morbidity was 23% and composed of pneumothorax (three), wound seroma (two), pleural effusion (one), and stabilizer break (one), occurring more frequently in groups B and C. There was no perioperative mortality. All patients were satisfied with the cosmetic results.

CONCLUSIONS

Repair of pectus excavatum in adult patients can be performed effectively through either open surgical technique or thoracoscopy, with no intraoperative complications and with excellent immediate results. Although the operative time for the Ravitch repair was longer, the hospital stay was significantly shorter than that for the video-assisted method.

Modified Nuss procedure in the treatment of recurrent pectus excavatum after open repair

OBJECTIVES

The purpose of this study was to evaluate the efficacy of the modified Nuss procedure with a subxiphoid incision in correcting recurrent pectus excavatum.

METHODS

From August 2006 to July 2010, 28 patients with recurrent pectus excavatum underwent a secondary repair using the modified Nuss procedure with a subxiphoid incision and bilateral thoracoscopy. Data concerning symptoms, operative course, complications, pulmonary function and early outcome were recorded.

RESULTS

Prior repairs of the reoperation patients included 16 Ravitch, 9 modified Ravitch and 3 sterno-turnover procedures. The median Haller index was 4.52 for the redo patients. Presenting symptoms included decreased endurance, dyspnoea on exertion, chest pain, frequent respiratory infections and palpitations. The median duration of reoperation was slightly longer than that of the primary surgeries. Blood loss and postoperative hospitalization were similar between groups. Complications from pectus reoperations included pneumothorax, pleural effusion, postoperative pain and wound infection in the lateral incision. There were no perioperative deaths or cardiac perforations. Initial postoperative results varied from excellent to good. The patients were followed up for 24-74 months. No steel bar malposition or stabilizer displacement was found in any case.

CONCLUSIONS

The modified Nuss procedure with subxiphoid incision and bilateral thoracoscopy can avoid cardiac injury to the greatest degree. It would be a minimally invasive and safe approach for patients with recurrent pectus excavatum after failed open repair.

Experience in minimally invasive Nuss operation for 406 children with pectus excavatum

BACKGROUND

This study was to investigate the advantages of thoracoscopy-assisted minimally invasive Nuss operation for the treatment of pectus excavatum (PE) in children.

METHODS

A total of 406 patients with PE (female: 93; male: 313) with an average age of 6.8 years (range: 3.5-17.5 years) were included in this study. Associated diseases included congenital heart disease in 9 patients and congenital pulmonary cyst in 2. The Haller index of the patients ranged from 3.35 to 7.23, with an average of 5.17±1.64. Minimally invasive Nuss operation was performed for all the patients.

RESULTS

The operations were performed successfully and no operative mortality occurred. The average blood loss during the operation was less than 10 mL and the operating time ranged from 30 to 85 minutes with an average of 45 minutes. The length of hospital stay ranged from 5 to 9 days with an average of 7 days. Struts were implanted in 12 (3.0%) of the 406 patients. Injury of the pericardium occurred in 1 patient during the operation. Early post-operative complications occurred in 9 patients with pneumothorax and 6 patients with pleural effusion, which were cured by puncture or drainage. Poor wound healing occurred in 4 patients (1.0%) and was cured by nutritional support. During a 3-month to 6-year follow-up, 2 patients had scoliosis and 3 patients had displacement of the strut, which was cured by a second Nuss operation. Allergy occurred in 2 patients: the symptoms were improved in 1 patient after conservative treatment, but the strut was removed in advance due to allergy in the other patient. Totally 154 patients (40.0%) underwent operation for strut removal. Excellent repair results were achieved in 387 (95.3%) patients, good repair results in 12 (3.0%), and fair results in 7 (1.7%).

CONCLUSIONS

Thoracoscopy-assisted Nuss operation has many advantages including small and masked incision, short operative time, minimal blood loss, fast recovery, less trauma, and satisfactory outcomes of repair. Nuss is a safe and reliable technique for repair of PE.

One hundred patients with recurrent pectus excavatum repaired via the minimally invasive Nuss technique--effective in most regardless of initial operative approach

PURPOSE

Controversy exists as to the best operative approach to use in patients with failed pectus excavatum (PE) repair. We examined our institutional experience with redo minimally invasive PE repair along with the unique issues related to each technique.

METHODS

We conducted an institutional review board-approved review of a prospectively gathered database of all patients who underwent minimally invasive repair of PE.

RESULTS

From June 1987 to January 2010, 100 patients underwent minimally invasive repair for recurrent PE. Previous repairs included 42 Ravitch (RAV) procedures, 51 Nuss (NUS) procedures, 3 Leonard procedures, and 4 with previous NUS and RAV repairs. The median Haller index at reoperation was 4.99 (range, 2.4-20). Fifty-five percent of RAV patients and 25% of NUS patients required 2 or more bars (P = .01). Two RAV patients had intraoperative nonfatal cardiac arrest owing to thoracic chondrodystrophy--1 at insertion and 1 upon removal. Bar displacements occurred in 12% RAV and 7.8% NUS patients (P = .05). Overall reoperation for bar displacement is 9%.

CONCLUSIONS

The minimally invasive NUS technique is safe and effective for the correction of recurrent PE. Patients with prior NUS repair can have extensive pleural adhesions necessitating decortication during secondary repair. Patients with a previous RAV repair may have acquired thoracic chondrodystrophy that may require a greater number of pectus bars to be placed at secondary repair and greater risk for complications. We have a greater than 95% success rate regardless of initial repair technique.

Indications and technique of Nuss procedure for pectus excavatum

Pectus excavatum most frequently involves the lower sternum and chest wall. Because the morphology varies, preoperative imaging for anatomic assessment and documentation of dimensions of the chest are important. Many modifications have been made to the minimally invasive procedure since it was first performed in 1987. As a result, there has been an increase in the number of patients seeking surgical correction. This article discusses the clinical features of pectus excavatum and reviews the preoperative considerations and the steps involved in the repair of the deformity.

Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients

OBJECTIVE

To review the technical improvements and changes in management that have occurred over 21 years, which have made the minimally invasive repair of pectus excavatum safer and more successful.

SUMMARY BACKGROUND DATA

In 1997, we reported our 10-year experience with a new minimally invasive technique for surgical correction of pectus excavatum in 42 children. Since then, we have treated an additional 1173 patients, and in this report, we summarize the technical modifications which have made the repair safer and more successful.

METHODS

From January 1987 to December 2008, we evaluated 2378 pectus excavatum patients. We established criteria for surgical intervention, and patients with a clinically and objectively severe deformity were offered surgical correction. The objective criteria used for surgical correction included computed tomography (CT) scans of the chest, resting pulmonary function studies (spirometry and/or plethysmography), and a cardiology evaluation which included echocardiogram and electrocardiogram. Surgery was indicated if the patients were symptomatic, had a severe pectus excavatum on a clinical basis and fulfilled two or more of the following: CT index greater than 3.25, evidence of cardiac or pulmonary compression on CT or echocardiogram, mitral valve prolapse, arrhythmia, or restrictive lung disease. Data regarding evaluation, treatment, and follow up have been prospectively recorded since 1994. Surgical repair was performed in 1215 (51%) of 2378 patients evaluated. Of these, 1123 were primary repairs, and 92 were redo operations. Bars have been removed from 854 patients; 790 after primary repair operations, and 64 after redo operations.

RESULTS

The mean Haller CT index was 5.15 ± 2.32 (mean ± SD). Pulmonary function studies performed in 739 patients showed that FVC, FEV1, and FEF25-75 values were decreased by a mean of 15% below predicted value. Mitral valve prolapse was present in 18% (216) of 1215 patients and arrhythmias in 16% (194). Of patients who underwent surgery, 2.8% (35 patients) had genetically confirmed Marfan syndrome and an additional 17.8% (232 patients) had physical features suggestive of Marfan syndrome. Scoliosis was noted in 28% (340). At primary operation, 1 bar was placed in 69% (775 patients), 2 bars in 30% (338), and 3 bars in 0.4% (4). Complications decreased markedly over 21 years. In primary operation patients, the bar displacement rate requiring surgical repositioning decreased from 12% in the first decade to 1% in the second decade. Allergy to nickel was identified in 2.8% (35 patients) of whom 22 identified preoperatively received a titanium bar, 10 patients were treated successfully with prednisone and 3 required bar removal: 2 were switched to a titanium bar, and 1 required no further treatment. Wound infection occurred in 1.4% (17 patients), of whom 4 required surgical drainage (0.4% of the total). Hemothorax occurred in 0.6% (8 patients); 4 during the postoperative period and four occurred late. Postoperative pulmonary function testing has shown significant improvement. A good or excellent anatomic surgical outcome was achieved in 95.8% of patients at the time of bar removal. A fair result occurred in 1.4%, poor in 0.8%, and recurrence of sufficient severity to require reoperation occurred in 11 primary surgical patients (1.4%). Five patients (0.6%) had their bars removed elsewhere. In the 752 patients, more than 1 year post bar removal, the mean time from initial operation to last follow up was 1341 ± 28 days (SEM), and time from bar removal to last follow-up is 854 ± 51 days. Age at operation has shifted from a median age of 6 years (range 1-15) in the original report to 14 years (range 1-31). The minimally invasive procedure has been successfully performed in 253 adult patients aged 18 to 31 years of age.

CONCLUSIONS

The minimally invasive repair of pectus excavatum has been performed safely and effectively in 1215 patients with a 95.8% good to excellent anatomic result in the primary repairs at our institution.

Incomplete left bundle branch block as an artefact caused by the Nuss procedure for pectus excavatum

AIMS

Nuss procedure is an established and well approved minimally invasive technique for the correction of pectus excavatum. Hereby an individually curved steel bar is inserted to stabilize the thorax. This study aimed to describe ECG changes associated with this procedure.

METHODS AND RESULTS

Electrocardiographs of 65 patients who underwent Nuss procedure in our Hospital were evaluated before and after bar implantation as well as after bar removal. In the Goldberger leads, there was a consistent reduction in the QRS amplitude in lead I. In the Wilson leads, the most prominent change was a reduction in the QRS amplitude and a novel r' wave forming a slightly elevated J-point in the left lateral leads. Additionally, we noticed the loss of the former small and physiological q wave in the same leads, typical for an incomplete left bundle branch block (ILBBB). These changes resolved after bar removal.

CONCLUSION

We describe the common finding of a reversible incomplete ILBBB after Nuss surgery. The reason for these ECG changes remain unclear. Since cardiac ischaemia, damage, or perioperative irritation of the pericardium is improbable and the alteration of the anatomic thoracic situation remains after bar explantation, we suspect an artefact through alteration of the electric field by the steel bar. Practitioners dealing with patients after Nuss procedure should be aware of this most probably harmless finding.

Minimally invasive repair of pectus excavatum deformity

This review is trying to address the effectiveness and sustainability of results following minimally invasive repair of pectus excavatum (MIRPE). The aim is to present these results for the benefit of clinicians and the patients. Literature search has revealed 179 hits, which were independently assessed and led to 80 publications being formally reviewed. Studies reporting results from less than 10 patients were excluded. Thirty-five studies were found to be reporting results from patients' and/or surgeons' perspective and they were included in this review. Data from the United Kingdom registry for MIRPE were also included. Results from over 2997 patients (age: <1-85 years) who had MIRPE and 1393 patients who had their metallic bar removed were assessed. The most common indication for surgery was cosmesis. There was a net gain with regard to self-esteem for 96-100% of the individuals. A percentage of procedures (0-20%) was assessed by surgeons as having an 'unsatisfactory outcome' and a number of patients (0-25%) reported an 'unsatisfactory end result.' However, these percentages are not necessarily referring to the same patients and an unsatisfactory result does not seem to affect the positive effect on self-esteem. The reported changes in social life, lung capacity, cardiovascular capacity, exercise capacity and general health are based on weak data and significant improvements, if any, are probably seen in a limited number of patients. The metallic bars were removed after 1.5-4.5 years and there is an overall 0-4.5% reported recurrence post-bar removal. In conclusion, MIRPE may improve cosmesis and self-esteem of patients with pectus excavatum deformity. Direct or indirect improvement in other physiological parameters may also help the 'well-being' of these patients and their social integration. There is a clear need for standardisation in the way results are reported in the literature and a socioeconomic analysis with regard to gains, benefits and costs related to MIRPE.

Retrospective review of reoperative pectus excavatum repairs

BACKGROUND/PURPOSE

Despite success of several techniques described for pectus excavatum repair, a minority of patients require multiple reoperations for recurrence or other complications. We aimed to review our experience in reoperative pectus excavatum repairs and to identify features correlating with need for additional reoperations.

METHODS

Charts were reviewed of all patients undergoing reoperative pectus excavatum repair for 3 years at a university-based children's hospital. Number and type of previous repairs, time between operations, lengths of stay, analgesia, and complications were recorded.

RESULTS

From February 2004 to December 2007, 170 pectus excavatum repairs were performed. Among these, 27 were reoperative. Overall, 18.2% of reoperative patients required subsequent additional reoperations. 21.1% of patients undergoing repeat open repairs and 33.3% of patients undergoing repeat minimally invasive repairs required further operative interventions. There was no need for additional repairs among patients who had open repairs after minimally invasive repairs, nor for any patients who had minimally invasive repairs after open repairs.

CONCLUSIONS

We conclude that patients with failed open repairs will have better success with minimally invasive reoperations, whereas patients with failed minimally invasive repairs will have better success with open reoperations. When faced with reoperative pectus excavatum, we recommend consideration of an alternative operative approach from the initial procedure.