Operative innovation to the "Nuss" procedure for pectus excavatum: operative and functional effects

Chondrotomy and sternotomy combined with the Nuss procedure for severe asymmetric pectus excavatum: how to do it

The correction of severe asymmetric pectus excavatum is still challenging, especially for adults with a rigid thorax. For the repair of asymmetric cases, we introduce our surgical techniques added to the Nuss procedure. Chondrotomy of the depressed and deformed costal cartilage to elevate the depressed side was performed in a 42-year-old female patient. The depressed chest wall was directly elevated using pectus bars. Her sternal rotation angle improved from 27° to 15° after bar removal. In a 26-year-old male patient, oblique sternotomy and chondrotomy were performed. The sternal rotation angle improved from 26° to 9° postoperatively. These techniques were effective for correcting severe asymmetric pectus excavatum in adults.

Surgical management of pectus excavatum in China: results of a survey amongst members of the Chinese Association of Thoracic Surgeons

Background

At present, there are no randomized trial or higher levels of evidence than case studies to guide thoracic surgeons in the field of thoracic deformities, typically for pectus excavatum. This study investigates the current clinical practices amongst the Chinese Association of Thoracic Surgeon (CATS) members in order to seek potential consensus and divergence.

Methods

A web-based questionnaire was designed by a subgroup of CATS Pectus Excavatum Management Working Group and was sent to all of the CATS members. The questionnaire was composed of 27 questions concerning debatable sections, including preoperative evaluations, indications, timings of surgery, anesthesia and analgesia methods, rehabilitations.

Results

A total of 385 questionnaires were mailed to available CATS members. Moreover, 208 questionnaires were retrieved, of them 170 were finally available for analysis. Results of high consensus were extracted. Besides well-known factors such as complaints of symptoms, a moderate to severe deformity by physical exam, a Haller CT index >3.2, pulmonary function deviance, and cardiology evaluation abnormality, cosmetic requests and severe social-psychological problems from deformity come to be the most common reasons (17.34% and 56.89%) for PE patients' demands for surgery, and also occupy high percentages (49.41% and 89.41%) in indications of surgery. Concerning CT scan, 3D reconstruction of the chest is performed additionally by two thirds (64.12%) of the investigated cohort. Two surgeons out of three (66.47%) responders consider the optimal age for surgery is 6-12 years old. After the Nuss procedure, the majority of responders (79.41%) agree on the removal of the bar 2-3 years after surgery. To deal with complicated or severe deformities, 84.71% of surgeons utilize the double bar or multiple bar techniques. The majority of responders (92.35%) prefer general anesthesia combined with intubation in PE surgery, as well as in the procedure of the Nuss bar removal (72.35%).

Conclusions

The survey reveals a remarkable consistency of practice patterns in several aspects. Adequate preoperative evaluations are needed. Cosmetic request and psychological discomfort from deformity are crucial indications for surgery. We had better perform PE surgery before patients' puberty and bar removal 3 years after surgery. Several surgical skills are fully debated to enhance orthopedic effect and diminish complications. General anesthesia combined with intubation is considered as a standard maneuver. Surgeons now pay more and more attention to perioperative rehabilitations. The given results can be used as evidence in guiding clinical practice in circumstances where no evidence of higher levels exists, although divergences exist. Future studies, especially randomized trials, are needed to establish clinical practice guidelines for thoracic surgeons in PE surgery.

Changes in resting pulmonary function testing over time after the Nuss procedure: A systematic review and meta-analysis

BACKGROUND

Pectus excavatum, the most common congenital chest wall deformity in pediatric patients, leads to pulmonary dysfunction. There is no consensus regarding the effectiveness of the Nuss procedure for recovering pulmonary function. In this meta- analysis, we focused on the changes that occur in pulmonary function after the Nuss procedure.

METHODS

We performed a literature search in the MEDLINE, Embase, Cochrane library and PubMed databases. The included studies were required to contain pulmonary function tests with results adjusted to predicted values both before and after the Nuss procedure. The key outcomes of interest in this analysis were pulmonary function measured as forced expiratory volume in 1s (FEV1) and forced vital capacity (FVC). Subgroup analyses were performed based on time since surgery and the mean ages of the patients when they underwent surgery by forest plots and meta-regressions.

RESULTS

Thirteen studies involving 465 participants were included in this review. The standard mean difference (SMD) observed in FEV1 and FVC after surgery were 0.17 (95% CI, 0.01-0.33, p=0.04) and -0.18 (95% CI, -0.41-0.06, p=0.14), respectively. The overall meta-regression SMD of FEV1 and FVC by time since surgery were 1.21 (95% CI, 1.04-1.41, p=0.020) and 1.38 (95% CI, 1.05-1.83, p=0.027), respectively. We found evidence of a temporal relationship between time at which pulmonary function tests were performed after surgery and predicted FEV1 and FVC values. The SMD of FEV1 (0.26, p=0.012) was slightly higher in group evaluated more than 2year after initial surgery.

CONCLUSIONS

Abnormal resting pulmonary functions tests performed prior to surgery showed an initial depression after surgery. The FEV1 of patients slightly increased at 2year post surgery compared with the baseline. Further studies with longer term follow-up are still needed to determine if pulmonary function could improve to normal after surgery.

LEVELS OF EVIDENCE

Level of evidence: 4 (based on lowest level of article analyzed in meta-analysis/systematic review).

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.

Technical consideration of the MOVARPE technique in intricate pectus excavatum deformity

Background

For the correction of pectus excavatum (PE) deformities in adolescents, adults, and generally in asymmetric cases, a semi-open approach called the MOVARPE (minor open videoendoscopically assisted repair of pectus excavatum) technique is used, consisting of standard pectus bar implantation hybridized with auxiliary sternum osteotomy and multiple chondrotomies. In this study, we report our experiences, discuss pros and cons, and provide technical refinements.

Methods

Between September 2005 and March 2015, 61 patients were selected to undergo the MOVARPE instead of the standard MIRPE (minimally invasive repair of pectus excavatum) procedure because of age or specific morphologic characteristics of PE. Patient age ranged from 14 to 45 years (mean 23.4 years).

Results

Auxiliary incisions for skeletal relaxation enabled symmetric remodeling and, in most cases, circumvented the need for a second pectus bar. The bars were left in position for a mean of 19.3 months (range: 12 to 35 months). There were no major complications. Minor complications such as pleural effusion, temporary pneumothorax, and mild recurrence of the deformity after bar removal were seen at rates similar to those for standard techniques. In the current study reporting outcomes of the previously described MOVARPE procedure, the authors saw no evidence of a possible disadvantage in the overall concept or execution of the procedure for the suggested indication.

Conclusion

From this experience, we can state that, as an alternative to the MIRPE technique, MOVARPE is a method that offers high efficacy, particularly for rigid and complex pectus excavatum deformities at or beyond puberty.

Nuss bar procedure: past, present and future

Repair of pectus excavatum began at the beginning of the 20th century before endotracheal intubation was standard practice. Surgeons therefore developed techniques that corrected the deformity using an open procedure via the anterior chest wall. Initial techniques were unsatisfactory, but by the 1930s the partial rib resection and sternal osteotomy technique had been developed and was used in combination with external traction post-operatively to prevent the sternum from sinking back into the chest. In 1949, Ravitch recommended complete resection of the costal cartilages and complete mobilization of the sternum without external traction, and in 1961 Adkins and Blades introduced the concept of a substernal strut for sternal support. The wide resection resulted in a very rigid anterior chest wall, and in some instances, the development of asphyxiating chondrodystrophy. The primary care physicians therefore became reluctant to refer the patients for repair. In 1987, Nuss developed a minimally invasive technique that required no cartilage or sternal resection and relied only on internal bracing by means of a sub-sternal bar, which is inserted into the chest through two lateral thoracic incisions and guided across the mediastinum with the help of thoracoscopy. After publication of the procedure in 1998, it became widely accepted and a flood of new patients suddenly started to appear, which allowed for rapid improvements and modifications of the technique. New instruments were developed specifically for the procedure, complications were recognized, and the steps taken to prevent them included the development of a stabilizer and the use of pericostal sutures to prevent bar displacement. Various options were developed for sternal elevation prior to mediastinal dissection to prevent injury to the mediastinal structures, allergy testing was implemented, and pain management improved. The increased number of patients coming for repair permitted studies of cardiopulmonary function, which showed that patients with a severe degree of pectus excavatum have right- sided cardiac compression, decreased filling, and decreased stroke volume. The degree of pulmonary restriction and obstruction is related to the degree of deformity and degree of cardiac displacement into the left chest. The indications for surgical repair have been clearly outlined, the procedure has been standardized, and post-operative management protocols are now available. A review of our prospective database showed that 98% of patients have a good to excellent outcome. This review of the "Past" outlines the progression of the surgical techniques during the 20th century, the review of the "Present" outlines the important modifications and results of the closed technique, and the review of the "Future" outlines the various new options that are becoming available for the treatment of pectus excavatum.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pain and anxiety management in minimally invasive repair of pectus excavatum

The Nuss procedure for the correction of Pectus Excavatum (PE) is associated with intense postoperative pain. Our strategy to control early postoperative pain is to combine epidural with intravenous analgesia. Our aim was to analyse our pain control strategy by reviewing all the PE cases treated at our institution. Sixty consecutive patients, aged between 12 and 26 years old, received the PE operation at our institution from January, 2007 to September, 2010. The median age was 16 (12-27) with a male/female ratio of about 7/1. An epidural catheter was employed in all the cases, with 38 patients (63%) requiring additional drugs to control pain, which remained in place for 74 hours (72-96). The pain score was higher in male patients, but lower in those younger than 16 years old. Moreover, patients that consumed benzodiazepines had a significant decrease in cumulative opioid intake (P = 0.0408). Both gender and age had an impact on pain control, while we noticed a synergistic effect between opiates and tranquillizers.

Dermatitis in patients undergoing the Nuss procedure for correction of pectus excavatum

BACKGROUND

The Nuss procedure was introduced in 1987 for the correction of pectus excavatum. In this procedure, a stainless steel bar is placed underneath the sternum.

OBJECTIVES

To report cutaneous reactions associated with Nuss bar placement.

METHODS

Over a period of 30 months, 50 patients underwent the Nuss procedure. The study population was limited to those who developed clinically significant cutaneous reactions postoperatively. Patient information was obtained from electronic medical records. All patients had been patch tested preoperatively with stainless steel discs supplied by the bar manufacturer. When performed, expanded patch testing was carried out in accordance with the North American Contact Dermatitis Group guidelines.

RESULTS

Postoperatively, 3 patients developed areas of protuberant granulation tissue at one or more incision sites. One patient developed localized oedema, dermatitis, and lymphadenopathy. Two of these 4 patients underwent further patch testing. Of these 2, 1 with dermatitis had a positive reaction to nickel and the other, with granulation tissue, tested negative for metal allergy.

CONCLUSIONS

Despite clinical evidence of cutaneous reactions or putative allergy, no patient required early removal of the bar(s). Cutaneous testing with stainless steel discs supplied by the bar manufacturer does not provide accurate screening for allergy to the implant used in the Nuss procedure.

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.