Complications and trends in minimally invasive repair of pectus excavatum: A large volume, single institution experience

The sandwich technique used for correction of pectus carinatum combined with Harrison sulcus

We aimed to investigate the feasibility of the sandwich technique to treat pectus carinatum combined with Harrison sulcus. We retrospectively analysed the clinical data of 38 paediatric patients with pectus carinatum combined with Harrison sulcus treated from June 2015 to October 2022. All the patients underwent surgery using the sandwich technique. The surgical conditions and postoperative outcomes of the patients and the satisfaction score of family members were analysed. Overall, the patients had a mean duration of surgery of 179.05 ± 36.01 min, intraoperative blood loss of 10.03 ± 2.77 mL, postoperative hospital stay of 6.89 ± 0.73 days, and postoperative satisfaction score of 89.4 ± 4.6. The incidence of surgical complications was 7.89%. The internal fixation stents were removed in 22 patients, and there was no recurrence during a follow-up 371.4 ± 6.3 days post-stent removal. These results were satisfactory. The use of the sandwich technique to treat this condition does not reduce the volume of the thorax after the procedure and results in an aesthetically pleasing incision, less complications, and fast postoperative recovery. Thus, it is a safe and effective method that is worthy of being promoted for clinical application.

'Short Bars Crossed' to Remodel the Entire Chest Wall in Children and Adolescents with Pectus Excavatum

BACKGROUND

The cross-bar technique of minimally invasive pectus excavatum (PE) correction remains underreported, which is especially true of pediatric patients. We therefore reviewed the experience of a Turkish and an Austrian center. An additional novelty characterizing both pediatric cohorts was the use of short bars.

METHODS

In a retrospective study, pediatric PE corrections involving 'short bars crossed' were analyzed for complications and intra-/postoperative outcomes. Cases with two or three bars were included, given that a horizontal third bar was placed whenever considered useful for upper-chest elevation. All bars were fitted with a single stabilizer near the surgical entry point. In the Austrian center, intercostal nerve cryoablation was used for pain management. Descriptive statistics are presented.

RESULTS

Seventy-eight patients ≤18 years old were evaluable at the Turkish (n = 56) and Austrian (n = 22) centers. Total median values were 16.2 (IQR: 15.1-17.4) years for age and 4.60 (IQR: 3.50-6.11) for Haller index. Ten mild or moderate complications (12.8%) were observed, including just one revision requirement due to bar migration (1.28%). Intercostal nerve cryoablation (n = 13) was associated with longer surgical procedures at 150 (IQR: 137-171) versus 80 (IQR: 60-100) minutes but with shorter hospital stays, given an IQR of 3-4 days versus 4-5 days.

CONCLUSION

'Short bars crossed'-with a single stabilizer in a ventral position close to the surgical entry point-ensure a wide distribution of forces, protect against bar migration, are safe and effective, and offer stability at an age characterized by growth and physical activity.

LEVEL OF EVIDENCE

IV.

Pectus Bar Dislocation: Comparison Between Three Different Stabilization Techniques Adopted in a Single Centre

BACKGROUND

Bar dislocation has always been considered a fearsome complication of Minimally Invasive Repair of Pectus Excavatum (MIRPE), therefore multiple techniques and types of stabilization have been introduced. The aim of the study is to compare different stabilization techniques in a cohort of patients operated by the same first operator.

METHODS

MIRPE was adopted at our institution in 2005. Data on MIRPE patients from January 2013 to December 2022 were collected prospectively and reviewed. Patients with a follow-up of at least 12 months were included. Throughout the years different ways of stabilization were used. Patients were divided in 3 groups according to the stabilization strategy adopted- Group A: no stabilizer; Group B: single bar fixation; Group C: bridge fixation. Dislocation was diagnosed if a bar rotated more than 30° or displaced laterally for more than 1.5 cm. We compared bar dislocation percentage of each group.

RESULTS

We positioned 733 bars in 468 patients. Group A included 113 bars (15.4%), Group B 415 bars (56.6%), Group C 205 bars (28%). No patients were lost at follow-up. Total dislocation rate was 4.1% (30 bars). Dislocation was observed in 10 bars of group A (8.8%), 20 bars of group B (4.8 %), 0 bars of group C (0%). Differences between groups were statistically significant.

CONCLUSIONS

The use of stabilizers reduced dislocation percentage. In particular, bridge fixation technique reduced to zero bar dislocation and is now our preferred technique of stabilization.

LEVEL OF EVIDENCE

III.

Modified bar bending method of thoracoscopic nuss procedure on pectus excavatum: a retrospective single-center study

BACKGROUND

Pectus excavatum (PE) is the most common disease of chest wall deformity, with an incidence of 1 in 300-400 births. Nuss procedure has proved to be the best surgical treatment method and has been widely used after clinical use for 30 years. We aimed to review the clinical data of pectus excavatum (PE) of thoracoscopic Nuss procedure adopted the Modified bar bending method of the six-point seven-section type, and compare it with the traditional curved bar bending method to explore the clinical application effect.

METHODS

Forty-six cases of clinical data were summarized of children with PE who adopted the treatment of the Modified bar bending method of the six-point seven-section type from January 2019 to December 2021, and 51 cases were compared of PE children who adopted the treatment of traditional curved bar bending method from January 2016 to December 2018, including the data of age, gender, preoperative symptoms, symmetry, Haller index, operation time, bar bending time, intraoperative bleeding, postoperative complications, bar migration, postoperative effect evaluation, etc. RESULTS: The Procedure duration (P = 0.008), bar bending time (P < 0.001), and duration of postoperative pain (P < 0.001) were reduced significantly, and the incidence of bar migration after surgery was reduced as well by the modified bar bending method. There was no difference compared with traditional Nuss produce, like the incidence of evaluation of postoperative effects (Excellent, P = 0.93; Good, P = 0.80; Medium, P = 1.00; Poor, P = 1.00), bar migration (P = 1.00), postoperative complications (P = 1.00), Clavien- Dindo classification of surgical complications (I = 0.165; II = 1.00; IIIa = 1.00; IIIb = 1.00; VI = 1.00; V = 1.00), operative safety, and operative validity.

CONCLUSION

Modified bar bending method of the six-point seven-section type, which is a kind of surgical method worth applying and popularizing, and the advantages of minimally procedure duration, bar bending time, and duration of postoperative pain, compared with the traditional bar bending method.

Complications following metal bar removal after Nuss repair are rare in a duocentric retrospective evaluation

PURPOSE

Minimally invasive pectus excavatum repair has gained widespread acceptance and its results and complications are well-described. However, there is a substantial debate on the risks and frequencies of complications following metal bar removal. We, therefore, aimed to analyse all complications that occurred during and after metal bar removal at our two paediatric surgical centres.

METHODS

Bar removal surgeries were identified via procedural codes and electronic records were reviewed using a pre-specified data extraction chart. Both intra- and postoperative complications were included and the latter scored according to Clavien-Dindo. We analysed the influence of the pre-specified potential predictors age, sex, and the number of implanted metal bars on the occurrence of complications using logistic regression.

RESULTS

We included 279 patients with a median age of 19 years (interquartile range 17-20 years). 15 patients experienced 17 complications. Of 11 postoperative complications, only an enlarging pleural effusion required a chest drain in local anaesthesia, resulting in a Claven-Dindo grade IIIa, whereas the remainder were classified as grade I. Neither age (adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.84-1.13, P = 0.73), nor sex (aOR 0.88, 95% CI 0.19-4.07, P = 0.87) or the number of bars (aOR 0.64, 95% CI 0.15-2.71, P = 0.547) did influence the occurrence of complications.

CONCLUSION

Complications following metal bar removal were scarce in our duocentric retrospective series and usually of minor relevance. However, to address the perceived paucity of data on the frequency and severity of complications following metal bar removal, further studies, including large database research is necessary.

Pushing the boundaries of minimally invasive repair of pectus excavatum: first experience with a 4-bar technique

Several modifications to minimally invasive repair of pectus excavatum have been reported to date. Of these, the use of multiple bars was a major development. At present, there are 2 established techniques: cross-bar and parallel bar placement. We used a combination of both parallel and cross-bar techniques in a 25-year-old male patient with deep, Grand-Canyon type pectus excavatum, placing a total of 4 bars and 4 stabilizers. The patient had no complications during the 7 months of postoperative follow-up. We share this case report as the first experience using this modified technique in the literature.

Three-Dimensional Printed Models for Preoperative Planning and Surgical Treatment of Chest Wall Disease: A Systematic Review

Introduction: In chest wall reconstruction, the main objectives are the restoration of the chest wall integrity, function, and aesthetic, which is often achieved with the placement of implants. We aimed to evaluate whether 3D printed models can be useful for preoperative planning and surgical treatment in chest wall reconstruction to improve the outcome of the surgery and to reduce the rate of complications. Methods: We conducted a systematic review of literature using PubMed, Scopus, Embase, and Google Scholar databases until 8 November 2021 with the following keywords: (“3D printing” or “rapid prototyping” or “three-dimensional printing” or “bioprinting”) and (“chest wall” or “rib” or “sternum” or “ribcage” or “pectus excavatum”). Results were then manually screened by two independent authors to select studies relevant to 3D printing application in chest wall reconstruction. The primary outcome was morphological correction, and secondary outcomes were changes in operating time and procedure-related complication rate. Results: Eight articles were included in our review. Four studies were related to pectus excavatum correction, two studies were related to rib fracture stabilization, and two studies were related to chest wall tumor resection and reconstruction. Seven studies reported 3D printing of a thorax model or template implants for preoperative planning and implant modeling, and one study reported 3D printing of a PEEK prosthesis for direct implantation. Four studies reported comparison with a conventionally treated control group, and three of them detected a shorter operative time in the 3D printing model-assisted group. Satisfactory morphological correction was reported in all studies, and six studies reported a good implant fitting with minimal need for intraoperative adjustments. There were no major intraoperative or postoperative complications in any of the studies. Conclusions: The use of 3D printing models in chest wall reconstruction seems to be helpful for the production of personalized implants, reducing intraoperative adjustments. Results of morphological correction and postoperative recovery after the 3D printing-assisted surgery were satisfactory in all studies with a low rate of complication. Our literature review suggests good results regarding prosthesis fitting, accuracy of surgical planning, and reduction in operative time in 3D printing-assisted procedures, although more evidence is needed to prove this observation.

A New Device for Thoracoscopic Cryoanalgesia in Pectus Excavatum Repair: Preliminary Single Center Experience

Introduction: Cryoanalgesia has been recently described as alternative technique for immediate and persistent pain treatment after pectus excavatum repair. Cryoanalgesia has the potentiality to reduce analgesic consumption and length of hospitalization. However, cryoanalgesia has not been standardized yet: the previous reports describe different techniques and systems and include only small series. In Europe, no reports on cryoanalgesia for pectus repair have been published so far. Materials and Methods: This is a prospective single center pilot study performed in adolescents undergoing minimally invasive pectus excavatum repair with a new cryoanalgesia system, using a probe designed specifically for thoracoscopy. This new double lumen probe has the theoretical advantage of freezing only in its tip, so reducing the risk of complications. Results: Seven patients undergoing pectus excavatum repair were treated with cryoanalgesia performed with the new probe. No complications of cryoanalgesia were reported. Total consumption of morphine during hospital stay was between 0.1 and 0.35 mg/kg, with no side effects reported. Mean time to discharge was 2.4 days. All patients reported a good pain control with a fair need of rescue medications for pain relief during the first week after discharge, and a very good pain control without need of rescue medications during following weeks. Conclusions: Our pilot study showed that the new cryoanalgesia device is efficacious in terms of pain control, hospital stay and resumption of post-operative activities. The cryoprobe designed allowed an easy and safe maneuver. A prospective trial is needed to better define the risks and benefits of this technique.