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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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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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Senica SO, Gasparella P, Soldatenkova K, Smits L, Ābola Z. Cardiac perforation during minimally invasive repair of pectus excavatum: a rare complication. J Surg Case Rep 2022; 2022:rjac538. [PMID: 36452283 PMCID: PMC9701555 DOI: 10.1093/jscr/rjac538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/03/2022] [Indexed: 09/26/2023] Open
Abstract
Life-threatening complications (LTCs) and negative results of surgical treatments often go unreported. Minimally invasive repair of pectus excavatum (MIRPE) represents a procedure with a low incidence of adverse outcomes. However, 15 potentially fatal cases of MIRPE-related heart injury have been published. We report a case of cardiac perforation (CP) during MIRPE. A 12-year-old female was admitted for elective repair of a severe asymmetric pectus excavatum. Preoperative computed tomography showed a Haller index of 4.9. MIRPE was performed under bilateral video-assisted thoracoscopy. After the placement of the pectus bar, cardiac arrhythmias, hypotension and bilateral hemothorax occurred. Emergency thoracotomy without pectus bar removal showed CP. The wound sites were repaired and the pectus bar was eventually successfully implanted. The patient was discharged on postoperative day 11. After 10 months, she remains asymptomatic. Reporting rare complications is essential for accurate calculations of the true prevalence of LTCs, maintaining high alertness in pediatric surgeons.
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Affiliation(s)
| | - Paolo Gasparella
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Graz 8036, Austria
| | - Ksenija Soldatenkova
- Department of Pediatric Surgery, Children's Clinical University Hospital, Riga 1004, Latvia
| | - Lauris Smits
- Department of Heart Surgery, Children's Clinical University Hospital, Riga 1004, Latvia
| | - Zane Ābola
- Department of Pediatric Surgery, Children's Clinical University Hospital, Riga 1004, Latvia
- Department of Pediatric Surgery, Riga Stradins University, Riga 1007, Latvia
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Minimally invasive repair of asymmetric pectus excavatum: An alternative technique to treating asymmetric morphology. J Pediatr Surg 2022; 57:1079-1082. [PMID: 35221034 DOI: 10.1016/j.jpedsurg.2022.01.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 11/23/2022]
Abstract
Minimally invasive repair of pectus excavatum or the Nuss procedure has become the standard operation for pectus excavatum repair. Pectus excavatum can be broadly divided into two categories: symmetric or asymmetric morphology. To optimize surgical outcomes of asymmetric pectus excavatum repair, previous work has proposed morphology-tailored bar shaping technique; the bar to be inserted is shaped asymmetrically to counter-balance the outer contour of the chest prior to the passage of the introducer across the chest. We describe an alternate approach that emphasizes precise introducer chest insertion and extraction and that highlights the direction of the introducer passage is from the higher asymmetric side to the lower contralateral side. The shape of the bar is determined after the introducer has been placed into the chest. This technique allows simultaneous compression of the higher asymmetric chest and elevation of the contralateral depressed side by the metal bar achieving excellent symmetric chest appearance. LEVEL OF EVIDENCE: Level V, Operative Technique.
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Wang L, Bi R, Xie X, Xiao H, Hu F, Jiang L. A Modfied Nuss Procedure for Recurrent Pectus Excavatum of Adults. Front Surg 2022; 8:814837. [PMID: 35155553 PMCID: PMC8825472 DOI: 10.3389/fsurg.2021.814837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Multiple organ dysfunction due to a rare complication of Nuss procedure for pectus excavatum: A case report. Chin J Traumatol 2021; 24:306-310. [PMID: 34384669 PMCID: PMC8563856 DOI: 10.1016/j.cjtee.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/22/2021] [Accepted: 07/27/2021] [Indexed: 02/04/2023] Open
Abstract
A 19-year-old male patient who suffered from sudden and repeated multiple organ dysfunction syndrome one month after the bar removal procedure of Nuss surgery for pectus excavatum was admitted to our department. With organ function supportive treatment, the etiology was finally identified to be a bone spur located at the inner border of the left costa due to repeated friction between the implanted steel bar and the rib, which damaged the heart repeatedly and induced the consequent acute cardiac tamponade. After operation, the patient was successfully managed and discharged. Follow-ups till three years indicated a good recovery.
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Obermeyer RJ, Goretsky MJ, Kelly RE, Frantz FW, Kuhn MA, McGuire MM, Duke DS, Paulson JF. Selective use of sternal elevation before substernal dissection in more than 2000 Nuss repairs at a single institution. J Pediatr Surg 2021; 56:649-654. [PMID: 32753276 DOI: 10.1016/j.jpedsurg.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/16/2020] [Accepted: 07/05/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND/PURPOSE Evaluate the safety of sternal elevation (SE) used selectively before creating the substernal tunnel during the Nuss procedure. METHODS An IRB-approved (01-05-EX-0175-HOSP), single institution, retrospective review was performed (1/1/1997-11/20/2017). Primary and secondary Nuss repairs (i.e., previous Nuss, Ravitch, thoracotomy, or sternotomy) are included. SE use, cardiac injuries, and pectus bar infections are reported. Chi square and Fisher's exact test (FE) were used (critical p < .05). RESULTS 2037 patients [(80% male; mean age 15.2 years (SD = 4.4, range 3-46); mean Haller index (HI) 5.3 (SD = 5.7, range 1.73-201)] underwent Nuss repair. SE was used before creating the substernal tunnel in 171 (8.4%): 160 (8.2%) of 1949 primary and 11 (12.5%) of 88 secondary repairs. SE use increased significantly [χ2(2) = 118.93; p < .001] over time and with increasing HI [χ2(3) = 59.9; p < .001]. No cardiac injuries occurred in primary repairs but two occurred in patients with previous sternotomy. Infection rates were not different with (2.9%) or without SE (1.8%) [χ2(1) =1.14; p = .285] and not higher with off-label VB (1.5%) versus other SE techniques (3.8%) [FE, p = .65)]. CONCLUSION Selective use of sternal elevation before substernal dissection during the Nuss procedure is safe but may not prevent cardiac injuries in patients with previous sternotomy. Infection rates were not increased with SE. TYPE OF STUDY Retrospective review. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Robert J Obermeyer
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA.
| | - Michael J Goretsky
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Robert E Kelly
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA; Old Dominion University, Norfolk, VA, USA
| | - Frazier W Frantz
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - M Ann Kuhn
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Margaret M McGuire
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Duane S Duke
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - James F Paulson
- Children's Hospital of The King's Daughters, Norfolk, VA, USA; Eastern Virginia Medical School, Norfolk, VA, USA; Old Dominion University, Norfolk, VA, USA; Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
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Kim DY, Jeong JY. Penetrating lung injury during Nuss procedure for pectus excavatum. J Cardiothorac Surg 2020; 15:184. [PMID: 32703242 PMCID: PMC7379775 DOI: 10.1186/s13019-020-01236-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/20/2020] [Indexed: 11/22/2022] Open
Abstract
Life-threatening complications including cardiac perforation by the clamp or pectus bar during Nuss procedure have rarely been occurred. A rare case of lung entrapment between the pectus bar and chest wall after Nuss procedure was also reported. Thoracoscopy allows for direct visualization of the operative field, which prevents or promptly perceive these intrathoracic organ injuries. Recently, we encountered a case of penetrating lung injury during the Nuss procedure for pectus excavatum. And we agree with Mennie et al. who concluded thoracoscopic vision during Nuss procedure reduces the risk of major complication. In addition, we would like to emphasize to keep in mind what to check for routines with thoracoscopy during Nuss procedure.
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Affiliation(s)
- Do Yeon Kim
- Department of Thoracic and Cardiovascular Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56 Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea
| | - Jin Yong Jeong
- Department of Thoracic and Cardiovascular Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56 Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea.
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Floccari LV, Sucato DJ, Ramo BA. Scoliosis Progression After the Nuss Procedure for Pectus Excavatum: A Case Report. Spine Deform 2019; 7:1003-1009. [PMID: 31731992 DOI: 10.1016/j.jspd.2019.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 01/10/2019] [Accepted: 01/12/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Pectus excavatum and scoliosis are associated conditions with a high rate of coincidence. However, there are no reports to guide surgeons on the management of adolescents with moderate scoliosis and pectus excavatum, because there are conflicting conclusions in the literature regarding how the Nuss procedure with substernal bar affects scoliosis. CASES In 2017, we encountered two patients with moderate scoliosis treated with a spinal orthosis. After undergoing the Nuss procedure for pectus excavatum, their scoliosis acutely progressed into surgical magnitude requiring posterior instrumented spinal fusion. The first patient progressed 26° despite the pre-Nuss radiographs showing him to be Risser 4/5, while the second patient also progressed 26° from the Nuss procedure. Both patients acknowledged noncompliance with brace wear because of discomfort after the Nuss procedure. However, their progression rate still doubles the rate of reported rapid accelerators, indicating that a significant component of curve progression is directly attributed to forces on the spine from the corrective maneuver with substernal bar. CONCLUSION The purpose of this case report is to describe the features of these two patients to help with clinical decision-making in patients with moderate scoliosis (curves >25°) who are contemplating the Nuss procedure for correction of pectus excavatum. We caution patients and providers that spinal deformity could worsen with surgical intervention of the pectus excavatum via the Nuss procedure and necessitate scoliosis surgery.
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Affiliation(s)
- Lorena V Floccari
- Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX, 75219, USA.
| | - Daniel J Sucato
- Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX, 75219, USA
| | - Brandon A Ramo
- Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX, 75219, USA
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Nissen AP, Kilbourne MJ, Jeschke R, Lee R, Rice RD. Delayed Presentation of Cardiac Perforation After Modified Ravitch Pectus Excavatum Repair. Ann Thorac Surg 2019; 109:e29-e31. [PMID: 31233721 DOI: 10.1016/j.athoracsur.2019.04.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022]
Abstract
Pectus excavatum repair using a Nuss bar is a widely performed procedure and generally regarded to be quite safe. Rare catastrophic cardiovascular complications have been previously reported, by even the most experienced surgeons. These cases typically present with fulminant cardiogenic shock and have an associated high mortality rate. We present a delayed and atypical presentation for a patient with a cardiac perforation after repair of pectus excavatum who underwent successful repair.
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Affiliation(s)
- Alexander P Nissen
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Michael J Kilbourne
- Department of Cardiothoracic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Robert Jeschke
- Department of Cardiothoracic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Richard Lee
- Division of Cardiothoracic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Robert D Rice
- Department of Cardiothoracic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia.
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Xu B, Xu T, Wang S, Li W, He T, Liu W. The use of nonthoracoscopic Nuss procedure for the correction of pectus excavatum by trans-esophageal echocardiography monitoring. Medicine (Baltimore) 2019; 98:e14387. [PMID: 30732178 PMCID: PMC6380846 DOI: 10.1097/md.0000000000014387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study was aimed to review the current experience regarding the correction of pectus excavatum by Nuss procedure with nonthoracoscopic assistance using trans-esophageal echocardiography monitoring.A total of 172 patients with pectus excavatum were surgically treated from August 2011 to August 2016. The sample size comprised 131 boys and 41 girls and the average age was 13 years and 2 months. A total of 144 cases were initially operated on, whereas 13 subjects exhibited postoperative recurrence following Ravitch repair of a pectus excavatum deformity and 15 cases experienced a history of median sternotomy. The intraoperative Haller index ranged from 3.6 to 14.2 (mean 4.1). The intraoperative TEE monitoring was conducted with middle-esophageal 4-champer view and middle-esophageal Aortic short axis view to detect the injury of heart and of the large vessels by the introducer and Nuss steel bars.The operation conducted in all patients was successful in the absence of severe complications. The time of operation ranged from 38 to 80 minutes (mean 50 minutes). The bleeding volume during the procedure was between 10 and 40 mL (mean 15 mL). The time from operation to discharge was from 5 to 7 days (mean 6 days). Pneumothorax occurred in 25 cases following the termination of the operation, including 9 cases of needle puncture aspiration and 6 cases of closed drainage. Pleural effusion occurred in 4 cases. No patients suffered from wood infection. Effusion occurred in 9 cases following 6 to 23 months, whereas dressing changes and surgical debridement were evident in 2 and 7 cases, respectively. The bars were removed in 82 of the 172 patients within 3 years. The progression of the thoracic wall was assessed for the period of 8 to 68 months following the surgery, during the follow-up period. The average time period of follow-up was 32 months.Nuss procedure with nonthoracoscopic assistance with trans-esophageal echocardiography monitoring for the correction of pectus excavatum was safe for all of the cases investigated. It exhibited lesser trauma and required a shorter time period.
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Affiliation(s)
- Bing Xu
- Department of Pediatric Surgery in the Center of Children Medicine
| | - Ting Xu
- Department of Anesthesiology
| | - Shan Wang
- Department of Medical Ultrasonics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Wenhua Li
- Department of Medical Ultrasonics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Taozhen He
- Department of Pediatric Surgery in the Center of Children Medicine
| | - Wenying Liu
- Department of Pediatric Surgery in the Center of Children Medicine
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Cohen NS, Goretsky MJ, Obermeyer RJ. Bleeding at Removal of Nuss Bar: Rare But Sometimes Significant. J Laparoendosc Adv Surg Tech A 2018; 28:1393-1396. [DOI: 10.1089/lap.2018.0175] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nina S. Cohen
- Departments of Pediatrics and Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Michael J. Goretsky
- Departments of Pediatrics and Surgery, Eastern Virginia Medical School, Norfolk, Virginia
- Department of Pediatric Surgery, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Robert J. Obermeyer
- Departments of Pediatrics and Surgery, Eastern Virginia Medical School, Norfolk, Virginia
- Department of Pediatric Surgery, Children's Hospital of The King's Daughters, Norfolk, Virginia
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13
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Notrica DM. Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review. Semin Pediatr Surg 2018; 27:133-150. [PMID: 30078484 DOI: 10.1053/j.sempedsurg.2018.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- David M Notrica
- Department of Surgery, Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, United States; Mayo Clinic College of Medicine, United States; University of Arizona College of Medicine Phoenix, United States .
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Tetteh O, Rhee DS, Boss E, Alaish SM, Garcia AV. Minimally invasive repair of pectus excavatum: Analysis of the NSQIP database and the use of thoracoscopy. J Pediatr Surg 2018; 53:1230-1233. [PMID: 29602550 DOI: 10.1016/j.jpedsurg.2018.02.089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/27/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The minimally invasive repair of pectus excavatum (MIRPE) has been widely accepted and has become a viable alternative to the open Ravitch technique. MIRPE has evolved over time with some advocating that a safe repair can be accomplished without direct visualization utilizing thoracoscopy. The MIRPE with and without a thoracoscopic approach has not been previously analyzed from a nationwide database to determine differences in safety and short-term outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) 2012-2015 database was used in identifying patients that had MIRPE using Current Procedural Terminology (CPT) codes and ICD-9CM/ICD-10CM postoperative diagnosis codes. Outcomes of interest were readmissions, reoperations, complications, cardiothoracic injury, operative time, and duration of hospital stay after surgery for MIRPE with and without thoracoscopy. Descriptive statistics, simple and multivariable logistic regressions, Fisher's exact, and Wilcoxon rank sum test were used to determine any differences in 30-day postoperative outcomes. RESULTS There were 1569 MIRPE cases included. 15.9% (N=249) of MIRPE were done without thoracoscopy. There were no significant differences with the use of thoracoscopy compared to without thoracoscopy in the rate of readmissions (2.5 vs 4.8%; p=0.06), reoperations (1.4 vs 2.0%; p=0.57), postoperative complications (2.6% vs 3.2%; p=0.52), and cardiothoracic injuries (0.2% vs 0.0%; p=1.00). Unadjusted odds ratios (ORs) for readmission and reoperation comparing MIRPE with thoracoscopy to MIRPE without thoracoscopy were 0.51 (p<0.05) and 0.71 (p=0.50), respectively. Adjusted ORs were 0.49 (p=0.04) and 0.71 (p=0.50), respectively. There were no reported deaths, but two cardiothoracic injuries were recorded in the group with thoracoscopy. MIRPE with thoracoscopy was associated with longer operative time (mean 13.0min; p=0.00) and longer hospital stay (mean 0.37days; p<0.01) compared to MIRPE without thoracoscopy. No data were available for the severity of the pectus defect. CONCLUSION MIRPE has a low adverse event rate with no difference in reoperations, postoperative complications, and cardiothoracic injuries with or without the use of thoracoscopy. There may be a higher rate of readmissions in the nonthoracoscopic group. While the technique used remains the surgeon's decision, the use of thoracoscopy may be unnecessary and is at an added cost. TYPE OF STUDY Treatment study (retrospective comparative study). LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Oswald Tetteh
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Daniel S Rhee
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Emily Boss
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Samuel M Alaish
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
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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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Song IH, Lee SJ, Lee SY. The usefulness of a trans-illuminated introducer during the Nuss procedure. Asian Cardiovasc Thorac Ann 2018; 26:377-381. [PMID: 29719984 DOI: 10.1177/0218492318772226] [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: 11/15/2022]
Abstract
Background There has been an increase in the number of patients undergoing the Nuss procedure for cosmetic purposes, thus increasing the need for safer surgery. However, there are reports of massive hemorrhage and organ damage during the Nuss procedure which involves dissection of the anterior mediastinum. We have developed the trans-illuminated introducer that allows safe surgery while maintaining a small surgical incision of less than 1 cm. Methods This study was a retrospective review of 306 patients aged 3-40 years who underwent the Nuss procedure using the trans-illuminated introducer at our hospital between April 2006 and December 2014. Results There were 29 (9.5%) early postoperative complications. The most common early complication was pneumothorax (15 cases, 4.9%). Five (1.6%) patients developed hemothorax in the early postoperative period, which occurred independently of the dissection process of the anterior mediastinum. None of these patients required reoperation or blood transfusion. There were no complications caused by the introducer during dissection of the anterior mediastinum. Conclusions Using the trans-illuminated introducer, we were able to dissect the anterior mediastinum without a major complication, such as massive hemorrhage from the mediastinum, while maintaining a small surgical incision for cosmetic purposes. Therefore, we consider that the trans-illuminated introducer is useful for improving the outcome of the Nuss procedure.
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Affiliation(s)
- In-Hag Song
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Hospital Cheonan, Seoul, Korea
| | - Seung Jin Lee
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Hospital Cheonan, Seoul, Korea
| | - Seock Yeol Lee
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Hospital Cheonan, Seoul, Korea
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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: 57] [Impact Index Per Article: 9.5] [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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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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Tilliet Le Dentu H, Lancien U, Sellal O, Duteille F, Perrot P. [Contribution of computer-aided design for the conception of custom-made implants in Pectus Excavatum surgical treatment. Experience of the Nantes plastic surgery unit]. ANN CHIR PLAST ESTH 2017; 63:1-10. [PMID: 29246660 DOI: 10.1016/j.anplas.2017.11.006] [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: 09/11/2017] [Accepted: 11/15/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pectus excavatum is the most common congenital chest malformation and is a common reason for consultation in plastic surgery. Our attitude is most often a filling of the depression with a custom-made silicone prosthesis. The objective of this work was to evaluate the interest of computer-aided design (CAD) of implants compared to the conventional plaster molds method. PATIENTS AND METHODS We have collected all the cases of custom-made silicone implants to treat funnel chests in our plastic surgery department. The quality of the results was evaluated by the patient, and in a blind manner by the surgical team using photographs and standardized surveys. The pre-operative delays, the operating time and length of hospital stays, the number of surgical recoveries, and the post-operative surgical outcomes were recorded. RESULTS Between 1990 and 2016, we designed 29 silicone thoracic implants in our department. Before 2012, implants were made from plaster chest molds (n=13). After this date, implants were designed by CAD (n=16). Patients rated their results as "good" or "excellent" in 77% and 86% of cases respectively in the plaster and CAD groups. The surgical team's ratings for CAD implant reconstructions were better than in the plaster group: 8.17 versus 6.96 (P=0.001). CAD implants were significantly less detectable than the plaster group implants. The operating time was reduced in the CAO group: 60.2 compared to 74.7minutes in the plaster group (P=0.04), as was the length of hospitalization: 3.5 versus 5.3 days (P=0.01). There were no significant differences between the two groups in terms of post-operative complications. CONCLUSION The management of pectus excavatum by a custom-made silicone implant is a minimally invasive method that provides good cosmetic results. The design of these implants is facilitated and qualitatively improved by CAD.
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Affiliation(s)
- H Tilliet Le Dentu
- Service de chirurgie plastique et reconstructrice, hôpital Hôtel-Dieu, centre des brûlés, CHU de Nantes, 44093 Nantes Cedex 01, France
| | - U Lancien
- Service de chirurgie plastique et reconstructrice, hôpital Hôtel-Dieu, centre des brûlés, CHU de Nantes, 44093 Nantes Cedex 01, France
| | - O Sellal
- Pharmacie centrale, hôpital Saint-Jacques, CHU de Nantes, 44093 Nantes Cedex 01, France
| | - F Duteille
- Service de chirurgie plastique et reconstructrice, hôpital Hôtel-Dieu, centre des brûlés, CHU de Nantes, 44093 Nantes Cedex 01, France
| | - P Perrot
- Service de chirurgie plastique et reconstructrice, hôpital Hôtel-Dieu, centre des brûlés, CHU de Nantes, 44093 Nantes Cedex 01, France.
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Shah SB, Hariharan U, Bhargava AK, Darlong LM. Anesthesia for minimally invasive chest wall reconstructive surgeries: Our experience and review of literature. Saudi J Anaesth 2017; 11:319-326. [PMID: 28757834 PMCID: PMC5516496 DOI: 10.4103/sja.sja_13_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Minimal access procedures have revolutionized the field of surgery and opened newer challenges for the anesthesiologists. Pectus carinatum or pigeon chest is an uncommon chest wall deformity characterized by a protruding breast bone (sternum) and ribs caused by an overgrowth of the costal cartilages. It can cause a multitude of problems, including severe pain from an intercostal neuropathy, respiratory dysfunction, and psychologic issues from the cosmetic disfigurement. Pulmonary function indices, namely, forced expiratory volume over 1 s, forced vital capacity, vital capacity, and total lung capacity are markedly compromised in pectus excavatum. Earlier, open surgical correction in the form of the Ravitch procedure was followed. Currently, in the era of minimally invasive surgery, Nuss technique (pectus bar procedure) is a promising step in chest wall reconstructive surgery for pectus excavatum. Reverse Nuss is a corrective, minimally invasive surgery for pectus carinatum chest deformity. A tailor-made anesthetic technique for this new procedure has been described here based on the authors’ personal experience and thorough review of literature based on Medline, Embase, and Scopus databases search.
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Affiliation(s)
| | - Uma Hariharan
- Department of Anaesthesia and Intensive Care, Dr. Ram Manohar Lohia Hospital and PGIMER, CHS, New Delhi, India
| | | | - Laleng M Darlong
- Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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Facchini F, Ghionzoli M, Martin A, Tanini S, Ugolini S, Lo Piccolo R, Messineo A. Regenerative Surgery in the Treatment of Cosmetic Defect Following Nuss Procedure. J Laparoendosc Adv Surg Tech A 2017; 27:748-753. [DOI: 10.1089/lap.2016.0217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Flavio Facchini
- Department of Pediatric Surgery, A. Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Marco Ghionzoli
- Department of Pediatric Surgery, A. Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Alessandra Martin
- Department of Pediatric Surgery, A. Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Sara Tanini
- Department of Pediatric Surgery, A. Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Sara Ugolini
- Department of Pediatric Surgery, A. Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Roberto Lo Piccolo
- Department of Pediatric Surgery, A. Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Antonio Messineo
- Department of Pediatric Surgery, A. Meyer Children's University Hospital, University of Florence, Florence, Italy
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Complications after pectus excavatum repair using pectus bars in adolescents and adults: risk comparisons between age and technique groups†. Interact Cardiovasc Thorac Surg 2017; 25:606-612. [DOI: 10.1093/icvts/ivx162] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 04/20/2017] [Indexed: 11/14/2022] Open
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Abstract
Advances in medical care may occur when a change in practice incorporates a new treatment or methodology. In surgery, this may involve the translation of a completely novel concept into a new procedure or device or the adaptation of existing treatment approaches or technology to a new clinical application. Regardless of the specifics, innovation should have, as its primary goal, the enhancement of care leading to improved outcomes from the patient's perspective. This policy statement examines innovation as it pertains to surgical care, focusing on some of the definitions that help differentiate applied innovation or innovative therapy from research. The ethical challenges and the potential for conflict of interest for surgeons or institutions seeking to offer innovative surgical therapy are examined. The importance of engaging patients and families as "innovation partners" to ensure complete transparency of expectations from the patient's and provider's perspectives is also examined, with specific emphasis on cultural competence and mutually respectful approaches. A framework for identifying, evaluating, and safely implementing innovative surgical therapy in children is provided.
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Minimally invasive repair of pectus excavatum in a 17-year-old boy with a history of congenital diaphragmatic hernia and lack of pericardium. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2016. [DOI: 10.1016/j.epsc.2016.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Takahashi T, Okazaki T, Yamataka A, Uchida E. Usefulness of Kent retractor and lifting hook for Nuss procedure. Pediatr Surg Int 2015; 31:1103-5. [PMID: 26263876 DOI: 10.1007/s00383-015-3764-2] [Citation(s) in RCA: 7] [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] [Accepted: 08/06/2015] [Indexed: 11/26/2022]
Abstract
Although the Nuss procedure for pectus excavatum has been widely employed, a variety of complications have been reported. The most dangerous complication is cardiac injury from the insertion of the introducer. To eliminate these complications, we present a sternum elevating technique using a Kent retractor and a lifting hook.
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Affiliation(s)
- Tsubasa Takahashi
- Department of Pediatric Surgery, Nippon Medical School Musashi Kosugi Hospital, 1-396 Kosugi-machi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan.
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Eiji Uchida
- Department of Surgery, Nippon Medical School, Tokyo, Japan
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Iwanaka T, Yamataka A, Uemura S, Okuyama H, Segawa O, Nio M, Yoshizawa J, Yagi M, Ieiri S, Uchida H, Koga H, Sato M, Soh H, Take H, Hirose R, Fukuzawa H, Mizuno M, Watanabe T. Pediatric Surgery. Asian J Endosc Surg 2015; 8:390-407. [PMID: 26708583 DOI: 10.1111/ases.12263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 08/21/2015] [Accepted: 08/21/2015] [Indexed: 12/25/2022]
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Minimally invasive repair of pectus excavatum in an adolescent with a history of a median sternotomy as an infant. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Notrica DM, McMahon LE, Johnson KN, Velez DA, McGill LC, Jaroszewski DE. Life-Threatening Hemorrhage During Removal of a Nuss Bar Associated With Sternal Erosion. Ann Thorac Surg 2014; 98:1104-6. [DOI: 10.1016/j.athoracsur.2013.10.097] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 10/21/2013] [Accepted: 10/25/2013] [Indexed: 11/28/2022]
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Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume, single institution experience. J Pediatr Surg 2014; 49:575-82. [PMID: 24726116 DOI: 10.1016/j.jpedsurg.2013.11.058] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 10/19/2013] [Accepted: 11/17/2013] [Indexed: 11/23/2022]
Abstract
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.
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Johnson WR, Fedor D, Singhal S. Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum. J Cardiothorac Surg 2014; 9:25. [PMID: 24506826 PMCID: PMC3922335 DOI: 10.1186/1749-8090-9-25] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 02/04/2014] [Indexed: 11/16/2022] Open
Abstract
This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric=0-21; adult 17-99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.
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Affiliation(s)
- William Rainey Johnson
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
| | - David Fedor
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
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Abstract
The aim of study was to introduce technical innovation of MIRPE which reduces the risk of cardiac injury. Modification of MIRPE method with semiflexible thoracoscope and sternum elevating technique has been used. Volkmann bone hook has been inserted percutaneously to the sternum. The hook elevates the sternum forward and enlarges the retrosternal space for safer passage of thoracoscopically guided introducer. Using semiflexible thoracoscope allows better view from various angles via one site of insertion. During the period 2005-2012, the MIRPE was performed on 29 girls and 151 boys; the mean age at the time of surgery was 15.9 years (range 13-18.7 years). The mean Haller index was 4.7 (range 2.7-20.5). The most common complication was pneumothorax (3.3 %) and the incidence of bar displacement was 2 %. The most serious complication was cardiac perforation when inserting Lorenz introducer. This occurred in a 16-year-old girl; she required urgent sternotomy with right atrial repair and recovered well. External elevation of sternum with the hook was used since this case. Subsequent 113 patients underwent surgery without any serious complications. Technical innovation using semiflexible thoracoscope and hook elevation of the sternum reduces the risk of cardiac injury. The hook opens the anterior mediastinum space effectively and makes the following dissection relatively safe and straightforward.
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Yüksel M, Özalper MH, Bostanci K, Ermerak NO, Cimşit Ç, Tasali N, Yildizeli B, Fevzi Batirel H. Do Nuss bars compromise the blood flow of the internal mammary arteries? Interact Cardiovasc Thorac Surg 2013; 17:571-5. [PMID: 23788198 DOI: 10.1093/icvts/ivt255] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Minimally invasive repair of pectus excavatum, the so-called Nuss procedure, has become a popular technique in recent years. The internal mammary arteries (IMAs) lie on the posterolateral surface of the sternum, and the Nuss bar is likely to obstruct the blood flow in these arteries. This obstruction could become important in the later stages of the lives of these young people if they were to require coronary artery bypass grafting. The goal of this study is to investigate the extent of obstruction of the IMAs caused by Nuss bars. METHODS Data were collected prospectively on all patients who underwent the Nuss procedure between October 2011 and May 2012. Patients with a history of pectus excavatum repair by open surgery and those who were younger than 16 years of age were excluded. Computed tomography-angiography (CTA) was performed for the detection of IMA blood flow preoperatively and on the 10th postoperative day. Blood flow in the IMAs was evaluated blindly by two radiologists and classified as blood flow unaffected (group I) or affected (group II) by comparing the assessment of preoperative and postoperative CTAs. The patients in group II were also categorized as having blood flow obstructed bilaterally, blood flow obstructed unilaterally and others (diminished unilaterally/diminished on one side or obstructed on the other side). RESULTS Thirty-four patients (31 male and three female; mean age 20.7 ± 4.2 years) underwent surgery. Blood flow was affected in 15 patients (44%), with bilateral obstruction in five, unilateral obstruction in seven, and unilateral diminished flow in two patients. In one patient, blood flow was diminished on one side and obstructed on the other. There was no significant difference between unaffected group I patients and affected group II patients in terms of sex, age, type of deformity, Haller index and the number of bars placed. CONCLUSIONS Nuss bars cause pressure on the IMAs, but a risk factor for this effect could not be identified. This is a relatively common clinical consequence of minimally invasive repair of pectus excavatum, and the long-term effects will be apparent following bar removal.
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Affiliation(s)
- Mustafa Yüksel
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey.
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Darlong LM. Pectus tunneloscopy: making Nuss procedure for pectus excavatum safe. Interact Cardiovasc Thorac Surg 2013; 17:233-6. [PMID: 23660736 DOI: 10.1093/icvts/ivt206] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The Nuss procedure for pectus excavatum involves the risk of cardiac injury during the creation of the retrosternal tunnel and during bar introduction or removal across the tunnel. A modified novel real-time technique for the safe introduction of the Nuss bar across the crucial retrosternal tunnel blind spot during introduction and removal is described. METHODS In 2012, we devised a technique for real-time endovision-guided introduction of the Nuss bar called pectus tunneloscopy. Between February 2012 and December 2012, 6 patients with pectus excavatum had their bar introduced across the tunnel using this technique. RESULTS This technique provided safe introduction and removal of the bar during the multiple times the bar is remodelled before final fixation. CONCLUSIONS Pectus tunneloscopy is a real-time endovision surgical technique, providing safe introduction of the bar across the crucial retrosternal tunnel blind spot.
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Affiliation(s)
- Laleng M Darlong
- Department of Thoracic Surgery and Thoracic Oncology, Chest Wall Deformity Clinic, Fortis Hospital, Noida, Delhi NCR, India.
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Takagi S, Oyama T, Tomokazu N, Kinoshita K, Makino T, Ohjimi H. A new sternum elevator reduces severe complications during minimally invasive repair of the pectus excavatum. Pediatr Surg Int 2012; 28:623-6. [PMID: 22526549 DOI: 10.1007/s00383-012-3087-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2010] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Although the Nuss procedure for pectus excavatum is widely employed, a variety of complications have been reported with relatively high frequency; those that involve cardiac and pericardial injuries can be life threatening. To reduce such dangers, we present here a newly developed sternal elevator. MATERIALS AND METHODS The elevator is horseshoe shaped. Its elevator side has the same curvature as a Nuss introducer, so that interference between devices is minimal and no extra skin incision is needed for the elevator insertion. The elevator holds the sternum forward and enlarges the retrosternal space for safer passage of thoracoscopically guided introducer. RESULTS The authors have used the elevator for 61 pectus excavatum cases between March 2004 and December 2009 without any major complications. The entire process of substernal tunneling was endoscopically observed, which eliminated any blunt and blind dissection, even in a significantly depressed funnel chest case. With the device, the sternum was effectively elevated again for the placement of the second plate in 30 cases. CONCLUSION Our newly developed sternum elevator makes the Nuss procedure safer and more affordable without introducing any extra scarring.
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Affiliation(s)
- Satoshi Takagi
- Department of Plastic, Reconstructive, and Aesthetic Surgery, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
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Becmeur F, Ferreira CG, Haecker FM, Schneider A, Lacreuse I. Pectus Excavatum Repair According to Nuss: Is It Safe to Place a Retrosternal Bar by a Transpleural Approach, Under Thoracoscopic Vision? J Laparoendosc Adv Surg Tech A 2011; 21:757-61. [DOI: 10.1089/lap.2011.0035] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- François Becmeur
- Department of Pediatric Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Cindy Gomes Ferreira
- Department of Pediatric Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Frank-Martin Haecker
- Department of Pediatric Surgery, University Children's Hospital, Basel, Switzerland
| | - Anne Schneider
- Department of Pediatric Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Isabelle Lacreuse
- Department of Pediatric Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Redlinger RE, Kelly RE, Nuss D, Kuhn MA, Obermeyer RJ, Goretsky MJ. One hundred patients with recurrent pectus excavatum repaired via the minimally invasive Nuss technique--effective in most regardless of initial operative approach. J Pediatr Surg 2011; 46:1177-81. [PMID: 21683218 DOI: 10.1016/j.jpedsurg.2011.03.048] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 03/26/2011] [Indexed: 12/01/2022]
Abstract
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.
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Abstract
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.
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Nuri T, Ueda K, Oba S, Nakai K, Hara M. Displacement of the bar after minimally-invasive repair of pectus excavatum. J Plast Surg Hand Surg 2010; 44:102-5. [DOI: 10.3109/02844310903569709] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Russell HM, Backer CL. Pediatric Thoracic Problems: Patent Ductus Arteriosus, Vascular Rings, Congenital Tracheal Stenosis, and Pectus Deformities. Surg Clin North Am 2010; 90:1091-113. [DOI: 10.1016/j.suc.2010.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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St Peter SD, Sharp SW, Ostlie DJ, Snyder CL, Holcomb GW, Sharp RJ. Use of a subxiphoid incision for pectus bar placement in the repair of pectus excavatum. J Pediatr Surg 2010; 45:1361-4. [PMID: 20620345 DOI: 10.1016/j.jpedsurg.2010.02.115] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2010] [Accepted: 02/23/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Since the first description of the Nuss repair for pectus excavatum, many technical variations have been described. Over the past 10 years, we have used a subxiphoid incision to allow finger guidance to protect the mediastinum which obviates the need for thoracoscopy. METHODS A retrospective review was conducted on all our patients who have undergone pectus excavatum repair from December 1999 to March 2009. Demographic, treatment, and outcome variables were recorded. All operations were performed with 2 lateral incisions, one subxiphoid incision, and 2 stabilizers. RESULTS During this timeframe, 307 patients underwent pectus bar placement. Mean age was 14.0 +/- 3.3 years, and 78% were male. Mean operating time was 50.0 +/- 15.9 minutes, length of hospitalization was 4.1 +/- 1.1 days, and time to bar removal was 33.0 +/- 7.3 months. There were no intraoperative events. Postoperative complications included a bar infection in 13 patients (4.2%), stabilizer displacement/discomfort requiring removal in 5 patients (1.6%), and bar rotation in 4 patients (1.3%). Rotation required operative correction in 3 cases and early removal in the other owing to a cracked sternum. No reoperations have been done for recurrence. CONCLUSIONS The subxiphoid guided technique is a simple, safe, and reproducible method for the minimally invasive repair of pectus excavatum that obviates the need for thoracoscopy.
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Affiliation(s)
- Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA.
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Minimally invasive repair of pectus excavatum: a novel morphology-tailored, patient-specific approach. J Thorac Cardiovasc Surg 2010; 139:379-86. [PMID: 20106400 DOI: 10.1016/j.jtcvs.2009.09.003] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Revised: 08/08/2009] [Accepted: 09/08/2009] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Minimally invasive repair of pectus excavatum, introduced by Nuss in 1998, has undergone a serious learning curve because of a lack of understanding on morphologies and repair techniques. To summarize the current status of minimally invasive repair of pectus excavatum, we reviewed and appraised our 10-year experience with a novel approach, a morphology-tailored technique, including diverse bar shaping, bar fixation, and techniques for adults. METHODS We analyzed the data of 1170 consecutive patients with pectus excavatum who underwent minimally invasive repair between August 1999 and September 2008. All pectus repairs were performed by the primary author (H.J.P.) with our modified technique. RESULTS The mean age was 10.3 years (range, 16 months to 51 years). There were 331 adult patients (>15 years) (28.3%). A total of 576 patients (49.2%) had bar removal after a mean of 2.5 years (range, 10 days to 7 years). The asymmetry index change (1.10-1.02, P < .001) demonstrated post-repair symmetry. Complication rates decreased through the 3 time periods (1999-2002 [n = 335]; 2003-2005 [n = 441]; 2006-2008 [n = 394]) as follows: pneumothorax rate (7.5% vs 4.3% vs 0.8%; P < .001) and bar displacement rate (3.8% vs 2.3% vs 0.5%; P = .002). Reoperation rate also decreased (4.8% vs 2.5% vs 0.8%; P = .002). Satisfaction outcomes were excellent in 92.7%, good in 5.9%, and fair in 1.4% of patients. After bar removal, 3 patients (0.6%) had minor recurrences. CONCLUSION Minimally invasive repair of pectus excavatum based on a novel morphology-tailored, patient-specific approach is effective for quality repair of the full spectrum of pectus excavatum, including asymmetry and adult patients. Continuous technical refinements have significantly decreased the complication rates and postoperative morbidity.
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Ohno K, Nakamura T, Azuma T, Yamada H, Hayashi H, Masahata K. Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation. J Pediatr Surg 2009; 44:2426-30. [PMID: 20006043 DOI: 10.1016/j.jpedsurg.2009.09.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Revised: 09/05/2009] [Accepted: 09/10/2009] [Indexed: 11/15/2022]
Abstract
PURPOSE In a few patients, cardiac perforation and aortic injury have occurred during the Nuss procedure for pectus excavatum. The article details a modification of this procedure that enables the prevention of fatal complications. METHODS Our subjects were 22 males and 13 females with pectus excavatum who were aged 8.2 +/- 3.7 years. Their Haller's computed tomography index was 5.2 +/- 1.5. An introducer is inserted into the pleura between the sternum and thymus instead of the thoracic depression under right thoracoscopic guidance. After the introducer reaches the internal cranial position of the left nipple, the thoracoscope is shifted to the left thoracic cavity. The introducer is subsequently guided to the left highest intercostal space under left thoracoscopic guidance. RESULTS A single bar was inserted in 34 patients; 2 bars were required in 1 patient. The operating time was 95 +/- 27 minutes and blood loss was 11 +/- 6 g. Cardiac perforation did not occur in any patient. CONCLUSIONS Our modified technique has certain advantages: (1) the introducer does not rub against the pericardium and heart; (2) the tip of the introducer can be observed at all times with a thoracoscope; (3) the anterior mediastinum between the left and right thoracic cavities is very narrow at the cranial level; (4) the introducer can be accurately directed to the left highest intercostal space; and (5) hemostasis and no injury of the bilateral thoracic organs can be confirmed.
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Affiliation(s)
- Koichi Ohno
- Department of Pediatric Surgery, Osaka City General Hospital, Osaka 534-0021, Japan.
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Furukawa H, Sasaki S, William M, Sekido M, Tsutsumida A, Oyama A, Yamamoto Y. Modification of thoracoscopy in pectus excavatum: Insertion of both thoracoscope and introducer through a single incision to maximise visualisation. ACTA ACUST UNITED AC 2009; 41:189-92. [PMID: 17701733 DOI: 10.1080/02844310701282054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Our modification of the Nuss procedure includes insertion of both the introducer and the thoracoscope through the same skin incision, which enables continuous visualisation of the tip of the introducer during blunt dissection across the mediastinum. From January 2001 to January 2005 we studied 32 consecutive patients whose ages ranged from 3 to 30 years. They had all undergone the modified procedure. The mean operating time was 1 hour 44 minutes (range 43 minutes-4 hours 20 minutes). Blood loss was less than 10 ml. There were no intraoperative bleed complications. The modification that we devised may minimise the risk of cardiothoracic and vascular injuries and the procedure is safe.
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Affiliation(s)
- Hiroshi Furukawa
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Hokkaido at Sapporo, Kita-ku, Sapporo, Japan
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Bouchard S, Hong AR, Gilchrist BF, Kuenzler KA. Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum. Semin Pediatr Surg 2009; 18:66-72. [PMID: 19348994 DOI: 10.1053/j.sempedsurg.2009.02.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This paper presents four severe cardiac injuries that occurred in patients who underwent the minimally invasive repair of pectus excavatum (MIRPE). These complications occurred in different clinical settings, namely in a patient with an extremely severe form of pectus, in a patient who had previously undergone an open repair, after a previous open heart surgery, and at the time of bar removal. The purpose of this article is to review the circumstances leading to these cardiac injuries, share what we have learned from these patients, and hopefully help avoid these complications in the future.
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Affiliation(s)
- Sarah Bouchard
- Department of Surgery, University of Montreal, Hôpital Sainte-Justine, Montreal, Quebec, Canada.
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Al-Assiri A, Kravarusic D, Wong V, Dicken B, Milbrandt K, Sigalet DL. Operative innovation to the "Nuss" procedure for pectus excavatum: operative and functional effects. J Pediatr Surg 2009; 44:888-92. [PMID: 19433163 DOI: 10.1016/j.jpedsurg.2009.01.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Accepted: 01/15/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The "Nuss" procedure for repair of pectus excavatum is performed with increasing frequency worldwide. We describe a technique of performing relaxing or "kerf" incisions along the cartilaginous ribs at the point of maximal chest wall concavity to facilitate retrosternal dissection and to reduce chest wall tension. The effects on operative parameters and long-term changes in cardiopulmonary function and appearance were evaluated prospectively. METHODS Thirty patients underwent a Nuss procedure for the period from 2001 to 2004. Fifteen patients underwent a modified Nuss (MN) with sternocostal "relaxing" incisions, and these were compared to 15 patients undergoing a standard Nuss (SN). Data were prospectively gathered and included the number of relaxing incisions, bar number, blood loss, duration of epidural analgesia, number of days to discharge, and preoperative and postoperative cardiopulmonary function measures. RESULTS The average Haller index of the SN group was 3.9 +/- 0.7 vs MN group index of 4.6 +/- 1.6 (P < .05). The median number of relaxing incisions in the study group was 4.0 +/- 0.7 (range 3 - 8). There were no significant differences between the study groups in any of the operative parameters analyzed, including blood loss, days of epidural requirements or days to reach functional independence. Nor were there differences in the improvement in subjective appearance, complications, pulmonary function, cardiac output at rest, oxygen transport or minute ventilation at maximal exercise. Subjectively, bar positioning and the intraoperative visualization was easier with the relaxing incisions. CONCLUSIONS The addition of sternocostal relaxing incisions to the standard Nuss procedure appears to facilitate retrosternal dissection and bar placement, but no changes in long-term function or cosmesis were noted. The use of relaxing incisions appears to be safe and may facilitate operative visualization of retrosternal structures.
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Affiliation(s)
- Ali Al-Assiri
- Division of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
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Liu SL, Li L, Cheng W, Hou WY, Huang LM, Wang WY, Zhang J, Cui L, Xie HW. Total Extrapleura Sternal Elevation for the Correction of Pectus Excavatum in Children. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S223-5. [PMID: 18976124 DOI: 10.1089/lap.2008.0117.supp] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shu-Li Liu
- Department of Pediatric Surgery, Peking University First Hospital, Beijing, China
| | - Long Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China
| | - Wei Cheng
- Departments of Paediatric Surgery, Paediatrics, and Surgery, Monash Medical Center, Clayton, Victoria, Australia
| | - Wen-Ying Hou
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China
| | - Liu-Ming Huang
- Department of Pediatric Surgery, Peking University First Hospital, Beijing, China
| | - Wen-Ya Wang
- Department of Pediatrics, The Second People's Hospital of Fengrun District, Hebei Province, China
| | - Jun Zhang
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China
| | - Long Cui
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China
| | - Hua-Wei Xie
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China
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Castellani C, Saxena AK, Zebedin D, Hoellwarth ME. Pleural and pericardial morbidity after minimal access repair of pectus excavatum. Langenbecks Arch Surg 2008; 394:717-21. [DOI: 10.1007/s00423-008-0448-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 12/02/2008] [Indexed: 12/01/2022]
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