Vascular thoracic outlet syndrome developed after minimally invasive repair of pectus excavatum

Post-operative arrest following pectus excavatum repair: A case report with a systematic review of the published case reports

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.

Thoracic Outlet Syndrome after Minimally Invasive Repair of Pectus Excavatum in a 15-Year-Old Boy: A Case Report

Nuss procedure has become the treatment of choice in pectus excavatum mainly because of the excellent functional and cosmetic results. Despite the good results, several complications have been reported. The aim of this study is to describe a case of thoracic outlet syndrome (TOS) after Nuss procedure and review the management of such rare complication. A 15-year-old boy otherwise healthy was submitted to Nuss procedure, with no perioperative complications. Two-weeks later, the patient complained of right-hand paresthesia, progressive weakness of the right arm and coldness. After imaging and electromyography, TOS diagnosis was established. Removal of the bar was proposed but refused by the patient. Conservative management with rehabilitation exercising and nerve nourishing was initiated. At 7 months, the patient recovered arm and hand function. Abrupt structural changes of thoracic cavity with marked elevation of the upper chest induce nerve and vascular compression arousing a TOS and should be acknowledged as one potential complication of Nuss procedure. Conservative management can be an alternative treatment to bar removal, showing good results on functional recovery in early stages of compression.

Thoracic outlet syndrome (TOS): A case report of a rare complication after Nuss procedure for pectus excavatum

RATIONALE

The Nuss procedure has become a major alternative operation for patients with pectus excavatum (PE).

PATIENT CONCERNS

We report a case of 27-year-old man with PE who developed thoracic outlet syndrome (TOS) after the Nuss procedure. The patient showed clinical symptoms of brachial plexus compression.

DIAGNOSES

Further evaluation demonstrated a narrowed space between the first rib and the anterior scalene muscle and compressing the brachial plexus and vessels.

INTERVENTIONS

Nerve nourishing medicine and rehabilitation exercising were taken to restore the muscle strength.

OUTCOMES

Several months later, the clinical symptoms disappeared.

LESSONS

Medicine and rehabilitation exercising may benefit the functional recovery of impaired nerve in TOS in the early stage of TOS.

Minimally invasive repair of pectus excavatum (MIRPE) in adults: is it a proper choice?

INTRODUCTION

The Nuss procedure is suitable for prepubertal and early pubertal patients but can also be used in adult patients.

AIM

To determine whether the minimally invasive technique (MIRPE) can also be performed successfully in adults.

MATERIAL AND METHODS

Between July 2006 and January 2016, 836 patients (744 male, 92 female) underwent correction of pectus excavatum with the MIRPE technique at our institution. The mean age was 16.8 years (2-45 years). There were 236 adult patients (28.2%) (> 18 years) - 20 female, 216 male. The mean age among the adult patients was 23.2 years (18-45 years). The recorded data included length of hospital stay, postoperative complications, number of bars used, duration of the surgical procedure and signs of pneumothorax on the postoperative chest X-ray.

RESULTS

The MIRPE was performed in 236 adult patients. The average operative time was 44.4 min (25-90 min). The median postoperative stay was 4.92 ±2.81 days (3-21 days) in adults and 4.64 ±1.58 (2-13) in younger patients. The difference was not statistically significant (p = 0.637). Two or more bars were used in 36 (15.8%) adult patients and in 44 (7.5%) younger patients. The difference was not statistically significant either (p = 0.068). Regarding the overall complications, complication rates among the adult patients and younger patients were 26.2% and 11.8% respectively. The difference was statistically significant (p = 0.007).

CONCLUSIONS

MIRPE is a feasible procedure that produces good long-term results in the treatment of pectus excavatum in adults.