Risk of serious perioperative complications with removal of double bars following the Nuss procedure

Use of Transesophageal Echocardiography for Enhanced Safety During Bar Removal Procedures After Minimally Invasive Repair of Pectus Excavatum

Background: Minimally invasive repair of pectus excavatum involves placement of retrosternal support (Nuss) bars. Hardware removal has been rarely associated with life-threatening hemorrhage from the heart, aorta, internal mammary arteries, and/or lung. There is no accepted standard intraoperative monitoring technique used during removal. We hypothesized that the use of transesophageal echocardiography (TEE) during Nuss bar removal would enhance safety of the procedure and be cost-effective. Methods: IRB-approved retrospective review of patients who underwent Nuss bar removal with intraoperative TEE monitoring over a 4-year period, from March 2013 to May 2017, was completed. Bar removal procedures were performed supine, under general anesthesia. TEE images were monitored and any distortion of the cardiac silhouette, new pericardial effusion, and/or cardiac arrhythmias would be considered evidence of possible bar adherence, triggering possible conversion to sternotomy or thoracotomy. Results: In total, 87 consecutive patients, mean age of 20 years, were identified. Bars had been in place for a mean of 30 months. Average procedure time was 67 minutes. No patients experienced arrhythmias, cardiac injury, or significant hemorrhage during removal. TEE gave excellent visualization of the cardiac silhouette and pericardium in all cases. No patient required insertion of an arterial line, a postoperative chest X-ray, or overnight hospitalization. Patients were discharged from the recovery room an average of 89 minutes postprocedure. Conclusion: TEE offers a minimally invasive safe way to visualize the pericardium and its contents during Nuss bar removal. Significant cardiac/mediastinal injuries should be immediately visible. The use of TEE is cost-effective and allows safe discharge the day of surgery.

[Influencing factors on operating times for metal bar removal after Nuss repair]

BACKGROUND

Metal bar removal after the Nuss repair procedure is prone to be cancelled in cases of operating time shortages due it being suitable to be postponed without harming patients. Consequently, planning operation times as exactly as possible could be one solution.

OBJECTIVE

Statistical modelling of operation times of metal bar removal after Nuss repair using the prespecified independent predictors of age, sex, intraoperative complications, and number of implanted metal bars.

MATERIAL AND METHODS

We included all patients whose operation notes included an operation time, which was modelled via linear regression and subject to internal validation via bootstrap. Exploratory analyses also consisted of the surgeon's experience, the number of stabilizers, the body mass index, and preceding re-do surgery for bar dislocation.

RESULTS

We included 265 patients (14% ♀) with a median age of 19 years (interquartile range 17-20 years), of whom 81% had 1 and 17% had 2 metal bars removed. The prespecified regression model was statistically significant (likelihood ratio 56; df = 5; P < 0.001) and had a bias corrected R2 of 0.148. Patient age influenced operation times by 2.1min per year of life (95% confidence interval 1.3-2.9min; P < 0.001) and 16min per explanted metal bar (95% confidence interval: 10-22min; P < 0.001).

CONCLUSION

The patient-specific factors of age and the number of explanted metal bars influenced the operation times and can be included into scheduling operation times.

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.

Minimization of the complications associated with bar removal after the Nuss procedure in adults

BACKGROUND

Pectus bar removal after Nuss repair is associated with the risk of major complications that are underreported. Of these, surgical bleeding is the main concern. Old age and placement of more than one bar are reported risk factors for pectus bar removal. In this study, we presented our experience regarding the modified skills required to minimize complications during bar removal, especially in adult patients.

METHODS

Consecutive patients who underwent pectus bar removal as the final stage of Nuss repair between August 2014 and December 2018 were included. The patients were positioned in the supine position. The bar(s) was (were) removed from the left side via the bilateral approach using the previous surgical scars after full dissection of the ends of the bar lateral to the hinge point and after straightening the right end of the bar. Bleeding was carefully checked after removal. An elastic bandage was wrapped around the chest after wound closure to prevent wound hematoma/seroma formation.

RESULTS

A total of 283 patients (260 male and 23 female), with a mean age of 22.8 ± 6.6 years at the time of the Nuss repair were included. The mean duration of pectus bar maintenance interval was 4.3 years (range: 1.9 to 9.8 years). A total of 200 patients (71%) had two bars. The mean estimated blood loss was 11.7 mL (range: 10 mL to 100 mL). Nine patients (3.1%) experienced complications, six had pneumothorax and three had wound hematoma. No major bleeding occurred. Adults and the use of more than one bar were not associated with a significantly higher rate of complications (P = 0.400 and P = 0.260, respectively).

CONCLUSIONS

Adult patients and removal of multiple bars were not risk factors for complications in our cohort. Skill in preventing intraoperative mediastinal traction, carefully controlling bleeding, and reducing the effect of dead space around the wounds could minimize the risk of bleeding complications. A multicentric study or case accumulation is needed to further evaluate the risk factors of removal pectus bar(s).

Lung Middle Lobe Laceration Needing Lobectomy as Complication of Nuss Bar Removal

Minimally invasive procedure for the treatment of pectus excavatum as described by Nuss has been used from 1987. The bar initially introduced blindly is now introduced under thoracoscopic control to increase safety of the procedure. It is usually removed two to three years after its insertion in a one-day procedure. Complications of the bar removal are rare but potentially serious. We report the case of a serious complication which occurred immediately after the Nuss bar removal. A 15-year-old boy underwent a Nuss procedure for a severe pectus excavatum without relevant complication. The bar has been removed two years after its insertion in a minimally invasive procedure. Unfortunately, he developed in the immediate postoperative period a hemopneumothorax due to a right middle lobe laceration which required a middle lobectomy by thoracotomy for hemostasis. Lesions of intrathoracic organs are a rare but potentially serious complication of the removal of the Nuss bar. We now propose to perform this procedure under thoracoscopic control to avoid it. In our experience, adhesions between the bar and the pleura are always present, and those with potential risk for bleeding or inducing intrathoracic organ lesions are suppressed prior to the bar removal.

Pectus updates and special considerations in Marfan syndrome

Congenital chest wall or pectus deformities including pectus excavatum (funnel chest) and pectus carinatum (pigeon chest) affect a significant proportion of the general population and up to 70% of patients with Marfan syndrome. Patients often experience significant morbidity and psychological distress, which can worsen with age. Here we discuss new techniques for both operative and non-operative treatment of pectus deformity, the importance of a welltimed intervention and special considerations in patients with Marfan syndrome.