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Akhtar M, Razick DI, Saeed A, Baig O, Kamran R, Ansari U, Sajid Z, Rahman JE. Complications and Outcomes of the Nuss Procedure in Adult Patients: A Systematic Review. Cureus 2023; 15:e35204. [PMID: 36960268 PMCID: PMC10031548 DOI: 10.7759/cureus.35204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 02/22/2023] Open
Abstract
Pectus excavatum is a congenital chest wall deformity, commonly identified in early childhood, creating a "sunken chest" appearance. Over time, the deformity can worsen, thus impacting cardiopulmonary function and creating significant body image disturbance in patients. The Nuss procedure is a minimally invasive technique in which a curved steel bar is introduced underneath the sternum through small bilateral thoracic incisions to correct the deformity. Most studies regarding the procedure to date focus on outcomes and complications in pediatric patients, however, few studies discuss these results in adult patients. This systematic review aims to analyze common complications and outcomes in patients over the age of 18 who have not undergone any prior intervention for pectus excavatum. The most common complications experienced in adult patients were displacement of the implanted steel bar, infection of the surgical site, pneumothorax, pleural effusion, and chronic postoperative pain. Reoperation was common in patients with a displacement of the bar, chronic pain, and bleeding. Additionally, adult patients routinely required a higher number of steel bars to be placed to correct the deformity. Despite evidence that the rate of complications increases with age, the majority of adult patients in our included studies were satisfied with the outcome of the procedure with indications of improved self-image and reduced preoperative symptoms such as dyspnea on exertion, palpitations, chest pain, and depression.
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Affiliation(s)
- Muzammil Akhtar
- Surgery, California Northstate University College of Medicine, Elk Grove, USA
| | - Daniel I Razick
- Surgery, California Northstate University College of Medicine, Elk Grove, USA
| | - Ali Saeed
- Internal Medicine, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Osamah Baig
- Ophthalmology, Lake Erie College of Osteopathic Medicine, Erie, USA
| | - Rafaay Kamran
- Molecular Biology, University of California Berkeley, Berkeley, USA
| | - Ubaid Ansari
- Internal Medicine, California Northstate University College of Medicine, Elk Grove, USA
| | - Zahra Sajid
- Biology, Cosumnes River College, Elk Grove, USA
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Jawitz OK, Raman V, Thibault D, Yerokun B, Zwischenberger BA, Kosinski AS, Allen MS, Harpole DH. Complications after Ravitch versus Nuss repair of pectus excavatum: A Society of Thoracic Surgeons (STS) General Thoracic Surgery Database analysis. Surgery 2021; 169:1493-1499. [PMID: 33494946 DOI: 10.1016/j.surg.2020.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are conflicting reports in the literature comparing outcomes after open Ravitch and minimally invasive Nuss procedures for pectus excavatum repair, and there is relatively little data available comparing the outcomes of these procedures performed by thoracic surgeons. METHODS The 2010 to 2018 Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients age 12 or greater undergoing open or minimally invasive repair of pectus excavatum. Patients were stratified by operative approach. Multivariable logistic regression was performed with a composite outcome of 30-day complications. RESULTS A total of 1,767 patients met inclusion criteria, including 1,017 and 750 patients who underwent minimally invasive pectus repair and open repair, respectively. Open repair patients were more likely to be American Society of Anesthesiologists (ASA) class III or greater (24% vs 14%; P < .001), have a history of prior cardiothoracic surgery (26% vs 14%; P < .001), and require longer operations (median 268 vs 185 minutes; P < .001). Open repair patients were more likely to require greater than 6 days of hospitalization (18% vs 7%; P < .001), undergo transfusion (7% vs 2%; P < .001), and be readmitted (8% vs 5%; P = .004). After adjustment, open repair was not associated with an increased risk of a composite of postoperative complications (odds ratio 0.99, 95% confidence interval 0.67-1.46). This finding persisted after propensity score matching (odds ratio 1.11, 95% confidence interval 0.74-1.67). CONCLUSION Pectus excavatum repair procedure type was not associated with the risk of postoperative complications after adjustment. Further investigation is necessary to determine the impact of pectus excavatum repair type on recurrence and patient reported outcomes, including satisfaction, quality of life, and pain control.
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Affiliation(s)
- Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Babatunde Yerokun
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Brittany A Zwischenberger
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Mark S Allen
- Department of Thoracic Surgery, Mayo Clinic, Rochester, MN
| | - David H Harpole
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Song IH, Lee SJ, Kim SS, Lee SY. Surgical Outcomes of Double Compression and Complete Fixation Bar System in Pectus Excavatum. Ann Thorac Surg 2018; 106:1025-1031. [PMID: 29890147 DOI: 10.1016/j.athoracsur.2018.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/26/2018] [Accepted: 05/14/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Minimally invasive repair of pectus excavatum is a widely used technique for correction of pectus excavatum. Yet despite the advancement in the surgical techniques, it is still associated with various complications, including bar displacement leading to reoperation. To overcome this problem, we developed the double compression and complete fixation bar (DCCF) system that consists of 2 metal bars that are inserted above and below the sternum and compressed to correct pectus excavatum. METHODS Patients who underwent pectus excavatum correction surgery at this center between April 2006 and March 2017 were divided into a DCCF system group and a conventional Nuss procedure group and their demographic, clinical, and surgical characteristics were compared. RESULTS A total of 220 patients underwent the DCCF system procedure and 306 patients underwent the conventional Nuss procedure. The DCCF system group had significantly shorter operation time (p < 0.001) and postoperative hospital admission time (p < 0.001) compared with the conventional Nuss procedure group. There were only 2 cases (0.9%) of postoperative complications in the DCCF system group, which was significantly less than that of the conventional Nuss procedure group (n = 64, 20.9%; p < 0.001). In particular, there were no cases of bar displacement in the DCCF system group. CONCLUSIONS The DCCF system was applied to surgical correction of pectus excavatum, which led to significant reduction in the operation time and postoperative hospital admission period, as well as reduced minimally invasive repair of pectus excavatum complication and bar displacement rates. Therefore, we recommend the application of the DCCF system to the surgical correction of pectus excavatum.
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Affiliation(s)
- In-Hag Song
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang, Republic of Korea
| | - Seung Jin Lee
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang, Republic of Korea.
| | - Seung Soo Kim
- Department of Pediatrics, Soonchunhyang University Cheonan Hospital, Soonchunhyang, Republic of Korea
| | - Seock Yeol Lee
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang, Republic of Korea
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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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Mao YZ, Tang S, Li S. Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis. J Pediatr Surg 2017; 52:1545-1552. [PMID: 28606386 DOI: 10.1016/j.jpedsurg.2017.05.028] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/16/2017] [Accepted: 05/29/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE To evaluate surgical outcomes of Nuss versus Ravitch repair of pectus excavatum via a systematic review and meta-analysis. METHODS Medline, PubMed, Cochrane, EMBASE, and Google Scholar databases were searched up to September 5, 2016 using the following search terms: pectus excavatum, funnel chest, Nuss; Ravitch, minimally invasive, and open surgery. Randomized controlled trials, two-arm prospective, and two-arm retrospective studies were eligible for inclusion. RESULTS Nineteen studies were included with a total of 1731 patients: 989 treated with Nuss and 742 treated with Ravitch. The overall analysis revealed that patients in the Nuss group had significantly shorter operation time (pooled SMD=-2.83, 95% CI=-3.76 to -1.90, p<0.001) and less blood loss (pooled SMD=-1.68, 95% CI=-2.28 to -1.09, P<0.001) than the Ravitch group. However, the length of hospital stay was similar between groups (pooled SMD=-0.55, 95% CI=-1.44 to 0.35, p=0.230). These findings were similar in the subgroup analysis for randomized and non-randomized controlled studies. Complications were not assessed due to inconsistent reporting across the included studies. CONCLUSIONS Our meta-analysis demonstrate that the Nuss procedure has a shorter operative time and less operative blood loss than the Ravitch procedure while the postoperative length of stay was similar. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Yong Zhong Mao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China..
| | - ShaoTao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Kanagaratnam A, Phan S, Tchantchaleishvili V, Phan K. Ravitch versus Nuss procedure for pectus excavatum: systematic review and meta-analysis. Ann Cardiothorac Surg 2016; 5:409-421. [PMID: 27747174 DOI: 10.21037/acs.2016.08.06] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pectus excavatum is the most common congenital chest wall deformity. The two most common surgical techniques for its correction are the modified Ravitch technique and the minimally invasive Nuss technique. Despite both procedures being used widely, data comparing them are scarce. METHODS We conducted a systematic review and meta-analysis of comparative studies to evaluate these procedures. A systematic search of the literature was performed from six electronic databases. Pooled meta-analysis was conducted using odds ratio (OR) and weighted mean difference (WMD). RESULTS A total of 13 studies comprising 1,432 pediatric (79.3%) and adult (20.7%) patients were identified, including 912 patients undergoing the Nuss procedure compared to 520 patients undergoing the Ravitch procedure. There was no significant difference found between the Nuss group versus Ravitch group in pediatric patients with regard to overall complications (OR =1.16; 95% CI: 0.61-2.19; I2=56%; P=0.65), reoperations (6.1% vs. 6.4%; OR =1.00; 95% CI: 0.40-2.50; I2=0%; P=1.00), wound infections (OR =0.58; 95% CI: 0.23-1.46; I2=0%; P=0.25), hemothorax (1.6% vs. 1.3%; OR =0.74; 95% CI: 0.21-2.65; I2=12%; P=0.64), pneumothorax (3.4% vs. 1.5%; OR =1.11; 95% CI: 0.42-2.93; I2=0%; P=0.83) or pneumonia (OR =0.15; 95% CI: 0.02-1.48; I2=0%; P=0.10). Adult patients undergoing the Nuss procedure had a higher incidence of overall complications (OR =3.26; 95% CI: 1.01-10.46; I2=0%; P=0.05), though there were far fewer studies that reported data. CONCLUSIONS These results suggest no difference between the Nuss and Ravitch procedures for pediatric patients, while in adults the Ravitch procedure resulted in fewer complications.
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Affiliation(s)
- Aran Kanagaratnam
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Steven Phan
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | | | - Kevin Phan
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
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