Complications and Outcomes of the Nuss Procedure in Adult Patients: A Systematic Review

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.

Complications after Ravitch versus Nuss repair of pectus excavatum: A Society of Thoracic Surgeons (STS) General Thoracic Surgery Database analysis

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.

Surgical Outcomes of Double Compression and Complete Fixation Bar System in Pectus Excavatum

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.

Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis

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.

Ravitch versus Nuss procedure for pectus excavatum: systematic review and meta-analysis

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.