Long-term Surveillance Comparing Satisfaction between the Early Experience of Nuss Procedure vs. Ravitch Procedure

Post bar removal results of pectus deformity patients who underwent minimally invasive correction

Introduction

The most common chest wall deformities are pectus excavatum and pectus carinatum. Surgical repair of these deformities via minimally invasive technique using pectus bars is commonly preferred by numerous thoracic surgeons. Despite this common choice for treatment, the duration of the bar stay, the bar removal process, the possible complications and ways to prevent them have been debated over the years and still there is no single decision.

Aim

To determine the decision making, surgical outcomes and negative factors in the bar removal process.

Material and methods

There were 1032 patients underwent bar removal between 2006-2020 and their data was recorded prospectively. We analyzed patients' demographics, family history, Haller index, bar count, body mass index, stabilizer and wire usage, length of hospital stay, time until bar removal, incision side and complications retrospectively.

Results

There was no significant correlation between BMI and surgery time (p = 0.748). There was no statistically significant correlation between the age groups and the number of pectus bars removed. The other factors showed no significant difference. The surgery time was found to be significantly longer in those with callus tissue (p = 0.002).

Conclusions

These findings suggest that pectus bars can be left in place for a shorter time than the standard 3-year interval without any additional recurrence risk and without compromising quality of life. As a result, patients with persistent pain after pectus repair should be well evaluated for the possibility of life-threatening complications during bar removal.

What Is the Appropriate Timing for Bar Removal After the Nuss Repair for Pectus Excavatum?

INTRODUCTION

The Nuss procedure for pectus excavatum requires that the sternal elevation be maintained by indwelling metal bars that are traditionally removed approximately 3 y after the repair.

METHODS

A retrospective cohort study was conducted of all patients who underwent primary Nuss repair from 2007 to 2018 in two institutions and had a follow-up of at least 24 mo. Pectus bars had been left in place beyond 3 y in patients concerned over possible recurrence after bar removal. Structured interviews were held to assess pain, chest tightness, or other discomfort, and any adverse events related to pectus bars. Results were compared between patients in whom pectus bars were removed after 3 y (standard group) and those in whom bars were left in place longer (extended bar duration group).

RESULTS

Two hundred and thirty-one patients (91% males, mean age 23.9 ± 8.3, mean Haller index 4.9 ± 2.3) were included. Bar duration was 30.6 ± 6.6 mo in the standard group (51 patients) versus 69.1 ± 26.3 mo in the extended group (180 patients). Some discomfort was reported by 81.6% in the standard group versus 62.9% in the extended group (P = 0.033), and discomfort occurring at least monthly or more often was only reported by 30% in the standard versus 30.3% in the extended group (P = 1.000). Quality of life improved in 92.6% of the standard group versus 94.7% of the extended group (P = 1.000). No significant adverse events were reported in either group.

CONCLUSIONS

Our data suggest that an extended bar duration after the Nuss repair may not cause any adverse event nor negatively affect quality of life.

Evolution of Technique and Results Following Permanent Open Repair for Pectus Deformities

Objective

Open correction of pectus deformities has evolved since its origin. We performed a Ravitch type repair using a permanent titanium plate fixed with screws and describe the procedure with outcomes after our modifications.

Methods

A retrospective review of 61 pectus excavatum and pectus carinatum cases from August 2013 to April 2021 was performed. Data were extracted from medical records and reported. In January 2016, we began administering satisfaction surveys at the 6-month postoperative visit; results are reported.

Results

The mean age of our cohort was 24.5 years; 43 (70%) were male. Fifty-four underwent pectus excavatum repair, 6 pectus carinatum repair, and 1 mixed repair. Median Haller index was 3.8. Mean operative duration was 98 minutes; mean blood loss was 116.4 mL. Median chest tube duration was 5.0 days; median hospital stay was 4 days. Reexploration for bleeding was 30% in the first 10 patients. Protocol changes including postponing chemical deep vein thrombosis prophylaxis, using intraoperative hemostatic agents, and using shorter implantation screws decreased this to 0% for the remaining cases. The most frequent complication was urinary retention (21.3%). Postoperative surveys were completed for 37 of 50 patients. Seventy-five percent reported health improved, 65% reported exercise capacity improved, 75% reported breathing improved, and 59% reported chest pain improved. Self-esteem improved from 6.6 ± 2.5 (of 10) before surgery to 8.2 ± 2.1 after surgery. Ninety percent were satisfied and 86% would have the operation again.

Conclusions

Ravitch type repair with permanent titanium plate fixation is a safe and effective procedure for correction of pectus excavatum and carinatum. Most patients experience improvement in preoperative symptoms.

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.

Pectus Excavatum: A Review of Diagnosis and Current Treatment Options

Osteopathic medicine places a special emphasis on the musculoskeletal system, and understanding how chest wall structure may influence function is critical. Pectus excavatum is a common congenital chest wall defect in which the sternum is depressed posteriorly. Patients may present with complaints of chest wall discomfort, exercise intolerance, and tachycardia. The medical implications, diagnosis, and treatment options for patients with pectus excavatum are reviewed.

Complex corrective procedure in surgical treatment of asymmetrical pectus excavatum

Aim

In this study we analysed the early and late results of surgical treatment of asymmetrical pectus excavatum using complex surgery combining the Ravitch procedure and the Nuss procedure in the same general anaesthesia.

Material and methods

Eighty out of 938 patients with pectus excavatum operated on between 2002 and 2013, 67 males and 13 females aged 11 to 49 years (mean: 19.2), underwent a complex surgical procedure. During surgery the Nuss procedure was usually performed first (one corrective bar was implanted in 35 patients and two bars were inserted in 45 patients). Because of the unsatisfactory cosmetic effect, additionally the Ravitch procedure was started. The bars were electively removed 3 years after the primary operation.

Results

No mortality was observed in the early postoperative period. Non-life-threatening and transient postoperative complications occurred in 44 (55%) patients. The most common was pleural effusion (21%), which in 50% of patients required pleural drainage. A satisfactory and stable correction effect was achieved in 88% of cases. Six of those patients required repeat surgery due to recurrence of deformity.

Conclusions

A complex corrective procedure is a successful method of surgical treatment in patients with asymmetrical pectus excavatum and is characterized by satisfactory postoperative results. The use of corrective bars enhances the cosmetic effect. The frequency of early, mostly non-life-threatening postoperative complications after a complex procedure is insignificantly higher than that after the Nuss procedure.

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.

Pectus Excavatum and Pectus Carinatum: Associated Conditions, Family History, and Postoperative Patient Satisfaction

Background

Pectus excavatum (PE) and pectus carinatum (PC) are the most common chest wall deformities. In this study, we aimed to characterize how patients obtained information about these deformities, as well as patients’ family history, associated medical problems, and postoperative satisfaction after the Nuss and Abramson procedures.

Methods

This cross-sectional retrospective study included patients who were operated by a single surgeon between 2006 and 2013. Follow-up calls were made after approval of our institution’s ethics committee. We reached 207 of the 336 PE patients (61.6%) and 73 of the 96 PC patients (76%).

Results

The majority of the patients were male (85% of the PE patients and 91.8% of the PC patients). The age of diagnosis of PE was 14.52±0.51 years and the age at the time of operation was 17.89±0.42 years; for PC patients, the corresponding ages were 15.23±0.55 years and 16.77±0.55 years, respectively. A total of 70% of the PE patients and 63.8% of the PC patients obtained information about pectus deformities through the Internet. In 27.1% of the PE patients with an associated anomaly, 57.1% (n=13) had scoliosis, while 41.1% of the PC patients with an associated anomaly had kyphosis (n=5). Postoperative satisfaction, as evaluated on a scale from 0 to 10, was 8.17±0.15 for PE patients and 8.37±0.26 for PC patients. The postoperative pain duration was 51.93±5.18 days for PE patients and 38.5±6.88 days for PC patients.

Conclusion

In this study, we found that most patients with pectus deformities were male. The Internet was an important resource for patients to learn about their deformities. Family history and associated anomalies were identified as important aspects for consideration in the clinical setting. The patients reported high levels of postoperative satisfaction, and pain management was found to be one of the most important elements of postoperative care.

Validity and reliability of the Turkish version of the nuss questionnaire modified for adults

BACKGROUND

Pectus excavatum (PE) is the most common chest wall deformity. The Nuss Questionnaire modified for Adults (NQmA) is a disease-specific health-related quality of life assessment tool for patients with pectus deformities. The aim of this study is to adapt the NQmA into Turkish.

METHODS

Two hundred and sixty-five patients with PE were participated, with an age range of 14 to 29 years. All patients underwent a physical examination and had not undergone corrective surgery. The Turkish version of the NQmA was completed by patients and their parents.

RESULTS

The content validity index based on expert opinions was 91% for the patient questionnaire and 96% for the parent questionnaire. The Cronbach's alpha value for the NQmA was found to be 0.805 for the patient questionnaire and 0.800 for the parent questionnaire. Exploratory factor analysis was used to assess construct validity. Two factors explained 51.1% of the total variance in the patient questionnaire (psychosocial: 31.145%, Cronbach's alpha=0.818; physical: 19.955%, Cronbach's alpha=0.862). In the parent questionnaire, two factors explained 51.422% of the total variance (psychosocial: 26.097%, Cronbach's alpha=0.743; physical: 25.325%, Cronbach's alpha=0.827). Construct validity was confirmed by confirmatory factor analysis.

CONCLUSION

The Turkish version of the NQmA was found to be valid and reliable for the assessment of quality of life in patients with PE.

Quality of life improves after minimally invasive repair of pectus excavatum

Background

Pectus excavatum is the most common chest wall deformity. This deformity may cause physical limitations and psychosocial problems. In this study, we aimed to investigate the effect of minimally invasive repair of pectus excavatum on the quality of life.

Methods

This study included 88 patients, aged 18.44 ± 3.93 years (85.2% male), who underwent minimally invasive repair of pectus excavatum; 40.9% had an associated anomaly or disease, and 17.0% had scoliosis. The patients and their parents completed the patient and parent forms of the Nuss questionnaire modified for adults preoperatively and 6 months after the operation.

Results

The patients’ median Nuss score increased from 31 (interquartile range 31–35) preoperatively to 43 (interquartile range 43–46) at 6 months after the operation ( p = 0.000). The parents’ preoperative score of 33 (interquartile range 29–36) increased to 38 (interquartile range 34–41; p = 0.000). Improvements in the physical and psychosocial component scores of the Nuss questionnaire were also significant in the patient ( p = 0.000, p = 0.000, respectively) and parent forms ( p = 0.005, p = 0.000, respectively).

Conclusions

Minimally invasive repair of pectus excavatum significantly improved the physical and psychosocial wellbeing of patients. Longitudinal studies are needed to determine the long-term changes related to quality of life.

Modified Robicsek procedure for pectus excavatum in adult patients

OBJECTIVES

The aim of this study was to clarify the short-term and mid-term outcomes of the modified Robicsek procedure using polypropylene mesh for adult pectus excavatum patients.

METHODS

Retrospective chart review was performed. Between 2001 and 2012, 46 consecutive adult patients underwent modified Ravitch repair using polypropylene mesh for pectus excavatum at our institution. There were 30 males and 16 females, with a median age of 25.5 (range: from 17 to 60). Potential risk factors for perioperative complications and early failure in pectus repair were analysed with χ(2) test or Fisher's exact test and Mann-Whitney test. Potential risk factors for postoperative mid-term recurrence were analysed using Cox proportional hazard regression model.

RESULTS

The postoperative follow-up interval was 7.0 ± 15.1 months (mean ± standard deviation). No mortality and 11 patients (24.0%) of morbidity, including 2 patients with temporary mesh infection, were noted. A lower preoperative %FEV1.0 predicted was a significant factor (P = 0.0088) of morbidity in multivariate analysis. Regarding chest morphology, early failure in 1 patient (2.2%) and mid-term recurrence in 1 patient (2.2%) were seen. Previous pectus repair (P = 0.0324) and severe asymmetry (P = 0.04) were significant factors of early failure in multivariate analysis, while no significant factor for mid-term recurrence was found.

CONCLUSIONS

Modified Robicsek procedure with a polypropylene mesh is associated with low incidences of early failure and mid-term recurrence. The procedure is recommended for adult pectus excavatum patients, including those with asymmetric or combined deformity as an initial or reoperative procedure.