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Deol PK, Hoover JD, Phillips JD. Use of Transesophageal Echocardiography for Enhanced Safety During Bar Removal Procedures After Minimally Invasive Repair of Pectus Excavatum. J Laparoendosc Adv Surg Tech A 2023; 33:1218-1222. [PMID: 37844062 DOI: 10.1089/lap.2022.0410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
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.
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Affiliation(s)
- Preeya K Deol
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - J David Hoover
- WakeMed Health and Hospitals, Pediatric Surgery, Raleigh, North Carolina, USA
| | - J Duncan Phillips
- WakeMed Health and Hospitals, Pediatric Surgery, Raleigh, North Carolina, USA
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Aly MR, Farina JM, Bostoros PM, Botros MM, Pulivarthi VS, Peterson MA, Lackey JJ, Jaroszewski DE. Risk Factors and Techniques for Safe Pectus Bar Removal in Adults After Modified Nuss Repair. Ann Thorac Surg 2023; 116:787-794. [PMID: 36549569 DOI: 10.1016/j.athoracsur.2022.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/26/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Nuss repair involves implants designed for removal after 2 to 3 years. Although rare, significant complications can occur with bar removal, and the incidence of these complications may be higher in adults. This study was performed to review complications and risk factors associated with bar removal and discuss strategies to improve operative safety. METHODS A retrospective study was performed including all patients after pectus excavatum repair who underwent Nuss implant removal at Mayo Clinic Arizona (Phoenix, AZ) from 2013 to 2022. RESULTS In total, 1555 bars were removed (683 patients; 71% men; median age, 34 years[(range, 15-71 years]). Of the removals, 12.45% of patients had bars placed at outside institutions. Major complications were rare, with bleeding most common (2.05%), followed by pneumothorax (0.88%), infection (0.59%), and effusions (0.44%). Most major bleeding (85.71%) occurred from the bar track during removal and was controlled by packing the track. One patient required subsequent hematoma evacuation and transfusion. Bleeding secondary to lung injury was also successfully controlled with packing. Bar removal in 1 patient with significantly displaced bars required sternotomy and cardiopulmonary bypass as a result of aortic injury. Risk factors identified for bleeding included sternal erosion (P < .001), bar migration (P < .001), higher number of bars (P = .037), and revision of a previous pectus repair (P = 0.001). Bar migration was additionally associated with major complications (P < .001). Older age, although a risk factor for overall complications (P = 0.001), was not a risk factor for bleeding. CONCLUSIONS Bar removal can be safely performed in most patients; however, significant complications, including bleeding, may occur. Identifying potential risk factors and being prepared for rescue maneuvers are critical to prevent catastrophic outcomes.
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Affiliation(s)
- Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Peter M Bostoros
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michael M Botros
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Venkata S Pulivarthi
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michelle A Peterson
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jesse J Lackey
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona.
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Heydweiller AC, König TT, Yavuz ST, Schwind M, Oetzmann von Sochaczewski C, Rohleder S. [Influencing factors on operating times for metal bar removal after Nuss repair]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:796-803. [PMID: 37353682 PMCID: PMC10447265 DOI: 10.1007/s00104-023-01914-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/25/2023]
Abstract
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.
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Affiliation(s)
- Andreas C Heydweiller
- Sektion Kinderchirurgie der Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Tatjana T König
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Mainz, Deutschland
| | - S Tolga Yavuz
- Klinik für Allgemeine Pädiatrie, Universitätsklinik Bonn, Bonn, Deutschland
| | - Martin Schwind
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Mainz, Deutschland
| | - Christina Oetzmann von Sochaczewski
- Sektion Kinderchirurgie der Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland.
- Sektion Kinderchirurgie, Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - Stephan Rohleder
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Mainz, Deutschland
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What Is the Appropriate Timing for Bar Removal After the Nuss Repair for Pectus Excavatum? J Surg Res 2023; 285:136-141. [PMID: 36669392 DOI: 10.1016/j.jss.2022.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 12/07/2022] [Accepted: 12/24/2022] [Indexed: 01/20/2023]
Abstract
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.
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Complications following metal bar removal after Nuss repair are rare in a duocentric retrospective evaluation. Pediatr Surg Int 2022; 38:1919-1924. [PMID: 36138322 PMCID: PMC9653328 DOI: 10.1007/s00383-022-05250-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 12/01/2022]
Abstract
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.
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Media AS, Christensen TD, Katballe N, Pilegaard HK, de Paoli FV. Incidence and severity of surgical complications after pectus excavatum bar removal. Interact Cardiovasc Thorac Surg 2021; 33:237-241. [PMID: 34310684 DOI: 10.1093/icvts/ivab077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/08/2021] [Accepted: 02/18/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Pectus bar removal is the final step of minimally invasive repair of pectus excavatum. Complication rates related to bar removal have been reported in 2-15% of patients and severe, near-fatal and fatal complications have been reported. No systematic assessment of complication severity or risk factors associated with bar removal has been reported in large study populations. The aim of this paper is to investigate the safety of the bar removal procedure with regard to complication rates and severities as well as assessment of risk factors. METHODS Between 2003 and 2019, 1574 patients underwent the bar removal procedure. Medical records were assessed retrospectively and complications registered. Complications were categorized in infections, bleedings and other complications. The severity of the surgical complications was systematically classified using the validated Clavien-Dindo classification. Furthermore, risk factors associated with complications were assessed. RESULTS The overall complication rate was 4.1% (Clavien-Dindo classification I-IV), mainly consisting of bleedings (1.3%) and infections (1.5%). Five cases of severe bleedings were registered (0.3%, Clavien-Dindo classification IV). Risk factors associated with complications during bar removal were greater age and removal of more than one bar. CONCLUSIONS The bar removal procedure is a safe and effective procedure. Both age and number of bars inserted should be considered prior to surgical correction of pectus excavatum as these factors predict complications related to bar removal.
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Affiliation(s)
- Ara Shwan Media
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Niels Katballe
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Frank Vincenzo de Paoli
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
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Anterior chest wall regression after Nuss bar removal in adult patients with pectus excavatum. Gen Thorac Cardiovasc Surg 2021; 69:1308-1312. [PMID: 33851302 DOI: 10.1007/s11748-021-01635-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Pectus excavatum repair with the Nuss procedure can be successfully performed in adults. After removing the pectus bars, the anterior chest wall may regress to some degree. The purpose of this study was to clarify the amount of improvement and regression of the chest wall after bar removal. METHODS In 45 adult patients who underwent the Nuss procedure, the sternovertebral distance (SVD) on lateral chest X-ray was measured (A) before the Nuss procedure, (B) before bar removal, and (C) after bar removal. The average SVD was compared, and the difference between A and C suggesting final sternal elevation and B and C suggesting regression was calculated. The correlation between the duration of bar in situ and the amount of regression was analyzed. RESULTS The average period of bar in situ was 34.9 ± 5.0 (range 23-45) months. The average SVD-A, SVD-B, and SVD-C values were 58.9 ± 20.0, 89.3 ± 19.1, and 81.6 ± 20.1 mm, respectively, with significant differences among them. Final sternal elevation was 22.7 ± 17.4 mm, and average regression was 7.6 ± 8.6 mm. The correlation coefficient between the duration of bar in situ and the amount of regression was 0.119, suggesting no clear correlation. CONCLUSIONS In spite of some degree of chest wall regression after bar removal, the Nuss procedure was effective for adult patients with pectus excavatum. The period of bar in situ and chest wall regression had little correlation.
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Haecker FM, Hebra A, Ferro MM. Pectus bar removal - why, when, where and how. J Pediatr Surg 2021; 56:540-544. [PMID: 33228972 DOI: 10.1016/j.jpedsurg.2020.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Despite its less invasive nature, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. On the other hand, Pectus bar removal (PBR) is often considered a simple procedure and often scheduled in an outpatient setting. However, several studies report near-fatal complications not only during bar placement, but also during bar removal. The aim of our study was to clarify why a pectus bar should be removed, timing for removal, where PBR should be performed, and overall setup for safe removal. METHODS A comprehensive review was performed in accordance with PRISMA guidelines, searching for articles published since 1998 in English. "Pectus bar removal AND (near-fatal) complications" were the applied terms. Inclusion criteria were articles reporting on the focus of PBR after MIRPE. Eligible study designs included (retrospective) case study series, case report and reviews. Full-text articles in which the technique in general was described were omitted. RESULTS Recently published results of an online survey raised awareness about type and number of possible complications during PBR. Furthermore, our comprehensive literature review identified only a few, but serious complications during PBR. CONCLUSIONS PBR has a high safety profile but in rare cases may be associated with major complications such as life-threatening hemorrhage from various thoracic sources. This risk is higher in patients with a history of complex MIPRE. In an effort to decrease these complications we recommend bilateral opening of surgical incisions, unbending the bar and meticulous mobilization of the bar. To manage these complications if they occur, we recommend removal in a hospital setting with adequate resources and personal including cardiac surgeons. If the postoperative course is uneventful discharge on the same day is reasonable.
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Affiliation(s)
- Frank-Martin Haecker
- Department of Pediatric Surgery, American Hospital Dubai, Dubai, U.A.E; Department of Pediatric Surgery, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland.
| | - Andre Hebra
- Nemours Children's Hospital, Orlando, FL, USA
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Hsieh MS, Tong SS, Wei BC, Chung CC, Cheng YL. Minimization of the complications associated with bar removal after the Nuss procedure in adults. J Cardiothorac Surg 2020; 15:65. [PMID: 32316997 PMCID: PMC7175579 DOI: 10.1186/s13019-020-01106-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
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).
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Affiliation(s)
- Min-Shiau Hsieh
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian-Gao RD, Xindian District, New Taipei City, 23143, Taiwan
| | - Shao-Syuan Tong
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian-Gao RD, Xindian District, New Taipei City, 23143, Taiwan
| | - Bo-Chun Wei
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian-Gao RD, Xindian District, New Taipei City, 23143, Taiwan
| | - Cheng-Chin Chung
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian-Gao RD, Xindian District, New Taipei City, 23143, Taiwan
| | - Yeung-Leung Cheng
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jian-Gao RD, Xindian District, New Taipei City, 23143, Taiwan. .,School of Medicine, Tzu Chi University, Hualien, Taiwan.
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Use of the bilateral erector spinae (ESP) block for postoperative analgesia following the removal of the Nuss bar. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2019. [DOI: 10.1097/cj9.0000000000000109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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De Wolf J, Brian E, Wurtz A. Letter to the Editor. J Pediatr Surg 2018; 53:857-858. [PMID: 29366505 DOI: 10.1016/j.jpedsurg.2017.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 12/17/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Julien De Wolf
- CHU Lille, Department of Thoracic Surgery, F-59000 Lille, France
| | | | - Alain Wurtz
- CHU Lille, Department of Thoracic Surgery, F-59000 Lille, France.
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Lung Middle Lobe Laceration Needing Lobectomy as Complication of Nuss Bar Removal. Case Rep Orthop 2018; 2018:8965641. [PMID: 29682380 PMCID: PMC5842718 DOI: 10.1155/2018/8965641] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/03/2018] [Accepted: 01/24/2018] [Indexed: 11/18/2022] Open
Abstract
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.
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Poola AS, Rentea RM, Weaver KL, St Peter SD. Routine use of chest radiographs in the post-operative management of pectus bar removal: necessity or futility. Pediatr Surg Int 2017; 33:619-622. [PMID: 28260191 DOI: 10.1007/s00383-017-4057-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND While there is literature on techniques for pectus bar removal, there are limited reports on post-operative management. This can include obtaining a postoperative chest radiograph (CXR) despite the minimal risk of associated intra-thoracic complications. This is a review of our experience with bar removal and lack of routine post-operative CXR. METHODS A single institution retrospective chart review was performed from 2000 to 2015. Patients who underwent a pectus bar removal procedure were included. We assessed operative timing of bar placement and removal, procedure length, intra-operative and post-operative complications and post-operative CXR findings, specifically the rate of pneumothoraces. RESULTS 450 patients were identified in this study. Median duration of bar placement prior to removal was 35 months (interquartile range 30 and 36 months). Sixtey-four patients obtained a post-operative CXR. Of these, only one (58%) film revealed a pneumothorax; this was not drained. A CXR was not obtained in 386 (86%) patients with no immediate or delayed complications from this practice. Median follow-up time for all patients was 11 months (interquartile range 7.5-17 months). DISCUSSION The risk for a clinically relevant pneumothorax is minimal following bar removal. This suggests that not obtaining routine imaging following bar removal may be a safe practice.
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Affiliation(s)
- Ashwini Suresh Poola
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Katrina L Weaver
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Shawn David St Peter
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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Bilgi Z, Ermerak NO, Çetinkaya Ç, Laçin T, Yüksel M. Risk of serious perioperative complications with removal of double bars following the Nuss procedure. Interact Cardiovasc Thorac Surg 2017; 24:257-259. [PMID: 27798060 DOI: 10.1093/icvts/ivw322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/25/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives The aim of this study is to present our experience with Nuss bar removal and evaluate potential risk factors. The Nuss procedure requires an operation to remove the bar 2-3 years after the initial correction. Although removal of the bar is generally believed to be safe, perioperative complications including major bleeding can occur. Methods All cases involving removal of the Nuss bar done since April 2007 were recorded in a prospective database. Data were collected on the amount of blood loss, the number of diagnostic interventions, operative management and postoperative course. Results Of a total of 246 (162 with single bars, 80 with double bars, 4 with triple bars) cases, 43 patients (17.5%) experienced perioperative complications. Five patients underwent secondary postoperative interventions; one patient required same-session emergency video-assisted thoracic surgery (VATS) due to major bleeding. Patients who had complications were significantly older than patients with no complications (20.5 ± 6.5 years vs 17.2 ± 5.9 years, P = 0.002). People having double bars removed were significantly more likely to have perioperative complications (12% vs 27%, P = 0.03) and complications requiring secondary interventions (n = 1 for a single bar, n = 5 for double bars, P = 0.01). Conclusions Major complications after removal of the Nuss bar occur with some frequency. Although the double-bar removals in our cohort were associated with major complications, the reasons are poorly understood. Immediate management of the complications may require multidisciplinary care. Multicentric pooling of cases is needed for better risk stratification.
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Affiliation(s)
- Zeynep Bilgi
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Nezih Onur Ermerak
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Çagatay Çetinkaya
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Tunç Laçin
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Mustafa Yüksel
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
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Abstract
The Nuss procedure is now the preferred operation for surgical correction of pectus excavatum (PE). It is a minimally invasive technique, whereby one to three curved metal bars are inserted behind the sternum in order to push it into a normal position. The bars are left in situ for three years and then removed. This procedure significantly improves quality of life and, in most cases, also improves cardiac performance. Previously, the modified Ravitch procedure was used with resection of cartilage and the use of posterior support. This article details the new modified Nuss procedure, which requires the use of shorter bars than specified by the original technique. This technique facilitates the operation as the bar may be guided manually through the chest wall and no additional stabilizing sutures are necessary.
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Affiliation(s)
- Hans Kristian Pilegaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark;; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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16
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Farach SM, Danielson PD, Chandler NM. The role of chest radiography following pectus bar removal. Pediatr Surg Int 2016; 32:705-8. [PMID: 27286887 DOI: 10.1007/s00383-016-3905-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Surgical correction of pectus excavatum (PE) via a minimally invasive approach involves placement of a steel bar, which is subsequently removed. The purpose of our study was to evaluate the incidence of pneumothorax and the role for chest radiography (CXR) in patients undergoing pectus bar removal. METHODS A retrospective review of 84 patients who underwent pectus bar removal from 2006 to 2014 was performed. Results of postoperative CXR, repeat imaging, need for chest thoracostomy tube placement, and complications were analyzed. RESULTS Mean Haller index prior to correction was 4.3 ± 0.9. The mean time between PE repair and bar removal was 2.3 ± 0.6 years. Sixty-one patients (72.6 %) had a postoperative CXR. Thirty-one (50.8 %) had no acute findings, 20 (32.8 %) had findings of atelectasis or subcutaneous emphysema, and 10 (16.4 %) had a pneumothorax. One patient (1.6 %) had a second postoperative CXR for a small pneumothorax and rib fractures. There were two complications (2.4 %). No chest tubes were placed for pneumothorax, and 95 % of patients were discharged the day of surgery. CONCLUSION Postoperative CXR following pectus bar removal is unnecessary given the low incidence of postoperative pneumothorax requiring intervention. Patients can be safely discharged the day of surgery without the need for routine postoperative chest imaging.
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Affiliation(s)
- Sandra M Farach
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, 601 5th Street South, Dept. 70-6600, 3rd Floor, Saint Petersburg, 33701, FL, USA.
| | - Paul D Danielson
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, 601 5th Street South, Dept. 70-6600, 3rd Floor, Saint Petersburg, 33701, FL, USA
| | - Nicole M Chandler
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, 601 5th Street South, Dept. 70-6600, 3rd Floor, Saint Petersburg, 33701, FL, USA
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17
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Park HJ, Kim KS. Pectus bar removal: surgical technique and strategy to avoid complications. J Vis Surg 2016; 2:60. [PMID: 29078488 DOI: 10.21037/jovs.2016.02.27] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 02/04/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pectus bar removal is the final stage of the procedure for minimally invasive repair of pectus excavatum. Based on our experience with one of the largest scale data, we would like to address the important issues in pectus bar removal, such as appropriate duration of bar maintenance, techniques for bar removal, and strategies to avoid complications. METHODS Between September 1999 and August 2015, we operated on 2,553 patients with pectus excavatum and carinatum using pectus bars for a minimally invasive approach. Among them, 1,821 patients (71.3%) underwent pectus bar removal as a final stage of pectus deformity repair, and their data were analyzed retrospectively to identify the outcomes and adverse effects of the pectus bar removal procedure. The mean age of the patients was 9.13 years (range, 16 months to 44 years) and the male to female ratio was 3.55. The study is approved by the Institutional Review Board (IRB), the ethical committee of Seoul St. Mary's Hospital. The IRB has exempted the informed consent from every patient in this study due to this is a retrospective chart review without revealing any patients' personal data. RESULTS Our technique involved straightening of the bar in a supine position. The overall mean duration of pectus bar maintenance was 2.57 years (range, 4 months to 14 years). The mean duration was 2.02 years (range, 4 months to 7 years) for children under 12 years, 2.99 years (range, 7 months to 9 years) for teenagers aged 12-20 years, and 3.53 years (range, 3 months to 14 years) for adults over 20 years. Forty-eight patients (2.6%) underwent bar removal more than 5 years after bar insertion and 58 patients (3.2%) underwent bar removal earlier than initially planned. The most common adverse reaction after bar removal was wound seroma including infection (43 patients, 2.36%). Recurrence after bar removal occurred in nine patients (0.49%), and seven of these required redo repair (0.38%). CONCLUSIONS Pectus bar removal is a safe and straightforward procedure with a low rate of complication.
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Affiliation(s)
- Hyung Joo Park
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Kyung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
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18
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Iwanaka T, Yamataka A, Uemura S, Okuyama H, Segawa O, Nio M, Yoshizawa J, Yagi M, Ieiri S, Uchida H, Koga H, Sato M, Soh H, Take H, Hirose R, Fukuzawa H, Mizuno M, Watanabe T. Pediatric Surgery. Asian J Endosc Surg 2015; 8:390-407. [PMID: 26708583 DOI: 10.1111/ases.12263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 08/21/2015] [Accepted: 08/21/2015] [Indexed: 12/25/2022]
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A simple technique for pectus bar removal using a modified Nuss procedure. J Pediatr Surg 2013; 48:1137-41. [PMID: 23701795 DOI: 10.1016/j.jpedsurg.2013.01.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 01/16/2013] [Accepted: 01/31/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although the Nuss procedure has been widely accepted as the standard procedure for the repair of pectus excavatum in children, adolescents, and even adults, few reports have documented the bar removal procedure as a whole. In this study, we retrospectively evaluated the safety and efficacy of a modified Nuss bar removal procedure. METHODS A total of 186 patients undergoing bar removal after the Nuss procedure were included in this study. All cases had unilateral incision (metallic stabilizers were used on one side in all patients). Patients were laid down in the supine position and given general anesthesia through a single lumen tracheal tube or laryngeal mask. The bar was pulled out along the thoracic wall without straightening or overturning through the original right incision. RESULTS The mean operation time for bar removal was 12 min (range: 8-20 min). The mean operative blood loss was 5 mL (range: 3-20 mL). No patient suffered from an infection at the incision after surgery, but 3 patients (1.6%) developed mild pneumothorax. All patients were discharged from the hospital within a day after the surgery. The bar in 133 patients (71.5%) was removed in 2 years after Nuss procedure but more than two and a half years in 53 patients (28.5%). The patients were followed up for 4 to 48 months with a mean of 21.4 months. No recurrence was observed during the follow-up period. CONCLUSIONS The Nuss bar can be safely and easily removed in 2 years or longer after the Nuss procedure. Our study suggests that, after removing the metallic stabilizer, the bar should be turned with the flipper to loosen it from the surrounding fibrous capsule and then pulled out along the original surgical incision without bending or turning.
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Chon SH, Shinn SH. A simple method of substernal bar removal after the Nuss procedure. Eur J Cardiothorac Surg 2011; 40:e130-1. [PMID: 21696977 DOI: 10.1016/j.ejcts.2011.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 04/30/2011] [Accepted: 05/03/2011] [Indexed: 11/29/2022] Open
Abstract
The Nuss procedure for pectus excavatum is a well-known technique. Although there are numerous reports on the Nuss procedure, the reports on its removal are few. Removal has been done with many variations in the supine position, which involves bending the bar or bringing the bar beneath the operating table, which can prove to be troublesome and dangerous. Our simple technique allows easy removal of the substernal bar without bar bending. This technique was used in 21 patients without complication.
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Affiliation(s)
- Soon-Ho Chon
- Department of Thoracic and Cardiovascular Surgery, Hanyang University Guri Hospital, Guri, Republic of Korea.
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