Routine postoperative chest X-ray is unnecessary following the Nuss procedure for pectus excavatum

Complication rates rise with age and Haller index in minimally invasive correction of pectus excavatum: A high-volume, single-center retrospective cohort study

OBJECTIVES

The study objectives were to describe the compounded complication rate of minimally invasive repair of pectus excavatum, identify predisposing risk factors, and evaluate the optimal timing of correction. Minimally invasive repair of pectus excavatum is the standard treatment for pectus excavatum and consists of 2 invasive procedures, for example, correction with bar insertion followed by bar removal after 2 to 3 years.

METHODS

A retrospective cohort study identifying children, adolescents, and adults of both genders corrected for pectus excavatum with minimally invasive repair of pectus excavatum between 2001 and 2022. Information on complications related to bar insertion and removal procedures for each individual patient was compiled into a compounded complication rate. Complication severities were categorized according to the Clavien-Dindo classification.

RESULTS

A total of 2013 patients were corrected by minimally invasive repair of pectus excavatum with a median age (interquartile range) for correction of 16.6 (5) years. Overall compounded complication rate occurred at a frequency of 16.4%, of which 9.3% required invasive reinterventions (Clavien-Dindo classification ≥IIIa). The complication rate related to bar insertion was 2.6-fold higher compared with bar removal (11.8% vs 4.5%, respectively). Multivariable analysis revealed age (adjusted odds ratio, 1.05; P < .001), precorrection Haller Index (adjusted odds ratio, 1.10; P < .033), and early-phase institutional experience (adjusted odds ratio, 1.59; P < .002) as independent predisposing risk factors. The optimal age of correction was 12 years, and the compounded complication rate correlated exponentially with age with a doubling time of 7.2 years. Complications increased 2.2-fold when the Haller index increased to 5 or more units.

CONCLUSIONS

Minimally invasive repair of pectus excavatum is associated with a high compounded complication rate that increases exponentially with age and high Haller Index. Consequently, we recommend repair during late childhood and early adolescence, and emphasize the importance of informing patients and relatives about the significant risks of adult correction as well as the need of 2 consecutive procedures taking the complication profile into account before planning surgery.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

"When to Nuss? patient age as a risk factor for complications of minimally invasive repair of pectus excavatum: a systematic review and meta-analysis"

PURPOSE

The optimal age for minimally invasive repair of pectus excavatum (MIRPE) is unclear; this study investigates the differences in complication rates among different age groups undergoing repair.

METHODS

PubMed and Embase databases were searched from inception to October 2020. To assess age as a risk factor for complications, odds ratios from relevant studies were analyzed using the Mantel-Haenszel method with a random-effects model for younger vs older patients. Specific complication rates were compared between the two cohorts using a chi-squared test.

RESULTS

Of the 4448 studies retrieved, 25 studies stratified complication data by age groups. From these studies, ten studies compared groups at ages < 18 and ≥ 18 and four studies compared ages < 20 and ≥ 20, and one study compared ages < 19 and ≥ 19. These fifteen studies reported on 5978 patients, with 1188 complications, for a complication rate of 19.87%. Older patients were more likely to have complications in a pooled analysis of studies comparing older vs younger patients (OR = 1.66, 95% CI = 1.28-2.14, heterogeneity I² = 49%). Specifically, older patients were significantly more likely to experience pneumothorax, pleural effusion, wound infection, bar displacement, and reoperations.

CONCLUSION

Increased age is a risk factor for complications of MIRPE. This supports repair of pectus excavatum prior to late adolescence.

The use of lung ultrasound compared to chest X-ray to diagnose pneumothorax following the Nuss procedure for pectus excavatum repair in children

BACKGROUND

Pectus Excavatum is the most common deformation of the skeletal chest wall, and the Nuss procedure is used to correct this deformation. Residual pneumothorax is a frequent postoperative complication after thoracoscopy. Primary aim of this prospective observational study was to compare the level of agreement among readers using lung ultrasound and chest X-ray.

METHODS

This was an inter-reader single-center prospective observational agreement study for lung ultrasound and chest X-ray. Three lung ultrasound evaluations were performed at the end of surgery in the operating room by two Consultant Anesthesiologist (A1 and A2) and by a medical student (A3). Chest X-ray was interpreted by a consultant Radiologist (R1) and a pool of 11 radiologists (collectively named R2). Cohen's kappa was used to evaluate the level of agreement between the two imaging techniques.

RESULTS

Sixty-eight pediatric patients were included in the study. The overall agreement among (A = Anesthesiologist) A1, A2, A3, (R = Radiologist) R1, and R2 in assessing pneumothorax was fair (k = 0.32; 95% CI 0.21-0.40). The stratified analysis showed moderate inter-reader agreement among lung ultrasound readers A1, A2, and A3 (k 0.58; 95% CI 0.44-0.71), as opposed to the fair agreement found among chest X-ray readers R1 and R2 (k = 0.39; 95% CI 0.18-0.60).

CONCLUSIONS

Our results support the use of lung ultrasound to diagnose pneumothorax after Nuss procedure. We found that the inter-reader accuracy was better with ultrasound compared to X-ray at our institution.

Reducing Unnecessary Chest X-Ray Films After Thoracic Surgery: A Quality Improvement Initiative

BACKGROUND

Previous work has identified that inpatient post-thoracic surgery chest x-ray films (CXR) are overutilized.

METHODS

A three-phase rapid cycle quality improvement initiative was performed to reduce empiric post-thoracic surgery CXR use by 25% over 1 year. We adapted evidence-based guidelines and implemented "plan-do-study-act" (PDSA) cycle methodology. The PDSA cycles included (1) education with literature and preintervention statistics; (2) electronic medical record order-set modification; and (3) audit and feedback with monthly status reports. Each cycle lasted 3 months. Use of CXR was tracked in the post-anesthesia care unit and as a daily rate of non-post-anesthesia care unit CXRs. Cost data were estimated from Centers for Medicare & Medicaid Services fees.

RESULTS

During the initiative, 292 thoracic surgery inpatients were monitored. Before intervention, 99% of patients (69 of 70) received a post-anesthesia care unit CXR, and the daily rate of other CXRs was 1.6. Overall, there was a significant reduction in CXR utilization (P < .001). Post-anesthesia care unit CXRs decreased by 42%, lowering to 89% (68 of 76) to 68% (50 of 74) to 57% (41 of 72) in PDSA cycles 1 through 3, respectively. The daily rate of other CXRs decreased by 38%, lowering to 1.4 to 1.3 to 1.0. Patient perioperative characteristics and health care quality measures were not different between cycles. After quality improvement implementation, cost savings were estimated to be at least $73,292 per year.

CONCLUSIONS

Implementation of our quality improvement initiative safely and systematically reduced empiric CXR use after inpatient thoracic surgery. Results will be used in future quality improvement initiatives to reduce unnecessary postoperative testing.

Enhancing recovery after minimally invasive repair of pectus excavatum

PURPOSE

There are variations in the perioperative management of patients who undergo minimally invasive repair of pectus excavatum (MIRPE). The purpose is to analyze the change in resource utilization after implementation of a standardized practice plan and describe an enhanced recovery pathway.

METHODS

A standardized practice plan was implemented in 2013. A retrospective review of patients who underwent MIRPE from 2012 to 2015 was performed to evaluate the trends in resource utilization. A pain management protocol was implemented and a retrospective review was performed of patients who underwent repair before (2010-2012) and after (2014-2015) implementation.

RESULTS

There were 71 patients included in the review of resource utilization. After implementation, there was a decrease in intensive care unit length of stay (LOS), and laboratory and radiologic studies ordered. There were 64 patients included in the pain protocol analysis. After implementation, postoperative morphine equivalents (3.3 ± 1.4 vs 1.2 ± 0.5 mg/kg, p < 0.01), urinary retention requiring catheterization (33 vs 14%, p = 0.07), and LOS (4 ± 1 vs 2.8 ± 0.8 days, p < 0.01) decreased.

CONCLUSION

The implementation of an enhanced recovery pathway is a feasible and effective way to reduce resource utilization and improve outcomes in pediatric patients who undergo minimally invasive repair of pectus excavatum.

Routine use of chest radiographs in the post-operative management of pectus bar removal: necessity or futility

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.

Short Nuss bar procedure

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.

Single centre experience on short bar technique for pectus excavatum

BACKGROUND

Pectus excavatum (PE) is the most frequent anomaly of the anterior chest wall. Before 2001, all patients in Denmark were referred to the plastic and reconstructive surgeon for implantation of a subcutaneous silicone prosthesis, because the modified Ravitch procedure was not used. Since 2001, all patients have been treated with a modified Nuss procedure, which today has become the gold standard for correction of PE.

METHODS

From September 2001 to March 2016, 1,713 patients have been operated by a modified Nuss procedure using the short bar at Aarhus University Hospital with a male-female ratio 6:1. The median age was 16 years (range 7-58 years). All operations were done in general anesthesia with epidural analgesia and all patients were operated by the same surgeon. All patients were seen routinely 6 weeks after surgery and the bars were removed after 3 years.

RESULTS

Patients were younger than 18 years in 1,109 cases (65%). The number of bars needed for optimal correction was one in 1,209 patients, two in 486 patients and three in 18 patients. The median length of bar changed from 11 inches to 10 inches during the study period. The annual number of procedures continued to rise during the study period [833 patients during the first 10 years and 880 patients in the last 6 years, though more patients received two bars in the later period, (34%) versus (24%)] and the proportion of patients older than 30 years increased from 7.7% to 10%. The average duration of the operation was 36 minutes (range 12-270 minutes) and did not change significantly during the study period, change in operation time which was around half an hour. The median postoperative hospital stay decreased over time from 6 to 2 days. There was no mortality.

CONCLUSIONS

The modified Nuss procedure with the short bar technique is effective for the correction of PE. The results are stable with a low rate of bar malrotations, and in may most cases can be done in less than an hour in experienced hands.

The role of chest radiography following pectus bar removal

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.

Nuss technique in pectus excavatum: a mono-institutional experience

BACKGROUND

Pectus excavatum (PE) is the most common anomaly of the anterior chest wall. Prior PE was corrected by a modified Ravitch operation, but since Nuss published his minimal technique in 1998, most surgeons have preferred this technique.

METHODS

Since 2001 the modified Nuss procedure has routinely been used for correction of more than 1,500 patients at Aarhus University Hospital. In the time period between January 1, 2011 and January 31, 2015, 675 patients have been corrected. The median age was 16 years (range, 11-58 years). All patients had preoperatively an epidural catheter and the operations were done in general anaesthesia. The postoperative pain treatment was planned for 4-5 weeks and the patients were routinely seen in the outpatient clinic 6 weeks after surgery and the bars removed after 3 years.

RESULTS

Four hundred-and-fifty patients had one bar, 216 patients with two bars and nine patients with three bars inserted. The median length of the bar was 10 inch. The median duration of the operation was 29 minutes. The median postoperative stay was 3 days. No death, cardiac perforation or deep infection occurred and only 5% of the patients experienced a complication.

CONCLUSIONS

The Nuss procedure should still be considered in the treatment of PE. To my opinion, it should be the choice for correction of PE. The short bar should be used to achieve the best stability of the system, to obtain a good cosmetic result, a reduced dysfunction motion of the chest wall and an increased cardiac performance.