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Media AS, Christensen TD, Katballe N, Juhl-Olsen P, Vad H, Petersen RH, Højsgaard A, Vincenzo de Paoli F. Complication rates rise with age and Haller index in minimally invasive correction of pectus excavatum: A high-volume, single-center retrospective cohort study. J Thorac Cardiovasc Surg 2024; 168:699-711. [PMID: 38340954 DOI: 10.1016/j.jtcvs.2024.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 01/09/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024]
Abstract
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.
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Affiliation(s)
- Ara S Media
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Katballe
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Vad
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Anette Højsgaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Frank Vincenzo de Paoli
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark.
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Laven IEWG, van Polen EJ, Vissers YLJ, de Loos ER. Scapula alata, a rare complication after minimally invasive repair of pectus excavatum. BMJ Case Rep 2024; 17:e260788. [PMID: 38802259 DOI: 10.1136/bcr-2024-260788] [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: 05/29/2024] Open
Abstract
A male patient in his early 30s underwent minimally invasive repair of pectus excavatum. According to standard Nuss bar procedure, a 30-degree thoracoscope was introduced through a right midaxillary 10 mm trocar in the 4th intercostal space. Two bars and five stabilisers were placed in a retromuscular position. After discharge, the patient experienced right upper back pain requiring prolonged opioid usage for three months and right scapular winging limiting functional activities. After conservative treatment with physiotherapy for 11 months, the patient still suffered from residual scapula alata with pain and muscle weakness. On suspicion of long thoracic nerve neuropraxia related to the thoracoscope placement, an electromyogram was conducted 16 months following surgery, revealing mild polyphasic potentials of the serratus anterior muscle without abnormal muscle unit action potential. After extended conservative therapy for another year, physical examination 28 months after surgery showed almost complete resolution of scapular winging.
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Affiliation(s)
- Iris E W G Laven
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
| | - Elise J van Polen
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
| | - Yvonne L J Vissers
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
| | - Erik R de Loos
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
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Keong DE, Tzeng IS, Htut N, Fan YJ, Hsieh MS, Cheng YL. Impact of delayed removal of pectus bar on outcomes following Nuss repair: a retrospective analysis. J Cardiothorac Surg 2024; 19:160. [PMID: 38549167 PMCID: PMC10976664 DOI: 10.1186/s13019-024-02685-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 03/24/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Usually, pectus bars are removed 3 years after the Nuss procedure in patients with pectus excavatum. However, the optimal timing for postoperative pectus bar removal remains undefined. Our study investigated the effects of delayed pectus bar removal after Nuss repairs. METHODS Retrospective data were collected on patients who underwent Nuss procedures for pectus excavatum and had their bars removed from August 2014 to December 2020. Patients with correction periods > 3 years were divided into group A (< 6 years) and group B (≥ 6 years). Propensity score matching was used to compare complications and radiological outcomes associated with bar removal. RESULTS Of the 542 patients who underwent bar removal, 451 (Group A: 419 patients, Group B: 32) had correction duration > 3 years. The average correction duration was 4.5 ± 1.4 years. After propensity score matching analysis, group B [median duration: 8.0 (6.0-16.2) years] exhibited significantly longer median operative times (85 vs. 55 min; P = 0.026), higher callus formation rates (68.8% vs. 46.9%; P = 0.029), and greater median intraoperative blood loss (35 vs. 10 mL; P = 0.017) than group A [median duration: 4.2 (3.0-5.9) years]. However, following bar removal, the groups showed no statistical differences in the surgical complication rates (group A: 6.3% vs. group B: 9.4%; P = 0.648) or median ratio of radiological improvement (an improvement on the Haller index on chest radiography; 21.0% vs. 22.2%; P = 0.308). CONCLUSIONS Delaying pectus bar removal after Nuss repair presents certain challenges but does not compromise overall outcomes. These findings suggest that a longer correction period may be unnecessary. However, further multicenter studies with long-term follow-up are warranted to assess long-term outcomes.
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Affiliation(s)
- Der-En Keong
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | | | - Nay Htut
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Yu-Jiun Fan
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Min-Shiau Hsieh
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Yeung-Leung Cheng
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.
- School of Medicine, Tzu Chi University, Hualien, Taiwan.
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Aly MR, Farina JM, Botros MM, Jaroszewski DE. Minimally invasive repair of pectus excavatum in adults: a review article of presentation, workup, and surgical treatment. J Thorac Dis 2023; 15:5150-5173. [PMID: 37868874 PMCID: PMC10587002 DOI: 10.21037/jtd-23-87] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/29/2023] [Indexed: 10/24/2023]
Abstract
Pectus excavatum (Pex) is one of the most common congenital deformities of the chest wall, with pectus constituting 90% of all chest wall deformities and excavatum being reported in almost 1:400 to 1:1,000 live births with predominant occurrence in males up to five times more than in females. Depending on the severity, presentation varies from mild cosmetic complaints to life limiting cardiopulmonary symptoms. Patients may develop symptoms as they age, and these symptoms may worsen over the years. A technique for minimally invasive repair for pectus excavatum (MIRPE) was introduced with the concept of temporarily implanting metal bars to correct the deformity. This has rapidly become the standard of care for the pediatric and adolescent patients. The use of MIRPE in adults, however, has been slower to adopt and more controversial. This is largely due to the increased calcification and rigidity of the chest wall in adults which can make the repair more complex and lead to a higher risk of complications. We present a literature review of the presentation, workup, and surgical treatment of adult patients with Pex undergoing MIRPE. Adult patients can, with advanced preoperative evaluations and technique modifications, undergo a highly successful repair resulting in symptom resolution and satisfying results.
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Affiliation(s)
- Mohamed R Aly
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Juan M Farina
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Michael M Botros
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
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Scalise PN, Demehri FR. The management of pectus excavatum in pediatric patients: a narrative review. Transl Pediatr 2023; 12:208-220. [PMID: 36891368 PMCID: PMC9986778 DOI: 10.21037/tp-22-361] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/10/2023] [Indexed: 02/04/2023] Open
Abstract
Background and Objective Pectus excavatum is the most common congenital chest wall anomaly, the hallmark of which is the caved-in appearance of the anterior chest. A growing body of literature exists surrounding methods of surgical correction, though considerable variability in management remains. The primary objectives of this review are to outline the current practices surrounding the care of pediatric patients with pectus excavatum and present emerging trends in the field that continue to impact the care of these patients. Methods Published material in English was identified utilizing the PubMed database using multiple combinations of the keywords: pectus excavatum, pediatric, management, complications, minimally invasive repair of pectus excavatum, MIRPE, surgery, repair, and vacuum bell. Articles from 2000-2022 were emphasized, though older literature was included when historically relevant. Key Content and Findings This review highlights contemporary management principles of pectus excavatum in the pediatric population, comprising preoperative evaluation, surgical and non-surgical treatment, postoperative considerations including pain control, and monitoring strategies. Conclusions In addition to providing an overview of pectus excavatum management, this review highlights areas that remain controversial including the physiologic effects of the deformity and the optimal surgical approach, which invite future research efforts. This review also features updated content on non-invasive monitoring and treatment approaches such as three-dimensional (3D) scanning and vacuum bell therapy, which may alter the treatment landscape for pectus excavatum in order to reduce radiation exposure and invasive procedures when able.
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Affiliation(s)
- P Nina Scalise
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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Andersen NH, Hauge EM, Baad-Hansen T, Groth KA, Berglund A, Gravholt CH, Stochholm K. Musculoskeletal diseases in Marfan syndrome: a nationwide registry study. Orphanet J Rare Dis 2022; 17:118. [PMID: 35248143 PMCID: PMC8898450 DOI: 10.1186/s13023-022-02272-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 02/20/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Marfan syndrome is associated with abnormalities in the musculoskeletal system including scoliosis, pectus deformities, protrusio acetabuli, and foot deformities. Over a life span, many patients with Marfan syndrome will need treatment; however, the musculoskeletal morbidity over a life span is not well described. The aim of the present study was to assess the overall burden of musculoskeletal disease in patients with Marfan syndrome.
Materials and methods
A registry-based, nationwide epidemiological study of patients with a Ghent II verified Marfan syndrome diagnosis from 1977 to 2014. Each patient was matched on age, and sex with up to 100 controls from the background population.
Results
We identified 407 patients with Marfan syndrome and 40,700 controls and compared their musculoskeletal diagnoses and surgical treatments using Cox proportional hazards ratio (HR). The risk of a registration of a musculoskeletal diagnosis in patients with Marfan syndrome was significantly increased compared to controls (HR: 1.94 (1.69–2.24). One out of six with Marfan syndrome was registered with scoliosis (HR: 36.7 (27.5–48.9). Scoliosis was more common in women with Marfan syndrome compared to men (HR: 4.30 (1.73–1.08)). One out of 11 were registered with a pectus deformity HR: 40.8 (28.1–59.3), and one out of six with a deformity of the foot. Primarily pes planus (HR: 26.0 (15.2–44.3). The proportion of patients with Marfan syndrome (94/407) that underwent musculoskeletal surgery was also significantly higher (HR: 1.76 (1.43–2.16)). The major areas of surgery were the spine, pectups correction, and surgery of the foot/ankle. Ten patients with Marfan syndrome had elective orthopedic surgery without being recognized and diagnosed with Marfan syndrome until later in life. None of these had scoliosis, pectus deformity or a foot deformity. Among patients with an aortic dissection, the age at dissection was 34.3 years in those with at least one major musculoskeletal abnormality. In patients without a major abnormality the age at dissection was 45.1 years (p < 0.01).
Conclusions
The extent of musculoskeletal disease is quite significant in Marfan syndrome, and many will need corrective surgery during their life span. Surgeons should be aware of undiagnosed patients with Marfan syndrome when treating patients with a Marfan syndrome like-phenotype.
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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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Del Frari B, Blank C, Sigl S, Schwabegger AH, Gassner E, Morawetz D, Schobersberger W. The questionable benefit of pectus excavatum repair on cardiopulmonary function: a prospective study. Eur J Cardiothorac Surg 2021; 61:75-82. [PMID: 34263302 PMCID: PMC8715845 DOI: 10.1093/ejcts/ezab296] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/03/2021] [Accepted: 05/13/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Since the introduction of the minimally invasive technique for repair of pectus excavatum (MIRPE), increasing numbers of patients are presenting for surgery. However, controversy remains regarding cardiopulmonary outcomes of surgical repair. Therefore, the aim of our prospective study was to investigate cardiopulmonary function, at rest and during exercise before surgery, first after MIRPE and then after pectus bar removal.
METHODS Forty-seven patients were enrolled in a prospective, open-label, single-arm, single-centre clinical trial (Impact of Surgical Treatments of Thoracic Deformation on Cardiopulmonary Function) [NCT02163265] between July 2013 and November 2019. All patients underwent a modified MIRPE technique for surgical correction of pectus excavatum (PE), called Minor Open Videoendoscopically Assisted Repair of Pectus Excavatum. The patients underwent pre- and postoperative chest X-ray, three-dimensional volume-rendering computer tomography thorax imaging, cardiopulmonary function tests at rest and during stepwise cycle spiroergometry (sitting and supine position) and Doppler echocardiography. Daily physical activity questionnaires were also completed. RESULTS The study was completed by 19 patients (15 males, 4 females), aged 13.9–19.6 years at the time of surgery. The surgical patient follow-up was 5.7 ± 7.9 months after pectus bar removal. No significant differences in cardiopulmonary and exercise parameters were seen after placement of the intrathoracic bar, or after pectus bar removal, compared to presurgery. CONCLUSIONS Our findings indicate that surgical correction of PE does not impair cardiopulmonary function at rest or during exercise. Therefore, no adverse effects on exercise performance should be expected from surgical treatment of PE via the modified MIRPE technique. Clinical trial registration number clinicaltrials.gov [ClinicalTrials.gov number, NCT02163265].
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Affiliation(s)
- Barbara Del Frari
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Cornelia Blank
- Department of Psychology and Sports Medicine, Institute of Sports Medicine, Alpine Medicine & Health Tourism (ISAG), University for Health Sciences, Medical Informatics and Technology (UMIT TIROL), Hall in Tyrol, Austria
| | - Stephan Sigl
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Anton H Schwabegger
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Eva Gassner
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - David Morawetz
- Department of Psychology and Sports Medicine, Institute of Sports Medicine, Alpine Medicine & Health Tourism (ISAG), University for Health Sciences, Medical Informatics and Technology (UMIT TIROL), Hall in Tyrol, Austria.,Institute for Sports Medicine, Alpine Medicine & Health Tourism (ISAG), Tirol Kliniken GmbH Innsbruck, Innsbruck, Austria
| | - Wolfgang Schobersberger
- Department of Psychology and Sports Medicine, Institute of Sports Medicine, Alpine Medicine & Health Tourism (ISAG), University for Health Sciences, Medical Informatics and Technology (UMIT TIROL), Hall in Tyrol, Austria.,Institute for Sports Medicine, Alpine Medicine & Health Tourism (ISAG), Tirol Kliniken GmbH Innsbruck, Innsbruck, Austria
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The Nuss procedure for pectus excavatum: An effective and safe approach using bilateral thoracoscopy and a selective approach to use multiple bars in 296 adolescent and adult patients. PLoS One 2020; 15:e0233547. [PMID: 32470011 PMCID: PMC7259695 DOI: 10.1371/journal.pone.0233547] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 05/07/2020] [Indexed: 11/19/2022] Open
Abstract
The Nuss procedure is a minimally invasive repair used to treat pectus excavatum. A bilateral thoracoscopy-assisted approach has been reported as a safe method for Nuss repair. The aim of this observational cohort study is to evaluate the application of the bilateral thoracoscopy-inspection to assist in the selection of the number of bars for correction of the pectus deformity in adolescents and adults. A retrospective chart review was performed on all adolescent and adult patients (296 patients: 257 male, 39 female; aged of 23.9 ± 7.7 years) with pectus excavatum primarily corrected with the modified Nuss repair from August 2014 to January 2018. The patients were divided into three age groups (A: 12 years ≦ age < 19 years, n = 73; B: 19 years ≦ age < 30 years, n = 175; C: age ≧ 30 years, n = 48). Advanced repair of deformed chest walls using more than one bar depended on the change detected via gross and perioperative thoracoscopy-inspection. The results showed that two or three pectus bars were used in 268 patients (90.5%). The overall complication rate after a postoperative follow-up of 28.6 ± 11 months was 6.8% (20/296), without mortality, major bleeding, or serious infectious complications. A multivariate logistic regression analysis showed that the complications were only associated with Haller index (adjusted OR = 1.2935, p = 0.0317) under controlling confounding factors. The postoperative sternovertebral distance was significantly improved from 7.3±1.6 to 10.1± 2.8 cm (p<0.001). The thoracoscopy-assisted approach of Nuss repair for correction of pectus excavatum was safe and effective approach and could also be used as an alternative approach for the selection of placed bars in adolescent and adult patients. Further studies regarding long-term outcomes are required.
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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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12
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Pérez D, Martel O, Yánez A, Cano JR, Cuadrado A, Torrent G, López L. Does the modelling of the pectus bar affect its stability? Rationale for using a short flat bar. Interact Cardiovasc Thorac Surg 2019; 30:11-17. [DOI: 10.1093/icvts/ivz217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/01/2019] [Accepted: 08/04/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Although the Nuss procedure for pectus excavatum is still associated with a non-negligible risk of postoperative bar displacement, the potential effects of the length and shape of the bar on its corrective ability and stability have not been sufficiently studied. The aim of this study was to determine how the modelling of the pectus bar affects its stability and whether an alternative configuration of the implant can improve clinical success.
METHODS
Simulated implantation of bars with different shapes and sizes in a computational model was carried out. A 250 N sternal force was applied to the bars, and the resulting forces and moments on the fixation points were identified. Afterwards, a clinical trial was carried out in a group of patients with pectus excavatum, some of whom received long inverted U-shaped bars and some of whom received implants designed from the computational results.
RESULTS
When U-shaped bars were tested, the sternal force generated unbalanced horizontal reaction forces (16 vs 61 N) and large reaction moments at the ends of the bar, conferring the tendency to slide and to rotate, respectively. No lateral or rotational destabilizing forces occurred in the case of a flat bar. Cosmetic outcomes, postoperative times and hospital stays were similar in both clinical groups. However, 2 cases (2/15) of bar flipping occurred in patients who received the conventional bar.
CONCLUSIONS
The shape of the bar is a determinant of its stability. A flat, shorter pectus bar provides adequate correction of the deformity with less tendency for bar displacement in the repair of pectus excavatum.
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Affiliation(s)
- David Pérez
- Thoracic Surgery Section, Hospital Universitario Insular de Gran Canaria, Las Palmas, Spain
| | - Oscar Martel
- Department of Mechanical Engineering, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Alejandro Yánez
- Department of Mechanical Engineering, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - José R Cano
- Thoracic Surgery Section, Hospital Universitario Insular de Gran Canaria, Las Palmas, Spain
| | - Alberto Cuadrado
- Department of Mechanical Engineering, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Gara Torrent
- Thoracic Surgery Section, Hospital Universitario Insular de Gran Canaria, Las Palmas, Spain
| | - Luis López
- Thoracic Surgery Section, Hospital Universitario Insular de Gran Canaria, Las Palmas, Spain
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13
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Combining Correction of Pectus Excavatum and Open Heart Surgery in a Single-Stage Procedure. Ann Thorac Surg 2019; 109:e71-e74. [PMID: 31494137 DOI: 10.1016/j.athoracsur.2019.07.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 11/20/2022]
Abstract
The presence of pectus excavatum in patients undergoing open heart surgery is rare, and no consensus has been reached regarding the surgical approach. Thus, this paper describes a single-stage procedure for correction of pectus excavatum with the modified Nuss procedure ad modum Pilegaard in 4 patients undergoing open heart surgery. Three of 4 patients successfully underwent the single-stage procedure. At follow-up after bar removal, all patients had no complications related to the Nuss bar, and all had excellent cosmetic results.
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14
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Davari H, Rahim MB, Ershadi R, Rafieian S, Mardani P, Vakili MR, Shirinzadeh A. First Iranian Experience of the Minimally Invasive Nuss Procedure for Pectus Excavatum Repair: A Case Series and Literature Review. IRANIAN JOURNAL OF MEDICAL SCIENCES 2018; 43:554-559. [PMID: 30214110 PMCID: PMC6123557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Pectus excavatum is the most common congenital deformity of the chest wall. The most frequently used techniques include Ravitch (costochondral resection) and Nuss (minimally invasive pectus repair of pectus excavatum [MIRPE]). The Nuss technique includes using temporary metallic bars without costochondral resection to correct the chest wall deformity. Modified MIRPE can be learned easily and performed safely with few complications. There are no reports of successful MIRPE in Iran, although the Ravitch technique is well known. In the present study, we report the first Iranian experience with the modified Nuss procedure in 5 patients with pectus excavatum (age range=13-48 y). All the patients suffered from low self-esteem, and one of them complained of low exercise capacity and occasional chest pain. With single-lung ventilation and sternal elevation, an introducer was entered into the right thoracic cavity and retrosternal tunneling was performed under thoracoscopic vision. The introducer was passed to the left thoracic cavity and exited on the left thoracic wall. A titanium plate bar was implanted and fixed with stabilizers. There were no cases of mortality, and all the patients were discharged in good conditions within 2 weeks. Postoperative complications consisted of 1 case of pneumothorax and 2 cases of fixed bar protrusion. The present case series indicated that a skilled thoracoscopic surgeon is able to do the Nuss procedure in Iranian patients with symmetrical pectus excavatum with few complications. However, mixed or redo cases require more expertise.
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Affiliation(s)
- Hamidreza Davari
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
| | - Mohammad Bagher Rahim
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
| | - Reza Ershadi
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
| | - Shahab Rafieian
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
| | - Parviz Mardani
- General Thoracic Surgeon, General Surgery Ward, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Rahim Vakili
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
| | - Ahmad Shirinzadeh
- General Thoracic Surgeon, General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran Iran;
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15
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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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16
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Kelly RE, Daniel A. Outcomes, quality of life, and long-term results after pectus repair from around the globe. Semin Pediatr Surg 2018; 27:170-174. [PMID: 30078488 DOI: 10.1053/j.sempedsurg.2018.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The procedure introduced by Donald Nuss in 1997 at the American Pediatric Surgical Association meeting has now been adopted by pediatric, thoracic, and plastic surgeons around the globe. Since its introduction, the Nuss procedure has been the subject of intense scrutiny. More than 20 years since the original publication, medical centers from around the world have reported their experience with the procedure and robust evidence now supports its safety and efficacy. Additionally, in collaboration with psychologists in Norfolk, a methodology was devised to measure the psychosocial as well as the physical benefits of the procedure. Extensive independent multinational and multi-institutional data demonstrate repair of pectus excavatum using the Nuss procedure results in marked improvement in both physical function and body image. This report reviews the outcomes, quality of life, and long-term results of numerous centers worldwide since the introduction of the procedure.
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Affiliation(s)
- Robert E Kelly
- Department of Surgery, Children's Hospital of The King's Daughters, 601 Children's Lane, Norfolk, VA 23507, United States; Clinical Surgery and Pediatrics, Eastern Virginia Medical School, Norfolk, VA, United States.
| | - Antarius Daniel
- Department of Surgery, Children's Hospital of The King's Daughters, 601 Children's Lane, Norfolk, VA 23507, United States
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17
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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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18
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Ewais MM, Chaparala S, Uhl R, Jaroszewski DE. Outcomes in adult pectus excavatum patients undergoing Nuss repair. PATIENT-RELATED OUTCOME MEASURES 2018; 9:65-90. [PMID: 29430201 PMCID: PMC5796466 DOI: 10.2147/prom.s117771] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.
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Affiliation(s)
- MennatAllah M Ewais
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Shivani Chaparala
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Rebecca Uhl
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
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