Minimally invasive repair of pectus excavatum (MIRPE) in adults: is it a proper choice?

Impact of delayed removal of pectus bar on outcomes following Nuss repair: a retrospective analysis

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.

Minimally invasive repair of pectus excavatum in adults: a review article of presentation, workup, and surgical treatment

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.

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

Introduction

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

Aim

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

Material and methods

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

Results

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

Conclusions

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

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

Pectus excavatum is a congenital chest wall deformity, commonly identified in early childhood, creating a "sunken chest" appearance. Over time, the deformity can worsen, thus impacting cardiopulmonary function and creating significant body image disturbance in patients. The Nuss procedure is a minimally invasive technique in which a curved steel bar is introduced underneath the sternum through small bilateral thoracic incisions to correct the deformity. Most studies regarding the procedure to date focus on outcomes and complications in pediatric patients, however, few studies discuss these results in adult patients. This systematic review aims to analyze common complications and outcomes in patients over the age of 18 who have not undergone any prior intervention for pectus excavatum. The most common complications experienced in adult patients were displacement of the implanted steel bar, infection of the surgical site, pneumothorax, pleural effusion, and chronic postoperative pain. Reoperation was common in patients with a displacement of the bar, chronic pain, and bleeding. Additionally, adult patients routinely required a higher number of steel bars to be placed to correct the deformity. Despite evidence that the rate of complications increases with age, the majority of adult patients in our included studies were satisfied with the outcome of the procedure with indications of improved self-image and reduced preoperative symptoms such as dyspnea on exertion, palpitations, chest pain, and depression.

"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.

Modified Nuss operation using introducer-bar complex for pectus excavatum in adults: a retrospective study

Background

Shortcoming of traditional Nuss operation on adults is gradually found in the clinical practice. A new kind of introducer-bar complex was introduced. However, there is limited evidence regarding its safety and efficacy. Therefore, a single center, retrospective study was conducted to address this issue.

Methods

Patients with pectus excavatum who underwent surgery between January 2015 and June 2017 were consecutively enrolled in this study. In all, 52 patients underwent the modified procedure using the introducer-bar complex (new procedure group), whereas 48 underwent the traditional anti-Nuss procedure (traditional procedure group). Outcomes analysis of balanced baseline was performed to compare the intraoperative and postoperative short-term outcomes.

Results

All patients in the new procedure group had shorter operation duration (51.54 ± 20.32 vs. 79.45 ± 13.88 min, p = 0.017), postoperative hospitalizations (4.77 ± 1.62 vs. 6.86 ± 2.18 days, p = 0.028), plate removal surgery durations (39.30 ± 8.97 vs. 60.30 ± 10.49 min, p < 0.001), and less blood loss during operation (6.25 ± 4.88 vs. 10.90 ± 5.75 ml, p = 0.003) than patients in the traditional procedure group. There was no significant difference in the length of incision, postoperative Haller index, cost, number of steel bars, postoperative surgical outcome and incidence of complications between the two groups.

Conclusion

Through the main clinical outcome were similar, our results shown that modified procedure may have the shorter operation time, postoperative hospital stay, and operation time for plate removal and less blood loss, which may bring potential clinical benefits to patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01624-6.

Safety and feasibility of rigid fixation by SternaLock Blu plates during the modified Ravitch procedure: a pilot study

Background

Patients with anterior chest wall deformities unsuitable for minimally invasive repair are commonly treated by the modified Ravitch procedure. Although rigid plate fixation of the sternal osteotomy has previously shown to facilitate adequate sternal union, its use is troubled by an implant removal rate of up to 23% due to local complaints or complications associated with bulky plates. In contrast, the use of thinner and therefore biomechanically weaker plates may result in a higher incidence of non- or mal-union. In this pilot study, we evaluate the feasibility, efficacy and safety of rigid sternal fixation by thin pre-shaped anatomical locking plates during the modified Ravitch procedure.

Methods

Between June 2018 and December 2019, all consecutive patients who underwent anterior chest wall deformity repair by the modified Ravitch procedure in our tertiary referral centre were included. Data was collected retrospectively. All pectus types were included. The sternal osteotomy was fixated using thin SternaLock Blu plates. Patients were followed for at least one year.

Results

Nine patients were included. The group consisted of six male and three female patients, with a median age of 20 years [interquartile range (IQR), 16–35 years]. Median duration of follow-up was 25 months (IQR, 16–28 months). No intraoperative complications occurred. No patients presented with symptomatic non- or mal-union. Plate removal was performed in one patient for atypical pain without relief. No other postoperative complications occurred.

Conclusions

Based on these pilot results, thin SternaLock Blu plates are deemed to be safe and effective in providing adequate rigid fixation of the sternal osteotomy during the modified Ravitch procedure. Compared to literature, the need for plate removal within 25 months after surgery was reduced.

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

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.

Minimization of the complications associated with bar removal after the Nuss procedure in adults

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).

Outcomes in adult pectus excavatum patients undergoing Nuss repair

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.

Video-assisted-thoracoscopic surgery in left-to-right Nuss procedure for pectus excavatum for prevention of serious complications - technical aspects based on 1006 patients

Introduction

Additional use of the video-assisted thoracoscopic surgery (VATS) technique in the Nuss procedure has been globally accepted for the improvement of safety of surgical treatment as well as for decreased frequency of serious intraoperative and postoperative complications.

Aim

To evaluate VATS in surgical treatment of patients with pectus excavatum by the left-to-right Nuss procedure for prevention of serious intra- and postoperative complications.

Material and methods

From 2002 to 2016, 1006 patients with pectus excavatum aged 7 to 62 years (mean: 18.6) underwent the Nuss procedure. There were 796 males and 210 females. The clinical records of all patients were analyzed retrospectively. The follow-up varied from 1 to 172 months (mean: 80.7 ±43).

Results

The early 30-day postoperative mortality was zero. Early thoracoscopy-dependent postoperative complications, the majority transient and non-life-threatening, occurred in 35.6% of patients. The most frequent complication was pneumothorax, diagnosed in 24.5% of patients. Two patients required repeat surgery. One patient required VATS pleurectomy due to persistent postoperative air leakage. In another patient left thoracotomy following bleeding from the pleural cavity was performed.

Conclusions

The use of VATS in the left-to-right Nuss procedure for pectus excavatum ensures the safety of surgical treatment and minimizes the occurrence of serious intra- and postoperative complications concerning injury of the mediastinum, lung, diaphragm or abdominal cavity.