Does A High Haller Index Impact Outcomes in Pectus Excavatum Repair?

OBJECTIVE

Severity for pectus excavatum includes Haller index >3.25. An extremely high Haller index (≥8) may influence surgical approach and complications. This study reviews outcomes of high Haller index patients after repair.

METHODS

A single institution retrospective analysis was performed on adult patients with Haller index ≥8 undergoing pectus excavatum repairs. For outcomes, a propensity-matched control group with a Haller index ≤4 was utilized.

RESULTS

In total, 64 cases (mean age 33.5 ±10.9 years, Haller index 13.1 ±5.0; 56% females) were included. A minimally invasive repair was successful in 84%. A hybrid procedure was performed in the remaining either to repair fractures of the ribs (8 patients) and sternum (5 patients) or when osteotomy and/or cartilage resection is required (10 patients). In comparison with the matched cohort (Haller index ≤4), high Haller index cases had longer operative times (171 vs. 133 minutes, p<.001), more frequently required Hybrid procedures (16% vs. 2%, p=0.005), experienced higher incidences of rib (22% vs. 3%, p=0.001) and sternal fractures (12% vs. 0%, p=0.003), and had increased repair with 3 bars (50% vs. 19%, p<0.001). There were no significant differences between the groups for length of hospital stay or postoperative 30-day complications.

CONCLUSION

Patients with an extremely high Haller index can be challenging cases with greater risks of fracture and need for osteotomy/cartilage resection. Despite this, minimally invasive repair techniques can be utilized in most cases without increased complications when performed by an experienced surgeon.

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.

Treatment of the congenital thoracic deformity pectus excavatum

Pectus excavatum is the most common chest wall deformity in the Czech Republic. This chest deformity is typically characterized by a wall depression with sternal rotation. If the excavation of the chest wall does not cause any physical or psychological problems, the patient does not need any specific treatment. However, if the deformity is painful, affects the function of the lungs, heart or results in psychological problems, we can propose an appropriate treatment for the specific age category of the patient. Up to 10 years, we choose a procedure that includes targeted exercises and rehabilitation; in the age group of 10-15 years, we can add to the exercises the vacuum bell therapy according to the patient's wishes and compliance; and in the age category of 16 years and above, the patient can be offered a surgical solution. The Nuss operation (so-called MIRPE - minimally invasive repair of pectus excavatum) is the gold standard in surgical treatment; during this surgery, a patient-shaped bar is inserted retrosternally into the patient's chest under thoracoscopic control and is left for 3 years. The aim of this article is to describe the most common modern methods used in the treatment of patients with pectus excavatum, supplemented by a historical overview.

Intercostal Nerve Cryoablation in Minimally Invasive Repair of Pectus Excavatum: Effect on Pulmonary Function

Introduction: Cryoablation of intercostal nerves is performed for pain control after minimally invasive repair of pectus excavatum (MIRPE). Cryoablation affects both sensory and motor neurons, resulting in temporary anesthesia to the chest wall and loss of intercostal motor function. The study objective is to determine the effect of cryoablation on incentive spirometry (IS) volumes, as a measure of pulmonary function, after MIRPE. Materials and Methods: A single-institution retrospective review of pediatric patients undergoing MIRPE was performed. All patients received a multimodal regimen (MMR) of analgesics postoperatively. Three groups were compared-cryoablation (CRYO), elastomeric pain pump (EPP), and MMR alone. The primary outcomes were postoperative IS volumes and IS volumes as a ratio of preoperative forced vital capacity (FVC). Secondary outcomes included pain scores, opioid use, length of stay (LOS), and infectious complications. Results: MIRPE was performed in 115 patients: 50 CRYO, 50 EPP, and 15 MMR alone. Groups were similar for demographics and pectus excavatum severity. Postoperative spirometry measurements were similar across groups: IS (CRYO 750 mL [500,961] versus EPP 750 mL [590,1019] versus MMR 696 mL [500,1037], P = .77); IS/FVC (CRYO 0.19 [0.14,0.26] versus EPP 0.20 [0.16,0.26] versus MMR 0.16 [0.15,0.24], P = .69). Although pain scores were also similar across groups, CRYO patients used less opioid (P < .05) and had shorter LOS (P < .05). Postoperative pneumonia was rare and similar across groups (P = 1.00). Conclusion: Intercostal nerve cryoablation during MIRPE does not adversely affect postoperative IS volumes or increase pneumonia rate, despite the temporary loss of motor innervation to intercostal muscles. Cryoablation provides effective pain control with less opioid use.

[Place of 3D custom-made implants after failure of modeling steno-chondro-plasties]

Most common congenital malformation of the thorax, Pectus Excavatum affects about one in 500 people. Several surgical or medical techniques have been proposed. Some are followed by complications or insufficient results even though their constant functional value is highly controversial. Secondary surgery with a deep customized 3D elastomer implant, may be an elegant effective and safe solution compared to others; it allows a good aesthetic result expected by patients in the absence of any respiratory or cardio-vascular functional context.

Postoperative management of pediatric patients undergoing minimally invasive repair of pectus excavatum: Where are we now?

PURPOSE

Minimally invasive repair of pectus excavatum (MIRPE) often leads to a painful and challenging recovery period. This study aims to describe the postoperative management of pediatric patients undergoing MIRPE and compare postoperative outcomes between patients using different routes of postoperative analgesia.

METHODS

Retrospective chart review of pediatric patients who underwent MIRPE from July 2003 to September 2019 at a single pediatric tertiary care center. Data on pain management and course of hospital stay were ascertained. Descriptive statistics, Mann-Whitney U and Pearson Chi-Square tests were used to analyze data. A p-value <0.05 was considered significant.

RESULTS

Of the 115 patients identified, 58 (50.4%) managed pain postoperatively using thoracic epidural and 57 (49.6%) used intravenous patient-controlled analgesia (IVPCA). The transition from the predominant use of epidural to IVPCA for MIRPE occurred between 2012 and 2013. Higher pain scores were reported by the IVPCA group at 6 h (p<0.001) and 12 h (p<0.001) postoperative. Patients using IVPCA had lower postoperative opioid consumption (p<0.001) and switched to oral opioids sooner than the epidural group (p<0.001). Fewer patients in the IVPCA group required urinary catheterization (p<0.001). Patients using IVPCA had a shorter hospital stay (4 days [IQR 4-5]) compared to the epidural group (5.5 [IQR 5-6]; p<0.001). Readmission was comparable at 3.48% in the total sample.

CONCLUSION

Patients using intravenous patient-controlled analgesia reported higher pain scores however, this route of analgesia was associated with shorter hospital stay. Prospective studies designed to address moderator variables are required to confirm findings and develop standardized recovery protocols.

"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.

Pulmonary function, exercise capacity and dyspnea in patients 7 ​years after Nuss surgery

PURPOSE

Pectus excavatum is a frequent thoracic malformation increasingly treated with minimally invasive methods (MIRPE), which are performed for cardio-respiratory problems and in some centers also for esthetic considerations. Theoretically, MIRPE may increase thoracic elastic recoil, work of breathing and cause emphysema. The aim of the present study was to determine whether teenagers who underwent MIRPE may expect normal thoracic cage development, cardio-respiratory function, exercise capacity and asymptomatic functioning.

MATERIAL AND METHODS

Fifty five patients (21.1 ​± ​3.0 years) who underwent MIRPE between 2000 and 2010 were assessed 6.8 (±2.4) years after surgery. Controls were matched for sex, age and height to the intervention participants. Spirometry, body plethysmography, diffusion capacity and the 6 ​min walking test (6MWT) were performed. Anteroposterior (AP) and transverse chest diameters were measured.

RESULTS

Participants who underwent MIRPE had normal pulmonary function, and exercise capacity. After adjustment for potential confounders, the intervention group had lower mean BMI [-1.88 ​± ​0.56 (kg/m²); p ​= ​0.001] and chest AP diameter [-2.79 ​± ​0.57 (cm); p ​< ​0.001], but higher residual volume (RV%) [12.98 ​± ​5.31 (%); p ​= ​0.001], RV% total lung capacity (TLC) [5.56 ​± ​0.92 (%); p ​< ​0.001], forced expiratory volume in 1 ​s/forced vital capacity (FEV₁/FVC) [2.64 ​± ​1.28 (%); p ​= ​0.039] and 6MWT distance [29.10 ​± ​13.02 (m); p ​= ​0.025].

CONCLUSIONS

Young adults who undergo MIRPE may expect normal pulmonary function and exercise capacity. Observed differences in air trapping require further assessment in terms of emphysema development risk.

Efficacy and Safety of Taulinoplasty Compared with the Minimally Invasive Repair of Pectus Excavatum Approach to Correct Pectus Excavatum

Background: Minimally invasive repair of pectus excavatum (MIRPE) technique is the current most used surgical method for pectus excavatum (PE) correction. To avoid MIRPE-required invasion of the mediastinum or pleural cavity, we developed taulinoplasty approach as an alternative option for the reduction of the sunken chest. Materials and Methods: This is a single-center unblind nonrandomized prospective pilot study, involving 26 MIRPE and 23 taulinoplasty patients. The primary safety endpoint was the presence of surgical complications, and the primary efficacy endpoint was Haller index measured postoperatively in taulinoplasty patients. Secondary endpoints were intensive care unit (ICU) and hospital length of stay (LOS), duration of surgical procedure, and postoperative pain management. Chi-square, Mann-Whitney, or Student "t" tests were used for comparison as appropriate. Results: There were no difference in median age (14.5 and 14 years), Haller index (4.63 and 4.17), or comorbidities. MIRPE and taulinoplasty procedures showed no difference regarding major or minor surgical complications. The efficacy endpoint of taulinoplasty was measured 5.5 (1.5-12) months after the procedure, exhibiting a significant reduction in the Haller index [4.17 (3.7-4.7) at baseline and 3.7 (2.9-4.1) postoperatively, P = .03]. Taulinoplasty required less surgical time (60.4 ± 15.5 versus 70.7 ± 15.9 minutes, P < .01); shorter ICU and hospital LOS (P < .01, respectively); and required fewer days of peridural, intravenous, and oral analgesia (P < .01, respectively). Conclusions: In this pilot study, taulinoplasty technique was as safe as the MIRPE approach and effective for the correction of PE, reducing surgical time, ICU and hospital LOS, and achieving better postoperative pain control.

Pectus cross bars increase hospital readmission rates due to serous pleural effusion

OBJECTIVE

Pectus Excavatum's (PE) surgical treatment should be patient specific. In this article, we aimed to compare parallel and cross bar variations of the Nuss method and analyze if there is any difference in results.

METHODS

In this study, a total of 891 patients treated with the Nuss method between August 2005 and February 2018 were considered. These were retrieved from a prospectively recorded PE database. Of these, 276 double-bar patients were included in the study. Patients with parallel bars (225 cases) and patients with crossed bars (51 cases) were compared in terms of age, gender, symmetry, family history, additional anomalies, mean operation time, postoperative hospital stay (days) and hospital readmission rate.

RESULTS

The mean age was measured at 20.7 for parallel bar patients and 20.1 for crossed bars patients. There was no statistically significant difference in terms of age, gender, and mean operation time between two groups. On the other hand, statistical significance was found between two groups when analyzing the deformities' symmetry, patients' family history and additional anomalies. The statistically significant difference of postoperative hospital stay between two groups is clinically negligible. Postoperative hospital readmission rates due to serous pleural effusion were found to be significantly increased in patients with crossed bars (p < 0.001).

CONCLUSION

While pleural effusion requiring readmission was statistically more frequent in cross bars, in centers where thoracentesis can be managed, Nuss method can still be applied safely, even in cases with difficult, complex deformities.

LEVEL OF EVIDENCE

III. Treatment study.

Failed preoperative vacuum bell therapy does not affect outcomes following minimally invasive repair of pectus excavatum

PURPOSE

It is unknown if failed preoperative vacuum bell (VB) treatment in patients undergoing minimally invasive repair of pectus excavatum (MIRPE), delays repair and/or affects postoperative outcomes.

METHODS

A retrospective data analysis including all consecutive patients treated at one single institution undergoing MIRPE was performed between 2000 and 2016. Patients were stratified into preoperative VB therapy versus no previous VB therapy.

RESULTS

In total, 127 patients were included. Twenty-seven (21.3%) patients had preoperative VB treatment for 17 months (median, IQR 8-34). All 27 patients stopped VB treatment due to the lack of treatment effect. Eight (47.1%) of 17 assessed VB patients showed signs of skin irritation or hematoma. VB treatment had no effect on length of hospital stay (p = 0.385), postoperative complications (p = 1.0), bar dislocations (p = 1.0), and duration of bar treatment (p = 0.174). Time spent in intensive care unit was shorter in patients with VB therapy (p = 0.007). Long-term perception of treatment including rating of primary operation (p = 0.113), pain during primary operation (p = 0.838), own perspective of look of chest (p = 0.545), satisfaction with the procedure (p = 0.409), and intention of doing surgery again (p = 1.0) were not different between groups.

CONCLUSIONS

Failed preoperative VB therapy had no or minimal effect on short-term outcomes and long-term perceptions following MIRPE.

Complications and trends in minimally invasive repair of pectus excavatum: A large volume, single institution experience

BACKGROUND/PURPOSE

Complication risk in minimally invasive repair of pectus excavatum (MIRPE) is not negligible, particularly during learning curve. We reviewed the complications of a large series, evaluated the correlation with technical details and learning curve, and presented the strategies implemented to reduce them.

METHODS

Data on MIRPE patients from 2005 to 2020 (divided in two groups: before and after 2013) were collected prospectively and reviewed. Complications were correlated to the number and type of bar/stabilizers, and to the surgeon learning curve.

RESULTS

We placed 783 bars (484 Biomet, 273 Intrauma and 26 others) in 600 patients and removed 524 bars in 436 patients. Complications occurred in 108 MIRPE (18%): 3.7% intraoperative, 14.3% postoperative. No cardiac perforations were reported; in the second period we had fewer complications (15.3% versus 28.2%) particularly in intraoperative ones (0.3% versus 9%), the intervention was faster (64 versus 83 min and 92 versus 127 for 1 and 2 bars) and hospitalization shorter (5 versus 7.5 days). Complication rate of bar removal was 2.7% (all Biomet bars): one intra-thoracic bleeding and 2 lung injuries.

CONCLUSIONS

MIRPE has a significant rate of complication, especially during learning curve. Postoperative complications are more frequent and less dependent on learning curve. Severe complications can be observed during bar removal. We have adopted new bars to reduce complications, but dislocation remains an unresolved problem.

Blood metal levels after minimally invasive repair of pectus excavatum

 

OBJECTIVES

Minimally invasive repair of pectus excavatum (MIRPE) is the most popular surgical approach for paediatric patients with pectus excavatum. A substernal stainless still bar is inserted and left in place for 3 years and then removed. Our goal was to investigate blood metal levels after MIRPE and to correlate them with surgical details, such as the numbers of bars and stabilizers and the length of time the bar was in place.

METHODS

Blood levels of iron, chromium, manganese, molybdenum and nickel were analysed in 130 teenagers (108 boys and 22 girls) who had MIRPE using inductively coupled plasma mass spectrometry. A total of 62 patients were operated on using MIRPE (study group) and 68 patients were evaluated at implant time (control group). Differences between the numbers of bars implanted and the presence or absence of stabilizers were also considered.

RESULTS

Significant increases in the levels of abnormal chromium were found in patients in the study group compared with the controls (P = 0.02). When we compared the group of patients with 2 or more bars with the group with 1 bar, the percentage of patients with a value above the threshold increased by 29 (P = 0.05). A significant increase in chromium levels was observed in patients with stabilizers (P = 0.03). Above-threshold levels of molybdenum were found in 5.1% of patients in the control group, but the number was not statistically significant (P = 0.09).

CONCLUSIONS

We demonstrated that stainless steel devices used in MIRPE can elevate blood metal levels in paediatric patients. Moreover, we demonstrated that the use of metal stabilizers is associated with higher metal levels, probably due to increased dispersion.

Quality of life outcomes after minimally invasive repair of pectus excavatum utilizing a new set of metallic bars and stabilizers

BACKGROUND/PURPOSE

The aim of the study was to evaluate the postoperative quality of life (QoL) of patients who underwent minimally invasive repair of pectus excavatum (MIRPE) with a newly designed bar and bar stabilizers.

METHODS

We conducted a prospective randomized study in which patients were operated either with standard perpendicular stabilizers (control group) or with the newly designed oblique stabilizers (intervention group). All patients were evaluated 6 months after the operation with the Pectus Excavatum Evaluation Questionnaire (PEEQ).

RESULTS

There were 16 patients in the control group and 14 in the intervention group. Mean age was 17 (SD: 3.3, range 14-27) years. There were no demographic differences between groups. Two patients in the control group and one in the intervention group were repaired with two bars instead of one. There was one reoperation in each group. There was a significant difference between the pre- and postoperative scores, in both groups, in the patient body image domain (control group: 9.5 to 3; p < 0.01; intervention group 10 to 3; p < 0.01), as well as in the psychosocial domain (control group: 13.5 to 24, p < 0.01; intervention group: 15 to 24, p < 0.01). With regards to the patients' perception of physical difficulties before and after MIRPE, the difference between pre- and postoperative scores was greater in the intervention group (8 to 12, p < 0.01) than in the control group (10 to 11, p = 0.04). The mean length of stay was 4.5 and 5 days in the intervention group and the control group, respectively.

CONCLUSION

Our study showed that patients who underwent MIRPE with the newly designed bars and stabilizers had non-inferior outcomes than patients reported in the literature who underwent MIRPE with standard bars and stabilizers. We found slightly better outcomes in patients in the intervention group compared to the control group, but larger studies will be needed to confirm if those differences are statistically significant.

LEVEL OF EVIDENCE

II.

The impact of an enhanced recovery perioperative pathway for pediatric pectus deformity repair

PURPOSE

Pediatric repair of chest wall deformities is associated with significant pain, morbidity, and resource utilization. We sought to determine outcomes of a perioperative enhanced recovery after surgery (ERAS) pathway for patients undergoing minimally invasive (Nuss) and traditional (Ravitch) corrective procedures.

METHODS

Our ERAS protocol was implemented in 2015. We performed a retrospective review of patients for Nuss or Ravitch procedures before and after ERAS implementation. Combined and procedure segregated bivariate analyses were conducted on postoperative outcomes and resource utilization.

RESULTS

There are 17 patients in the pre-intervention group (Nuss = 13 and Ravitch = 4) compared to 38 patients in the post-intervention group (Nuss = 28 and Ravitch = 10). Protocol implementation increased utilization of pre-operative non-narcotic medication. The combined and Nuss post-intervention groups had a significant decrease in epidural duration and time to enteral medications, but had increased total postoperative opioid usage. The Ravitch post-intervention group had a significant decrease in intra-operative narcotics and discharge pain scores. There were no differences in length of stay or complications.

CONCLUSION

Implementation of our ERAS protocol standardized pectus perioperative care, but did not improve postoperative opioid usage, complications, or resource utilization. Alterations in the protocol may lead to achieving desired goals of better pain management and decreased resource utilization.

Safety-string: A handy maneuver to control pectus bar removal bleeding complications

The pectus bar removal procedure is often considered a simple, straightforward surgery with a low incidence of complications. However, life-threatening bleeding complications have been reported requiring major measures for hemostatic control. Our objective is to share a simple maneuver that our group has systematically included in the bar removal procedure to facilitate bleeding control in case hemorrhage occurs.

A New Device for Thoracoscopic Cryoanalgesia in Pectus Excavatum Repair: Preliminary Single Center Experience

Introduction: Cryoanalgesia has been recently described as alternative technique for immediate and persistent pain treatment after pectus excavatum repair. Cryoanalgesia has the potentiality to reduce analgesic consumption and length of hospitalization. However, cryoanalgesia has not been standardized yet: the previous reports describe different techniques and systems and include only small series. In Europe, no reports on cryoanalgesia for pectus repair have been published so far. Materials and Methods: This is a prospective single center pilot study performed in adolescents undergoing minimally invasive pectus excavatum repair with a new cryoanalgesia system, using a probe designed specifically for thoracoscopy. This new double lumen probe has the theoretical advantage of freezing only in its tip, so reducing the risk of complications. Results: Seven patients undergoing pectus excavatum repair were treated with cryoanalgesia performed with the new probe. No complications of cryoanalgesia were reported. Total consumption of morphine during hospital stay was between 0.1 and 0.35 mg/kg, with no side effects reported. Mean time to discharge was 2.4 days. All patients reported a good pain control with a fair need of rescue medications for pain relief during the first week after discharge, and a very good pain control without need of rescue medications during following weeks. Conclusions: Our pilot study showed that the new cryoanalgesia device is efficacious in terms of pain control, hospital stay and resumption of post-operative activities. The cryoprobe designed allowed an easy and safe maneuver. A prospective trial is needed to better define the risks and benefits of this technique.

Life-threatening complications and mortality of minimally invasive pectus surgery

The prevalence and type of life-threatening complications related to the minimally invasive repair of pectus excavatum (MIRPE) and bar removal are unknown and underreported. The purpose of this communication is to make surgeons aware of the risk of these life threatening complications as well as the modifications which have been developed to prevent them.

METHODS

Data related to life-threatening complications of Pectus Excavatum (PE) patients was obtained from four sources: 1. A survey of Chest Wall International Group (CWIG) surgeons who specialize in repairing congenital chest wall malformations, 2. Papers and case reports presented at CWIG meetings, 3. Review of medico-legal cases from the USA and 4. A systematic review of the literature related to major complications post MIRPE.

RESULTS

From 1998 to 2016, we identified 27 published cases and 32 unreported life-threatening complications including: cardiac perforation, hemothorax, major vessel injury, lung injury, liver injury, gastrointestinal problems, and diaphragm injury. There were seven cases of major complications with bar removal (reported and non-reported) with two lethal outcomes. Mortality data with bar placement surgery: Four published death cases and seven unpublished death cases. The overall incidence of minor & major complications post MIRPE has been reported in the literature to be 2-20%. The true incidence of life-threatening complications and mortality is not known as we do not know the overall number of procedures performed worldwide. However, based on data extrapolated from survey information, the pectus bar manufacturer in the USA, literature reports, and data presented at CWIG meetings as to the number of cases performed we estimated that approximately fifty thousand cases have been performed and that the incidence of life-threatening complications is less than 0.1% with many occurring during the learning curve. Analysis of the cases identified in our survey revealed that previous chest surgery, pectus severity and inexperience were noted to be significant risk factors for mortality.

CONCLUSIONS

Published reports support the safety and efficacy of MIRPE; however major adverse outcomes are underreported. Although major complications with MIRPE and pectus bar removal surgery are very rare, awareness of the risk and mortality of life-threatening complications is essential to ensure optimal safety. Factors such as operative technique, patient age, pectus severity and asymmetry, previous chest surgery, and the surgeon's experience play a role in the overall incidence of such events. These preventable events can be avoided with proper training, mentoring, and the use of sternal elevation techniques.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level IV.

Nuss Procedure for a Patient with Negative Haller Index

Introduction  Minimally invasive repair for pectus excavatum (MIRPE) is controversial in extremely severe cases of pectus excavatum (PE) and an open repair is usually favored. Our aim is to describe a case of a patient with an extremely severe PE that underwent a minimally invasive approach. Case report  An 8-year-old girl with severe sternum depression was assessed. She had a history of exercise intolerance, nocturnal dyspnea, fatigue, and shortness of breath. Chest computed tomography showed that sternum depression was posterior to the anterior vertebral column; therefore, Haller and correction index could not be measured. Spirometry indicated an obstructive ventilation pattern (forced expiratory volume in 1 second = 74.4%), and echocardiogram revealed a dilated inferior vena cava, mitral valve prolapse with normal ventricular function. After multidisciplinary committee evaluation, a MIRPE approach was performed. All symptoms had disappeared at the 3-month postoperative follow-up; the desired sternum shape was achieved and normalization of cardiopulmonary function was observed. The Nuss bars were removed after a 2-year period. After 18-month follow-up, the patient can carry out normal exercise and is content with the cosmetic result. Conclusion  Nuss procedure is feasible in our 8-year-old patient. In this case, both the Haller and correction index were not useful to assess the severity of PE. Therefore, under these circumstances, other radiologic parameters have to be taken into consideration for patient evaluation.

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.

Pulmonary function in pectus excavatum patients before repair with the Nuss procedure

OBJECTIVES

Whether the origin of symptoms in pectus excavatum patients (Pex) is related to reduced pulmonary function or impaired cardiovascular performance is debatable. However, pulmonary function testing (PFT) is still part of the evaluation prior to surgical repair in Pex. The purpose of this study was to corroborate our hypothesis that the majority of Pex that qualified for surgery present preoperatively with normal or close to normal PFT.

METHODS

After institutional review board approval, preoperative PFT data of Pex who underwent surgical repair were analyzed retrospectively: total lung capacity (TLC), vital capacity (VC), functional residual capacity, forced expiratory volume in 1 second (FEV1) and maximal expiratory flow at 25% of FVC (MEF25).

RESULTS

82 patients aged from 9 to 27 years (average, 15 years) underwent PFT. A restrictive pattern (VC<80%) was observed in 45%, an obstructive pattern (FEV1 < 75 %) in 35%, and a normal total lung capacity in 62% of the Pex. No significant correlation was noted between the increasing severity of the Haller index and the PFT.

CONCLUSION

Adolescent Pex without relevant respiratory symptoms have nearly a normal lung function. We suggest to skip PFT from the routine preoperative assessment in asymptomatic Pex.

Pain and anxiety management in minimally invasive repair of pectus excavatum

The Nuss procedure for the correction of Pectus Excavatum (PE) is associated with intense postoperative pain. Our strategy to control early postoperative pain is to combine epidural with intravenous analgesia. Our aim was to analyse our pain control strategy by reviewing all the PE cases treated at our institution. Sixty consecutive patients, aged between 12 and 26 years old, received the PE operation at our institution from January, 2007 to September, 2010. The median age was 16 (12-27) with a male/female ratio of about 7/1. An epidural catheter was employed in all the cases, with 38 patients (63%) requiring additional drugs to control pain, which remained in place for 74 hours (72-96). The pain score was higher in male patients, but lower in those younger than 16 years old. Moreover, patients that consumed benzodiazepines had a significant decrease in cumulative opioid intake (P = 0.0408). Both gender and age had an impact on pain control, while we noticed a synergistic effect between opiates and tranquillizers.