Biocompatible Cable Ties Are an Alternative to Metal Stabilizers for Bar Securement During Minimally Invasive Pectus Excavatum Repair

Background: Bar stabilization during minimally invasive pectus excavatum repair (MIRPE) is critical to avoid dislodgement. Multiple techniques are described including stabilizers, wires, and sutures. This retrospective study compared bar movement and outcomes between existing techniques and ZipFix™, a biocompatible cable tie. Methods: Patients ≤20 years of age who underwent MIRPE with ZipFix between January 2021 and September 2022 were compared with historical controls who underwent repair by same surgeons between January 2018 and December 2020 using stabilizers or polydioxanone suture (PDS). Demographics, clinical details, and outcomes were compared using Kruskal-Wallis and chi-square tests. Results: Of the 116 patients who underwent repair, 45 had bars secured with ZipFix (39%) and 71 (61%) were historical controls (35 stabilizer, 36 PDS). Median (interquartile range) age was 15 (14-16) years and Haller index was 3.9 (3.6-4.5). Nine (8%) patients required two bars. Haller index and use of second bar were comparable between stabilization techniques (P > .05). In total, 49 patients (40%) reported any pain at 1 month and this was similar between stabilization techniques (P = .45). Median bar movement was greater for bars secured with PDS than with ZipFix or stabilizers at 1 month (5.5 versus 2.3 versus 3.3°, P = .010) and last follow-up (6.5 versus 2.1 versus 3.6°, P < .001). One patient whose bar was secured with PDS required revision for dislodgement. Conclusion: Pectus bar stabilization with ZipFix is a safe alternative to metal stabilizers and both techniques are superior to suture stabilization alone. The use of ZipFix may be preferred given its lower cost and ease of use.

Pectus excavatum. Surgical treatment: Structural or aesthetic?

INTRODUCTION

Pectus excavatum is a wall deformity that often warrants medical evaluation. In most cases, it's a purely visual aesthetic alteration, while in others, it comes with symptoms. Several surgical techniques have been described, but their outcomes are difficult to assess due to the heterogeneity of presentations and the lack of long-term follow-up. We present our experience as thoracic surgeons, assessing correction as either structural (remodeling of the thoracic cage through open surgery) or aesthetic (design and implantation of a customized 3D prosthesis).

MATERIAL AND METHODS

Retrospective observational study of the indication for surgical treatment of pectus excavatum carried out by a team of thoracic surgeons and the short- to mid-term results.

RESULTS

Between 2021 and 2023, we treated 36 cases surgically, either through thoracic cage remodeling techniques or with 3D prostheses. There were few minor complications, and the short- to mid-term results were positive: alleviation of symptoms or compression of structures when present, or aesthetic correction of the defect in other cases.

CONCLUSIONS

Surgery for pectus excavatum should be evaluated for structural correction of the wall or aesthetics. In the former, thoracic cage remodeling requiring cartilage excision and possibly osteotomies is necessary. In the latter, the defect is corrected with a customized 3D prosthesis.

Presence of manubrium-sternum joint does not assure sufficient elevation of sternum in Nuss procedure for pectus excavatum patients

BACKGROUND

The manubrium and body of the sternum are connected by the manubrium-sternum joint (MSJ). In performing the Nuss procedure for pectus excavatum patients, the body of the sternum is elevated as the operator flips correction bars upside down. Theoretically, the presence of the MSJ should allow elevation of the sternum body. However, does the MSJ secure sufficient elevation of the sternum? This study aims to elucidate this clinical question.

METHODS

Seventy-four adult pectus excavatum patients with moderate to serious deformity (with Haller Index being equal to or greater than 5) were included in the study. The MSJ was open in all patients. For 29 patients, the sternum was elevated by only bar flipping (Non-Separation Group); for 45 patients, the sternum was horizontally separated after bar flipping (Separation Group). Whether or not additional elevation for Separation Group patients results from the division was observed, and the degree of the additional elevation was evaluated. Furthermore, 74 patients subjectively evaluated postoperative pain and gave scores with a Visual Analog Scale ranging from 0 (no pain) to 10 (intolerable pain). The VAS scores were compared between the two groups.

RESULTS

In the Separation Group, the sternums of all patients achieved additional elevation from sternum separation. The pain scores were lower for the Separation Group than for the Non-Separation Group.

CONCLUSION

Even when the MSJ is present, horizontal separation enhances the elevation of the sternum. Furthermore, horizontal separation of the sternum reduces postoperative pain.

Demographics of Anterior Chest Wall Deformity Patients: A Tertiary Children's Hospital Experience

INTRODUCTION

Anterior chest wall deformities consist of abnormal development of the chest, with the most common congenital deformities being pectus excavatum (PE) and pectus carinatum (PC). Surgical series are common, but less research is present assessing the demographics of all who present for initial evaluation. The purpose of this study is to describe the patient characteristics of those who present for ambulatory surgical evaluation.

METHODS

Data were collected from initial patient visits to an established multispecialty chest wall deformities program at a large Children's Hospital from 2017 to 2021. Variables assessed included primary diagnosis, age, sex, race/ethnicity, and whether surgical correction was performed.

RESULTS

A total of 1510 children were evaluated: 50.0% (n = 755) with PE, 43.3% (n = 653) with PC, 2.7% (n = 41) with mixed chest wall deformities, 0.7% (n = 10) with Poland syndrome, 1.1% (n = 17) with Currarino-Silverman syndrome, and 2.3% (n = 34) with other anterior chest wall deformities. Males and females presented at mean age of 12.8 (4.2) and 10.9 (5.5) years, respectively (P = 0.001). White children represented 61.1% of the overall population while Hispanic children represented 26.3%. White, non-Hispanic children represented 61.9% and 71.5% and Hispanic children represented 26.0% and 26.3% of the PE and PC populations, respectively.

CONCLUSIONS

Most patients seen in an urban chest wall deformities clinic were White, non-Hispanic; however, the proportion of other groups such as Hispanic and Asian is greater in this cohort than previously described. Further research is ongoing to ascertain the extent to which disease predisposition versus access to care play roles in this population.

Measurement and Thermodynamic Modeling of Energy Flux During Intercostal Nerve Cryoablation

INTRODUCTION

Intercostal nerve cryoablation is an increasingly adopted technique to decrease postoperative pain in patients undergoing surgical correction of pectus excavatum (SCOPE). Concerns regarding cryo-induced systemic hypothermia have been raised in pediatric patients; however, assessment of a cooled cryoprobe on body temperature has not been performed. We aimed to determine the energy flux from a maximally cooled cryoprobe and model the possible effects on a whole-body system.

METHODS

To directly measure energy flux, a maximally cooled cryoSPHERE probe (AtriCure, Inc, Mason, OH) was isolated in a well-mixed water bath at 37°C. Real-time temperatures were recorded. Three models were created to estimate intraoperative flux. Perioperative temperatures of 50 patients who received cryoablation during SCOPE were compared to 50 patients who did not receive cryoablation.

RESULTS

Direct calorimetry measured average energy flux of the maximally cooled cryoprobe to be 28 J/s. Thermodynamic modeling demonstrated the following: 1) The highest possible cryoprobe flux is less than estimated basal metabolic rate (BMR) of the average teenager undergoing SCOPE and 2) Flux in a best model of human tissue energy transfer using available literature is far less than the effects of BMR and insensible losses. Clinically, there were no significant differences in the minimum intraoperative, end procedure or first postoperative body temperatures for patients who received cryoablation and those who did not.

CONCLUSIONS

Cryoprobe flux is significantly fewer joules per second than BMR. Furthermore, in a clinical series there were no empiric differences in body temperature due to cryoablation employment, contradicting concerns regarding hypothermia secondary to cryoablation.

Consumer Wearables Define a Normative Recovery Trajectory Following the Modified Nuss Procedure

INTRODUCTION

The modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers' expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit.

METHODS

This observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts.

RESULTS

Of 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18.

CONCLUSIONS

We have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool.

Case report-Every thoracic surgeon's nightmare: cardiac and lung perforation during placement of Nuss bar for pectus excavatum

Introduction

The prevalence of life-threatening complications (LTCs) related to the minimally invasive repair of pectus excavatum (MIRPE) is unknown and underreported. The aim of this study is to contribute to the real prevalence of these rare but dramatic complications and show what went wrong in order to prevent it in the future.

Case presentation

A 15-year-old boy affected by pectus excavatum with severe asymmetric deformity of the chest wall was evaluated for elective corrective surgery. Preoperative computed tomography showed a Haller index of 5.7 and a correction index of 0.40. MIRPE was performed under right video-assisted thoracoscopy. Cardiac arrhythmias occurred after placement of the bar introducer. The introducer was removed, and massive bleeding was noted. Emergency Clamshell thoracotomy was performed, and cardiac surgeon was alerted immediately. A first pulmonary wound was found and controlled. Two cardiac lacerations were found: on the interventricular wall and on the right atrium. Under cardiopulmonary bypass, cardiac lacerations were sutured and other three pulmonary wounds were repaired. An urgent fasciotomy was performed for compartmental syndrome of the right lower art after femoral cannulation. Pulmonary distress occurred; the patient was admitted on ECMO (ExtraCorporeal Membrane Oxygenation) in intensive care unit. Right lower lobectomy was carried out on the fifth postoperative day due to massive pulmonary bleeding requiring temporary tracheostomy. The patient was discharged to rehabilitation after 3 months with no brain injuries, minor hearing loss, and tracheostomy.

Conclusion

We want to maintain the high alertness required for this procedure. Reporting these scaring complications contributes to the real prevalence of LTCs. We suggest the use of bilateral thoracoscopy and crane elevator in severe sternal defects. We also suggest to have a cardiac surgeon available in the hospital owing to cardiac perforation.

Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review

Introduction

The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature.

Methods

An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if p-value was <0.05.

Results

A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC.

Conclusion

The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE.

Development and clinical application of a new sternal zenithal traction system in video-assisted percutaneous thoracoplasty

INTRODUCTION

Video-assisted percutaneous thoracoplasty involves a complex surgical access with risk of damaging vital structures during the procedure. Historically, different traction and sternal elevation systems have been applied during the intervention to minimize the risk associated with the passage of the instruments between the sternum and the pericardium.

MATERIAL AND METHODS

A new sternal traction system is presented by means of an illustrated description. Clinical and sociodemographic data were extracted from the 36 patients operated in our center for Pectus Excavatum between July 2017 and August 2021. The Haller index was not applied as a criterion to determine the use or not of the sternal traction system. Patients were classified according to whether the sternal traction system (TE) or not (ST) had been employed. Statistical analysis of the data collected was performed with STATA, version 15.0 (StataCorp).

RESULTS

Both groups were comparable. Haller's Index was 4.19 ± 0.7 for the sternal traction (TE) group and 3.79 ± 0.3 for the no sternal traction (ST) group. In 25 of the patients the described traction system was used, and in 11 no traction system was used. All patients were operated on by the same surgeon. The mean operative time in minutes was 97.73 ± 46.2 for the ST group and 88.13 ± 18.1 for the TE group (p = 0.87). The mean total days of admission was 7.67 ± 0.82 (TE) and 7.73 ± 1.35 (ST). Mean days of intravenous PCA was 6.08 ± 0.72 (TE) and 5.89 ± 1.45 (ST). The mean number of epidural PCA days was 3.79 ± 0.5 (TE) and 3.36 ± 0.5 (ST) (p = 0.01). All patients presented a favorable postoperative evolution. None of the patients presented discomfort at the level of the sternal wounds during hospitalization. Cosmetic evolution was favorable in all patients.

CONCLUSIONS

The sternal traction system presented provides safety when performing retrosternal dissection and placement of the thoracoplasty bar, leading to a decrease in surgical time in cases with a Haller Index higher than 3.5. There have been no complications associated with its use, nor has there been an increase in the number of days of hospitalization or analgesic requirements. There are no aesthetic sequelae for the patients.

A pilot study of multi-modal pain management for same-day discharge after minimally invasive repair of pectus excavatum (Nuss procedure) in children

BACKGROUND

Despite advancements in minimally invasive repair of pectus excavatum (MIRPE), Nuss procedure, postoperative pain control remains challenging. This report covers a multimodal regimen using bilateral single-shot paravertebral block (PVB) and bilateral thoracoscopic intercostal nerve (T3-T7) cryoablation, leading to significant reduction in length of stay (LOS) and high rate of same-day discharge.

METHODS

This is a comparative study of pain management protocols for patients undergoing the Nuss procedure at a single center from 2016 through 2020. All patients underwent the the same surgical technique for the treatment of pectus excavatum at a single center. Patients received bilateral PVB with continuous infusion (Group 1, n = 12), bilateral PVB with infusion and right-side cryoablation (Group 2, n = 9), or bilateral single-shot PVB and bilateral cryoablation (Group 3, n = 17). The primary outcome was LOS with focus on same-day discharge, and the secondary outcome was decreased opioid usage.

RESULTS

Eleven of 17 patients in Group 3 (65%) (bilateral single-shot PVB and bilateral cryoablation) were discharged the same day as surgery. The remaining Group 3 patients were discharged the following day with no complications or interventions. Compared to Group 1 (no cryoablation), Group 3 had shorter LOS (median 4.4 days vs. 0.7 days, respectively, p < 0.001) and significantly decreased median opioid use on the day of surgery (0.92 mg/kg vs. 0.47 mg/kg, p = 0.006).

CONCLUSION

Findings demonstrate the feasibility of multimodal pain management for same-day discharge after the Nuss procedure. Future multisite studies are needed to investigate the superiority of this approach to established methods.

LEVEL OF EVIDENCE

III.

Modified Nuss procedure for the treatment of pectus excavatum: Experience of 259 patients

BACKGROUND

Pectus excavatum is not rare in China. Many treatments for this disease have proved to have many shortcomings. Nuss procedure has been a ground-breaking technology, but it also has some disadvantages. Hence, this study was conducted to review our experience in the use of modified Nuss procedure in our hospital.

METHODS

Data from 259 patients suffered from pectus excavatum between August 2020 and August 2021 who were treated with modified Nuss procedure was analyzed retrospectively.

RESULT

Age was from 3 to 37 years. The average was 15.54 years. The male was 213 cases and the female was 46 cases. The time patients or their family members found pectus excavatum varied. 10 cases had been repaired previously when patients were admitted in our hospital. The clinical symptoms also varied. Each case had an improvement in Haller index. The average of the postoperative hospitalization was 3.97 days. Most cases were inserted 1 bar. Complication rate was also very low. All patients or their parents or their guardians were satisfied with the appearance of the chest wall after operation. There was no death in the whole observation period.

CONCLUSION

From our experience, this modified Nuss procedure have obtained optimistic outcomes with more minimal invasion and low complication rate. This surgical method may be applied to many other hospitals in the future.

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.

Novel Nuss Bar Fixation Using ZipFix for Pectus Excavatum

BACKGROUND

Bar displacement is one of the most serious complications following the Nuss procedure for pectus excavatum repair. This paper reports a novel method of bar fixation using ZipFix, a biocompatible cable-tie implant, and shares a series of patients and outcomes.

METHODS

This paper describes the ZipFix stabilisation method and presents a case series of 20 patients with pectus excavatum who underwent the Nuss procedure and ZipFix stabilisation between July 2015 and September 2020.

RESULTS

A total of 34 ZipFixes were implanted in 20 patients. Six (6) patients had one ZipFix placed and 14 patients had two ZipFixes implanted: 13 were bilateral and one patient had two ZipFixes placed on the right. There was one incidence of asymptomatic posterior superior displacement of the right bar. Two (2) patients had wound infections and one patient had a previously placed bar adjusted and secured with a ZipFix. All patients had full correction of their chest wall deformity with no recurrence.

CONCLUSIONS

This case series shows that the use of ZipFix for Nuss bar fixation is feasible using this technique.

Infectious complications of intercostal nerve cryoablation mediated by perioperative hypothermia during pediatric Nuss procedure

BACKGROUND

Intercostal nerve cryoablation (cryoanalgesia) is increasingly used for pain control in minimally invasive repair of pectus excavatum (MIRPE) by Nuss procedure. Cryoanalgesia may lower core body temperature and increase the risk of postoperative infectious complications. We investigated cryoanalgesia effects on infectious complications following MIRPE.

METHOD

We performed a retrospective review of patients undergoing MIRPE at our institution. Patients treated via multimodal analgesia with cryoanalgesia (Cryo) were compared to patients treated via multimodal analgesia +/- elastomeric pain pumps (Non-cryo). Core body and intraoperative minimum/maximum temperatures were recorded. Primary outcomes were wound infection and pneumonia; secondary outcome was length of stay (LOS). Fisher's Exact and Mann-Whitney U tests compared proportions and medians respectively, p-value ≤ 0.05 being significant.

RESULTS

80 patients were included, 35(43.7%) Cryo and 45(56.3%) Non-cryo. There were no significant differences in median [IQR] for age(15[13.3,16.0];p =0.86), number of bars inserted (2[1,2];p = 0.57), or operative time(123.5[98.3, 148.8]; p = 0.11) between the two groups. We found no significant differences in median [IQR] minimum temperature (35.4°C [35.0,35.8];p = 0.76), median change in intraoperative temperature (-0.13°C [-0.44,0.00];p = 0.94) or median recovery temperature (-1.10°C [-1.56,-0.65]; p = 0.59) between Cryo and Non-cryo. PACU temperature was significantly lower in the Cryo group, 36.4°C [36.2,36.6] p = 0.04. There were no postoperative wound infections in either group and no significant difference in incidence of postoperative pneumonia (8.57% versus 2.22%,p =  0.31) or median[IQR] for LOS (4[3,4];p = 0.57), between Cryo and Non-cryo patients.

CONCLUSION

Although cryoanalgesia for MIRPE resulted in lower core body temperature, there appears to be no significant difference between Cryo and Non-Cryo patients for LOS or infectious complications.

"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.

Intercostal cryoablation during Nuss procedure: A large volume single surgeon's experience and outcomes

BACKGROUND

Recent studies have shown intercostal cryoablation(IC) during the Nuss procedure decreases hospital length of stay(LOS) and opioid administration. However, few studies have also evaluated the risk of postoperative complications related to IC.

METHODS

We performed a single center retrospective analysis of all patients who underwent Nuss procedure by one surgeon from 2/2016 to 2/2020, comparing intraoperative IC to other pain management modalities(non-IC). Primary outcomes were postoperative complications, hospital LOS, and opioid administration. Multivariate analysis was performed with outcomes reported as regression coefficients(RC) or odds ratios(OR) with 95% confidence interval.

RESULTS

IC was associated with decreased hospital LOS (RC -1.91[-2.29 to -1.54], less hospital opioid administration (RC -4.28[-5.13 to -3.43]), and less discharge opioid administration (RC -3.82[-5.23 to -2.41]). With respect to postoperative complications, IC decreased the odds of urinary retention (OR 0.16[0.06 to 0.44]); however, increased the odds of slipped bars requiring reoperation (OR 36.65[5.04-266.39]).

CONCLUSIONS

Our single surgeon experience controls for surgeon variability and demonstrates intraoperative IC for the Nuss procedure is an effective pain management modality that decreases hospital LOS and opioid use during hospitalization and at discharge; however, it is associated with increased odds of slipped bars requiring reoperation.

LEVEL OF EVIDENCE

III.

Initial experience with 3D printing in the use of customized Nuss bars in pectus excavatum surgery

INTRODUCTION

Pectus excavatum (PE) surgical repair according to Nuss procedure is based on the intrathoracic insertion of one (or more) metallic bars for anatomical defect repair. Number of bars, bar length, bar shape, and thoracic insertion site are established during surgery, according to patient morphology, CT-scan, and especially the surgeon's experience.

OBJECTIVE

To assess the usefulness of the design, simulation, and 3D printing of customized Nuss bars for each patient.

MATERIAL AND METHODS

A prospective descriptive study of all patients undergoing PE surgery under 3D printing from June to December 2019 was carried out. Curvature, bar length, and optimal intercostal space were designed based on diagnostic CT-scan, and they were 3D printed full size. The resulting model was reproduced preoperatively on the usual prosthetic material, sterilized, and kept until surgery.

RESULTS

The study cohort consisted of 6 patients. Median age was 15 years old (interquartile range: 14.25-15.25), median Haller index was 4.05 (interquartile range: 3.5-4.49), and repair index was 36.98% (interquartile range: 33.86-38.48%). A Nuss bar was introduced in all cases, without requiring removal or re-insertion. Median operating time was 79.5 minutes (interquartile range: 72.5-103). No postoperative complications were noted during follow-up (12 months).

CONCLUSIONS

The preoperative design of Nuss bars with customized shape and size facilitates surgical planning. It also allows for the most optimal and accurate morphological repair possible, according to patient anatomy, thus reducing the risk of requiring removal and/or re-insertion, and therefore, of surgical complications.

An Initial 5-Year Single-Center Experience of 365 Patients Undergoing the Video-Assisted Thoracoscopic Surgery for Nuss Procedure for Pectus Excavatum in Resource-Scare Setting

Background: Little is known about video-assisted thoracoscopic surgery in the Nuss procedure (VATS-NUSS) and its postoperative outcomes in the resource-scarce conditions in clinical practice such as Vietnam. Available evidence in the literature was mostly reported from large institutions in developed countries. Hence, this study was conducted to review our initial large single-center experience in the use of the VATS-NUSS for patients with pectus excavatum (PE) within 5 years.

Methods: Data from 365 consecutive PE patients between January 2015 and December 2019 who were surgically treated with VATS-NUSS were retrospectively analyzed.

Results: Of 365 patients, median age at operation was 15.61 ± 3.73 years (range = 5–27 years), most being child and adolescent. Three hundred nine patients (84.65%) were male. PE was commonly detected at puberty (n = 328, 89.9%). Postoperatively, early complications consisted of pneumothorax (n = 5, 1.37%), pleural bleeding/pleural fluid (n = 2, 0.55%), pleural hematoma (n = 1, 0.27%), pneumonia (n = 1, 0.27%), surgical wound infection (n = 1, 0.27%), incision fluid accumulation (n = 3, 0.82%), metal bar infection (n = 1, 0.27%), atelectasis (n = 3, 0.82%), and fever (n = 8, 2.19%). Late complications included surgical wound infection (n = 2, 0.55%), metal bar deviation (n = 5, 1.37%), metal bar allergy (n = 10, 2.74%), recurrent PE (n = 2, 0.55%), and persistent PE (n = 5, 1.37%). No deaths occurred. In 175 patients (47.95%) experiencing bar removal, mean operative time for bar removal was 34.09 ± 10.61 min, and the length of hospitalization following bar removal was 2.4 ± 1.34 days; the most frequent complication was pneumothorax (n = 19, 10.85%). One wound infection and one incision fluid accumulation happened following bar removal. Favorable midterm to long-term postoperative outcomes were achieved.

Conclusions: From the beginning of the Vietnamese surgeons' experience, VATS-NUSS application obtained favorable outcomes with minimizing the occurrence of serious intraoperative and postoperative complications. Current rare evidence enables to give a real picture in the application, modification, and development of VATS-NUSS in the countries having similar resource-scarce conditions.

Does the Nuss procedure for treating pectus excavatum compromise the long term internal mammary artery flow? A systematic review

INTRODUCTION

The Nuss procedure is the most common procedure used to treat patients with pectus excavatum. The effect of the Nuss bars on the long-term internal mammary artery flow (IMA) is not well studied. This could have an impact on patients requiring a coronary artery bypass grafting surgery after the Nuss procedure. We performed a systematic review to study the impact of the Nuss bars on the IMA long term flow.

METHODS

A Medline search from January 1990 to August 2020 was performed using [Nuss OR thoracoscopic pectus OR minimally invasive pectus] AND [Internal mammary OR Internal thoracic OR IMA OR ITA]. English language papers only were included. This trial was registered with PROSPERO under registration number CRD42021234010.

RESULTS

A total of 48 papers were identified using the reported search, of which three represented the best evidence to answer the clinical question. One study looked at the IMA flow via computed tomography (CT)-angiography on the 10th postoperative day after the Nuss procedure and found 15 out of 34 patients (44%) to have abnormal IMA blood flow but with no clinical consequences. Two studies looked at the IMA flow after removal of the Nuss-bar. The first study utilized CT-angiography on the 5th postoperative day after Nuss-bar removal and found four out of the six patients studied (67%) to have abnormal flow. The last study was composed of 19 patients and looked at IMA flow during the presence of the Nuss-bars and after its removal utilizing Doppler-angiography. It found 11 out of 19 patients (58%) to have abnormal blood flow with the bars in place. After removal of the bars, only two patients (10%) were found to have unilateral IMA obstructed flow.

CONCLUSION

In patients undergoing the Nuss procedure for management of pectus excavatum, the internal mammary artery flow is compromised in 44%-58% of patients with the bar in situ. When these patients are assessed 10 days following removal of the bar, some reversal of compromised IMA flow is evident. However, in up to 67% of patients, abnormal IMA flow remains. Further studies are required to determine whether this abnormal flow is permanent, which will require examining patients at longer follow-up intervals. Patients undergoing coronary artery bypass grafting who have a history of a Nuss procedure should receive preoperative IMA imaging.

Adult pectus excavatum repair: national outcomes of the Nuss and Ravitch procedures

Background

National data is limited on pectus excavatum, the most common chest wall deformity which is often repaired using the Ravitch and Nuss procedures. The purpose of the study was to describe demographics and outcomes of adult patients who underwent surgical repair of pectus excavatum via open and minimally invasive thoracoscopic methods.

Methods

A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2018 was performed, capturing patients 18 years or older with pectus excavatum as the postoperative diagnosis. Patients were placed into two groups of minimally invasive (Nuss) and open (Ravitch) repair procedure code. Baseline characteristics and postoperative outcomes were analyzed.

Results

A total of 168 adult patients were captured. Most of these patients were white (84.52%) male (69.64%) and 26 years old on average. Median operative time was longer in the open repair group [250 (IQR, 173-308) versus 122 (IQR, 94-160) minutes, P<0.0001]. Median length of stay was five days (IQR, 4-6) in the open group and three days (IQR, 2-4) in the minimally invasive group (P=0.2873).

Conclusions

Complications after repair of pectus excavatum occur at similar rates between open and minimally invasive repair. Though minimally invasive repair decreases operative time and may decrease length of stay, the decision of type of procedure depends upon clinical scenario and factors unique to the individual patient.

From bench to bedside: 3D reconstruction and printing as a valuable tool for the chest wall surgeon

BACKGROUND/PURPOSE

The development of computer-aided design/manufacturing and digital image technology shows promise to revolutionize several medical and surgical fields. In this context, we propose a different approach for minimally invasive repair of pectus excavatum (MIRPE) including preoperative planning, ambulatory template fitting, and implant customization.

METHODS

We prospectively collected data on 130 consecutive patients who underwent a novel process of implant customization for MIRPE between November 2015 and September 2019 at our institution. This process consisted of: 1) preoperative planning using 3D computed tomography scan reconstruction and 3D printing of the implant template, 2) an ambulatory fitting session with the template, and 3) manufacture of a custom made, prebent, metallic implant based on the 3D printed templates. We described the process in detail and analyzed the "implant-deformity" match, need for rebending, modification of the curvature or shape of the pectus implant intraoperatively, and accuracy of the number of bars planned preoperatively.

RESULTS

Preoperative planning including 3D reconstruction and printing resulted in a 92.3% optimal "implant-deformity" anatomic match. Minimal rebending without flipping of the implants was required in 5.4% of the patients. In two cases (1.5%), the implants were too short, and they tended to sink into the intercostal space, and in one case (0.8%), the patient's chest was extremely asymmetric, and the implant had to be removed and rebent intraoperatively. The number of implants planned preoperatively was precise in 100%.

CONCLUSIONS

In this study, we demonstrated that minimally invasive repair of pectus excavatum assisted by preoperative planning, ambulatory template fitting, and implant customization enables an excellent anatomic match, leading to minimal rebending, and avoiding implant flipping or removal after retrosternal passage as well as accuracy in the number of bars programmed preoperatively.

TYPE OF STUDY

Prospective registry.

LEVEL OF EVIDENCE

III.

Applicability of Clavien-Dindo classification in Nuss procedure surgical complications

OBJECTIVES

Nuss procedure is a safe surgery but not exempt from complications. Clavien-Dindo classification (1992) allows complications of any surgery to be recorded. Our objective was to prove its applicability in the study of Nuss procedure complications.

MATERIAL AND METHODS

We present a retrospective series of PE patients undergoing surgery from January 2010 to January 2018. Nuss procedure associated morbidity prior to bar removal was studied. Complications were stratified according to Clavien-Dindo classification.

RESULTS

A total of 31 patients were included. Mean age was 14.67 years (4-27 years), with a mean Haller index of 6.06 (3.35-14.14) and a mean correction index of 41.2% (16-87%). Clavien-Dindo classification I-IIIb mild complications were recorded in 35.48% of patients. Seroma was found in 4 patients (12%), of whom 1 had superinfection and 1 had wound dehiscence. In 6 patients, bar and/or stabilizer mobilization was noted, and in 1 patient, postoperative acute pulmonary edema (3%) was observed. Of the 11 patients with complications, only 6 required re-intervention -5 as a result of prosthesis mobilization, and 1 as a result of infection not resolved with intravenous antibiotic therapy.

CONCLUSIONS

Clavien-Dindo classification is being increasingly used as a way of unifying surgical complication criteria by comparing results. Our study demonstrated that such classification is a feasible and reproducible method when it comes to reflecting Nuss procedure morbidity and comparing it with other groups.

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.

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.

Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis

BACKGROUND/PURPOSE

To evaluate surgical outcomes of Nuss versus Ravitch repair of pectus excavatum via a systematic review and meta-analysis.

METHODS

Medline, PubMed, Cochrane, EMBASE, and Google Scholar databases were searched up to September 5, 2016 using the following search terms: pectus excavatum, funnel chest, Nuss; Ravitch, minimally invasive, and open surgery. Randomized controlled trials, two-arm prospective, and two-arm retrospective studies were eligible for inclusion.

RESULTS

Nineteen studies were included with a total of 1731 patients: 989 treated with Nuss and 742 treated with Ravitch. The overall analysis revealed that patients in the Nuss group had significantly shorter operation time (pooled SMD=-2.83, 95% CI=-3.76 to -1.90, p<0.001) and less blood loss (pooled SMD=-1.68, 95% CI=-2.28 to -1.09, P<0.001) than the Ravitch group. However, the length of hospital stay was similar between groups (pooled SMD=-0.55, 95% CI=-1.44 to 0.35, p=0.230). These findings were similar in the subgroup analysis for randomized and non-randomized controlled studies. Complications were not assessed due to inconsistent reporting across the included studies.

CONCLUSIONS

Our meta-analysis demonstrate that the Nuss procedure has a shorter operative time and less operative blood loss than the Ravitch procedure while the postoperative length of stay was similar.

LEVELS OF EVIDENCE

Level III.

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.

Anesthesia for minimally invasive chest wall reconstructive surgeries: Our experience and review of literature

Minimal access procedures have revolutionized the field of surgery and opened newer challenges for the anesthesiologists. Pectus carinatum or pigeon chest is an uncommon chest wall deformity characterized by a protruding breast bone (sternum) and ribs caused by an overgrowth of the costal cartilages. It can cause a multitude of problems, including severe pain from an intercostal neuropathy, respiratory dysfunction, and psychologic issues from the cosmetic disfigurement. Pulmonary function indices, namely, forced expiratory volume over 1 s, forced vital capacity, vital capacity, and total lung capacity are markedly compromised in pectus excavatum. Earlier, open surgical correction in the form of the Ravitch procedure was followed. Currently, in the era of minimally invasive surgery, Nuss technique (pectus bar procedure) is a promising step in chest wall reconstructive surgery for pectus excavatum. Reverse Nuss is a corrective, minimally invasive surgery for pectus carinatum chest deformity. A tailor-made anesthetic technique for this new procedure has been described here based on the authors’ personal experience and thorough review of literature based on Medline, Embase, and Scopus databases search.

Short Nuss bar procedure

The Nuss procedure is now the preferred operation for surgical correction of pectus excavatum (PE). It is a minimally invasive technique, whereby one to three curved metal bars are inserted behind the sternum in order to push it into a normal position. The bars are left in situ for three years and then removed. This procedure significantly improves quality of life and, in most cases, also improves cardiac performance. Previously, the modified Ravitch procedure was used with resection of cartilage and the use of posterior support. This article details the new modified Nuss procedure, which requires the use of shorter bars than specified by the original technique. This technique facilitates the operation as the bar may be guided manually through the chest wall and no additional stabilizing sutures are necessary.

Ravitch versus Nuss procedure for pectus excavatum: systematic review and meta-analysis

BACKGROUND

Pectus excavatum is the most common congenital chest wall deformity. The two most common surgical techniques for its correction are the modified Ravitch technique and the minimally invasive Nuss technique. Despite both procedures being used widely, data comparing them are scarce.

METHODS

We conducted a systematic review and meta-analysis of comparative studies to evaluate these procedures. A systematic search of the literature was performed from six electronic databases. Pooled meta-analysis was conducted using odds ratio (OR) and weighted mean difference (WMD).

RESULTS

A total of 13 studies comprising 1,432 pediatric (79.3%) and adult (20.7%) patients were identified, including 912 patients undergoing the Nuss procedure compared to 520 patients undergoing the Ravitch procedure. There was no significant difference found between the Nuss group versus Ravitch group in pediatric patients with regard to overall complications (OR =1.16; 95% CI: 0.61-2.19; I²=56%; P=0.65), reoperations (6.1% vs. 6.4%; OR =1.00; 95% CI: 0.40-2.50; I²=0%; P=1.00), wound infections (OR =0.58; 95% CI: 0.23-1.46; I²=0%; P=0.25), hemothorax (1.6% vs. 1.3%; OR =0.74; 95% CI: 0.21-2.65; I²=12%; P=0.64), pneumothorax (3.4% vs. 1.5%; OR =1.11; 95% CI: 0.42-2.93; I²=0%; P=0.83) or pneumonia (OR =0.15; 95% CI: 0.02-1.48; I²=0%; P=0.10). Adult patients undergoing the Nuss procedure had a higher incidence of overall complications (OR =3.26; 95% CI: 1.01-10.46; I²=0%; P=0.05), though there were far fewer studies that reported data.

CONCLUSIONS

These results suggest no difference between the Nuss and Ravitch procedures for pediatric patients, while in adults the Ravitch procedure resulted in fewer complications.

Single centre experience on short bar technique for pectus excavatum

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

The Nuss procedure is suitable for prepubertal and early pubertal patients but can also be used in adult patients.

AIM

To determine whether the minimally invasive technique (MIRPE) can also be performed successfully in adults.

MATERIAL AND METHODS

Between July 2006 and January 2016, 836 patients (744 male, 92 female) underwent correction of pectus excavatum with the MIRPE technique at our institution. The mean age was 16.8 years (2-45 years). There were 236 adult patients (28.2%) (> 18 years) - 20 female, 216 male. The mean age among the adult patients was 23.2 years (18-45 years). The recorded data included length of hospital stay, postoperative complications, number of bars used, duration of the surgical procedure and signs of pneumothorax on the postoperative chest X-ray.

RESULTS

The MIRPE was performed in 236 adult patients. The average operative time was 44.4 min (25-90 min). The median postoperative stay was 4.92 ±2.81 days (3-21 days) in adults and 4.64 ±1.58 (2-13) in younger patients. The difference was not statistically significant (p = 0.637). Two or more bars were used in 36 (15.8%) adult patients and in 44 (7.5%) younger patients. The difference was not statistically significant either (p = 0.068). Regarding the overall complications, complication rates among the adult patients and younger patients were 26.2% and 11.8% respectively. The difference was statistically significant (p = 0.007).

CONCLUSIONS

MIRPE is a feasible procedure that produces good long-term results in the treatment of pectus excavatum in adults.

Revision of failed, recurrent or complicated pectus excavatum after Nuss, Ravitch or cardiac surgery

Pectus excavatum (PE) can recur after both open and minimally invasive repair of pectus excavatum (MIRPE) techniques. The cause of recurrence may differ based on the initial repair procedure performed. Recurrence risks for the open repair are due to factors which include incomplete previous repair, repair at too young of age, excessive dissection, early removal or lack of support structures, and incomplete healing of the chest wall. For patients presenting after failed or recurrent primary MIRPE repair, issues with support bars including placement, number, migration, and premature removal can all be associated with failure. Connective tissue disorders can complicate and increase recurrence risk in both types of PE repairs. Identifying the factors that contributed to the previous procedure's failure is critical for prevention of another recurrence. A combination of surgical techniques may be necessary to successfully repair some patients.

Minimally invasive repair of pectus excavatum

Pectus excavatum, an acquired or congenital depression of the anterior chest wall, is the most commonly occurring chest wall deformity. Patients with pectus excavatum experience psychosocial and physiologic consequences such as impaired social development and pulmonary and/or cardiac dysfunction as a result of the deformity. Traditionally, repair of the defect was performed with a major open operation, the most common being based on modifications of the Ravitch procedure. In the late 1990's, the operative approach was challenged with a new minimally invasive technique described by Dr. Donald Nuss. This approach utilizes thoracoscopic visualization with small incisions and placement of a temporary metal bar positioned behind the sternum for support it while the costal cartilages remodel. Since introduction, the minimally invasive repair of pectus excavatum (MIRPE) has become accepted in many centers as the procedure of choice for repair of pectus excavatum. In experienced hands, the procedure has excellent outcomes, shorter procedural length, and outstanding cosmetic results. However, proper patient selection and attention to technical details are essential to achieve optimal outcomes and prevent significant complications. In the following, we describe our perspective on pectus excavatum deformities, operative planning, and technical details of the MIRPE procedure.

Risk factors and management of Nuss bar infections in 1717 patients over 25 years

PURPOSE

An increase in postoperative infections after Nuss procedures led us to seek risks and review management. We report potential risk factors and make inferences for prevention of infections.

METHODS

An IRB-approved retrospective chart review was used to evaluate demographic, clinical, surgical, and postoperative variables of patients operated on between 10/1/2005 and 6/30/2013. Those with postoperative infection were evaluated for infection characteristics, management, and outcomes with univariate analyses.

RESULTS

Over this 8-year period (2005-2013), 3.5% (30) of 854 patients developed cellulitis or infection, significantly more than 1.5% (13) in our previous report of 863 patients, 1987-2005 (p=.007). The most frequent organism cultured was methicillin-sensitive Staphylococcus aureus. Patients who were given clindamycin preoperatively (5 of 26 patients) had higher infection rates than those who received cefazolin (25 of 828) (19% vs 3%, p<.001). Patients treated with a peri-incisional ON-Q (I-Flow, Kimberly-Clark, Irvine, CA) also had higher infection rates (8.3% vs 2.4%, p<.001). Of the 30 patients who developed an infection, eighteen (60%) with cellulitis or superficial infections did not require surgical treatment or early bar removal. The other twelve patients (40%) with deep hardware infections required an average of 2.2 operations (range 1-6), with 3 (25%) requiring removal of their stabilizer and 3 (25%) requiring early bar removal. None of these three patients experienced recurrence of pectus excavatum at 2 to 4 years of follow-up.

CONCLUSION

Preoperative antibiotic selection and use of ON-Q's may influence infection rates after Nuss repair. Nuss bars could be preserved in 90% of all patients with an infection and even 75% of those with a deep hardware infection. Attempts to retain the bar when an infection occurs may help prevent pectus excavatum recurrence. Level of Evidence=III.

Epidural analgesia versus intravenous patient-controlled analgesia following minimally invasive pectus excavatum repair: a systematic review and meta-analysis

BACKGROUND/PURPOSE

The minimally invasive pectus excavatum repair (MIPER) is a painful procedure. The ideal approach to postoperative analgesia is debated. We performed a systematic review and meta-analysis to assess the efficacy and safety of epidural analgesia compared to intravenous Patient Controlled Analgesia (PCA) following MIPER.

METHODS

We searched MEDLINE (1946-2012) and the Cochrane Library (inception-2012) for randomized controlled trials (RCT) and cohort studies comparing epidural analgesia to PCA for postoperative pain management in children following MIPER. We calculated weighted mean differences (WMD) for numeric pain scores and summarized secondary outcomes qualitatively.

RESULTS

Of 699 studies, 3 RCTs and 3 retrospective cohorts met inclusion criteria. Compared to PCA, mean pain scores were modestly lower with epidural immediately (WMD -1.04, 95% CI -2.11 to 0.03, p=0.06), 12 hours (WMD -1.12; 95% CI -1.61 to -0.62, p<0.001), 24 hours (WMD -0.51, 95%CI -1.05 to 0.02, p=0.06), and 48 hours (WMD -0.85, 95% CI -1.62 to -0.07, p=0.03) after surgery. We found no statistically significant differences between secondary outcomes.

CONCLUSIONS

Epidural analgesia may provide superior pain control but was comparable with PCA for secondary outcomes. Better designed studies are needed. Currently the analgesic technique should be based on patient preference and institutional resources.

Comparison of the Nuss and sternal turnover procedures for primary repair of pectus excavatum

BACKGROUND

Pectus excavatum (PE) is a common chest wall deformity. There are several surgical alternatives for the repair of PE. In our practice, the sternal turnover (STO) procedure had been performed for decades. In 2008, we started treating PE patients with the Nuss procedure. Our objective of this study is to compare these two procedures.

METHODS

A retrospective chart review was conducted on 50 patients undergoing pectus excavatum repairs from March 2005 to January 2013, including 20 patients with the STO procedure and 30 patients with the Nuss procedure. Patients were evaluated for type of repair performed, operating time, drainage after operation, length of postoperative stay, complications, and cosmetic results.

RESULTS

The mean age of the STO group was 11.0 years and that of the Nuss group was 15.0 years (p = 0.353). The Nuss procedure had a much shorter mean operating time, a less mean drainage after operation, and a shorter mean time to drainage tube removal than those of the STO procedure. The rate of complication was 40.0% (8/20) in the STO group and 33.3% (10/30) in the Nuss group. Follow-up data indicated that 90% (18/20) of patients in the STO group and 96.7% (29/30) of patients in the Nuss group regarded the results as good or excellent (p = 0.965).

CONCLUSION

Our data suggests that both the STO and Nuss procedures are equally safe and effective correction methods. However, less trauma, faster recovery, and better cosmetic results are the benefits of the Nuss procedure.

Does repair of pectus excavatum improve cardiopulmonary function?

A best evidence topic was written according to a structured protocol. The question addressed was 'Does repair of pectus excavatum (PE) improve cardiopulmonary function?' One hundred and sixty-eight papers were found using the reported search, 19 level III evidence papers and three meta-analyses were relevant. Studies were divided into four groups based on the surgical technique applied and pulmonary and cardiac functions in these groups were analysed. The meta-analyses show conflicting results for improvements in pulmonary and cardiac functions when comparing surgical techniques, while four more recent studies show improved long-term results using the Nuss technique. The best evidence of papers studying the PE repair using the minimally invasive Nuss technique demonstrates a decrease in pulmonary function during the early postoperative period, however, there is a small but significant improvement during the late postoperative period and after bar removal. The best evidence for cardiac function in this group suggests an early improvement that is sustained during further follow-up. The best evidence of papers studying the PE repair using the Ravitch technique shows that pulmonary function decreased during the early postoperative period, however, there is a small but significant improvement during the late postoperative period. The best evidence for cardiac function in this group suggests an early improvement that is sustained during further follow-up. The best evidence of papers studying the PE repair using other techniques (modified Daniel's technique, modified Baronofsky's technique, sterno-costal turn-over technique and sterno-costal elevation technique) or where surgical techniques used were not described (preceding year 1985) suggests that there is no improvement in pulmonary function after surgery. There is some evidence that certain aspects of cardiac function improved after surgery in this group.