Complications and Outcomes of the Nuss Procedure in Adult Patients: A Systematic Review (original) (raw)
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Pectus excavatum is the most common congenital anterior chest wall deformity, with an incidence of 1:400 to 1:1000. Surgical strategy has evolved with the revolutionary idea of Donald Nuss, who was a pioneer in the operative correction of this deformity using minimally invasive surgery. The aim of this paper is to compare the preliminary results of pectus excavatum repair in two University Centers with a moderate number of patients using the standard Nuss procedure and its modification, the extrapleural thoracoscopic approach. The statistical analysis showed no significant difference for the patient’s age (14.52 ± 3.70 vs. 14.57 ± 1.86; p = 0.95) and the CT Haller index (4.17 ± 1.58 vs. 3.78 ± 0.95; p = 0.32). A statistically significant difference was noted for the duration of a pectus bar implant (2.16 ± 0.24 vs. 2.48 ± 0.68; p = 0.03) between the Maribor and Novi Sad Center. We report 14 complications (28%), including dislocation of the pectus bar (10%), pleural effusion (8%), wo...
Outcomes in adult pectus excavatum patients undergoing Nuss repair
Patient Related Outcome Measures, 2018
Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.
Nuss procedure in adult pectus excavatum: a simple artifice to reduce sternal tension
Interactive CardioVascular and Thoracic Surgery, 2013
Nowadays the Nuss operation represents the standard surgical choice for pectus excavatum repair in children and teenagers. Some concerns have been raised regarding its applicability in adults, as compared with younger patients, in view of the higher rate of complications after surgery. We describe an easy trick that has been performed on a 36-year-old man with a moderate pectus excavatum after an unsatisfactory Nuss procedure. It consisted of a T-shaped partial anterior sternotomy, performed after positioning Q3
EFFECTS Of The NUSS PROCEDURE On CHEST WALL KINEMATICS In ADOLESCENTS With PECTUS EXCAVATUM
Respiratory physiology & neurobiology, 2012
No data are available on the effects of the Nuss procedure on volumes of chest wall compartments (the upper rib cage, lower rib cage and abdomen) in adolescents with pectus excavatum. We used optoelectronic plethysmography (OEP) to provide a quantitative description of chest wall kinematics before and 6 months after the Nuss procedure at rest and during maximal voluntary ventilation in 13 subjects with pectus excavatum. An average 11% increase in chest wall volume was accommodated within the upper rib cage (p= 0.0001) and to a lesser extent within the abdomen and lower rib cage. Tidal volumes did not significantly change during the study. The repair effect on chest wall kinematics did not correlate with the Haller index of deformity at baseline. Six months of the Nuss procedure do increase chest wall volume without affecting chest wall displacement and rib cage configuration.
European Journal of Cardio-Thoracic Surgery, 2006
Objective: In 1998, Dr Donald Nuss proposed minimally invasive repair of pectus excavatum (MIRPE) which did not require the osteochondrous parts of the anterior chest wall to be resected. The paper aims at presenting the authors' own 6 years of experience in funnel chest repair with MIRPE technique. Also, many technical problems of this method are discussed. Materials and methods: Between 1999 and 2005, 461 patients (99 female and 362 male, aged 3-31 years, mean age 15.2 years) with pectus excavatum were operated with the Nuss technique. All patients were operated-on according to the original operative protocol proposed by Donald Nuss. With growing experience, own modifications were introduced. Insertion of two bars was done in 17.4%, transverse sternotomy in adolescents with rigid anterior chest wall in 7.8%, limited excision of the rib cartilages in 5.9%, and parasternal fixation of the bar to prevent it from rotating in 59.7% of patients. Results: There were no deaths. Intraoperative complications were noted in 19 (4.1%) patients and postoperative ones were observed in 43 (9.3%) patients. The operative time ranged from 25 to 130 min (52 min on average). In 192 (41.6%) patients, an epidural block was used. The hospital stay ranged from 4 to 12 days with the mean of 5.3 days. A redo procedure for the bar rotation was necessary in 13 (2.8%) patients. The support bar has been removed in 260 (56.4%) patients so far. In all the patients, an adequate contour of the anterior chest wall has been maintained. Conclusions: MIRPE proposed by Nuss has all the features of a minimally invasive procedure and is straightforward. Better clinical results are achievable in patients under 12 years of age with a symmetric deformity. In older patients (over 15 years of age) with a rigid chest or with an asymmetric deformity, additional procedures are required to achieve a comprehensive correction of the deformity. Recent results and forward clinical observations may give proof to establish MIRPE as a method of choice in funnel chest correction.
A 10-year review of a minimally invasive technique for the correction of pectus excavatum
Journal of Pediatric Surgery, 1998
The aim of this study was to assess the results of a 10-year experience with a minimally invasive operation that requires neither cartilage incision nor resection for correction of pectus excavatum. From 1987 to 1996, 148 patients were evaluated for chest wall deformity. Fifty of 127 patients suffering from pectus excavatum were selected for surgical correction. Eight older patients underwent the Ravitch procedure, and 42 patients under age 15 were treated by the minimally invasive technique. A convex steel bar is inserted under the sternum through small bilateral thoracic incisions. The steel bar is inserted with the convexity facing posteriorly, and when it is in position, the bar is turned over, thereby correcting the deformity. After 2 years, when permanent remolding has occurred, the bar is removed in an outpatient procedure. Of 42 patients who had the minimally invasive procedure, 30 have undergone bar removal. Initial excellent results were maintained in 22, good results in four, fair in two, and poor in two, with mean follow-up since surgery of 4.6 years (range, 1 to 9.2 years). Mean follow-up since bar removal is 2.8 years (range, 6 months to 7 years). Average blood loss was 15 mL. Average length of hospital stay was 4.3 days. Patients returned to full activity after 1 month. Complications were pneumothorax in four patients, requiring thoracostomy in one patient; superficial wound infection in one patient; and displacement of the steel bar requiring revision in two patients. The fair and poor results occurred early in the series because (1) the bar was too soft (three patients), (2) the sternum was too soft in one of the patients with Marfan's syndrome, and (3) in one patient with complex thoracic anomalies, the bar was removed too soon. This minimally invasive technique, which requires neither cartilage incision nor resection, is effective. Since increasing the strength of the steel bar and inserting two bars where necessary, we have had excellent long-term results. The upper limits of age for this procedure require further evaluation.
Annals of Surgery, 2010
Objective: To review the technical improvements and changes in management that have occurred over 21 years, which have made the minimally invasive repair of pectus excavatum safer and more successful. Summary Background Data: In 1997, we reported our 10-year experience with a new minimally invasive technique for surgical correction of pectus excavatum in 42 children. Since then, we have treated an additional 1173 patients, and in this report, we summarize the technical modifications which have made the repair safer and more successful. Methods: From January 1987 to December 2008, we evaluated 2378 pectus excavatum patients. We established criteria for surgical intervention, and patients with a clinically and objectively severe deformity were offered surgical correction. The objective criteria used for surgical correction included computed tomography (CT) scans of the chest, resting pulmonary function studies (spirometry and/or plethysmography), and a cardiology evaluation which included echocardiogram and electrocardiogram. Surgery was indicated if the patients were symptomatic, had a severe pectus excavatum on a clinical basis and fulfilled two or more of the following: CT index greater than 3.25, evidence of cardiac or pulmonary compression on CT or echocardiogram, mitral valve prolapse, arrhythmia, or restrictive lung disease. Data regarding evaluation, treatment, and follow up have been prospectively recorded since 1994. Surgical repair was performed in 1215 (51%) of 2378 patients evaluated. Of these, 1123 were primary repairs, and 92 were redo operations. Bars have been removed from 854 patients; 790 after primary repair operations, and 64 after redo operations. Results: The mean Haller CT index was 5.15 ± 2.32 (mean ±SD). Pulmonary function studies performed in 739 patients showed that FVC, FEV 1 , and FEF 25-75 values were decreased by a mean of 15% below predicted value. Mitral valve prolapse was present in 18% (216) of 1215 patients and arrhythmias in 16% (194). Of patients who underwent surgery, 2.8% (35 patients) had genetically confirmed Marfan syndrome and an additional 17.8% (232 patients) had physical features suggestive of Marfan syndrome. Scoliosis was noted in 28% (340). At primary operation, 1 bar was placed in 69% (775 patients), 2 bars in 30% (338), and 3 bars in 0.4% (4). Complications decreased markedly over 21 years. In primary operation patients, the bar displacement rate requiring surgical repositioning decreased from 12% in the first decade to 1% in the second decade. Allergy to nickel was identified in 2.8% (35 patients) of whom 22 identified preoperatively received a titanium bar, 10 patients were treated successfully with prednisone and 3 required bar removal: 2 were switched to a titanium bar, and 1 required no further treatment. Wound
European Journal of Cardio-Thoracic Surgery
OBJECTIVES: Patients with pectus excavatum (PE) after prior sternotomy for cardiac surgery present unique challenges for repair of PE. Open repairs have been recommended because of concerns about sternal adhesions and cardiac injury. We report a multi-institutional experience with repair utilizing substernal Nuss bars in this patient population. METHODS: Surgeons from the Chest Wall International Group were queried for experience and retrospective data on PE repair using substernal Nuss bars in patients with a history of median sternotomy for cardiac surgery (November 2000 to August 2015). A descriptive analysis was performed. RESULTS: Data for 75 patients were available from 14 centres. The median age at PE repair was 9.5 years (interquartile range 10.9), and the median Haller index was 3.9 (interquartile range 1.43); 56% of the patients were men. The median time to PE repair was 6.4 years (interquartile range 7.886) after prior cardiac surgery. Twelve patients (16%) required resternotomy before support bar placement: 7 preemptively and 5 emergently. Sternal elevation before bar placement was used in 34 patients (45%) and thoracoscopy in 67 patients (89%). Standby with cardiopulmonary bypass was available at 9 centres (64%). Inadvertent cardiac injury occurred in 5 cases (7%) without mortality. CONCLUSIONS: Over a broad range of institutions, substernal Nuss bars were used in PE repair for patients with a history of sternotomy for cardiac surgery. Several technique modifications were reported and may have facilitated repair. Cardiac injury occurred in 7% of cases, and appropriate resources should be available in the event of complications. Prophylactic resternotomy was reported at a minority of centres.