Reducing cardiac injury during minimally invasive repair of pectus excavatum

Minimally invasive repair of pectus excavatum (MIRPE) provides a minimal access approach to correct pectus excavatum deformities. Cardiovascular complications represent a rare but catastrophic complication of this cosmetic operation. We describe a modification to the technique following a case of cardiac puncture.     

Complications of the minimally invasive repair of pectus excavatum

Background

Minimally invasive repair of pectus excavatum (MIRPE) has become widely popular since its introduction in the late 1990s by Nuss. We describe 1 unusual complication after MIRPE and 1 life-threatening bleeding during removal of the pectus bar.

Methods

We report the cases of 2 patients in a single institution, more than 100 MIRPE procedures performed so far, and review of literature.

Cases

A 14-year-old girl presented 6 months after MIRPE in another institution. During removal of the pectus bar, a massive hemorrhage from both chest wounds occurred, requiring emergency sternotomy. Arrosion of a pulmonary vessel close to the metal bar had led to the bleeding. The second case was a bilateral sternoclavicular dislocation after MIRPE, which has not caused symptoms so far, in a 13-year-old girl.

Conclusions

Numerous operative and postoperative complications after MIRPE are feasible. This is the first report of a life-threatening bleeding during removal of the pectus bar. Minimally invasive repair of pectus excavatum procedure and removal of the pectus bar should only occur in specialized institutions with wide experience in thoracic surgery.     

The minimally invasive Nuss technique for recurrent or failed pectus excavatum repair in 50 patients

Purpose

The aim of this study was to demonstrate the efficacy of the minimally invasive technique for recurrent pectus excavatum.

Methods

Fifty patients with recurrent pectus excavatum underwent a secondary repair using the minimally invasive technique. Data were reviewed for preoperative symptomatology, surgical data, and postoperative results.

Results

Prior repairs included 27 open Ravitch procedures, 23 minimally invasive (Nuss) procedures, and 2 Leonard procedures. The prior Leonard patients were also prior Ravitches and are therefore counted only once in the analyses. The median age was 16.0 years (range, 3-25 years). The median computed tomography index was 5.3 (range, 2.9-20). Presenting symptoms included shortness of breath (80%), chest pain (70%), asthma or asthma symptoms (26%), and frequent upper respiratory tract infections (14%). Both computed tomography scan and physical exam confirmed cardiac compression and cardiac displacement. Cardiology evaluations confirmed cardiac compression (62%), cardiac displacement (72%), mitral valve prolapse (22%), murmurs (24%), and other cardiac abnormalities (30%). Preoperative pulmonary function tests demonstrated values below 80% normal in more than 50% of patients. Pectus repair was done using a single pectus bar (66%), 2 bars (32%), or 3 bars (2%). Stabilizers were used in 88% of the patients. Median length of surgical time did not significantly differ from that of primary surgeries. Complications were slightly higher than those in primary repairs and included pneumothorax requiring chest tube (14%), hemothorax (8%), pleural effusion requiring drainage (8%), pericarditis (4%), pneumonia (4%), and wound infection (2%). There were no deaths or cardiac perforations. Initial postoperative results were excellent in 70%, good in 28%, and fair in 2%. Late complications of bar shift requiring revision occurred in 8%. Seventeen patients have had bar removals with 9 patients being more than 1 year postremoval. For the 17 patients who are postremoval, excellent results have been maintained in 8 (47%), good in 7 (41%), fair in 1 (6%), and failed in 1 (6%). There have been no recurrences postremoval.

Conclusions

Although failed or recurrent pectus excavatum repairs are technically more challenging, reoperative correction by the Nuss procedure has met with excellent success.     

Postpericardiotomy syndrome after minimally invasive repair of pectus excavatum

Minimally invasive repair of pectus excavatum (MIRPE) was first reported in 1998 and has gained wide acceptance since then. A 17-year-old girl who had undergone thoracotomy and cardiac surgery for transposition of great vessels at the age of 18 months presented with a deep, long pectus excavatum with asymmetry. After initial uneventful postoperative clinical course after MIRPE, the patient had bilateral pleural and pericardial effusion on the sixth postoperative day. Suspecting postpericardiotomy syndrome, systemic steroids were administered, and the symptoms resolved without affecting wound healing. Manifestation of a pericardial effusion combined with bilateral pleural effusion after MIRPE, especially in patients after cardiac surgery, may indicate a postpericardiotomy syndrome that can be treated successfully by intravenous steroids.     

Management of postoperative infections after the minimally invasive pectus excavatum repair

Purpose

Pectus excavatum is frequently repaired using the minimally invasive placement of a substernal bar (Nuss procedure). Infectious complications after the Nuss procedure are potentially devastating. To date, the management of postoperative infectious complications has not been well described.

Methods

A retrospective review of all patients (N = 168) who underwent the Nuss procedure from January 1, 1997, to October 1, 2003, at our institution was performed. Six patients (4%) had postoperative infections, and their medical records were reviewed.

Results

Of the 6 patients, 5 underwent operative drainage for wound abscesses that developed 2 to 76 weeks postoperatively. The other patient developed cellulitis 12 months postoperatively and was treated effectively with antibiotics alone. Recurrent infections were treated in 3 of 6 patients, one of whom eventually required removal of the bar resulting in a mild, residual pectus excavatum defect. One of 6 patients has had the substernal bar removed electively. The remaining 4 continue to be without clinically apparent infection at this time and are over 1 year removed from their infection.

Conclusions

Although uncommon, infectious complications after the Nuss procedure require complex management strategies. Despite recurrent infection in some cases, most infectious complications occurring after the minimally invasive repair can be effectively treated without having to remove the substernal bar.     

Minimally invasive repair of pectus excavatum in patients with Marfan syndrome and marfanoid features

Purpose

The presence of a pectus excavatum (PE) requiring surgical repair is a major skeletal feature of Marfan syndrome. Marfanoid patients have phenotypic findings but do not meet all diagnostic criteria. We sought to examine the clinical and management differences between Marfan syndrome patients and those who are marfanoid compared with all other patients undergoing minimally invasive PE repair.

Methods

A retrospective institutional review board-approved review was conducted of a prospectively gathered database of all patients who underwent minimally invasive repair of PE. Patients were grouped according to diagnosis of Marfan syndrome (MAR), Marfanoid appearance (OID), and all others (ALL). Patient demographics, preoperative imaging and testing, operative strategy, complications, and postoperative surveys were evaluated. Fisher's Exact test and χ² were applied for statistical analysis.

Results

From June 1987 to September 2008, 1192 patients underwent minimally invasive PE repair (MAR = 33, OID = 212, ALL = 947). There was a significantly higher proportion of females with either MAR or OID who underwent repair (21.5%vs 15.5%, P = .04). The MAR patients had significantly more severe PE determined by computed tomography index (MAR = 8.75, OID = 5.82, ALL = 4.94, P < .0001) and required multiple pectus bars (≥2) to be placed during operation (MAR = 58%, OID = 36%, ALL = 29%, P = .001). There was a trend toward higher wound infection rates in MAR patients (MAR = 6%, OID = 1.4%, ALL = 1.3%, P = .07). The recurrence rate was similar among all groups (MAR = 0%, OID = 2%, ALL = 0.7%, P = .12). Successful outcome from surgeon perspective in either MAR or OID patients was similar to ALL (98%vs 98%, P = .88) and correlated well with patient satisfaction after repair (96%vs 95%, P = .43).

Conclusions

Minimally invasive PE repair is safe in patients with Marfan syndrome or marfanoid features with equally good results. Patients with Marfan syndrome have clinically more severe PE requiring multiple bars for chest repair and may have slightly higher wound infection rates. Patients are satisfied with minimally invasive repair despite a phenotypically more severe chest wall defect.     

Minimally invasive thoracoscopic repair of unilateral pectus carinatum

Thoracoscopic repair of pectus excavatum as described by Nuss has become a well established method of repair. However, minimally invasive intrathoracic repair of pectus carinatum has not been reported in literature. We report a case of successful thoracoscopic repair of unilateral pectus carinatum.     

微创漏斗胸矫形术治疗漏斗胸53例报告

目的探讨微创漏斗胸矫形术（minimally invasive repair of pectus excavatum或Nuss手术）的近期效果。方法53例均在气管插管全麻下手术。双侧胸壁做横行切口，在胸腔镜下将塑形之矫形板由右胸腔经胸骨后穿至左胸腔，翻转矫形板，将胸骨抬起矫正胸骨凹陷，矫形板两侧用固定片固定于肋骨。矫形板放置2年后取出。结果53例均顺利完成手术，手术时间30-240min，平均47min，无术中并发症。术后住院2～14d，平均6．1d。术后疼痛超过1周1例；气胸7例；皮下气肿11例；矫形板旋转3例；单侧固定片滑脱4例；切口感染3例，其中2例被迫将矫形板取出，1例经清创换药伤口愈合。53例随访3-28个月，平均15．6月，优42例，良4例，一般3例，差4例。结论Nuss手术治疗小儿漏斗胸近期效果满意。     

超声引导下双侧竖脊肌平面阻滞联合全麻在微创漏斗胸修复术中的应用

目的 观察超声引导下双侧竖脊肌平面阻滞(ESPB)联合全身麻醉应用于微创漏斗胸修复术(MIRPE)的安全性和有效性.方法 选择2018年3月至2020年3月行MIRPE的青少年患者60例,男52例,女8例,年龄14～18岁,BMI 15～23 kg/m2,ASAⅠ或Ⅱ级.采用随机数字表法将青少年患者分为两组:ESPB联...     

Reduced hospitalization cost for patients with pectus excavatum treated using minimally invasive surgery

Background: Currently, few data exist regarding the relative costs associated with open and minimally invasive pectus excavatum repair. The aim of this study was to compare the surgical and hospitalization costs for these two surgical techniques and to identify factors responsible for cost differences. Methods: A retrospective review of hospital charts, patient and parent questionnaires, and hospital accounting records was performed for 68 patients who underwent surgical correction of pectus excavatum between June 1996 and December 1999. Results: In this series, 25 patients underwent open repair, whereas 43 patients underwent minimally invasive repair of pectus excavatum (MIRPE). The patient ages ranged from 4 to 19 years. The average ages for open repair (12 years) and MIRPE (11 years) did not differ significantly. As compared with open repair, MIRPE was associated with a 27% lower overall cost of hospitalization (p < 0.05). The operating room costs were 12% higher for the patients who underwent MIRPE (p < 0.05). The mean operative time for open repair was 3 h 15 min, whereas MIRPE required 1 h 10 min (p < 0.001). The hospital stay for open repair averaged 4.4 days, as compared with 2.4 days for MIRPE (p < 0.001). In contrast to other published series, the postoperative analgesia after MIRPE in this series consisted of narcotics, ketorolac, and methocarbamol. No patient received epidural analgesia, regardless of the repair technique selected. The postoperative complication rate was 4% in the open group and 14% in the MIRPE group. Most of the patients treated with either open or MIRPE reported postoperative oral narcotic usage for 2 weeks or less and returned to routine activities within 3 weeks. The patients and parents alike reported good to excellent overall outcomes in 85% or more of the open repair cases and 90% or more of the MIRPE cases. Conclusions: These data demonstrate for the first time that the use of an alternate pain management strategy including, narcotics, NSAIDs, and methocarbamol, but without epidural catheters, results in reduced hospital length of stay and decreased overall hospitalization costs for MIRPE, as compared with open pectus repair. This cost benefit was achieved without compromising pain management or patient satisfaction with surgical care.     

Experience with FiberWire for pectus bar attachment

Background

Minimally invasive repair of pectus excavatum has become an established method for repair of pectus excavatum. Bar displacement or rotation remains the most common complication of this repair requiring return to the operating room.

Methods

Retrospective review of all patients at a single institution who underwent repair of pectus excavatum using FiberWire for bar stabilization between December 2009 and March 2013 was undertaken.

Results

93 patients underwent minimally invasive pectus repair using FiberWire during the study period. The patients included 73 males and 20 females, with an average age of 14.6 years (range 7–21 years). Mean operative time was 102 minutes (range 56–198 minutes). No patients developed wound complications, two patients developed pain because of bar migration and required return to the OR, and no patients had recurrence of their pectus defect because of bar migration during the study period. Median length of follow-up was 17 months (range 3–36 months).

Conclusion

Stabilization of pectus bars using circumferential rib fixation with FiberWire at multiple points on both sides of the bar appears to be effective in preventing bar rotation and displacement, and requires minimal change to the operation as it has been previously described. Early experience shows a low rate of complications.     

Blood metal levels after minimally invasive repair of pectus excavatum

 Open in a separate windowOBJECTIVESMinimally 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.METHODSBlood 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.RESULTSSignificant 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).CONCLUSIONSWe 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.     

Erosion of the Nuss bar into the internal mammary artery 4 months after minimally invasive repair of pectus excavatum

The minimally invasive repair of pectus excavatum has become increasingly popular. Life-threatening complications have included bleeding and cardiac perforation. There have been a number of delayed cases of bleeding, many of which never demonstrated a clear source. We present a case of a delayed acute bleed from the Nuss bar eroding into the internal mammary artery 4 months after bar placement.     

One hundred patients with recurrent pectus excavatum repaired via the minimally invasive Nuss technique--effective in most regardless of initial operative approach

Purpose

Controversy exists as to the best operative approach to use in patients with failed pectus excavatum (PE) repair. We examined our institutional experience with redo minimally invasive PE repair along with the unique issues related to each technique.

Methods

We conducted an institutional review board-approved review of a prospectively gathered database of all patients who underwent minimally invasive repair of PE.

Results

From June 1987 to January 2010, 100 patients underwent minimally invasive repair for recurrent PE. Previous repairs included 42 Ravitch (RAV) procedures, 51 Nuss (NUS) procedures, 3 Leonard procedures, and 4 with previous NUS and RAV repairs. The median Haller index at reoperation was 4.99 (range, 2.4-20). Fifty-five percent of RAV patients and 25% of NUS patients required 2 or more bars (P = .01). Two RAV patients had intraoperative nonfatal cardiac arrest owing to thoracic chondrodystrophy—1 at insertion and 1 upon removal. Bar displacements occurred in 12% RAV and 7.8% NUS patients (P = .05). Overall reoperation for bar displacement is 9%.

Conclusions

The minimally invasive NUS technique is safe and effective for the correction of recurrent PE. Patients with prior NUS repair can have extensive pleural adhesions necessitating decortication during secondary repair. Patients with a previous RAV repair may have acquired thoracic chondrodystrophy that may require a greater number of pectus bars to be placed at secondary repair and greater risk for complications. We have a greater than 95% success rate regardless of initial repair technique.     

Modified Nuss procedure with a novel steel bar in patients with pectus excavatum post-congenital heart surgery

 Open in a separate windowOBJECTIVESPectus excavatum (PE) can be secondary in patients who underwent sternotomy for cardiac surgery. Retrosternal adhesions increase the complexity and risk of traditional Nuss repair. Thus, we summarized the outcomes of our modified Nuss procedure using a newly designed bar.METHODSA retrospective analysis was performed on 35 patients who underwent modified PE repair after open heart surgery from January 2011 to July 2019. The surgery was performed using a novel bar with no need for intraoperative reshaping and rotation, assisted by thoracoscopy and subxiphoid incision when necessary.RESULTSThere were 19 males and 16 females with a median age of 5.3 years (interquartile range, 4.1–10.9) at PE repair. All patients underwent the modified procedure uneventfully with no death. The median operating time was 70 min. Twenty-nine (82.9%) patients required subxiphoid incision assistance. There was 1 case (2.8%) with unexpected sternotomy due to intraoperative bleeding. The median length of postoperative hospital stay was 4 days. During the median 3.5 years of follow-up, no bar dislocation was found and 30 (85.7%) patients had their bars removed with no recurrence recorded. After PE repair, the Haller index improved significantly (2.6 ± 0.4 vs 4.9 ± 1.3, P < 0.05) and further decreased till the time of bar removal (2.5 ± 0.4 vs 2.6 ± 0.4, P < 0.05). All patients were satisfied with the cosmetic outcome.CONCLUSIONSThe novel bar can be placed and removed easily with a low rate of adverse events. This modified Nuss procedure seems to be a safe, effective and convenient approach for the management of PE after cardiac surgery.     

Recent experiences with minimally invasive pectus excavatum repair "Nuss procedure".

Objective: To review the new technical modifications and results of 668 patients who have had pectus excavatum repair utilizing the minimally invasive technique. Methods: A retrospective chart review was conducted of 668 patients undergoing minimally invasive pectus repair from 1987 through July 2004. Since 1997, a standardized treatment pathway was implemented. Preoperative evaluation included computed tomography (CT) scan, pulmonary function tests, and cardiac evaluations with electrocardiogram and echocardiogram. Indications for operation included at least 2 of the following: progression of the deformity, Haller CT index greater than 3.25, mitral valve prolapse, cardiac compression or displacement, pulmonary function studies that indicate restrictive or obstructive airway disease, previous failed open or minimally invasive pectus repair. Technical and design modifications since 1998 have included routine thoracoscopy, the use of an introducer/dissector for creating the substernal tunnel, elevating the sternum, and routine use of a wired lateral stabilizer and polydioxanone suture (PDS) sutures around the bar and underlying rib to prevent bar displacement. The bar is removed as an outpatient procedure in 2 to 4 years. Results: In 668 patients undergoing minimally invasive pectus repairs, single bars were used in 78.1% and double in 21.7%. Lateral stabilizers were applied in 99.8% and were wired for further stability in 71%. Bar shifts before the use of stabilizers were 14.3%, which decreased to 4.6% after stabilizers were placed and 0.8% with a wired stabilizer and PDS sutures. Results were excellent in 78.5%, good in 13.1%, fair in 4.7% and failed in 3.7% after more than 1 year post bar removal. Conclusion: The minimally invasive technique has evolved into an effective method of pectus excavatum repair. Modifications of the technique have reduced complications. Long-term results continue to be excellent. Read at the Fifty-seventh Annual Meeting of the Japanese Association for Thoracic Surgery, Educational Lecture, Sapporo, October 20–22, 2004.     

Stiffness reduction of the rib cage to perform a minimally invasive pectus excavatum repair: biomechanical evaluation

 Open in a separate windowOBJECTIVESTo study the influence of sternal transection and costal chondrotomies on the stiffness and stresses in the rib cage of adult patients undergoing Nuss pectus excavatum procedure. METHODSFour pectus excavatum models with different Haller indexes were created by parameterizing a 3D model of a rib cage obtained based on a computed tomography scan of a patient with no pectus deformity. Using the finite element method, insertion of intrathoracic bars into all models was simulated in 3 conditions, namely, non-intervened, transverse sternal section and costal chondrotomies. Stiffness, stress distribution and maximum stresses for each case were obtained and compared.RESULTSTransverse sternotomy provided a reduction of 44% to 54% in the stiffness of the rib cage, depending on the Haller index analysed, while chondrotomies promoted a stiffness reduction of 70%. Stress distribution in the rib cage followed similar pattern for all the tested Haller index, but the maximum stress decreased by 36% when performing a transverse sternotomy, whereas when performing costal chondrotomies, it decreased by 47%.CONCLUSIONSComputational results report that transverse sternotomy reduces appreciably the stiffness of the rib cage, while costal chondrotomies promote even a higher stiffness reduction. Thus, these surgical procedures could improve the clinical outcomes of adult patients undergoing a pectus excavatum repair.     

Pushing the boundaries of minimally invasive repair of pectus excavatum: first experience with a 4-bar technique

Several modifications to minimally invasive repair of pectus excavatum have been reported to date. Of these, the use of multiple bars was a major development. At present, there are 2 established techniques: cross-bar and parallel bar placement. We used a combination of both parallel and cross-bar techniques in a 25-year-old male patient with deep, Grand-Canyon type pectus excavatum, placing a total of 4 bars and 4 stabilizers. The patient had no complications during the 7 months of postoperative follow-up. We share this case report as the first experience using this modified technique in the literature.