When patients choose: comparison of Nuss, Ravitch, and Leonard procedures for primary repair of pectus excavatum

Background/Purpose

Pectus excavatum is a common chest wall deformity, and several procedures have been developed for its correction. We allow patients to choose among Leonard, Nuss, and Ravitch procedures. This study aimed to determine which procedure most patients select and the resultant outcomes.

Methods

Charts were reviewed of all pectus excavatum repairs performed for 4 years by a practice covering a university-based children's hospital. Procedure choice, operative time, length of stay, analgesia, fees, and complications were recorded.

Results

The Ravitch procedure was chosen by 60.9% of our patients, Leonard procedure by 23.9%, and Nuss procedure by 15.2%. Operative times were not significantly different among the groups. The mean length of stay was 2.2 days (Ravitch), 1.5 days (Leonard), and 3.9 days (Nuss) (P < .005). Epidural analgesia/patient-controlled analgesia pump requirements were 50% (Ravitch), 5% (Leonard), and 100% (Nuss). The mean charges were $27,414 (Ravitch), $18,094 (Leonard), and $43,749 (Nuss) (P < .05). The overall complication rate was 16.3%. The complications among each group were as follows: Ravitch, 14.3%; Leonard, 9.1%; and Nuss, 35.7%.

Conclusions

We allow patients to choose among Leonard, Ravitch, and Nuss procedures for repair of pectus excavatum. Most select the Ravitch procedure. Length of stay, fees, analgesic needs, and complication rate were highest among patients in the Nuss group; all of these variables were lowest in the Leonard group.     

Comparison of the Nuss and the Ravitch procedure for pectus excavatum repair: a meta-analysis

Purpose

Pectus excavatum is the most common chest wall deformity in children. Two procedures are widely applied—the Nuss and the Ravitch. Several comparative studies are published evaluating both procedures with inconsistent results. Our objective was to compare the Nuss procedure to the Ravitch procedure using systematic review and meta-analysis methodology.

Methods

All publications describing both interventions were sought through the Cochrane Central Register of Controlled Trials (CENTRAL) database, MEDLINE, and EMBASE. The statistical analysis was performed using RevMan 5 software. Odds ratios (OR) and weighted mean differences (WMDs) with 95% confidence intervals are presented.

Results

No randomized trials were identified. Nine prospective and retrospective studies were identified and were included in this study. There was no significant difference in overall complication rates between both techniques (OR, 1.75 (0.62-4.95); P = .30). Looking at specific complications, the rate of reoperation because of bar migration or persistent deformity was significantly higher in the Nuss group (OR, 5.68 (2.51-12.85); P = .0001). Also, postoperative pneumothorax and hemothorax were higher in the Nuss group (OR, 6.06 [1.57-23.48]; P = .009 and OR, 5.60 [1.00-31.33]; P = .05), respectively. Duration of surgery was longer with the Ravitch (WMD, 69.94 minutes (0.83-139.04); P = .05). There was no difference in length of hospital stay (WMD, 0.4 days (−2.05 to 2.86); P = .75) or time to ambulation after surgery (WMD, 0.33 days [−0.89 to 0.23]; P = .24). Among studies looking at patient satisfaction, there was no difference between both techniques.

Conclusions

Our results suggest no differences between the Nuss procedure vs the Ravitch procedure with respect to overall complications, length of hospital stay, and time to ambulation. However, the rate of reoperation, postoperative hemothorax, and pneumothorax after the Nuss procedure were higher compared to the Ravitch procedure. No studies showed a difference in patient satisfaction.     

Postoperative opioid analgesic use after Nuss versus Ravitch pectus excavatum repair

Background/Purpose

Anticipated postoperative pain may affect procedure choice in patients with pectus excavatum. This study aims to compare postoperative pain in patients undergoing Nuss and Ravitch procedures.

Methods

A 5 year retrospective review was performed. Data on age, gender, Haller index, procedure, pain scores, pain medications, and length of hospital stay were collected. Total inpatient opioid administration was converted to morphine equivalent daily dose per kilogram (MEDD/kg) and compared between procedures.

Results

One hundred eighty-one patients underwent 125 (69%) Nuss and 56 (31%) Ravitch procedures. Ravitch patients were older (15.7 yo vs 14.6 yo, p = 0.004) and had a higher Haller index (5.21 vs 4.10, p = < 0.001). Nuss patients had higher average daily pain scores, received 25% more opioids (MEDD/kg 0.66 vs. 0.49, p = < 0.001), and received twice as much IV diazepam/kg. In the multivariate analysis, higher MEDD/kg correlated with both the Nuss procedure and older age in the Nuss group. Opioid administration did not correlate with Haller index or Nuss bar fixation technique. Increased NSAID administration did not correlate with lower use of opioids.

Conclusion

The Nuss procedure is associated with greater postoperative pain compared to the Ravitch procedure. Opioid use is higher in older patients undergoing the Nuss procedure, but is not associated with severity of deformity.     

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.     

Nuss手术矫治复杂漏斗胸

目的 总结Nuss手术治疗复杂漏斗胸的临床经验.方法 2006年9月至2009年10月,采用Nuss于术治疗169例漏斗胸病儿,其中复杂漏斗胸45例,术前常规行胸部CT和心脏B超等检查.有合并症者同时行合并症矫治,极重度和严重不对称漏斗胸分别采用剑突下小切口辅助、个性化钢板、多钢板放置、斜行放置钢板等方法完成矫治.结果 45例均顺利完成手术,平均手术时间54 min,术后4例出现少量气胸或皮下气肿,术后平均住院7天.矫形效果为优秀30例,良好13例,中等2例.所有病儿均获得随访,效果满意.结论 对复杂漏斗胸术前必须完善诊断,并分别和综合采用多种改良的Nuss手术方法,可以达到较好的矫治效果.     

胸腔镜下Nuss手术治疗小儿漏斗胸38例报告

目的探讨胸腔镜下Nuss手术治疗小儿漏斗胸的疗效和安全性。方法胸腔镜监视下用穿通器在胸骨凹陷最低点水平，两腋中线之间，于胸膜外经胸骨后穿通一遂道，放置支撑板将凹陷胸骨抬起，支撑板两端安装固定器。5例使用进口器械，33例使用国产器械。结果38例均在胸腔镜辅助下顺利完成手术，手术时间40～80min，平均50min。术中出血量5～30ml，平均16ml。36例放置1根钢板支撑，2例放置2根钢板支撑。术后气胸4例，皮下气肿16例，右侧固定器滑脱1例，钢板轻度翻转1例。术后住院7～21d，平均8d。38例随访3～22个月，平均11个月，优36例，良2例，优良率100％。结论胸腔镜辅助下Nuss手术治疗小儿漏斗胸方法安全可靠，疗效好，手术最佳时机3～12岁。     

双支架Nuss手术治疗青少年漏斗胸

目的 探讨使用双支架治疗青少年大范围漏斗胸微创Nuss手术的适应证、可行性和手术方法及效果.方法 31例中男24例,女7例;年龄14～18岁,平均(15.32±3.12)岁.根据Hallar指数均评价为中到重度,凹陷范围为4个肋间以上.选择胸腔镜辅助Nuss手术两点或者多点双支架支撑固定法手术.结果 均采用双支架在胸腔镜辅助下顺利完成Nuss手术.术后住院5～10天,平均(7.48±1.95)天;随访4个月到5年.术中发生出血2例,支架滑动移位和间断疼痛2个月各1例,均治愈.结论 胸腔镜辅助双支架矫正大面积、不对称漏斗胸的Nuss手术对青少年是一种安全、有效的方法.

Abstract：

Objective To investigate the indication, feasibility and technique of minimally invasive nuss procedure with thoracoscope by using double braces in the treatment of wide-scope pectus excavatum repairing in adolescence. Methods 31 patients including 24 boys and 7 girls, suffered from pectus excavtum were corrected by nuss procedure under thoracoscope.The average age was (15.32 ± 3.89)years (ranged, 14 years and 18 years). All cases were moderate to severe degree according to Hallar index with depression scope of 4 ribs or more. A couple of braces of two-point or multipoint fixation for thoracoscopic-assisted nuss procedure were used. Results The procedure was successfully completed under thoracoscopy in all patients. Double braces were utilized in 27 cases, double are bars were required in 4 cases, and multipoint fixations were in 6 patients. The postoperative hospital stay was 5-11 days [average, ( 7.48 ± 1.95 ) days]. The duration of following up was one month to three years. The perioperative complications included intraoperative hemorrhage in 2 patients, bar invertion with displacement in 1, and interrupted pain for two months in 1. All patients recovered after expectant treatment. Conclusion Nuss procedure with double braces for the correction of a large area of asymmetric pectus excavatum under thoracoscopy is safe and effective technique for adolescence.     

Quality-of-life outcomes after surgical correction of pectus excavatum: a comparison of the Ravitch and Nuss procedures

Purpose

The purpose of this study was to compare clinical and health-related quality-of-life (HRQL) outcomes within a group of patients treated for pectus excavatum (PE).

Methods

A retrospective 3-year review of patients undergoing Nuss or Ravitch correction of PE was performed. Health-related quality-of-life assessment was performed using the Child Health Questionnaire (CHQ-CF87) and the 17-item Pectus Excavatum Evaluation Questionnaire, and results were compared between groups and with age-matched CHQ-CF87 normative data.

Results

Forty-three patients (39 males; 91%) underwent surgery; 19 (44%) by Nuss procedure. Duration of postoperative opioid analgesia and length of hospital stay (LOS) were significantly longer in Nuss patients. The overall survey response rate was 53%. The groups differed significantly in the CHQ on one item (Change in Health). On the Pectus Excavatum Evaluation Questionnaire, Nuss patients reported being “less bothered” by the appearance of their chest. Compared to Australian age-matched norms, the aggregate PE sample showed better scores for family activity domain and worse scores in mental health, general health perceptions, change in health, bodily pain, and self-esteem.

Conclusions

Patients undergoing surgery for PE by either Nuss or Ravitch procedure have similar clinical and HRQL outcomes, but as a group have poorer HRQL scores than age-matched population norms.     

胸腔镜下钢板植入胸骨抬举术治疗小儿漏斗胸

目的探讨胸腔镜下钢板植入胸骨抬举术（Nuss手术）治疗小儿漏斗胸中的疗效。方法胸腔镜辅助下,经右侧切口用钝剥离器沿胸骨后穿过纵隔至对侧胸壁切口,牵引已塑形好的合金钢板凸面朝后拖过胸骨后方,调整位置后,翻转钢板使凹陷的胸骨和前胸壁抬高。结果11例均顺利完成手术,手术时间50—85min,平均67min;术中出血量5—20ml,平均10ml。优9例,良1例,中1例。8例随访2—15个月,平均6．4月,外观维持良好。结论胸腔镜下Nuss手术治疗小儿漏斗胸创伤小、出血少、操作简便、恢复快、效果满意,值得推广。     

不同镇痛方法在儿童漏斗胸Nuss手术术后的应用

背景漏斗胸（pectus excavatum,PE）为最常见的先天性胸廓畸形,Nuss手术为目前常用的手术方式,虽属微创手术,但术后疼痛剧烈,严重影响患儿术后恢复及生活质量。良好的镇痛能促进康复并提高患儿及家属满意度,故Nuss手术术后镇痛具有重要意义。目的对儿童PENuss手术术后镇痛的研究进展予以综述。内容常用的镇痛方式有静脉镇痛、胸段硬膜外镇痛、肋间神经阻滞、椎旁神经阻滞及多模式镇痛等,另外催眠疗法及术后焦虑处理对Nuss术后疼痛也有一定缓解作用。趋向上诉镇痛方法各有优缺点,如何根据患者及医院情况为Nuss手术患儿制定个性化的术后镇痛方案仍待进一步研究。     

CT在漏斗胸诊断和微创Nuss手术中的作用

目的 探讨CT在漏斗胸术前诊断和微创Nuss手术中的应用.方法 2002年7月到2008年9月648例NUSS手术病例均行术前CT检查,分析病人胸廓的畸形程度、分型、与周围脏器的关系和发现合并症,对手术进行指导和评价.结果 648例均顺利完成手术,CT分度为中度73例(11.27%),重度575例(88.73%).对称型407例(62.81%),偏心型83例(12.81%),不均衡型158例(24.38%).术前发现其他合并症116例(17.90%),CT检查确诊55例,占发现合并症的47.41%;55例中28例同期进行了手术.结论 CT能有效评价胸廓的畸形程度、分型、指导手术的入路、减少并发症的发生,并能进一步发现其他先天畸形等合并症,还是漏斗胸微创Nuss手术的术前常规检查和重要评估手段.     

Anesthetic management for the minimally invasive Nuss procedure in 21 patients with pectus excavatum

The aim of this study was to assess the anesthetic management and postoperative analgesic effect of continuous epidural infusion for the minimally invasive Nuss procedure. A total of 21 operated cases were analyzed retrospectively. Thoracoscopy was used in all cases. General anesthesia with endotracheal intubation was induced and maintained with oxygen, air, sevoflurane, and fentanyl in all cases. Thoracic epidural anesthesia was performed after induction at the level between Th4 and 12. When the bar was placed via insertion under the sternum, six patients exhibited sinus tachycardia and one showed premature atrial contraction for 2–4 beats before recovering spontaneously within 1 min. Operations were uneventful. The mean operating time was 115 min and anesthetic time was 193 min. In X-ray findings, residual pneumothorax and pleural effusion were found in seven (33.3%) and eight (38.0%) patients, respectively. In all cases, these symptoms were resolved spontaneously within 5 days. Epidural fentanyl (0.3 μg·kg⁻¹·h⁻¹) in 0.125% bupivacaine (0.15 ml·kg⁻¹·h⁻¹) or 0.2% ropivacaine (0.15 ml·kg⁻¹·h⁻¹) were used for 3 days to relieve postoperative pain. Postoperatively, 12 (57.1%) patients required no additional analgesics, and 4 (19.0%) patients required a single dose of dicrofenac sodium or pentazocine. Although the Nuss procedure is minimally invasive, we should pay attention to the possibility of many intra- and postoperative complications. Continuous epidural infusion of fentanyl with local anesthetics provides effective postoperative pain relief and prevents complications such as bar displacement after the Nuss procedure.     

胸腔镜微创Nuss手术治疗小儿漏斗胸

目的:探讨胸腔镜辅助下漏斗胸矫形术(Nuss手术)的优越性。方法:在胸腔镜辅助下实施漏斗胸矫形术2例。结果:手术过程顺利,手术时间分别为35、30m in,术中出血1~2m l,均恢复顺利,分别于术后第4天和第5天出院,分别随诊1年和10个月无任何并发症出现。结论:Nuss手术具有切口小而隐蔽、手术时间短、出血少、活动早、手术创伤小、无手术瘢痕、矫形效果好等优点,手术方法安全可行,值得推广。     

Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation

Purpose

In a few patients, cardiac perforation and aortic injury have occurred during the Nuss procedure for pectus excavatum. The article details a modification of this procedure that enables the prevention of fatal complications.

Methods

Our subjects were 22 males and 13 females with pectus excavatum who were aged 8.2 ± 3.7 years. Their Haller's computed tomography index was 5.2 ± 1.5. An introducer is inserted into the pleura between the sternum and thymus instead of the thoracic depression under right thoracoscopic guidance. After the introducer reaches the internal cranial position of the left nipple, the thoracoscope is shifted to the left thoracic cavity. The introducer is subsequently guided to the left highest intercostal space under left thoracoscopic guidance.

Results

A single bar was inserted in 34 patients; 2 bars were required in 1 patient. The operating time was 95 ± 27 minutes and blood loss was 11 ± 6 g. Cardiac perforation did not occur in any patient.

Conclusions

Our modified technique has certain advantages: (1) the introducer does not rub against the pericardium and heart; (2) the tip of the introducer can be observed at all times with a thoracoscope; (3) the anterior mediastinum between the left and right thoracic cavities is very narrow at the cranial level; (4) the introducer can be accurately directed to the left highest intercostal space; and (5) hemostasis and no injury of the bilateral thoracic organs can be confirmed.     

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.     

Health-related quality of life after Nuss procedure for pectus excavatum: a cross-sectional study

Open in a separate window OBJECTIVESPectus excavatum (PE) can cause both physical and psychosocial symptoms and affect patients’ health-related quality of life. Previous international studies have shown that the Nuss procedure increases both self-esteem and body image. The aim of the study was to evaluate the health-related quality of life in patients who have undergone the Nuss procedure for PE.METHODSThe study had a cross-sectional multicentre design. All patients (N = 420) who underwent the Nuss procedure for PE in 3 cardiothoracic departments in Sweden from 2000 to 2019 were invited to answer the RAND-36 and Nuss Questionnaire modified for adults. Genders were compared using the Mann–Whitney U-test. Patients were divided into groups based on age at time of surgery (<20, 20–30 or >30 years) and analysed by the Kruskal–Wallis H-test with post-hoc analyses.RESULTSA total of 236 patients returned the questionnaires; 82.2% were males. Men scored significantly better on the modified Nuss Questionnaire total (P = 0.01) and psychosocial (P = 0.02) subscales. Patients who had surgery at <20 years of age had significantly better scores on the same scales (P = 0.007 and 0.006, respectively) compared to patients aged 20–30 years at the time of surgery. However, no significant difference was seen in comparison with patients >30 years. Patients who had their bar removed had significantly better values on both scales.CONCLUSIONSMale gender, young age at surgery and bar removal seem to be associated with better health-related quality of life after the Nuss procedure for PE.     

Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum

Background/Purpose

The minimally invasive Nuss procedure is emerging as the preferred technique for repair of pectus excavatum. Original methods of pectus bar placement have been modified to improve safety and efficacy and avoid cardiothoracic complications. The currently reported modifications to facilitate retrosternal pectus bar placement include routine use of right thoracoscopy or a subxiphoid incision. The purpose of this article is to describe additional modifications of the Nuss procedure to improve safety and efficacy.

Methods

A retrospective analysis was performed on 51 patients who have had a thoracoscopic-assisted Nuss procedure at The Children's Hospital, Denver, Colo, between 1999 and 2002. Technical modifications included patient positioning, routine use of left thoracoscopy, and an Endo-kittner.

Results

Fifty-one patients have successfully undergone the Nuss procedure using the new modifications. Surgical time ranged from 45 to 120 minutes. There have been no intraoperative or postoperative bleeding complications. There have been 2 large pneumothoraces requiring needle thoracenteses in the operating room before extubation. No chest tubes were required postoperatively. Subjectively, all patients have been satisfied with their surgical correction. Average length of hospital stay was 4 to 6 days.

Conclusions

By using left chest thoracoscopy and Endo-kittner dissectors, the risk of cardiothoracic injury can be eliminated. Moreover, other methods to ensure safe substernal dissection are unnecessary.     

Surgical correction of pectus excavatum

It has been observed that some patients who had correction of funnel chest deformity by methods which failed to provide fixed elevation of the involved sternal segment developed progressive sagging in later years in spite of looking good at the operating table. This has led to the adoption of a new technique of double sternal support. This procedure has resulted in 35 of 37 children (94%) being classified as excellent or satisfactory. This double support was initially established in 1959 by overlapping the upper transsected sternum while maintaining elevation of the lower end with a soft tissue sling of perichondrium and intercostal muscle. Beginning in 1961, a rigid bridge of rib or stainless steel bar was substituted at the lower end of the sternum. This has provided better support and the current preference of using the steel bar has been validated in this group of patients. The few disappointments were related to removal of the bar earlier than desired, failure to excise all the protruding sternal cartilage stumps or rib graft tips and inability to cover the lateral sternal edges with pectoral muscles. If possible, the steel bar should not be removed before 12 mo. When these pitfalls were avoided, the results were almost uniformly excellent. The wisdom of excising all depressed cartilaginous segments, as advocated by Ravitch in 1949,⁴ has been substantiated. A submammary transverse incision has provided an excellent cosmetic appearance. The morbidity has been low and the mortality zero.In spite of the absence of objective evidence of cardiopulmonary dysfunction, there seems to be an almost uniform improvement in appearance and in patient activity following successful correction of the funnel chest. The latter may be as much a psychological response as a physiologic one. The low morbidity, satisfactory long term results, and general improvement in the patient's body image and outlook on life indicate the need to offer correction of the severe pectus excavatum deformity to low risk children.