Nuss operation for pectus excavatum: a single-institution experience

Background  

The Nuss procedure for repair of pectus excavatum (PE) has been accepted worldwide because of minimal invasiveness and excellent cosmetic results. We summarized our experience with the treatment of 115 patients aged 2.7–18 years.     

漏斗胸外科治疗:30年406例经验回顾

目的复习漏斗胸外科治疗30年经验并讨论相关应用研究结果。方法406例2～18岁漏斗胸于1975-2005年3月在四川大学华西医院小儿外科接受手术治疗（包括23例外出手术）。后期病例接受了CT、心肺功能检查，以及在相关的应用研究中，对手术操作不断完善。早期8例施行胸骨翻转术（sternoturnover），其余病例均施行胸骨上举术（sternal elevation）。上举术主要包括从肋软骨膜下切除畸形的肋软骨，胸骨前的横向楔形切骨术，金属板横向穿过矫形后的胸骨体予以固定。要获得好的矫形效果，在手术操作中及术后要求做到下列5点：①保护肋软骨与肋骨连接部（costochondral junction）；②将切开的软骨膜缝合修复呈“管套”状；③不切断与胸骨缘相连的肋间束；④将金属板向前弯曲为适度的“弓”形；⑤术后体疗，如维持挺胸姿势和与扩胸有关的锻炼，金属支架（metalstrut）固定1年。结果312例获1～16年随访。3例复发，其中2例需再次手术。少数病例前胸壁外形不够理想，但胸骨后面与椎体前面之间距离增大，使心脏位置及心功能恢复，达到同龄健康儿童水平，而大多数患儿同时获得了正常的胸廓外观。术后肺功能的恢复则较缓慢。结论认真做到改良手术操作中要求的5点，是获得远期手术良好效果的关键。最适当的手术时机是3～7岁。改良胸骨上举术可获得良好的胸廓塑形与心肺功能的迅速恢复，并发症低，远期疗效好。     

MRI for the evaluation of pectus excavatum

Pectus excavatum, the most common congenital deformity of the anterior chest wall, is both a cosmetic and functional abnormality. The degree of abnormal chest wall deformity determines its functional effect, particularly its cardiac and pulmonary impact. Although CT scanning is the most widely used cross-sectional imaging technique used to measure the Haller index, the radiation exposure is reason to seek other alternatives. At our institution, we have introduced a rapid MRI technique for this purpose, which utilizes a single-axial 2-D FIESTA acquisition.     

The physiologic impact of pectus excavatum repair

The adverse physiologic effects of pectus excavatum and subsequent resolution following correction have been a subject of controversy. There are numerous accounts of patients reporting subjective improvement in exercise tolerance after surgery, but studies showing clear and consistent objective data to corroborate this phenomenon physiologically have been elusive. This is partially due to a lack of consistent study methodologies but even more so due to a mere paucity of data. As experts in the repair of pectus excavatum, it is not uncommon for pediatric surgeons to operate on adult patients. For this reason, this review evaluates the contemporary literature to provide an understanding of the physiologic impact of repairing pectus excavatum on pediatric and adult patients separately.     

Quantification of pectus excavatum: Anatomic indices

Pectus excavatum is the most common chest wall deformity in children. The central portion of the chest is displaced posteriorly relative to the remainder of the anterior chest wall. Quantification of defect severity can be performed with multiple imaging modalities or external thoracic measures, but is most commonly quantified by the Haller Index (HI) or Pectus Correction Index (PCI). These two measures provide a measure of the chest based on cross sectional imaging, most commonly CT scans, allowing for standard comparison and definitions of pectus defects. The purpose of this article is to describe the creation, calculation, and limitations of the methods quantifying pectus defects.     

Operative correction of pectus excavatum

The Rehbein operation for pectus excavatum has been in use at the Children's Hospital of Bremen since 1955. This procedure involves presternal sternum fixation: after mobilization of the concavity, the elevated sternum is held in a position of slight overcorrection by steel splints and metal bands that are left in place for 3 years. The operation is most likely to succeed in children between 6 and 8 years or over 12 years of age. Surgery is indicated for all severe deformities; moderate forms should be operated upon only when ventilation disturbance, cardiac displacement, or psychological disorders are present. The operative results with this procedure are comparable to those achieved by other operations: we had good results in 69.2%, satisfactory in 18.3% and poor in 12.5% of cases.     

Single incision Nuss procedure for pectus excavatum

Purpose  

To describe a unique single incision modification of the Nuss procedure and compare results to a historical cohort of standard Nuss patients.     

改良胸骨翻转术治疗小儿先天性漏斗胸20年经验

目的总结近20年采用改良胸骨翻转术治疗先天性漏斗胸120例的经验。方法1985～2004年，手术治疗先天性漏斗胸120例，男98例，女22例，年龄2～15岁，体重10-28kg。有反复呼吸道感染史48例，活动耐量减低45例。心电图有不完全性右束支传导阻滞38例，心室肥厚26例，窦性心律失常31例，T波改变或心肌劳损55例。X线胸片均显示有不同程度的心脏左移。肺功能检查有限制型通气障碍24例。漏斗胸指数（FI）大于0．3有43例，FI在0．2～0．3之间有71例，FI小于0．2有6例。结果全组病例术后均见明显效果。早年1例发生胸骨缺血坏死。肺不张和／或肺部感染6例，胸腔积液3例，伤口感染2例，均痊愈出院。术后住院7～40d（平均10d）。随访1～15年，胸骨呈正常平坦，无一复发。结论改良胸骨翻转术治疗先天性漏斗胸近远期效果满意。     

The treatment of pectus excavatum: results of a mininvasive surgical technique on the first 50 patients

AIM: Pectus excavatum is the commonest thoracic congenital malformation, but its treatment remains not well known. The authors present the results of the mini-invasive repair at G. Gaslini Institute of Genoa, Italy. METHODS: Nuss mini-invasive repair avoids anterior scars. The correction is achieved by the introduction under thoracoscopy of a retrosternal curve bar that is rotated by 180 degrees . Postoperatory pain is managed by an epidural catheter. In all the operated patients we evaluated the clinical pre-operatory parameters (spirometric, radiological and cardiological data), the surgical details and the results. RESULTS: Fifty patients were operated, 43 of them males, ranging from 7 and 22 years of age, with an average of 17 years of age. Only 8 of them were asymptomatic and required surgery for psychological reasons. The 74% presented some stress dyspnea. Some impairment in spirometric parameters were observed in 28% and mitral valve prolapse in 30%. The only significant intra-operative complication was a bleeding from a thoracic wall vessel that required a left emergency minimal thoracotomy. Postoperative complications were: 2 pneumothorax (drained for 24 hours), 2 transitory pulmonary atelectasis, 1 hemothorax in a patient with coagulation deficit, 3 wound problems (1 infection and 2 hematomas). The esthetical score after surgery, according to the patients, was 9.15 on average, in a scale from 1 to 10. None rated less than 7. The pain score with the same scale was rated 6.8 on average. CONCLUSION: The Nuss technique is safe and guarantees very satisfactory esthetical results.     

微创手术矫治漏斗胸125例

目的探讨不同术式的微创手术矫治漏斗胸的特点及疗效。方法2003年3月至2008年2月,采用微创手术方法治疗漏斗胸125例。其中电视胸腔镜辅助微创手术52例;小切口直视微创手术28例;小切口不损伤胸肋骨微创手术15例;Nuss手术30例。除Nuss手术外,全部病人均选择钢板、克氏针倒T形内固定。结果手术后均恢复顺利,1例内固定钢板滑脱,术后3d重新手术固定。1例Nuss手术病人发生中量血胸。其余无重要并发症。术后胸片、CT复查胸骨位置全部恢复正常。随访2个月至2年,4例有胸壁局限性凹陷,其余病人效果满意。结论本文报告的微创手术方法创伤小,疗效好。手术年龄以3—5岁为宜。如胸骨凹陷较重,临床症状多,主张在2～3岁手术,并可选择不损伤胸骨和肋骨的微创术式。     

A better incision for pectus excavatum repair: avoiding the keloid triangle

The most common approach to the pepair of pectus excavatum and pectus carinatum deformities is via a central transverse submammary incision. The subsequent suprasternal scar is conspicuous and prone to hypertrophic and keloid scarring. To avoid the keloid triangle and to produce a less noticeable scar, we have utilized bilateral inframammary incisions for repairs of five female and two male patients with pectus defects. This approach provides excellent access for cartilage resection, sternotomy, and sternal tupport without increasing opearative time or compromising operative exposure. On follow-up for up to 25 months, all patients have had excellent cosmetic and functional results. Chest wall configuration and stability, wound healing, and scar formation have all been without complication. No keloid or hypertrophic scars have developed. To date, there has been no recurrence of pectus defects. We believe bilateral inframammary incisions are a superior approach for pectus repairs by enchancing cosmesis with less noticeable scars and fewer hypertropic and keloid scars, all without compromising operative exposure or increasing operative time.     

Early complications of the Nuss procedure for pectus excavatum: a prospective study

The Nuss procedure is a minimally invasive method for the correction of pectus excavatum, with several centers reporting its successful application. Complications related to the Nuss procedure are not uncommon and life-threatening complications have been reported. This study focuses on the incidence and management of complications in a series of 167 children and adults with funnel chest corrected by Nuss procedure. Guidelines and strategies to avoid the most common and typical complications are proposed. All patients with funnel chest, operated between April 2000 and 2006 were evaluated prospectively. Our surgical approach involved the submuscular insertion of the pectus bar under right-sided thoracoscopic control. The bar was secured in most cases with one stabilizer on the right side on the underlying rib to prevent bar displacement. Postoperative pain was primarily managed by epidural catheters. All data in the patient report forms was prospectively entered in a database. All complications were documented and classified into major or minor complication. A major complication was noted, if an organ injury occurred or if a significant surgical intervention became necessary. A minor complication was documented, if either an endoscopy or an evacuation of fluid or gas from the thorax by puncture were necessary. One hundred and sixty seven patients (136 males and 31 females) with a mean age of 16.3 (range 5-40 years) were included in this study. Major complications occurred in seven patients (4.2%) and consisted of one intraoperative heart perforation, one piercing of the liver with the trocar, bar infections (n = 2) and significant bar displacement (n = 3). Minor complications were seen in 122 patients (73.1%) and consisted of breakage of wires used to secure the lateral stabilizer plate (n = 48), pleural effusions (n = 28), intraoperative rupture of the intercostal muscle (n = 15), pericardial tears without clinical significance (n = 7) and lung atelectasia (n = 4). Major complications related to the Nuss procedure were rare but preventable and could mainly be attributed to the learning curve. Most minor complications can be avoided by changing the technique, e.g. fixation of the bar and the stabilizer onto the underlying rib, use of PDS cords instead of metal wires to fix the bar and the stabilizer, entrance into and exit of the thorax medial to the rim of the pectus excavatum, etc. Some complications are related to the technique, such as minor pleural effusion or remaining gas in the thorax. Clear guidelines in regard to the technique are presented to prevent the majority of complications and thereby shorten the learning curve.     

Late-onset vital complication after the Nuss procedure for pectus excavatum

The Nuss procedure is the most popular technique for correction of pectus excavatum recently. Life-threatening complications associated with the procedure are very rare. We report a 13-year-old boy who developed late-onset bilateral hemothorax with hypovolemic shock 5 months after the Nuss procedure. In literature review, this is the first case of the late-onset life-threatening bilateral hemothorax with hypovolemic shock ever reported.     

Minimally invasive surgical repair of pectus excavatum

The minimally invasive repair of pectus excavatum has become widely accepted. The number of patients presenting for repair has increased dramatically. There have been many technical improvements over 20 years that have made the procedure much safer and more successful. The complications have been identified and preventative measures instituted. The long-term results have shown a 95% good to excellent outcome, and patient satisfaction studies have shown similar results.