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.     

Open repair of pectus excavatum and carinatum deformities with minimal cartilage resection

BACKGROUND: Numerous modifications of the Ravitch open repair of pectus excavatum (PE) and carinatum (PC) have been used by surgeons with inconsistent results. METHODS: During a 3-year period, 275 consecutive patients underwent open repair of PE and PC using a new less invasive technique. A small chip of costal cartilage was resected medially and laterally from each deformed cartilage, allowing it to barely touch the sternum and rib (laterally) after the sternum had been elevated or depressed, and twisted to the desired position. A support strut used for all patients was routinely removed within 6 months. RESULTS: With mean follow-up of 17 months, all but 5 patients regarded the results as very good or excellent. There were no major complications or deaths. CONCLUSION: Open repair using minimal cartilage resection is effective for all variations of PE and PC in patients of all ages, causes only mild pain, and produces good physiologic and cosmetic results.     

The effect of thoracoscopy upon the repair of pectus excavatum

Background/aims

The Nuss procedure is the most commonly performed operation to correct pectus excavatum (PE). Thoracoscopic assistance has been anecdotally noted to improve the safety of this operative approach. This study aimed to compare complications and clinical outcomes before and after the introduction of thoracoscopy in a single-center.

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.     

Pectus bar repair of pectus excavatum in patients with connective tissue disease

Purpose

Few studies address the surgical correction of pectus excavatum (PE) in patients with connective tissue disease (CTD). We have identified the preoperative characteristics, postoperative complications, and outcomes of patients with CTD undergoing bar repair of PE and compared these outcomes to a control group without CTD.

Methods

A retrospective review of patients undergoing primary repair of PE with a bar procedure from 1997 to 2006 identified 22 patients with CTD. Of those, 20 (90.9%) had their bars removed. We identified 223 patients of similar age without CTD whose bars were removed. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes.

Results

Among those with CTD, the median age at repair was 15.5 years, with a mean pectus index of 4.0 ± 1.4. Three patients (13.6%) experienced bar displacement or upper sternal depression requiring surgical revision. Only 1 patient recurred after bar removal. Rates of bar displacement, upper sternal depression, and recurrence were not statistically different than those in the comparison group.

Conclusions

Patients with CTD benefit from primary bar repair of PE and experience excellent operative outcomes after repair, with complication rates being no different than those found in similarly aged control patients.     

Surgical treatment of pectus excavatum: 30 years 398 patients of experiences

Purpose

The aim of the study is to review the surgical experiences with pectus excavatum (PE) chest deformities at the Department of Pediatric Surgery, West China Hospital of Sichuan University (Sichuan, PR China), during a 30-year period.

Method

Records of 398 PE patients (396 congenital, 2 acquired) who underwent surgical repair between 1975 and 2005 were reviewed. Modified sternal elevation was applied in all patients. Repair was performed with subperiosteal resection of the abnormal cartilages, transverse wedge osteotomy of the anterior sternum, and internal support with a metal strut for 1 year. Five technical details were strictly followed for each case. Three hundred twelve patients (78.39%) were followed up from 1 to 16 years.

Result

There were no deaths. Normal contour of the costal cage was constructed postoperatively in 98.74% (393/398) of the patients. Exercise tolerance was improved, and cardiac function recovered to the healthy level of same age. But pulmonary function recovered slowly after surgery.

Conclusions

The 5 technical details are key principles for sternal elevation. Normal appearance of chest wall can be recovered; normal cardiopulmonary function can be restored by the modified sternal elevation with excellent long-term physiologic, cosmetic results and low rate of complications.     

Pleural and pericardial morbidity after minimal access repair of pectus excavatum

Purpose  The aim of this study was to evaluate the pleural and pericardial morbidity in patients that had undergone pectus excavatum corrections using minimal access repair of pectus excavatum (MARPE) at a single center. Materials and methods  Data from patients after MARPE from 2000 to 2007 were prospectively collected. Patients with pneumothorax and pleural and pericardial effusions were identified. Results  One hundred eighty patients were corrected by MARPE. Eighty-four were identified to have pleural or pericardial morbidities. Pneumothorax was documented in 33 patients and five required placement of a chest tube. Pleural effusions were recorded in 53 and were found to recur in four patients. Drainage was necessary in 18 patients. Pericardial effusions were observed in five patients; in two cases, they were associated with recurring pleural effusions, suggesting postcardiomyotomy syndrome. Conclusions  MARPE is associated with a high rate of pleural and pericardial morbidities, but only a small number requires interventions.     

Impact of pectus excavatum on pulmonary function before and after repair with the Nuss procedure

Background/Purpose

Patient reports of preoperative exercise intolerance and improvement after surgical repair of pectus excavatum (Pex) have been documented but not substantiated in laboratory studies. This may be because no study has been large enough to determine if pulmonary function tests (PFTs) in the Pex population are significantly different from the normal population, and none has assessed improvement in pulmonary function after Nuss bar removal.

Methods

The authors studied PFT results in 408 Pex patients before repair and in a subset of 45 patients after Nuss procedure and bar removal. Significance of differences in percent predicted (using Knudson's equations) was tested using t tests (parametric) or sign tests (nonparametric). Normal was defined as 100% of predicted for forced vital capacity (FVC), forced expired volume in 1 second (FEV₁), and forced expiratory flow (FEF_25%-75%).

Results

Preoperatively, FVC and FEV₁ medians were lower than the normal by 13%, whereas the FEF_25-75 median was lower than normal by 20% (all P < .01). The postoperative group had statistically significant improvement after surgery for all parameters. Patients older than 11 years at the time of surgery had lower preoperative values and larger mean post-bar removal improvement than the younger patients. An older patient with a preoperative FEF_25-75 score of 80% of normal would be predicted by these data to have a postoperative FEF_25-75 of 97%, indicating almost complete normalization for this function.

Conclusions

These results demonstrate that preoperatively Pex patients as a group have decreased lung function relative to normal patients. After Nuss procedure and bar removal, we show a small but significant improvement in pulmonary function. These results are consistent with patient reports of clinical improvement and indicate the need for more in-depth tests of cardiopulmonary function under exercise conditions to elucidate the mechanism.     

Surgical repair of pectus excavatum relieves right heart chamber compression and improves cardiac output in adult patients—an intraoperative transesophageal echocardiographic study

Background

Cardiac compression in pectus excavatum (PE) deformity and effect of PE surgery on cardiac function in adults have been debated. We examined the effect of PE correction on right heart size and cardiac output.

Methods

A retrospective evaluation was performed of 168 adult patients who underwent a modified Nuss PE repair with intraoperative transesophageal echocardiography from 2011 to 2014. Seventeen patients with prior PE repair undergoing bar removal acted as controls.

Results

Mean age was 33.0 years (range, 18 to 71 years). There was an increase in right atrium (15.1%), tricuspid annulus (10.9%), and right ventricular outflow tract (6.1%) size after surgery (all P < .0001). Right ventricular cardiac output measured in a subset of 42 patients improved by 38%. No change in chamber size or cardiac output occurred before and after bar removal surgery in the control group.

Conclusions

Surgical correction of PE deformity caused a significant improvement in right heart chamber size and cardiac output.     

微创技术同期治疗漏斗胸合并先天性心脏病

目的 探讨应用微创技术同期治疗漏斗胸合并先天性心脏病(先心)的方法及可行性.方法 2006年7月至2011年6月应用双微创技术6例,其中男4例,女2例;年龄4～6岁5月,平均5岁4月;体重16 ～ 20 kg,平均(18.00±1.79) kg.CT Haller指数3.9 ～5.0,平均(4.35±0.43).其中4例行室间隔缺损微创伞封术(3例膜部和1例主动脉瓣下室间隔缺损,缺损直径4 ～5 mm);2例行中央型继发孔房间隔缺损微创伞封术,直径12～16mm.先心微创术后行Nuss手术,术后常规放置心包纵隔引流管.结果 手术顺利,术后5～11h拔除气管插管,平均(8.17±2.04)h.48h拔除心包纵隔引流管.无手术死亡、大出血及胸腔脏器损伤等危险并发症.术后检查先心封堵效果良好,肺复张良好.术后出现1例切口延期愈合,经治疗后,均顺利出院.3例行钢板取出术,效果满意.结论 微创技术同期治疗合并先心的漏斗胸安全、满意,避免了二次手术所带来的困难和风险.     

The vacuum chest wall lifter: an innovative, nonsurgical addition to the management of pectus excavatum

Purpose

This report describes the authors' experience using a vacuum to pull the abnormal chest wall outward in patients with pectus excavatum.

Methods

A suction cup was used to create a vacuum at the chest wall. A patient-activated hand pump was used to reduce pressure up to 15% below atmospheric pressure. The device was used by 60 patients (56 males, 4 females), aged 6.1 to 34.9 years (median, 14.8 years), for a minimum of 30 minutes, twice a day, up to 5 hours per day (median, 90 minutes). Patient progress was documented using photography, radiography, and plaster casts of the defect. In 14 children this method was used during the Nuss procedure to enlarge the retrosternal space for safer passage of the introducer.

Results

Follow-up occurred between 2 and 18 months (median, 10 months). Computed tomographic scans showed that the device lifted the sternum and ribs within 1 to 2 minutes; this was confirmed thoracoscopically during the Nuss procedure. The suction cup enlarged the retrosternal space for safer passage of the introducer. Initially, the sternum sank back after few minutes. After 1 month, an elevation of 1 cm was noted in 85% of the patients. After 5 months, the sternum was lifted to a normal level in 12 patients (20%) when evaluated immediately after using the suction cup. All patients exhibited moderate subcutaneous hematoma, although the skin was not injured. One patient suffered from transient paresthesis in the right arm and leg. Two patients experienced orthostatic disturbances during the first application of the suction cup. There were no other complications.

Discussion

In patients with pectus excavatum, application of a vacuum effectively pulled the depressed anterior chest wall forward. The initial results proved dramatic, although it is not yet known how much time is required for long-term correction.

Conclusions

This vacuum method holds promise as a valuable adjunct treatment in both surgical and nonsurgical correction of pectus excavatum.     

Nuss procedure for patients with pectus excavatum with a history of intrathoracic surgery

BackgroundThe aim of this study was to demonstrate the feasibility and safety of the Nuss procedure for patients with pectus excavatum (PE) with a history of intrathoracic surgery.PatientsFrom April 2010 to December 2013, we performed 6 cases of PE repair in patients with a history of intrathoracic surgery. The causes of previous operations were congenital cystic adenomatoid malformation in 4 patients and congenital diaphragmatic hernia in 2. The patients’ median age was 5 years (range, 4–9 years) and median preoperative pectus severity index was 4.63 (range, 3.42–10.03). Their intraoperative and postoperative courses were reviewed retrospectively.ResultsThe mean overall operation time was 127.5 ± 17.0 minutes, and the mean operation time for endoscopic pneumolysis was 28.8 ± 12.3 minutes. Intraoperative exploration for pleural adhesion revealed that the endoscopic approach in the previous operation was associated with low pleural adhesion, and the open thoracotomy or laparotomy approach was associated with low to high pleural adhesion. One patient developed a pneumothorax on the first postoperative day. All the other patients had uneventful postoperative courses. All the patients received bar removal 2–3 years after bar insertion. One patient developed atelectasis after bar removal. All the other patients had an uneventful postoperative course. The mean postoperative follow-up time after bar removal was 20.1 ± 14.7 months.ConclusionsHistory of intrathoracic surgery seems not a contraindication for the Nuss procedure. However, perioperative complications should be carefully monitored in both the bar insertion and removal operations.     

Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: A large volume,single institution experience

Background

The safety and efficacy of minimally invasive pectus excavatum repair have been demonstrated over the last twenty years. However, technical details and perioperative management strategies continue to be debated. The aim of the present study is to review a large single-institution experience with the modified Nuss procedure.

Methods

A retrospective review was performed of patients who underwent primary pectus excavatum repair at a single tertiary hospital via a modified Nuss procedure that included: no thoracoscopy, retrosternal dissection achieved via a left-to-right thoracic approach, four-point stabilization of the bar, and no routine epidural analgesia. Data collected included demographics, preoperative symptoms, operative characteristics, hospital charges and postoperative outcomes.

Results

A total of 336 pediatric patients were identified. No cardiac perforations occurred and the rate of pericarditis was 0.6%. Contemporary rates of bar displacement have fallen to 1.2%. Routine use of chlorhexidine scrub reduced superficial site infections to 0.7%. Two patients (0.6%) with severe recurrence required reoperation. Bars were removed after an average period of 31.7(SD 13.2) months, with satisfactory cosmetic and functional results in 94.9% of cases.

Conclusions

We report here a single-institution large volume experience, including modifications to the Nuss procedure that make the technique simpler and safer, improve results, and minimize hospital charges.     

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.     

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.     

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.