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.     

Mechanical occlusion of the inferior vena cava: An early complication after repair of pectus excavatum using the Nuss procedure

The Nuss procedure is the most widely used surgical procedure to correct pectus excavatum. Although it is a minimally invasive approach, a number of major early complications, such as heart perforation, have been reported. We describe a 15-year-old boy in whom acute occlusion of the inferior vena cava developed after a Nuss repair. The diagnosis was confirmed by emergency postoperative CT examination, and treatment consisted of immediate removal of the Nuss bar.     

微创Nuss手术治疗小儿漏斗胸的疗效探讨

目的：探讨在胸腔镜辅助下Nuss手术治疗小儿漏斗胸的临床疗效。方法：收集2008年10月至2011年12月采用微创Nuss手术治疗小儿漏斗胸23例的病历资料,其中对称性漏斗胸19例,非对称性漏斗胸4例。结果：本组23例均顺利完成Nuss手术,畸形得到满意矫正,手术时间40～70min,手术后住院时间5～9d。术后2例出现气胸（小于10％未予特殊处理）,3d后消失,1例出现轻度皮下气肿。术后随访1个月～3年,1例3个月后钢板移位而再手术,1例出院后2周出现右侧胸腔积液,经抗感染及右侧胸腔穿刺后积液消失。余患儿均无不适,2例患儿3年后取出钢板,畸形矫治满意。结论：微创Nuss手术治疗小儿漏斗胸,创伤小,恢复快,畸形矫治满意,方法安全可行。     

螺旋CT在先天性漏斗胸中的应用价值

目的:利用螺旋CT研究Haller指数、胸骨凹陷深度和心脏旋转角在漏斗胸诊治中的价值.方法:70例漏斗胸患儿手术前后均行螺旋CT检查.Haller指数测定法:胸部最大内横径与同层面最小前后内径的比值.心脏旋转角:椎体前缘矢状线及其与心尖连线的夹角.在横轴面CT图像上测量胸骨凹陷深度(d).测量患者组和正常对照组手术前后...     

Family study of the inheritance of pectus excavatum

Background

The most common congenital deformity of the chest wall is pectus excavatum, a malformation that is present in between 1 in 400 and 1 in 1000 live births and causes the body of the sternum to be displaced, producing a depression. There are many different shapes of the pectus, and multiple factors probably contribute to the final form. The etiology of pectus excavatum is uncertain, but a familial tendency has been found in clinical experience, where it may be seen in more than one sibling. Pectus excavatum is commonly associated with connective tissue disorders such as Marfan and Ehlers Danlos syndromes. Extensive literature review failed to identify articles documenting families with multiple affected members.

Purpose

The purpose of this study was to collect evidence that pectus excavatum is familial and may be an inherited disorder.

Methods

Using the Children's Surgical Specialty Group database at Children's Hospital of The King's Daughters, families with more than one affected individual were selected. With Institutional Review Board-approved informed consent, 34 families agreed to participate. Family histories were obtained, and a 4-generation pedigree was constructed for each family. Forty questions were asked about each individual's medical history, and comprehensive systems review included features of connective tissue-related problems. Inheritance patterns for each family were determined by pedigree analysis.

Results

A total of 14 families suggested autosomal dominant inheritance, 4 families suggested autosomal recessive inheritance, and 6 families suggested X-linked recessive inheritance. Ten families had complex inheritance patterns. Pectus excavatum occurred more frequently in males than in females (1.8:1). Long arms, legs, and fingers; high-arched palate; mitral valve prolapse; heart arrhythmia; scoliosis; double jointedness; flexibility; flat feet; childhood myopia; poor healing; and easy bruising were commonly associated with pectus excavatum.

Conclusions

Pedigree analysis of 34 families provides evidence that pectus excavatum is an inherited disorder, possibly of connective tissue. Although some families demonstrate apparent Mendelian inheritance, most appear to be multifactorial.     

Infectious complications after the Nuss repair in a series of 863 patients

Purpose

A nemesis of surgical implants is infection. We evaluated the various infectious complications after Nuss repair of pectus excavatum in 863 patients over 18 years.

Methods

After institutional review board approval, a retrospective review of a prospectively gathered database of patients was performed who underwent minimally invasive repair of pectus excavatum and developed an infection. All patients received intravenous antibiotics before surgery continuing until discharge. Patients with a persistent fever after operation were discharged with oral antibiotics.

Results

From January 1987 to September 2005, 863 patients underwent a minimally invasive pectus excavatum repair and 13 (1.5%) developed postoperative infections. These included 6 bar infections, 4 cases of cellulitis, and 3 stitch abscesses. Cellulitis was defined as erythema and warmth which responded to a single course of antibiotics. Bar infections were defined as an abscess in contact with the bar. Surgical drainage and long-term antibiotics resolved 3 of these abscesses, whereas 3 patients required early bar removal (1 after 3 months and 2 after 18 months). Cultures identified a single organism in each case and Staphylococcus aureus was the most common organism (83%) identified, and all being methicillin sensitive. All infections occurred on the side of the stabilizer if a stabilizer had been placed.

Conclusions

Infectious complications after Nuss repair are uncommon and occurred in 1.5% of our patients. Published rates of postoperative infection range from 1.0% to 6.8%. Superficial infections responded to antibiotics alone. Bar infection occurred in only 0.7% and required surgical drainage and long-term antibiotics. Only 3 of these (50% of bar infections and 0.34% overall) required early bar removal at 3 and 18 months because of recurring infections. Early bar removal should be a rare morbidity with the Nuss repair.     

双肺移植同期Nuss手术治疗造血干细胞移植术后闭塞性细支气管炎综合征合并胸廓畸形长期生存1例

目的  探讨双肺移植同期Nuss手术治疗造血干细胞移植术后闭塞性细支气管炎综合征（BOS）合并漏斗胸的疗效。方法  2015年3月24日,1例造血干细胞移植术后BOS合并漏斗胸患者在南京医科大学附属无锡市人民医院胸外科暨肺移植中心接受体外膜肺氧合（ECMO）辅助下双肺移植术,同期行Nuss手术矫治漏斗胸,手术顺利,术后予抗炎、抗真菌预防治疗,予他克莫司+吗替麦考酚酯+肾上腺皮质激素三联免疫抑制方案治疗。结果  患者术后恢复顺利,于术后25 d出院,术后2年拆除胸部Nuss钢板,胸廓畸形得到纠正,术后接受长期随访,截止至投稿日,患者存活3年余,肺功能恢复良好,生活质量满意。结论  双肺移植同期Nuss手术是治疗终末期BOS合并胸廓畸形的有效办法。     

胸骨上举术后第2、3肋软骨前凸畸形

目的 探讨胸骨上举术后并发第２和／或第３肋软骨前凸畸形的表现及其原因。方法 对５例胸骨上举术后并发第２和／或第３肋软骨前凸畸形的患儿资料进行分析。结果 １５２例随访资料完整的漏斗胸患儿中发现５全术后第２和／或第３肋软骨前凸畸形的患儿,发生率为３．２９％。５例中男３例,女２例,年龄４～１５．２岁。术后发现该畸形的时间为１０～２３个月,平均１４．８个月。侧位胸片示胞廓较扁平。其中１全再次手术切除畸形肋     

Modified Nuss procedure for the treatment of pectus excavatum: Experience of 259 patients

BackgroundPectus excavatum is not rare in China. Many treatments for this disease have proved to have many shortcomings. Nuss procedure has been a ground-breaking technology, but it also has some disadvantages. Hence, this study was conducted to review our experience in the use of modified Nuss procedure in our hospital.MethodsData from 259 patients suffered from pectus excavatum between August 2020 and August 2021 who were treated with modified Nuss procedure was analyzed retrospectively.ResultAge was from 3 to 37 years. The average was 15.54 years. The male was 213 cases and the female was 46 cases. The time patients or their family members found pectus excavatum varied. 10 cases had been repaired previously when patients were admitted in our hospital. The clinical symptoms also varied. Each case had an improvement in Haller index. The average of the postoperative hospitalization was 3.97 days. Most cases were inserted 1 bar. Complication rate was also very low. All patients or their parents or their guardians were satisfied with the appearance of the chest wall after operation. There was no death in the whole observation period.ConclusionFrom our experience, this modified Nuss procedure have obtained optimistic outcomes with more minimal invasion and low complication rate. This surgical method may be applied to many other hospitals in the future.