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.     

非胸腔镜剑突下小切口与胸腔镜辅助Nuss手术治疗漏斗胸的临床观察

目的 探讨非胸腔镜剑突下小切口（剑突组）与胸腔镜辅助（胸腔镜组）Nuss手术治疗漏斗胸的不同及优势。方法 2016年至2019年我科收治漏斗胸手术患者59例,平均年龄16±3.82岁,33例行非胸腔镜剑突下小切口Nuss手术,26例行胸腔镜辅助Nuss手术,比较年龄、Haller指数、手术时间,出血量,术后出院时间等。结果 两组患者均获得满意效果,剑突组与胸腔镜组在年龄,Haller指数、手术时间,出血量上均无统计学差异,而剑突组出院时间短于胸腔镜镜组。术后6 h至术后24 h,疼痛感明显增强,而术后48 h疼痛则减轻,而术后24 h剑突组疼痛感较胸腔镜轻,有统计学意义。剑突组术后胸腔积液（33.3%）发生率高于胸腔镜组（15.4%）,而剑突组气胸（27.3%）发生率则低于胸腔镜组（42.3%）。胸腔镜组一例非对称性漏斗胸术后2周出现心包积液,双侧大量胸腔积液,治疗后康复出院,其余患者均平稳。结论 针对对称性漏斗胸患者,非胸腔镜剑突下小切口与胸腔镜辅助Nuss手术,手术时间、出血量等均无明显差异,均可获得满意效果,而针对非对称或复杂漏斗胸,剑突下小切口安全性则更有保证。     

Epidural analgesia versus intravenous patient-controlled analgesia following minimally invasive pectus excavatum repair: a systematic review and meta-analysis

Background/Purpose

The minimally invasive pectus excavatum repair (MIPER) is a painful procedure. The ideal approach to postoperative analgesia is debated. We performed a systematic review and meta-analysis to assess the efficacy and safety of epidural analgesia compared to intravenous Patient Controlled Analgesia (PCA) following MIPER.

Methods

We searched MEDLINE (1946–2012) and the Cochrane Library (inception–2012) for randomized controlled trials (RCT) and cohort studies comparing epidural analgesia to PCA for postoperative pain management in children following MIPER. We calculated weighted mean differences (WMD) for numeric pain scores and summarized secondary outcomes qualitatively.

Results

Of 699 studies, 3 RCTs and 3 retrospective cohorts met inclusion criteria. Compared to PCA, mean pain scores were modestly lower with epidural immediately (WMD − 1.04, 95% CI − 2.11 to 0.03, p = 0.06), 12 hours (WMD − 1.12; 95% CI − 1.61 to − 0.62, p < 0.001), 24 hours (WMD − 0.51, 95%CI − 1.05 to 0.02, p = 0.06), and 48 hours (WMD − 0.85, 95% CI − 1.62 to − 0.07, p = 0.03) after surgery. We found no statistically significant differences between secondary outcomes.

Conclusions

Epidural analgesia may provide superior pain control but was comparable with PCA for secondary outcomes. Better designed studies are needed. Currently the analgesic technique should be based on patient preference and institutional resources.     

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.     

微创Nuss手术治疗儿童漏斗胸的研究进展

漏斗胸是一种胸壁凹陷性畸形,Nuss手术是治疗漏斗胸的一种微创手术,具有创伤小、操作简便、并发症少、手术效果良好等优点,已成为治疗漏斗胸的首选术式。随着Nuss手术的不断改良以及腔镜技术的提高,Nuss手术的适用范围不断扩大,胸腔镜辅助Nuss手术在临床应用广泛。作者在Pubmed、万方数据、中国知网等数据库,以漏斗胸、Nuss手术、手术治疗为关键词,查阅相关文献,将微创Nuss手术治疗漏斗胸的概况、技术要点、争议及改良方法等作一综述。虽然Nuss手术的发展给漏斗胸患儿带来福音,但其临床应用的具体问题和中远期疗效仍需进一步研究。     

Nuss手术矫治漏斗胸412例

目的 探讨非胸腔镜辅助下Nuss手术治疗漏斗胸的手术方法并总结治疗经验.方法 2005年10月到2011年6月非胸腔镜辅助下Nuss手术治疗漏斗胸412例,其中男329例,女83例.年龄2岁8个月～28岁5个月,平均7岁8个月.其中102例行内固定取出手术.结果 患儿均顺利完成手术,无术中严重并发症发生.手术平均40 min,出血(10±2) ml.结论 非胸腔镜辅助Nuss手术安全可行,并且不用进入胸腔操作,手术创伤更小,耗时更短,微创效果更好.     

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.     

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.