Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients
Abstract
Purpose: The aim of this study is to review the new technical modifications and results of 303 patients who have had pectus excavatum repair utilizing the minimally invasive technique. Methods: A retrospective chart review was conducted of 303 patients undergoing minimally invasive pectus repair from 1987 through August 2000. Since 1997, a standardized treatment pathway was implemented, and 261 of the 303 patients have been treated on this pathway. Preoperative evaluation included computed tomography (CT) scan, pulmonary function tests (PFT), and cardiac evaluations with electrocardiogram (EKG) and echocardiogram. Indications for operation included at least 2 of the following: progression of the deformity, exercise intolerance or restrictive disease on PFT, Haller CT index greater than 3.2, mitral valve prolapse (MVP), or cardiac compression. Technical and design modifications since 1998 have included routine thoracoscopy, the use of an introducer/dissector for creating the substernal tunnel and elevating the sternum, and routine use of a wired lateral stabilizer to prevent bar displacement. The bar is removed as an outpatient procedure in 2 to 4 years. Results: In 303 patients undergoing minimally invasive pectus repairs, single bars were used in 87% and double in 13%. Lateral stabilizers were applied in 70% of patients and were wired for further stability in 65%. Bar shifts before the use of stabilizers were 15%, which decreased to 6% after stabilizers were placed and 5% with a wired stabilizer. Excellent results were noted in 85% with failure in only 1 patient. Complications included pneumothorax with spontaneous resolution in half of the patients and pericarditis in 7. Conclusions: The minimally invasive technique has evolved into an effective method of pectus excavatum repair. Modifications of the technique have reduced complications. Long-term results continue to be excellent.
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Novel Nuss Bar Fixation Using ZipFix for Pectus Excavatum
2022, Heart Lung and CirculationBar displacement is one of the most serious complications following the Nuss procedure for pectus excavatum repair. This paper reports a novel method of bar fixation using ZipFix, a biocompatible cable-tie implant, and shares a series of patients and outcomes.
This paper describes the ZipFix stabilisation method and presents a case series of 20 patients with pectus excavatum who underwent the Nuss procedure and ZipFix stabilisation between July 2015 and September 2020.
A total of 34 ZipFixes were implanted in 20 patients. Six (6) patients had one ZipFix placed and 14 patients had two ZipFixes implanted: 13 were bilateral and one patient had two ZipFixes placed on the right. There was one incidence of asymptomatic posterior superior displacement of the right bar. Two (2) patients had wound infections and one patient had a previously placed bar adjusted and secured with a ZipFix. All patients had full correction of their chest wall deformity with no recurrence.
This case series shows that the use of ZipFix for Nuss bar fixation is feasible using this technique.
Selective use of sternal elevation before substernal dissection in more than 2000 Nuss repairs at a single institution
2021, Journal of Pediatric SurgeryEvaluate the safety of sternal elevation (SE) used selectively before creating the substernal tunnel during the Nuss procedure.
An IRB-approved (01-05-EX-0175-HOSP), single institution, retrospective review was performed (1/1/1997–11/20/2017). Primary and secondary Nuss repairs (i.e., previous Nuss, Ravitch, thoracotomy, or sternotomy) are included. SE use, cardiac injuries, and pectus bar infections are reported. Chi square and Fisher's exact test (FE) were used (critical p < .05).
2037 patients [(80% male; mean age 15.2 years (SD = 4.4, range 3–46); mean Haller index (HI) 5.3 (SD = 5.7, range 1.73–201)] underwent Nuss repair. SE was used before creating the substernal tunnel in 171 (8.4%): 160 (8.2%) of 1949 primary and 11 (12.5%) of 88 secondary repairs. SE use increased significantly [χ2(2) = 118.93; p < .001] over time and with increasing HI [χ2(3) = 59.9; p < .001]. No cardiac injuries occurred in primary repairs but two occurred in patients with previous sternotomy. Infection rates were not different with (2.9%) or without SE (1.8%) [χ2(1) = 1.14; p = .285] and not higher with off-label VB (1.5%) versus other SE techniques (3.8%) [FE, p = .65)].
Selective use of sternal elevation before substernal dissection during the Nuss procedure is safe but may not prevent cardiac injuries in patients with previous sternotomy. Infection rates were not increased with SE.
Retrospective review.
IV
Pectus bar removal – why, when, where and how
2021, Journal of Pediatric SurgeryDespite its less invasive nature, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. On the other hand, Pectus bar removal (PBR) is often considered a simple procedure and often scheduled in an outpatient setting. However, several studies report near-fatal complications not only during bar placement, but also during bar removal. The aim of our study was to clarify why a pectus bar should be removed, timing for removal, where PBR should be performed, and overall setup for safe removal.
A comprehensive review was performed in accordance with PRISMA guidelines, searching for articles published since 1998 in English. “Pectus bar removal AND (near-fatal) complications” were the applied terms. Inclusion criteria were articles reporting on the focus of PBR after MIRPE. Eligible study designs included (retrospective) case study series, case report and reviews. Full-text articles in which the technique in general was described were omitted.
Recently published results of an online survey raised awareness about type and number of possible complications during PBR. Furthermore, our comprehensive literature review identified only a few, but serious complications during PBR.
PBR has a high safety profile but in rare cases may be associated with major complications such as life-threatening hemorrhage from various thoracic sources. This risk is higher in patients with a history of complex MIPRE. In an effort to decrease these complications we recommend bilateral opening of surgical incisions, unbending the bar and meticulous mobilization of the bar. To manage these complications if they occur, we recommend removal in a hospital setting with adequate resources and personal including cardiac surgeons. If the postoperative course is uneventful discharge on the same day is reasonable.
Repair of Pectus Excavatum
2021, Cohen's Comprehensive Thoracic AnesthesiaPectus excavatum is a congenital chest wall deformity characterized by a sternal depression, which typically begins at the manubrium and ends toward the xiphoid. At young age, the pectus excavatum causes no complaints, but as children become more active when they grow up, symptoms of shortness of breath on exertion, lack of endurance, and exercise tolerance appears. A frequent reason to seek medical attention is cosmetic concern. The most common surgical treatments are the Nuss procedure and the Ravitch procedure. Several modifications of the original operation exists. Compared with the Ravitch operation, the Nuss operation duration is much shorter and had lower blood loss. Length of hospital stay was similar. The overall anesthesia and surgery-related complication rate of the Nuss procedure is between 15% and 20%. A common complication is a small pneumothorax and pleural effusion. Chest tube drainage is not always necessary. Life-threatening complications are estimated to be 0.1%. The most devastating complication, cardiac perforation, is rather seldom. Anesthesiologists should be aware of this. Adequate pain therapy is essential to prevent discomfort and allow coughing, which is important to prevent pulmonary complications. Thoracic epidural is most frequently used as a primary analgesic modality. Compared with Ravitch, Nuss patients also had higher average daily pain scores and received more opioids, although both groups received an thoracic epidural. It is unique that a minimally invasive technique produces more pain. Many alternative pain therapies are possible. A hospital protocol should be established for optimal postoperative care.
From bench to bedside: 3D reconstruction and printing as a valuable tool for the chest wall surgeon
2020, Journal of Pediatric SurgeryThe development of computer-aided design/manufacturing and digital image technology shows promise to revolutionize several medical and surgical fields. In this context, we propose a different approach for minimally invasive repair of pectus excavatum (MIRPE) including preoperative planning, ambulatory template fitting, and implant customization.
We prospectively collected data on 130 consecutive patients who underwent a novel process of implant customization for MIRPE between November 2015 and September 2019 at our institution. This process consisted of: 1) preoperative planning using 3D computed tomography scan reconstruction and 3D printing of the implant template, 2) an ambulatory fitting session with the template, and 3) manufacture of a custom made, prebent, metallic implant based on the 3D printed templates. We described the process in detail and analyzed the “implant-deformity” match, need for rebending, modification of the curvature or shape of the pectus implant intraoperatively, and accuracy of the number of bars planned preoperatively.
Preoperative planning including 3D reconstruction and printing resulted in a 92.3% optimal “implant-deformity” anatomic match. Minimal rebending without flipping of the implants was required in 5.4% of the patients. In two cases (1.5%), the implants were too short, and they tended to sink into the intercostal space, and in one case (0.8%), the patient's chest was extremely asymmetric, and the implant had to be removed and rebent intraoperatively. The number of implants planned preoperatively was precise in 100%.
In this study, we demonstrated that minimally invasive repair of pectus excavatum assisted by preoperative planning, ambulatory template fitting, and implant customization enables an excellent anatomic match, leading to minimal rebending, and avoiding implant flipping or removal after retrosternal passage as well as accuracy in the number of bars programmed preoperatively.
Prospective registry.
III.
Predicting Aesthetic Outcome of the Nuss Procedure in Patients with Pectus Excavatum
2023, Seminars in Thoracic and Cardiovascular SurgeryPatients suffering from pectus excavatum often experience psychosocial distress due to perceived anomalies in their physical appearance. The ability to visually inform patients about their expected aesthetic outcome after surgical correction is still lacking. This study aims to develop an automatic, patient-specific model to predict aesthetic outcome after the Nuss procedure. Patients prospectively received preoperative and postoperative 3-dimensional optical surface scanning of their chest during the Nuss procedure. A prediction model was composed based on nonlinear least squares data-fitting, regression methods and a 2-dimensional Gaussian function with adjustable amplitude, variance, rotation, skewness, and kurtosis components. Morphological features of pectus excavatum were extracted from preoperative images using a previously developed surface analysis tool to generate a patient-specific model. Prediction accuracy was evaluated through cross-validation, utilizing the mean root squared deviation and maximum positive and negative deviations as performance measures. The prediction model was evaluated on 30 (90% male) prospectively imaged patients. The model achieved an average root mean squared deviation of 6.3 ± 2.0 mm, with average maximum positive and negative deviations of 12.7 ± 6.1 and –10.2 ± 5.7 mm, respectively, between the predicted and actual postoperative aesthetic result. Our developed 2-dimensional Gaussian model based on 3-dimensional optical surface images is a clinically promising tool to predict postsurgical aesthetic outcome in patients with pectus excavatum. Prediction of the aesthetic outcome after the Nuss procedure potentially improves information provision and expectation management among patients. Further research should assess whether increasing the sample size may reduce deviations and improve performance.