A Next-Generation Pectus Excavatum Repair Technique: New Devices Make a Difference

Park, Hyung Joo; Kim, Kyung Soo; Lee, Sungsoo; Jeon, Hyun Woo

doi:10.1016/j.athoracsur.2014.08.026

Cited by 40 publications

(24 citation statements)

References 16 publications

(28 reference statements)

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“…Especially when the wires were broken into pieces, we had to find wire fragments with an aid of C-arm fluoroscopy. After using the claw fixator (15) and bridge devices (16), the procedure was sped up and became simpler.…”

Section: Discussionmentioning

confidence: 99%

Pectus bar removal: surgical technique and strategy to avoid complications

Park¹,

Kim²

2016

J. Vis. Surg.

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Background: Pectus bar removal is the final stage of the procedure for minimally invasive repair of pectus excavatum. Based on our experience with one of the largest scale data, we would like to address the important issues in pectus bar removal, such as appropriate duration of bar maintenance, techniques for bar removal, and strategies to avoid complications.Methods: Between September 1999 and August 2015, we operated on 2,553 patients with pectus excavatum and carinatum using pectus bars for a minimally invasive approach. Among them, 1,821 patients (71.3%) underwent pectus bar removal as a final stage of pectus deformity repair, and their data were analyzed retrospectively to identify the outcomes and adverse effects of the pectus bar removal procedure. The mean age of the patients was 9.13 years (range, 16 months to 44 years) and the male to female ratio was 3.55.The study is approved by the Institutional Review Board (IRB), the ethical committee of Seoul St. Mary's Hospital. The IRB has exempted the informed consent from every patient in this study due to this is a retrospective chart review without revealing any patients' personal data. Results:Our technique involved straightening of the bar in a supine position. The overall mean duration of pectus bar maintenance was 2.57 years (range, 4 months to 14 years). The mean duration was 2.02 years (range, 4 months to 7 years) for children under 12 years, 2.99 years (range, 7 months to 9 years) for teenagers aged 12-20 years, and 3.53 years (range, 3 months to 14 years) for adults over 20 years. Forty-eight patients (2.6%) underwent bar removal more than 5 years after bar insertion and 58 patients (3.2%) underwent bar removal earlier than initially planned. The most common adverse reaction after bar removal was wound seroma including infection (43 patients, 2.36%). Recurrence after bar removal occurred in nine patients (0.49%), and seven of these required redo repair (0.38%).Conclusions: Pectus bar removal is a safe and straightforward procedure with a low rate of complication. technique of bar removal and to disclose the complications that occurred and countermeasures to avoid them. Patients and methodsBetween September 1999 and August 2015, we operated on 2,553 patients with pectus excavatum and carinatum using pectus bars for a minimally invasive approach. Among them, 1,821 patients (71.3%) underwent pectus bar removal as a final stage of pectus deformity repair, and their data were analyzed retrospectively to identify the outcomes and adverse effects of the pectus bar removal procedure. The mean age of the patients was 9.13 years (range, 16 months to 44 years) and the male to female ratio was 3.55. Surgical techniques of the procedureUnder general anesthesia with a single-lumen endotracheal intubation, the patient was positioned supine with their arms hanging freely to the overhead strut of the ether screen. Both groins were prepared and draped routinely for emergency cardiopulmonary bypass via femoral artery and vein cannulation in case of bleeding during bar...

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Section: Discussionmentioning

confidence: 99%

Pectus bar removal: surgical technique and strategy to avoid complications

Park¹,

Kim²

2016

J. Vis. Surg.

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“…Use of a different interspace was recommended should intercostal stripping and lateral displacement occur. Medial stabilizer placement, "claw" and figure of eight suture reinforcement of the ribs bordering the stripped intercostal space can also be performed (9). The utilization of forced sternal elevation may also help facilitate bar placement and rotation and minimize intercostal stripping (10,11).…”

Section: Recurrence After Primary Mirpementioning

confidence: 99%

Revision of failed, recurrent or complicated pectus excavatum after Nuss, Ravitch or cardiac surgery

Jaroszewski¹,

Ewais²,

Lackey³

et al. 2016

J. Vis. Surg.

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Pectus excavatum (PE) can recur after both open and minimally invasive repair of pectus excavatum (MIRPE) techniques. The cause of recurrence may differ based on the initial repair procedure performed. Recurrence risks for the open repair are due to factors which include incomplete previous repair, repair at too young of age, excessive dissection, early removal or lack of support structures, and incomplete healing of the chest wall. For patients presenting after failed or recurrent primary MIRPE repair, issues with support bars including placement, number, migration, and premature removal can all be associated with failure. Connective tissue disorders can complicate and increase recurrence risk in both types of PE repairs.Identifying the factors that contributed to the previous procedure's failure is critical for prevention of another recurrence. A combination of surgical techniques may be necessary to successfully repair some patients.

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“…In the decade since the MIRPE procedure was first published, many modifications have been made to make the procedure safer and more efficient including: addition of thoracoscopy, stabilizers, pericostal sutures, sternal elevation before tunneling, instruments designed specifically for the procedure, prophylactic antibiotics, and optimization of pain control (37). It is anticipated that this trend will continue and that the procedure and instruments will constantly be improved (17,18).…”

Section: Futurementioning

confidence: 99%

“…However the addition of pericostal sutures in 2002 reduced bar displacement to less than 1% when combined with the stabilizer (16). Park has also developed several new devices such as a "claw fixator" and "hinge plate" to help prevent bar displacement (17).…”

mentioning

confidence: 99%

“…Initially, a more cephalad tunnel was created superior to the deepest point of the defect with one tunneler, before passing a second tunneler under the deepest point. Later, sternal elevation prior to substernal dissection was developed and found to be facilitated by using a variety of retractors, towel clamps, Klobe's suction cup, or Park's "Crane Technique" (16,17).…”

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confidence: 99%

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Nuss bar procedure: past, present and future

Nuss¹,

Obermeyer²,

Kelly³

2016

Ann. Cardiothorac. Surg.

218

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Repair of pectus excavatum began at the beginning of the 20 th century before endotracheal intubation was standard practice. Surgeons therefore developed techniques that corrected the deformity using an open procedure via the anterior chest wall. Initial techniques were unsatisfactory, but by the 1930s the partial rib resection and sternal osteotomy technique had been developed and was used in combination with external traction post-operatively to prevent the sternum from sinking back into the chest. In 1949, Ravitch recommended complete resection of the costal cartilages and complete mobilization of the sternum without external traction, and in 1961 Adkins and Blades introduced the concept of a substernal strut for sternal support. The wide resection resulted in a very rigid anterior chest wall, and in some instances, the development of asphyxiating chondrodystrophy. The primary care physicians therefore became reluctant to refer the patients for repair. In 1987, Nuss developed a minimally invasive technique that required no cartilage or sternal resection and relied only on internal bracing by means of a sub-sternal bar, which is inserted into the chest through two lateral thoracic incisions and guided across the mediastinum with the help of thoracoscopy. After publication of the procedure in 1998, it became widely accepted and a flood of new patients suddenly started to appear, which allowed for rapid improvements and modifications of the technique. New instruments were developed specifically for the procedure, complications were recognized, and the steps taken to prevent them included the development of a stabilizer and the use of pericostal sutures to prevent bar displacement. Various options were developed for sternal elevation prior to mediastinal dissection to prevent injury to the mediastinal structures, allergy testing was implemented, and pain management improved. The increased number of patients coming for repair permitted studies of cardiopulmonary function, which showed that patients with a severe degree of pectus excavatum have right-sided cardiac compression, decreased filling, and decreased stroke volume. The degree of pulmonary restriction and obstruction is related to the degree of deformity and degree of cardiac displacement into the left chest. The indications for surgical repair have been clearly outlined, the procedure has been standardized, and post-operative management protocols are now available. A review of our prospective database showed that 98% of patients have a good to excellent outcome. This review of the "Past" outlines the progression of the surgical techniques during the 20 th century, the review of the "Present" outlines the important modifications and results of the closed technique, and the review of the "Future" outlines the various new options that are becoming available for the treatment of pectus excavatum.

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A Next-Generation Pectus Excavatum Repair Technique: New Devices Make a Difference

Cited by 40 publications

References 16 publications

Pectus bar removal: surgical technique and strategy to avoid complications

Pectus bar removal: surgical technique and strategy to avoid complications

Revision of failed, recurrent or complicated pectus excavatum after Nuss, Ravitch or cardiac surgery

Nuss bar procedure: past, present and future

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