Analysis of the Nuss Procedure for Pectus Excavatum in Different Age Groups

Advances in the management of pectus deformities in children

“…The theory is supported by the work of Castellani et al which showed that forced vital capacity after implant removal reached normal values, and was not significantly different from preoperative FVC (p = 0.117) [47]. Spinal distortion, wound infection, pneumothorax, pleural and pericardial effusion, bar displacement, allergy to the bar, overcorrection in PE patients leading to PC, bleeding from erosion of costal arteries due to movement of the ribs against the bar resulting in hemothorax, aortic laceration, cardiac arrhythmia, and cardiac perforation have all been reported as operative complications of the Nuss procedure [2,37,41,[48][49][50]. Patients greater than 15 years of age are at higher risk for complications due to the higher force necessary to elevate the sternum to the desired level [41].…”

“…Extensive destruction of the perichondrium and rib growth centers may result in failure of further chest wall development and subsequent pulmonary hypertension, tricuspid regurgitation, and restrictive lung disease [39,40]. Furthermore, despite improvement in postoperative cosmesis, the skin incision utilized in the Ravitch procedure results in a large vertical midline chest wall scar, effectively replacing the original aesthetic concern, the pectus deformity, with a different one [2,9,15,37,41]. However, despite these complications, the Ravitch procedure was widely accepted as the gold-standard of treatment until 1998, and continues to be performed by many pediatric surgeons today.…”

“…Spinal distortion, wound infection, pneumothorax, pleural and pericardial effusion, bar displacement, allergy to the bar, overcorrection in PE patients leading to PC, bleeding from erosion of costal arteries due to movement of the ribs against the bar resulting in hemothorax, aortic laceration, cardiac arrhythmia, and cardiac perforation have all been reported as operative complications of the Nuss procedure [2,37,41,[48][49][50]. Patients greater than 15 years of age are at higher risk for complications due to the higher force necessary to elevate the sternum to the desired level [41]. Thus, the technique has not been as favorable in the adult population, as decreased chest flexibility in this population predisposes them to higher postoperative complications and residual pain that interferes with a return to normal functional status [2,10].…”

“…A minimally invasive reverse Nuss procedure for the treatment of PC employs a similar procedure, though the bar is placed in front of the sternum and fixed to the ribs in a compressing position [2]. Proposed advantages to the minimally invasive Nuss procedure includes shorter operative times, minimal blood loss of less than 90 mL, immediate postoperative extubation, avoidance of instability of the chest wall, maintenance of chest wall elasticity and absence of a large surgical incision, making the Nuss procedure more suited to address psychosocial issues associated with pectus deformity [37,41,44,45]. Disadvantages of this minimally invasive repair includes considerable analgesic requirement, a challenging postoperative course in regards to pain control, increased length of hospitalization, and longer and more severe limitations in activity when compared with the open Ravitch procedure [2,4,23,45,46].…”

“…The limited dissection required for this procedure represented a less invasive approach to corrective repair when compared to other procedures, and is a specific consideration in the pediatric population, given the likelihood of these patients developing lifelong complications secondary to extensive chest wall resection [39]. For this repair, also called a minimally invasive repair of PE (MIRPE), a horizontal passage is created underneath the sternum through two small lateral incisions, and under thoracoscopic guidance, a convex bar is inserted through the passage and then rotated to achieve sternal elevation [41]. A minimally invasive reverse Nuss procedure for the treatment of PC employs a similar procedure, though the bar is placed in front of the sternum and fixed to the ribs in a compressing position [2].…”