Minimization of the complications associated with bar removal after the Nuss procedure in adults

Abstract

Background: Pectus bar removal after Nuss repair is associated with the risk of major complications that are underreported. Of these, surgical bleeding is the main concern. Old age and placement of more than one bar are reported risk factors for pectus bar removal. In this study, we presented our experience regarding the modified skills required to minimize complications during bar removal, especially in adult patients. Methods: Consecutive patients who underwent pectus bar removal as the final stage of Nuss repair between August 2014 and December 2018 were included. The patients were positioned in the supine position. The bar(s) was (were) removed from the left side via the bilateral approach using the previous surgical scars after full dissection of the ends of the bar lateral to the hinge point and after straightening the right end of the bar. Bleeding was carefully checked after removal. An elastic bandage was wrapped around the chest after wound closure to prevent wound hematoma/seroma formation. Results: A total of 283 patients (260 male and 23 female), with a mean age of 22.8 ± 6.6 years at the time of the Nuss repair were included. The mean duration of pectus bar maintenance interval was 4.3 years (range: 1.9 to 9.8 years). A total of 200 patients (71%) had two bars. The mean estimated blood loss was 11.7 mL (range: 10 mL to 100 mL). Nine patients (3.1%) experienced complications, six had pneumothorax and three had wound hematoma. No major bleeding occurred. Adults and the use of more than one bar were not associated with a significantly higher rate of complications (P = 0.400 and P = 0.260, respectively). Conclusions: Adult patients and removal of multiple bars were not risk factors for complications in our cohort. Skill in preventing intraoperative mediastinal traction, carefully controlling bleeding, and reducing the effect of dead space around the wounds could minimize the risk of bleeding complications. A multicentric study or case accumulation is needed to further evaluate the risk factors of removal pectus bar(s).

Nuss bar removal without straightening is a safe technique: a single center experience

“…However, our study strengthens the evidence that removal without straightening of the bar is a safe technique and is at least non-inferior to bilateral incisions and straightening of the bar in terms of complication rates. This holds also true for the secondary outcome measures (i.e., procedural duration, blood loss and hospital stay) (3,17,21,22) although length of stay is strongly influenced by local discharge criteria.…”

“…This relatively low complication rate suggests that straightening of the Nuss bar is not necessary to increase safety of the procedure. Several techniques and maneuvers for removal of the bar have been described so far (1)(2)(3)(4)(5)(6)(7)(8)17). Our method of removal consists of extraction along the thoracic curvature without prior straightening while the patient is positioned (19,20) as also used in the present study.…”

“…In addition, Kelly et al (22) observed three pneumothoraxes requiring intervention in their 854-patient sample. Hsieh et al (17) report their institutional experience with partially unbending the bar. They reopen both incisions, but only unbend the right side of the bar.…”

Complications following metal bar removal after Nuss repair are rare in a duocentric retrospective evaluation

“…This is not surprising, as the survey authors already noted [ 11 ], it is often the case that reports focus on complication rates during the Nuss repair, while complications during bar removal are only colorandi causa as it was in this case, too [ 21 ]. Another group investigated the potential effects of age and separated their cohort of 283 patients with a complication rate of 3.2% (9/283) into adults and adolescents, but found no difference between them [ 22 ]. A finding that remains inconclusive, because the overall event rate is quite low and the authors did employ univariate statistics comparing proportions, but not regression analysis as one would have expected to establish an association of a potentially relevant predictor of complications.…”

“…A finding that remains inconclusive, because the overall event rate is quite low and the authors did employ univariate statistics comparing proportions, but not regression analysis as one would have expected to establish an association of a potentially relevant predictor of complications. Interestingly, this is the only report so far that also assessed minor complications, which were less frequent than the more severe pneumothorax [ 22 ].…”