Pectus bar removal: surgical technique and strategy to avoid complications

Abstract

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...

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

“…Various modified methods and their related risks have been described for reducing the complications involving the patient's history, specially designed and customized instruments, or modifications to the procedure (see Table 3) [11,[17][18][19][20][21][22][23][24][25]. The modifications in the surgical procedure could be classified into four major categories: (1) patient's position during surgery, (2) wound incisions, (3) bending of the end of the bar before removal, and (4) bar rotation during removal [24].…”

“…However, there have been successive reports of severe complications, including massive hemothorax and death [10][11][12][13][14][15][16][17][18][19]. Therefore, some physicians suggested improvements to the surgical equipment and methods used for the removal to reduce surgical complications in a recent decade [11,[17][18][19][20][21][22][23][24]. Although some recent studies have discussed the occurrence of these surgical complications, disparate results were reported in large patient cohorts [11,[18][19][20]22].…”

“…Therefore, some physicians suggested improvements to the surgical equipment and methods used for the removal to reduce surgical complications in a recent decade [11,[17][18][19][20][21][22][23][24]. Although some recent studies have discussed the occurrence of these surgical complications, disparate results were reported in large patient cohorts [11,[18][19][20]22]. The statistical data from a large-scale questionnaire survey of physicians from the Chest Wall International Group (CWIG) who have performed such surgeries showed that the incidence of these surgical complications was underestimated and that some severe complications have not been reported [16].…”

“…The CWIG data revealed that more than half of the physicians felt that it was easier to perform surgeries on younger patients. Some modifications of surgical skill for pectus bar removal have been described for reducing the complications [17][18][19][20][21][22][23][24]. Therefore, in this study, we aimed to assess the differences in our modifications on skill and the recent surgical data on pectus bar removal.…”

Modifications and Further Development of the Original Nuss Procedure: Blessing or Curse?

“…Recurrence occurred in 0.49%. 35 Removing the bar with incision on only one side (the side with the stabilizer) requires comment. Initially, the operation was done on children younger than 10 years; not only is their chest very pliable, but it is close to cylindrical on cross section.…”