Experience in 100 cases with the Nuss procedure using a technique for stabilization of the pectus bar

Abstract

The Nuss procedure is a new, minimally invasive technique for the repair of pectus excavatum. We describe our experience with this operation, in a relatively large series in a single institution, and introduce our technical modification for stabilizing the pectus bar. In 107 patients (75 male and 32 female) with pectus excavatum who underwent the Nuss procedure, age at operation ranged from 3 to 23 years old (mean: 7.5+/-4.1) and Haller's CT index ranged from 33 to 2.6 (mean: 6.1+/-3.5). To stabilize the pectus bars, we tied the rib and both edges of the bars with surgical steel wire, 0.8 mm in diameter, using a Duchenne needle to guide the wire behind the rib. Average operating time with this technique (n=100) was 48+/-20 min. The stability of pectus bars after the operation was assessed by lateral chest X-ray films. The position of the center of the pectus bars, facing the sternum at right angles, was classified as excellent. A minimal bar displacement of less than 45 degrees was classified as incomplete. The position of the bars that had rotated 90 degrees was classified as poor. The post-operative course was uneventful in all cases except for three patients who showed wound infection, hemothorax or pneumothorax, independently. Two patients required wire removal due to skin irritation as a late complication. Five patients underwent re-operations due to bar displacement. Among them, only two cases were included in the group of wire fixation. Only five teen-aged patients required a lateral stabilizing bar. Lateral chest X-ray films of 100 patients showed that the position of the pectus bar was excellent in 86 cases, incomplete in 12 cases and poor in two cases. In 70 patients aged less than 10 years, the position in 91% was excellent and in 9% was incomplete. In 30 patients aged 10 years and older, 14 required two pectus bars and the results were excellent in all cases. The other 16 patients with a single bar showed excellent results in eight (50%) cases, incomplete in six (37.5%) and poor in two (12.5%). The wire-fixation technique was safe, effective and time efficient to perform in young cases. Teen-aged patients, however, were at high risk of bar displacement. Therefore, the use of two bars and lateral stabilizing bars are recommended for these high-risk patients.