The Nuss procedure for pectus excavatum: An effective and safe approach using bilateral thoracoscopy and a selective approach to use multiple bars in 296 adolescent and adult patients

Abstract

The Nuss procedure is a minimally invasive repair used to treat pectus excavatum. A bilateral thoracoscopy-assisted approach has been reported as a safe method for Nuss repair. The aim of this observational cohort study is to evaluate the application of the bilateral thoracoscopy-inspection to assist in the selection of the number of bars for correction of the pectus deformity in adolescents and adults. A retrospective chart review was performed on all adolescent and adult patients (296 patients: 257 male, 39 female; aged of 23.9 ± 7.7 years) with pectus excavatum primarily corrected with the modified Nuss repair from August 2014 to January 2018. The patients were divided into three age groups (A: 12 years ≦ age < 19 years, n = 73; B: 19 years ≦ age < 30 years, n = 175; C: age ≧ 30 years, n = 48). Advanced repair of deformed chest walls using more than one bar depended on the change detected via gross and perioperative thoracoscopy-inspection. The results showed that two or three pectus bars were used in 268 patients (90.5%). The overall complication rate after a postoperative follow-up of 28.6 ± 11 months was 6.8% (20/296), without mortality, major bleeding, or serious infectious complications. A multivariate logistic regression analysis showed that the complications were only associated with Haller index (adjusted OR = 1.2935, p = 0.0317) under controlling confounding factors. The postoperative sternovertebral distance was significantly improved from 7.3±1.6 to 10.1± 2.8 cm (p<0.001). The thoracoscopy-assisted approach of Nuss repair for correction of pectus excavatum was safe and effective approach and could also be used as an alternative approach for the selection of placed bars in adolescent and adult patients. Further studies regarding long-term outcomes are required.

Fig 1. Flow chart of patient selection.

Fig 2. Bilateral uniport thoracoscope-assisted technique for mediastinal dissection.

(A) A 30° 5-mm thoracoscope was inserted via a 3-cm skin incision on the right lateral chest wall and the introducer was applied for mediastinal dissection (B) Checking of the pleural cavity and mediastinum and a right-to-left mediastinal dissection under direct thoracoscopic inspection (C) After the tip of the introducer crossed the midline, the thoracoscope was shifted to the wound on the left side of the chest and a substernal tunnel was created (D) Aberrant vessels in the mediastinal pleura were avoided to prevent injury during mediastinal dissection.

Fig 3. Thoracoscopy-guided repair of a chest wall deformity in a 16-year-old patient.

(A) Thoracoscopic view of the deformed chest wall with cardiac compression (B)-(D) Internal changes in the deformed chest wall after the placement of one to three support bars (white arrows).

Fig 4. Radiologic changes of the chest wall before and after repair (SVD: Sternovetebral Distance).

(A) and (B) Demonstration of the preoperative and postoperative (2 years after surgical repair) SVD in a 23-year-old woman (C) and (D) Box plots of preoperative and postoperative changes in SVD in the different age groups and number of support bar(s).