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Peri-operative data on the nuss procedure in children with pectus excavatum: independent survey of the first 20 years' data

Journal of Cardiothoracic Surgery20083:40

DOI: 10.1186/1749-8090-3-40

Received: 20 March 2008

Accepted: 04 July 2008

Published: 04 July 2008

Abstract

Objective

To review the literature and assess the cumulative data on the Nuss operation in children on its twenty years' anniversary: The Nuss procedure corrects the pectus excavatum by minimal access semi-permanent insertion of metal bars in order to reduce the deformity and refashion the contour of the growing thorax. The advantage over previous techniques is avoidance of osteochondrotomies and thence allowance for normal growth of the thorax.

Study design

PubMed search was performed. Primary outcomes were mortality, morbidity and individual complications. Secondary outcomes were procedure time and hospital stay.

Results

We merged the data from 19 reports comprising 1949 children of mean age 10.6 years.

No mortality was observed and the procedure was associated with morbidity of 15.4%. The commonest complications are bar-related adverse events (5.7%) and pneumothorax (3.5%). The average procedure time and the average hospital stay were 68 minutes and 5.5 days respectively.

Conclusion

20 years of initial evidence suggests that the Nuss group of procedures is a safe minimal access option for correction of pectus excavatum in childhood.

Introduction

The cardiothoracic surgeons are moving towards minimally invasive techniques. Such a technique is the Nuss repair (alias Minimally Invasive Repair of Pectus Excavatum or Miniature Access Pectus Excavatum Repair) for pectus excavatum (funnel chest) [1], the commonest chest wall anomaly in humans [2], first described in 1594 by Johannes Schenk, occurring in approximately 1 in every 400 births, males being afflicted 5 times more often than females. The indication for correction is primarily cosmetic, although the potential for cardiorespiratory improvement can be considered.

The original Nuss technique has being previously described [1, 24]. Its principle is the permanent reduction of the bone deformity by insertion of one (or more) malleable metal bars in order to refashion the contour of the growing thorax.

Advantages and disadvantages of the Nuss in relation to open techniques (such as Ravitch [2] and Willital-Hegemann that include extensive thoracic incisions and multiple thoracic osteochondrectomies (resections of ribs and cartilage) are presented in Table 1.
Table 1

Perceived advantages and disadvantages of minimal access strategy for correction of pectus in childhood in comparison to pre-existing conventional techniques

Advantages

Disadvantages

Short hospital stay

Cost of thoracoscopy and equipment

Minimal trauma

Second procedure for bar removal

Allowance for skeletal growth

Capnothorax in thoracoscopy

The principal advantage over these techniques is avoidance of osteochondrotomies and thence allowance for normal growth of the thorax, as subperichondral resection of the costal cartilages may halt the growth of the thoracic cage in toddlers and adolescents.

The metalwork is later removed as a day-case operation (nor requiring overnight stay in hospital) under general anaesthesia.

The Nuss operation can be performed with or without use of thoracoscopy. The selection of age for the Nuss varies with clinical, personal and socio-economical reasons (such as change of school and fear of intimidation by new peers), while removal of bars is scheduled within two to three years from the insertion. In Britain, some surgeons prefer to perform Nuss around the age of 10, before the child changes schools and thence is exposed to new peers. Some other surgeons will perform Nuss earlier, deciding on parental preference and individual clinical circumstances.

Materials and methods

We searched the literature with a simple strategy :

PubMed search

Last Date performed: 31 December 2006

Search keyword ‘Nuss’, language English, Humans, children

Cross-validation by hand search to identify case series and exclude isolated case reports.

Primary outcomes: Mortality, morbidity, individual complications

Secondary outcomes: Procedure time and hospital stay.

Descriptive and summary statistics were performed. Denominators were related to actual data. Missing data were not defaulted.

Results

Selection of reports

18 series of Nuss on children were identified (Table 2), originating from one or more of seven countries, or one of five of the United States of America.

Table 2

The series merged, 20 years of Nuss operations in children 1987–2006

Reference

number

Patients

operated

Type of study

Number of

centres

Comment

1

329

Retrospective

One

Series update on ref. 24

3

21

Comparative

One

 

4

52

Retrospective

One

 

5

335

Retrospective

One

Encompasses ref. 19

6

53

Retrospective

One

 

10

22

Retrospective

One

 

11

40

Retrospective

Not reported

 

12

172

Retrospective

Eight

 

13

31

Retrospective

One

 

15

20

Retrospective

One

Modified technique

16

36

Comparative

One

 

23

27

Retrospective

One

Subgroup of all-age cohort

8*

107

Comparative

One

Similar data to ref. 9

9*

107

Retrospective

Not reported

Similar data to ref. 8

14

80

Comparative

One

 

17**

35

Comparative

One

Same centre as ref. 18

18**

21

Retrospective

One

Same centre as ref. 17

22

461

Retrospective

One

 

Total

1949

   

Of these, there were at least three reports preceded by others with apparently overlapping cohorts, [2] by [20, 3] by [13] and [14, 5] by [19] so we utilised data from the larger and more up to date ones [2, 3, 5].

Interestingly, two reports from neighbouring countries [Japan, South Korea, [8, 9]) over a similar period had the same number of subjects (107 each), similar but not identical demographics (age, gender) and similar outcomes. Both reports have being included separately in our survey. Two reports from the same centre seemed to report on separate cohorts [17, 18] and have being also included separately in our survey.

Demographics (Table 3)

Table 3

Cumulative perioperative data on 20 years of Nuss operations in children 1987–2006

Reference

number

Patient

number

Average Age

Average

Operating

Time

Average

Hospital Stay

1

329

11 years

Not reported

5 days

3

21

14.4 years

53'

Not reported

4

52

Unknown

106'

3.9 days

5

335

8 years

Not reported

Not reported

6

53

9 years

76'

8.9 days

10

22

15.5 years

Not reported

13.4 days

11

40

17.6 years

126'

Not reported

12

172

15.1 years

76'

Not reported

13

31

14.5 years

Not reported

4 days

15

20

14 years

75'

5.5 days

16

36

12.3 years

96'

5.5 days

8

107

7.9 years

67'

8 days

9

107

7.5 years

48'

Not reported

14

80

11.5 years

53'

3.7 days

17

35

9.5 years

198'

4.8 days

18

21

8.2 years

Not reported

4.9 days

22

461

15.2 years

52'

5.3 days

23

27

5.9 years

52'

4.9 days

Total

1949

10.6 years

68'

5.5 days

1949 children have had Nuss operations. Mean age was 10.6 years, ratio male: female 77:23.

Morbidity and Mortality

No mortality was observed and the incidence of morbidity was 15.4%. The most commonly reported complications were:
  1. 1.

    Bar-related events (bar displacement requiring revision) (111 events, incidence 5.7%) and

     
  2. 2.

    Pneumothorax (68 events including those treated without chest drain, overall incidence 3.5%).

     
The incidence of wound infection was 2.2%, the incidence of other pleuropulmonary complications including effusions and atelectasis/pneumonia was 2%. Other complications were less common (Table 4).
Table 4

Complications of 20 years of Nuss operations in children 1987–2006

Complication

Cumulative

Bar-related adverse events

111 (37%)

Pneumothorax

68(23%)

Other Pleuropulmonary, except pneumothorax

39(13%)

Wound infection

43(14%)

Pericardial effusion

28(9%)

Hemothorax

12(4%)

Total

301

Other Perioperative Data

The average length of operation in minutes was 68 minutes (range 28–200).

Average Hospital stay was 5.5 days (range 2–27 days).

Conclusion

We hope that this brief independent survey will offer the necessary peri-operative data on this now well-established cosmetic intervention in children: The Nuss procedure has been performed all around the world with no reported mortality for 20 years (1987–2007), indicated primarily for cosmesis in the paediatric sufferer of pectus excavatum. Potential cardiorespiratory improvement is not as yet confirmed, whilst the co-existence of Marfan's syndrome can be ruled out by pre-operative echocardiography.

The variations of the Nuss procedure stem from thoracoscopic or open, and then thoracoscopy with single or double-lumen ventilation (in toddlers double lumen ventilation may be cumbersome given their tracheal size). Bar stabilisers have evolved as a valid addition to the technique [11].

Pneumothorax and bar-related events (pain, dislocation or infection) may complicate the procedure and are the primary post operative points of concern. Pneumothorax is as expected, commoner with thoracoscopy: the technique may involve carbon dioxide insufflation (capnothorax [25] where single lumen tracheal intubation is utilised.

Our observations reinforce these of a previous smaller multi-centre cumulative report on 251 cases 7 years ago [21] and a recent case review by the inventor of the technique [24].

The advantages of this procedure include the following: the short hospital stay and limited invasion surgery which allows for growth in the skeleton as opposed to the ostochondrectomies (Table 1). On the balance is the obvious cost of the thoracoscopy and specialised equipment as well as the second outpatient-day case procedure of removal of the bar(s).

We have now reached the point of adequate experience with Nuss that the purchasers may decide on strategies after careful individual cost-effectiveness assessment. Most workers timed the operation at an age appropriate to the cosmetic expectations of the patient and family considering the growth spurt of teenagers, namely prior to the early teens. It is not unusual to perform Nuss in young adults as a matter of surgeon's and patient's preference, where care should be exercised for the bar recipient not to be exposed to vigorous activity prior to removal of the bar as displacement is a recognised complication associated with contact sports, trauma or intense manual labour[26].

Limitations of the study and future research

Not all reported series include the data for the variables studied, the length of postoperative in-hospital stay being one important one. This might have an impact on the results. Post operative hospital stay is a surrogate index of performance, especially in paediatric populations. It is evident in the literature that the available data have not been based in comparative high quality studies and patient based outcomes such as Health Related Quality of life and patient satisfaction which are important considerations in therapeutic decision making. Also the long-term results of the procedure are not being discussed in this paper.

Declarations

Authors’ Affiliations

(1)
Department of Biosurgery & Surgical Technology, Imperial College London, St. Mary's Hospital

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© Protopapas and Athanasiou; licensee BioMed Central Ltd. 2008

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.