- Email: [email protected]
Hybrid Nuss Procedure for Pectus Excavatum With Severe Retrosternal Adhesions After Sternotomy
Hybrid Nuss Procedure for Pectus Excavatum With Severe Retrosternal Adhesions After Sternotomy Shuai Li, MD,* Dehua Yang, PhD,* Yazhen Ma, MD, Shao-tao Tang, MD, Li Yang, MD, Shiwang Li, MD, Guoqing Cao, MD, Kang Li, PhD, Xi Zhang, MM, and Xingjian Hu, PhD
Background. The most striking feature of pectus excavatum (PE) after previous congenital heart disease (CHD) surgery through a median sternotomy is the postsurgical adhesions between the sternum and heart. For patients with severe adhesions, passing the introducer can be difficult and hazardous when performing a Nuss repair. We describe a hybrid Nuss procedure using a small subxiphoid incision for blunt and sharp anterior mediastinal dissection and using a thoracoscope to ensure the whole process of dissection is under direct visualization. Methods. A retrospective case review was conducted of PE patients (previous CHD operation) who had undergone the hybrid Nuss procedure between January 2012 and June 2015. Demographic, treatment, and outcome variables were recorded. Results. Eleven patients were included. The mean age was 4.7 ± 1.7 years (range, 3.2 to 8.9). The mean Haller
index based on computed tomography was 4.15 ± 0.78 (range, 3.2 to 5.8). All cases were the symmetric type. Mean operating time was 95.5 ± 8.4 minutes (range, 80 to 110); mean blood loss was 15 ± 2.3 mL; and mean length of hospitalization was 6.0 ± 1.4 days (range, 4 to 8). There was no pneumothorax, cardiac injury, wound infection, discomfort requiring removal, or bar rotation at the average 27-month (range, 9 to 50) follow-up. Two patients had the bars removed. No reoperations were performed owing to recurrence. Conclusions. The hybrid Nuss procedure is a safe, simple modification of the Nuss repair for patients with severe retrosternal adhesions. This procedure achieves dissection with direct visualization. Hence, the risk of death due to cardiac perforation can be prevented.
S
heart injury. The presence of PE represents a technical challenge to pediatric surgeons because of the adhesion between the sternum and the displaced heart with an incomplete or missing pericardium [4]. Heart perforation is more likely to occur when surgeons dissect the postsurgical adhesions during the Nuss procedure. Technical modifications can be applied, such as sternum elevation, bilateral thoracoscopy to increase exposure, and special endoscopic devices to create the substernal tunnel. However, possible heart perforation cannot be completely prevented even if these techniques are combined. We reported in 2014 the PE operation on patients with previous median sternotomy for congenital heart disease (CHD), and a solution using a subxiphoid incision (blunt dissection to increase tactile feedback) and bilateral thoracoscopy was recommended to cases with severe adhesion beneath the sternum [5]. Unfortunately, we encountered a heart perforation during dissection using a finger through the subxiphoid incision. Then, continual modifications were applied using blunt and sharp dissection from the subxiphoid incision and thoracoscopy on the right side and in the subxiphoid incision to ensure the whole process of dissection in the retrosternal space
ince its introduction by Nuss in 1998, the minimally invasive repair of pectus excavatum (PE) has gained significant popularity among patients and surgeons. However, some patients have new, severe complications, such as heart injury. Castellani and associates [1] observed seven minor pericardial tears during bar implantation (4.2% of patients in their series). Becmeur and colleagues [2] reviewed eight accidents that occurred, despite a bilateral thoracoscopy [3] or dissection using two additional ports to proceed with blunt dissection. Practice has shown that cardiac injuries during the Nuss procedure occur most frequently during the blind passage of the introducer into the retrosternal space. The risk of injury is higher for PE patients with a previous heart surgery that utilized a median sternotomy, although several modifications may decrease the risk of Accepted for publication Oct 4, 2016. *Drs Shuai Li and Dehua Yang are co-first authors. Presented at the Sixteenth Annual Meeting of the Chest Wall International Group, Hong Kong, China, May 13–15, 2015. Address correspondence to Dr Tang, Department of Pediatric Surgery, 1277 Jie Fang Ave, Wuhan 430022, China; email: [email protected].
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier Inc.
(Ann Thorac Surg 2017;103:1573–7) Ó 2017 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.10.001
GENERAL THORACIC
Departments of Pediatric Surgery and Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan; and Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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was under direct visualization. The initial results of this technique are satisfactory.
Patients and Methods
GENERAL THORACIC
Patients This study was approved by the Ethics Committee of the Union Hospital of Tongji Medical College, Huazhong University of Science and Technology. In all, 11 patients who underwent the hybrid Nuss procedure for postoperative PE after surgery for CHD in our hospital between January 2012 and June 2015 were included in this retrospective study. There were 7 boys and 4 girls with a mean age of 4.7 years (range, 3.2 to 8.9). The mean Haller index based on computed tomography scans was 4.15 0.78 (range, 3.2 to 5.8; Table 1). All 11 cases were the symmetric type according to the simplified version of Park’s classification [6]. The parents’ consent for the operation was obtained after they had been informed of the surgical indications, complications, possible outcomes, and limitations of the Nuss procedure. Patient characteristics, operative time, length of hospital stay, efficiency of operation, and postoperative complications were recorded.
Surgical Technique The main steps were as follows. In addition to the two vertical axillary incisions, a 1.5-cm subxiphoid incision was made to allow the surgeon’s finger to bluntly dissect the retrosternal space. The surgeon’s finger was used to push the pericardium away from the chest wall and then to introduce the introducer through the retrosternal space (Fig 1). When performed as far below the sternum as possible, this dissection can be very easy for mild adhesion cases. Then, the appropriate tunnel was created under the muscle layer. The surgeon then passed the bar introducer from the right axillary incision through the tunnel next to the sternum onto the surgeon’s finger that was placed in the retrosternal space to guide the
introducer out through the subxiphoid incision. Umbilical tape was introduced through the passage and was used to pull the bar out. The bar was rotated and fixed with one stabilizer in the right end. For cases with severe, tight adhesions and when blunt dissection with the fingers did not work, a retractor was used to elevate the sternum (Fig 2), and a thoracoscope was introduced through the subxiphoid incision to supply direct visualization. The dissection was performed using forceps placed through the subxiphoid incision under thoracoscopy, as close to the bottom of the sternum as possible (Fig 3). Postoperative pain was controlled using intravenous analgesia pumps for 48 hours and oral nonsteroidal antiinflammatory drugs 5 days thereafter. Physical activity was restricted for 12 weeks. The bars were left in place for 3 years.
Follow-Up Postoperative follow-up occurred at 1, 3, 12, and 24 months. After bar removal, follow-up occurred once per month for the next 6 months and then once per year. Follow-up assessments included a physical examination, chest radiography or computed tomography scan, and cardiac ultrasonography. According to the Nuss criteria [7], the outcome of the operation can be divided into our grades: excellent, if the preoperative symptoms were resolved and chest appearance is normal; good, if the preoperative symptoms were resolved and chest appearance is improved; fair, if the preoperative symptoms were improved but appearance is not completely normal; and poor, if the preoperative symptoms were not improved and appearance is not completely normal.
Statistical Analysis Descriptive characteristics are presented as mean SD. Data analysis was performed using SPSS 18.0 (SPSS Inc, Chicago, IL).
Table 1. Data of the Patients Pt. No.
Sex
CHD
1 M VSD 2 M VSD 3 M TOF 4 F ASD 5 M ASD, VSD 6 F VSD 7 M TGA, PDA 8 M VSD 9 F ASD 10 F VSD 11 M ASD, VSD Average, mean SD
Age at Sternotomy (months)
Age at PE Repair (years)
Haller Index
Operative Time (minutes)
Follow-Up (months)
15 11 6 25 10 12 3 10 15 13 11 .
3.6 4.3 3.2 8.9 5 5.4 3.2 3.7 6.2 4.1 4.2 4.71 1.672
3.6 3.8 4.1 4 3.9 3.2 4.2 3.3 5.2 5.8 4.5 4.15 0.780
101 89 105 97 87 99 110 80 95 96 92 95.5 8.44
50 42 35 33 29 27 24 18 15 13 9 26.82 12.695
ASD ¼ atrial septal defect; CHD ¼ congenital heart disease; F ¼ female; M ¼ male; PDA ¼ patent ductus arteriosus; PE ¼ pectus excavatum; Pt. No. ¼ patient number; TGA ¼ transposition of great arteries; TOF ¼ tetralogy of Fallot; VSD ¼ ventricular septal defect.
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Fig 1. (A, B) Blunt dissection of the retrosternal space using the surgeon’s finger (arrow).
Outcome
Eleven PE patients, after surgery for CHD, with severe adhesions in the retrosternal space underwent the hybrid Nuss procedure. Retrospective analysis was performed, and the initial outcomes were recorded. The mean operative time was 95.5 8.4 minutes (range, 80 to 110). The mean blood loss was 15 2.3 mL. The mean length of hospital stay was 6.0 1.4 days (range, 4 to 8). The mean time to detect pectus excavatum was 3.6 months (range, 1 to 10) after heart surgery. The mean follow-up time was 27 months (range, 9 to 50; Table 1).
According to the Nuss criteria, the initial observations revealed that all patients had excellent results. Two patients had their bars removed, and the results were excellent.
Antibiotics Patients were administered perioperative antibiotics to prevent postoperative infections. All patients received antibiotic treatment for 7 days.
Complications No deaths or cardiac perforations occurred. Early postoperative complications included asymptomatic pneumothorax in 1 patient. None of the patients required a chest tube. No patients had wound hematomas, and no infections occurred. No patients had hemothorax or bar displacement.
Fig 2. Elevation of the sternum using a retractor with appropriate power.
Comment Major cardiac injuries during the Nuss procedure appear to be rare, but they are certainly not all reported. The true incidence of these complications remains unknown [3]. These cases demonstrate an unacceptable life-threatening complication risk for a cosmetic surgery despite their low incidence rate. Technical modifications of the Nuss procedure have been made in attempt to prevent heart injuries. Ohno and colleagues [8] proposed to begin the dissection between the sternum and thymus to avoid the most dangerous space between the pectus excavatum and pericardium. This technique was not safe enough for our patients [8]. It is undeniable that direct visualization of the mediastinum during bar passage is intuitively safer and comforting. The use of bilateral thoracoscopy has also been reported for both children and adults to facilitate safe passage of the bar between the sternum and mediastinum [9, 10]. Other modifications have reported using an endoscopic saphenous vein harvesting device [11] or endovascular Kittner dissectors [12] to create the substernal tunnel using thoracoscopic guidance without additional incisions or pleural insufflation. These techniques still limit manual dissection and the physical protection of the heart as the bar is passed. Recently, elevation of the anterior chest wall to assure the safety of the heart during the Nuss procedure has been reported (more often in severe cases) [13–15]. Jeong and Lee [16] combined the crane technique and dissection under thoracoscopy along the mid axillary line and had no cardiac bleeding in 61 consecutive patients. St Peter and colleagues [17] used a small subxiphoid incision to allow the surgeon to pass a finger under the lower sternum and bluntly dissect the retrosternal space without thoracoscopy. A finger between the heart and the bar provides excellent tactile feedback (which is most lacking during endoscopic
GENERAL THORACIC
Results
GENERAL THORACIC
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Fig 3. (A) General operation scene. (B) Dissection using hemostatic forceps (Hf) through a subxiphoid incision using thoracoscope as close to the bottom of the sternum (s) as possible; arrow indicates the tense adhesion between myocardium and sternum. (C) View by thoracoscope from incision in right side of chest. (f ¼ finger; h ¼ heart; i ¼ introducer; s ¼ sternum.)
surgery) and an assumption that cardiac injuries are prevented. However, in cases with severe postoperative adhesions in the mediastinum, the previous methods cannot ensure that injury does not occur, and the occurrence of damage cannot be identified. Potential risk still exists because of the blind dissection or poor tactile feedback. However, the advantages of the methods described provide a way of thinking when determining the most appropriate modification of the Nuss procedure for these patients. As we previously reported [5], adhesions were present in all cases, and only a small number of these cases were severe. For the patients with a displaced heart and an incomplete or missing pericardium, the myocardium was adhered directly to the sternum, and dissection required tearing the myocardium from the sternum. In these cases, excessive elevation may increase the risk of heart rupture. However, accuracy, tactile feedback, and visualization are essential. Here, we introduced a hybrid Nuss procedure using a subxiphoid incision and multiple thoracoscope placements (through right axillary and subxiphoid incisions) to dissect the substernal space under direct visualization with excellent tactile feedback. There are four advantages of this new procedure. First, no special equipment is required. Second, the tactile feedback is good for the probe and when dissecting with the fingers. Third, for severe adhesions, when dissecting with the fingers does not work, dissecting under direct visualization using thoracoscopy through a subxiphoid incision is safer and more comfortable. Fourth, heart perforation can be best controlled through a subxiphoid incision by adding pressure to the bleeding heart and performing resternotomy instantly in case heart injury is identified. Furthermore, a subxiphoid incision occurs during the previous heart operation. Therefore, no additional wounds are needed (Fig 4). There is one disadvantage to this procedure. An additional 10 minutes is needed to create and close the subxiphoid incision. As this incision is an effective modification, the additional 10 minutes is worth it. In this series, the age at Nuss repair is younger than it was previously reported in some publications [18].
However, other studies emphasized that, unlike the more invasive procedures (eg, Ravitch procedure or sternal turnover), Nuss procedure did not interfere with growth plates. It was believed that Nuss repair can be done at any age [19]. Importantly, they concluded that the potential higher recurrence rate in children aged 5 years and younger was mostly because these patients kept their bars in place for less than 3 years [18]. Recent study focusing on the optimal age for pectus repair revealed that routine early repair of pectus excavatum in patients older than 3 years of age was safe and effective and did not increase the recurrence rate. And earlier repair was recommended to avoid asymmetry transformation of the deformity, to enhance the patients’ growth potential, to decrease the complications [20, 21], and to stabilize hemodynamic function [22]. In our practice, repairing the pectus deformity with a previous sternotomy before school age is recommended. The shortcomings of this study include its relatively short follow-up time and the small sample size. That can be explained by the paper’s major aim—to introduce a novel modified operation technique and its clinical experience from a single institution. In 2014, we have
Fig 4. Postoperative photograph of chest.
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This study was supported by the Public Welfare Research, and special funds were received from National Health and Family Planning of China (no. 201402007) and the Fundamental Research Funds for the Central Universities (HUST: 2015LC023).
References 1. Castellani C, Schalamon J, Saxena AK, Hoellwarth ME. Early complications of the Nuss procedure for pectus excavatum: a prospective study. Pediatr Surg Int 2008;24:659–66. 2. Becmeur F, Ferreira CG, Haecker FM, Schneider A, Lacreuse I. Pectus excavatum repair according to Nuss: is it safe to place a retrosternal bar by a transpleural approach, under thoracoscopic vision? J Laparoendosc Adv Surg Tech A 2011;21:757–61. 3. Bouchard S, Hong AR, Gilchrist BF, Kuenzler KA. Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum. Semin Pediatr Surg 2009;18:66–72. 4. Sacco Casamassima MG, Wong LL, Papandria D, et al. Modified Nuss procedure in concurrent repair of pectus excavatum and open heart surgery. Ann Thorac Surg 2013;95:1043–9. 5. Li S, Tang ST, Tong Q, et al. Nuss repair of pectus excavatum after surgery for congenital heart disease: experience from a single institution. J Thorac Cardiovasc Surg 2014;148:657–61. 6. Zeng Q, Zhang N, Chen CH, He YR. Classification of the pectus excavatum and minimally invasive Nuss procedure. Zhonghua Wai Ke Za Zhi 2008;46:1160–2.
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7. Redlinger RE, Kelly RE, Nuss D, Kuhn MA, Obermeyer RJ, Goretsky MJ. One hundred patients with recurrent pectus excavatum repaired via the minimally invasive Nuss technique—effective in most regardless of initial operative approach. J Pediatr Surg 2011;46:1177–81. 8. Ohno K, Nakamura T, Azuma T, Yamada H, Hayashi H, Masahata K. Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation. J Pediatr Surg 2009;44:2426–30. 9. Cheng YL, Lee SC, Huang TW, Wu CT. Efficacy and safety of modified bilateral thoracoscopy-assisted Nuss procedure in adult patients with pectus excavatum. Eur J Cardiothorac Surg 2008;34:1057–61. 10. Palmer B, Yedlin S, Kim S. Decreased risk of complications with bilateral thoracoscopy and left-to-right mediastinal dissection during minimally invasive repair of pectus excavatum. Eur J Pediatr Surg 2007;17:81–3. 11. Jacobs JP, Quintessenza JA, Morell VO, Botero LM, van Gelder HM, Tchervenkov CI. Minimally invasive endoscopic repair of pectus excavatum. Eur J Cardiothorac Surg 2002;21: 869–73. 12. Hendrickson RJ, Bensard DD, Janik JS, Partrick DA. Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum. J Pediatr Surg 2005;40:1312–4. 13. Johnson WR, Fedor D, Singhal S. A novel approach to eliminate cardiac perforation in the Nuss procedure. Ann Thorac Surg 2013;95:1109–11. 14. Kim D, Idowu O, Palmer B, Kim S. Anterior chest wall elevation using a T-fastener suture technique during a Nuss procedure. Ann Thorac Surg 2014;98:734–6. 15. Park HJ, Jeong JY, Jo WM, et al. Minimally invasive repair of pectus excavatum: a novel morphology-tailored, patientspecific approach. J Thorac Cardiovasc Surg 2010;139: 379–86. 16. Jeong JY, Lee J. Use of needlescope and crane technique to avoid cardiac injury in Nuss procedure. Ann Thorac Surg 2014;98:386–7. 17. St Peter SD, Sharp SW, Ostlie DJ, Snyder CL, Holcomb GW, Sharp RJ. Use of a subxiphoid incision for pectus bar placement in the repair of pectus excavatum. J Pediatr Surg 2010;45:1361–4. 18. Nuss D, Kelly RE. Indications and technique of Nuss procedure for pectus excavatum. Thorac Surg Clin 2010;20: 583–97. 19. Goretsky MJ, Kelly RE, Croitoru D, Nuss D. Chest wall anomalies: pectus excavatum and pectus carinatum. Adolesc Med 2004;15:455–71. 20. Kim Do H, Hwang JJ, Lee MK, Lee DY, Paik HC. Analysis of the Nuss procedure for pectus excavatum in different age groups. Ann Thorac Surg 2005;80:1073–7. 21. Park HJ, Sung SW, Park JK, Kim JJ, Jeon HW, Wang YP. How early can we repair pectus excavatum: the earlier the better? Eur J Cardiothorac Surg 2012;42:667–72. 22. Rousse N, Juthier F, Prat A, Wurtz A. Staged repair of pectus excavatum during an aortic valve-sparing operation. J Thorac Cardiovasc Surg 2011;141:e28–30.
GENERAL THORACIC
published another report containing 17 pediatric patients (younger than 5 years old) among 30 cases who have received this operation [5]. Those patients have been kept in follow-up for more than 5 years till now. All of them had their bars removed 3 years after the Nuss repair, and no recurrence has been observed. Based on this promising preliminary data, we are introducing this technique modification to other medical centers in China and plan to gather further results to get more objective evaluations and reliable conclusions. In general, the common feature of patients with PE after sternotomy is the postsurgical adhesion between the sternum and heart. The safest surgical treatment, theoretically, for severe cases is dissection under direct visualization with excellent tactile feedback. Our single-center experiences have demonstrated that the hybrid Nuss procedure with combined application of an additional subxiphoid incision, multiple thoracoscope placements, and a sternum elevation technique could be the best therapeutic solution.
LI ET AL HYBRID NUSS PROCEDURE FOR SEVERE ADHESIONS
Background. The most striking feature of pectus excavatum (PE) after previous congenital heart disease (CHD) surgery through a median sternotomy is the postsurgical adhesions between the sternum and heart. For patients with severe adhesions, passing the introducer can be difficult and hazardous when performing a Nuss repair. We describe a hybrid Nuss procedure using a small subxiphoid incision for blunt and sharp anterior mediastinal dissection and using a thoracoscope to ensure the whole process of dissection is under direct visualization. Methods. A retrospective case review was conducted of PE patients (previous CHD operation) who had undergone the hybrid Nuss procedure between January 2012 and June 2015. Demographic, treatment, and outcome variables were recorded. Results. Eleven patients were included. The mean age was 4.7 ± 1.7 years (range, 3.2 to 8.9). The mean Haller
index based on computed tomography was 4.15 ± 0.78 (range, 3.2 to 5.8). All cases were the symmetric type. Mean operating time was 95.5 ± 8.4 minutes (range, 80 to 110); mean blood loss was 15 ± 2.3 mL; and mean length of hospitalization was 6.0 ± 1.4 days (range, 4 to 8). There was no pneumothorax, cardiac injury, wound infection, discomfort requiring removal, or bar rotation at the average 27-month (range, 9 to 50) follow-up. Two patients had the bars removed. No reoperations were performed owing to recurrence. Conclusions. The hybrid Nuss procedure is a safe, simple modification of the Nuss repair for patients with severe retrosternal adhesions. This procedure achieves dissection with direct visualization. Hence, the risk of death due to cardiac perforation can be prevented.
S
heart injury. The presence of PE represents a technical challenge to pediatric surgeons because of the adhesion between the sternum and the displaced heart with an incomplete or missing pericardium [4]. Heart perforation is more likely to occur when surgeons dissect the postsurgical adhesions during the Nuss procedure. Technical modifications can be applied, such as sternum elevation, bilateral thoracoscopy to increase exposure, and special endoscopic devices to create the substernal tunnel. However, possible heart perforation cannot be completely prevented even if these techniques are combined. We reported in 2014 the PE operation on patients with previous median sternotomy for congenital heart disease (CHD), and a solution using a subxiphoid incision (blunt dissection to increase tactile feedback) and bilateral thoracoscopy was recommended to cases with severe adhesion beneath the sternum [5]. Unfortunately, we encountered a heart perforation during dissection using a finger through the subxiphoid incision. Then, continual modifications were applied using blunt and sharp dissection from the subxiphoid incision and thoracoscopy on the right side and in the subxiphoid incision to ensure the whole process of dissection in the retrosternal space
ince its introduction by Nuss in 1998, the minimally invasive repair of pectus excavatum (PE) has gained significant popularity among patients and surgeons. However, some patients have new, severe complications, such as heart injury. Castellani and associates [1] observed seven minor pericardial tears during bar implantation (4.2% of patients in their series). Becmeur and colleagues [2] reviewed eight accidents that occurred, despite a bilateral thoracoscopy [3] or dissection using two additional ports to proceed with blunt dissection. Practice has shown that cardiac injuries during the Nuss procedure occur most frequently during the blind passage of the introducer into the retrosternal space. The risk of injury is higher for PE patients with a previous heart surgery that utilized a median sternotomy, although several modifications may decrease the risk of Accepted for publication Oct 4, 2016. *Drs Shuai Li and Dehua Yang are co-first authors. Presented at the Sixteenth Annual Meeting of the Chest Wall International Group, Hong Kong, China, May 13–15, 2015. Address correspondence to Dr Tang, Department of Pediatric Surgery, 1277 Jie Fang Ave, Wuhan 430022, China; email: [email protected].
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier Inc.
(Ann Thorac Surg 2017;103:1573–7) Ó 2017 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.10.001
GENERAL THORACIC
Departments of Pediatric Surgery and Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan; and Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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was under direct visualization. The initial results of this technique are satisfactory.
Patients and Methods
GENERAL THORACIC
Patients This study was approved by the Ethics Committee of the Union Hospital of Tongji Medical College, Huazhong University of Science and Technology. In all, 11 patients who underwent the hybrid Nuss procedure for postoperative PE after surgery for CHD in our hospital between January 2012 and June 2015 were included in this retrospective study. There were 7 boys and 4 girls with a mean age of 4.7 years (range, 3.2 to 8.9). The mean Haller index based on computed tomography scans was 4.15 0.78 (range, 3.2 to 5.8; Table 1). All 11 cases were the symmetric type according to the simplified version of Park’s classification [6]. The parents’ consent for the operation was obtained after they had been informed of the surgical indications, complications, possible outcomes, and limitations of the Nuss procedure. Patient characteristics, operative time, length of hospital stay, efficiency of operation, and postoperative complications were recorded.
Surgical Technique The main steps were as follows. In addition to the two vertical axillary incisions, a 1.5-cm subxiphoid incision was made to allow the surgeon’s finger to bluntly dissect the retrosternal space. The surgeon’s finger was used to push the pericardium away from the chest wall and then to introduce the introducer through the retrosternal space (Fig 1). When performed as far below the sternum as possible, this dissection can be very easy for mild adhesion cases. Then, the appropriate tunnel was created under the muscle layer. The surgeon then passed the bar introducer from the right axillary incision through the tunnel next to the sternum onto the surgeon’s finger that was placed in the retrosternal space to guide the
introducer out through the subxiphoid incision. Umbilical tape was introduced through the passage and was used to pull the bar out. The bar was rotated and fixed with one stabilizer in the right end. For cases with severe, tight adhesions and when blunt dissection with the fingers did not work, a retractor was used to elevate the sternum (Fig 2), and a thoracoscope was introduced through the subxiphoid incision to supply direct visualization. The dissection was performed using forceps placed through the subxiphoid incision under thoracoscopy, as close to the bottom of the sternum as possible (Fig 3). Postoperative pain was controlled using intravenous analgesia pumps for 48 hours and oral nonsteroidal antiinflammatory drugs 5 days thereafter. Physical activity was restricted for 12 weeks. The bars were left in place for 3 years.
Follow-Up Postoperative follow-up occurred at 1, 3, 12, and 24 months. After bar removal, follow-up occurred once per month for the next 6 months and then once per year. Follow-up assessments included a physical examination, chest radiography or computed tomography scan, and cardiac ultrasonography. According to the Nuss criteria [7], the outcome of the operation can be divided into our grades: excellent, if the preoperative symptoms were resolved and chest appearance is normal; good, if the preoperative symptoms were resolved and chest appearance is improved; fair, if the preoperative symptoms were improved but appearance is not completely normal; and poor, if the preoperative symptoms were not improved and appearance is not completely normal.
Statistical Analysis Descriptive characteristics are presented as mean SD. Data analysis was performed using SPSS 18.0 (SPSS Inc, Chicago, IL).
Table 1. Data of the Patients Pt. No.
Sex
CHD
1 M VSD 2 M VSD 3 M TOF 4 F ASD 5 M ASD, VSD 6 F VSD 7 M TGA, PDA 8 M VSD 9 F ASD 10 F VSD 11 M ASD, VSD Average, mean SD
Age at Sternotomy (months)
Age at PE Repair (years)
Haller Index
Operative Time (minutes)
Follow-Up (months)
15 11 6 25 10 12 3 10 15 13 11 .
3.6 4.3 3.2 8.9 5 5.4 3.2 3.7 6.2 4.1 4.2 4.71 1.672
3.6 3.8 4.1 4 3.9 3.2 4.2 3.3 5.2 5.8 4.5 4.15 0.780
101 89 105 97 87 99 110 80 95 96 92 95.5 8.44
50 42 35 33 29 27 24 18 15 13 9 26.82 12.695
ASD ¼ atrial septal defect; CHD ¼ congenital heart disease; F ¼ female; M ¼ male; PDA ¼ patent ductus arteriosus; PE ¼ pectus excavatum; Pt. No. ¼ patient number; TGA ¼ transposition of great arteries; TOF ¼ tetralogy of Fallot; VSD ¼ ventricular septal defect.
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Fig 1. (A, B) Blunt dissection of the retrosternal space using the surgeon’s finger (arrow).
Outcome
Eleven PE patients, after surgery for CHD, with severe adhesions in the retrosternal space underwent the hybrid Nuss procedure. Retrospective analysis was performed, and the initial outcomes were recorded. The mean operative time was 95.5 8.4 minutes (range, 80 to 110). The mean blood loss was 15 2.3 mL. The mean length of hospital stay was 6.0 1.4 days (range, 4 to 8). The mean time to detect pectus excavatum was 3.6 months (range, 1 to 10) after heart surgery. The mean follow-up time was 27 months (range, 9 to 50; Table 1).
According to the Nuss criteria, the initial observations revealed that all patients had excellent results. Two patients had their bars removed, and the results were excellent.
Antibiotics Patients were administered perioperative antibiotics to prevent postoperative infections. All patients received antibiotic treatment for 7 days.
Complications No deaths or cardiac perforations occurred. Early postoperative complications included asymptomatic pneumothorax in 1 patient. None of the patients required a chest tube. No patients had wound hematomas, and no infections occurred. No patients had hemothorax or bar displacement.
Fig 2. Elevation of the sternum using a retractor with appropriate power.
Comment Major cardiac injuries during the Nuss procedure appear to be rare, but they are certainly not all reported. The true incidence of these complications remains unknown [3]. These cases demonstrate an unacceptable life-threatening complication risk for a cosmetic surgery despite their low incidence rate. Technical modifications of the Nuss procedure have been made in attempt to prevent heart injuries. Ohno and colleagues [8] proposed to begin the dissection between the sternum and thymus to avoid the most dangerous space between the pectus excavatum and pericardium. This technique was not safe enough for our patients [8]. It is undeniable that direct visualization of the mediastinum during bar passage is intuitively safer and comforting. The use of bilateral thoracoscopy has also been reported for both children and adults to facilitate safe passage of the bar between the sternum and mediastinum [9, 10]. Other modifications have reported using an endoscopic saphenous vein harvesting device [11] or endovascular Kittner dissectors [12] to create the substernal tunnel using thoracoscopic guidance without additional incisions or pleural insufflation. These techniques still limit manual dissection and the physical protection of the heart as the bar is passed. Recently, elevation of the anterior chest wall to assure the safety of the heart during the Nuss procedure has been reported (more often in severe cases) [13–15]. Jeong and Lee [16] combined the crane technique and dissection under thoracoscopy along the mid axillary line and had no cardiac bleeding in 61 consecutive patients. St Peter and colleagues [17] used a small subxiphoid incision to allow the surgeon to pass a finger under the lower sternum and bluntly dissect the retrosternal space without thoracoscopy. A finger between the heart and the bar provides excellent tactile feedback (which is most lacking during endoscopic
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Fig 3. (A) General operation scene. (B) Dissection using hemostatic forceps (Hf) through a subxiphoid incision using thoracoscope as close to the bottom of the sternum (s) as possible; arrow indicates the tense adhesion between myocardium and sternum. (C) View by thoracoscope from incision in right side of chest. (f ¼ finger; h ¼ heart; i ¼ introducer; s ¼ sternum.)
surgery) and an assumption that cardiac injuries are prevented. However, in cases with severe postoperative adhesions in the mediastinum, the previous methods cannot ensure that injury does not occur, and the occurrence of damage cannot be identified. Potential risk still exists because of the blind dissection or poor tactile feedback. However, the advantages of the methods described provide a way of thinking when determining the most appropriate modification of the Nuss procedure for these patients. As we previously reported [5], adhesions were present in all cases, and only a small number of these cases were severe. For the patients with a displaced heart and an incomplete or missing pericardium, the myocardium was adhered directly to the sternum, and dissection required tearing the myocardium from the sternum. In these cases, excessive elevation may increase the risk of heart rupture. However, accuracy, tactile feedback, and visualization are essential. Here, we introduced a hybrid Nuss procedure using a subxiphoid incision and multiple thoracoscope placements (through right axillary and subxiphoid incisions) to dissect the substernal space under direct visualization with excellent tactile feedback. There are four advantages of this new procedure. First, no special equipment is required. Second, the tactile feedback is good for the probe and when dissecting with the fingers. Third, for severe adhesions, when dissecting with the fingers does not work, dissecting under direct visualization using thoracoscopy through a subxiphoid incision is safer and more comfortable. Fourth, heart perforation can be best controlled through a subxiphoid incision by adding pressure to the bleeding heart and performing resternotomy instantly in case heart injury is identified. Furthermore, a subxiphoid incision occurs during the previous heart operation. Therefore, no additional wounds are needed (Fig 4). There is one disadvantage to this procedure. An additional 10 minutes is needed to create and close the subxiphoid incision. As this incision is an effective modification, the additional 10 minutes is worth it. In this series, the age at Nuss repair is younger than it was previously reported in some publications [18].
However, other studies emphasized that, unlike the more invasive procedures (eg, Ravitch procedure or sternal turnover), Nuss procedure did not interfere with growth plates. It was believed that Nuss repair can be done at any age [19]. Importantly, they concluded that the potential higher recurrence rate in children aged 5 years and younger was mostly because these patients kept their bars in place for less than 3 years [18]. Recent study focusing on the optimal age for pectus repair revealed that routine early repair of pectus excavatum in patients older than 3 years of age was safe and effective and did not increase the recurrence rate. And earlier repair was recommended to avoid asymmetry transformation of the deformity, to enhance the patients’ growth potential, to decrease the complications [20, 21], and to stabilize hemodynamic function [22]. In our practice, repairing the pectus deformity with a previous sternotomy before school age is recommended. The shortcomings of this study include its relatively short follow-up time and the small sample size. That can be explained by the paper’s major aim—to introduce a novel modified operation technique and its clinical experience from a single institution. In 2014, we have
Fig 4. Postoperative photograph of chest.
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This study was supported by the Public Welfare Research, and special funds were received from National Health and Family Planning of China (no. 201402007) and the Fundamental Research Funds for the Central Universities (HUST: 2015LC023).
References 1. Castellani C, Schalamon J, Saxena AK, Hoellwarth ME. Early complications of the Nuss procedure for pectus excavatum: a prospective study. Pediatr Surg Int 2008;24:659–66. 2. Becmeur F, Ferreira CG, Haecker FM, Schneider A, Lacreuse I. Pectus excavatum repair according to Nuss: is it safe to place a retrosternal bar by a transpleural approach, under thoracoscopic vision? J Laparoendosc Adv Surg Tech A 2011;21:757–61. 3. Bouchard S, Hong AR, Gilchrist BF, Kuenzler KA. Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum. Semin Pediatr Surg 2009;18:66–72. 4. Sacco Casamassima MG, Wong LL, Papandria D, et al. Modified Nuss procedure in concurrent repair of pectus excavatum and open heart surgery. Ann Thorac Surg 2013;95:1043–9. 5. Li S, Tang ST, Tong Q, et al. Nuss repair of pectus excavatum after surgery for congenital heart disease: experience from a single institution. J Thorac Cardiovasc Surg 2014;148:657–61. 6. Zeng Q, Zhang N, Chen CH, He YR. Classification of the pectus excavatum and minimally invasive Nuss procedure. Zhonghua Wai Ke Za Zhi 2008;46:1160–2.
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7. Redlinger RE, Kelly RE, Nuss D, Kuhn MA, Obermeyer RJ, Goretsky MJ. One hundred patients with recurrent pectus excavatum repaired via the minimally invasive Nuss technique—effective in most regardless of initial operative approach. J Pediatr Surg 2011;46:1177–81. 8. Ohno K, Nakamura T, Azuma T, Yamada H, Hayashi H, Masahata K. Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation. J Pediatr Surg 2009;44:2426–30. 9. Cheng YL, Lee SC, Huang TW, Wu CT. Efficacy and safety of modified bilateral thoracoscopy-assisted Nuss procedure in adult patients with pectus excavatum. Eur J Cardiothorac Surg 2008;34:1057–61. 10. Palmer B, Yedlin S, Kim S. Decreased risk of complications with bilateral thoracoscopy and left-to-right mediastinal dissection during minimally invasive repair of pectus excavatum. Eur J Pediatr Surg 2007;17:81–3. 11. Jacobs JP, Quintessenza JA, Morell VO, Botero LM, van Gelder HM, Tchervenkov CI. Minimally invasive endoscopic repair of pectus excavatum. Eur J Cardiothorac Surg 2002;21: 869–73. 12. Hendrickson RJ, Bensard DD, Janik JS, Partrick DA. Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum. J Pediatr Surg 2005;40:1312–4. 13. Johnson WR, Fedor D, Singhal S. A novel approach to eliminate cardiac perforation in the Nuss procedure. Ann Thorac Surg 2013;95:1109–11. 14. Kim D, Idowu O, Palmer B, Kim S. Anterior chest wall elevation using a T-fastener suture technique during a Nuss procedure. Ann Thorac Surg 2014;98:734–6. 15. Park HJ, Jeong JY, Jo WM, et al. Minimally invasive repair of pectus excavatum: a novel morphology-tailored, patientspecific approach. J Thorac Cardiovasc Surg 2010;139: 379–86. 16. Jeong JY, Lee J. Use of needlescope and crane technique to avoid cardiac injury in Nuss procedure. Ann Thorac Surg 2014;98:386–7. 17. St Peter SD, Sharp SW, Ostlie DJ, Snyder CL, Holcomb GW, Sharp RJ. Use of a subxiphoid incision for pectus bar placement in the repair of pectus excavatum. J Pediatr Surg 2010;45:1361–4. 18. Nuss D, Kelly RE. Indications and technique of Nuss procedure for pectus excavatum. Thorac Surg Clin 2010;20: 583–97. 19. Goretsky MJ, Kelly RE, Croitoru D, Nuss D. Chest wall anomalies: pectus excavatum and pectus carinatum. Adolesc Med 2004;15:455–71. 20. Kim Do H, Hwang JJ, Lee MK, Lee DY, Paik HC. Analysis of the Nuss procedure for pectus excavatum in different age groups. Ann Thorac Surg 2005;80:1073–7. 21. Park HJ, Sung SW, Park JK, Kim JJ, Jeon HW, Wang YP. How early can we repair pectus excavatum: the earlier the better? Eur J Cardiothorac Surg 2012;42:667–72. 22. Rousse N, Juthier F, Prat A, Wurtz A. Staged repair of pectus excavatum during an aortic valve-sparing operation. J Thorac Cardiovasc Surg 2011;141:e28–30.
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published another report containing 17 pediatric patients (younger than 5 years old) among 30 cases who have received this operation [5]. Those patients have been kept in follow-up for more than 5 years till now. All of them had their bars removed 3 years after the Nuss repair, and no recurrence has been observed. Based on this promising preliminary data, we are introducing this technique modification to other medical centers in China and plan to gather further results to get more objective evaluations and reliable conclusions. In general, the common feature of patients with PE after sternotomy is the postsurgical adhesion between the sternum and heart. The safest surgical treatment, theoretically, for severe cases is dissection under direct visualization with excellent tactile feedback. Our single-center experiences have demonstrated that the hybrid Nuss procedure with combined application of an additional subxiphoid incision, multiple thoracoscope placements, and a sternum elevation technique could be the best therapeutic solution.
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