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Patient Satisfaction After Minimally Invasive Repair of Pectus Excavatum in Adults: Long-Term Results of Nuss Procedure in Adults
Patient Satisfaction After Minimally Invasive Repair of Pectus Excavatum in Adults: Long-Term Results of Nuss Procedure in Adults Maria Grazia Sacco Casamassima, MD, Colin Gause, MD, Seth D. Goldstein, MD, Omar Karim, MD, Abhishek Swarup, MD, Kimberly McIltrot, DPN, Jingyan Yang, MHS, Fizan Abdullah, MD, PhD, and Paul M. Colombani, MD, MBA Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York; and Division of Pediatric Surgery, All Children’s Hospital Johns Hopkins Medicine, St. Petersburg, Florida
Background. Extensive literature has proved that the Nuss procedure leads to permanent remodeling of the chest wall in pediatric patients with pectus excavatum (PE). However, limited long-term follow-up data are available for adults. Herein, we report a single-institution experience in the management of adult PE with the Nuss procedure, evaluating long-term outcomes and overall patient satisfaction after bar removal. Methods. Adult patients who underwent PE repair with a modified Nuss procedure between January 1998 and June 2011 were retrospectively identified. Outcomes of interest were postoperative pain, recurrence, and patient satisfaction. A modified single-step Nuss questionnaire was administered to evaluate patient satisfaction and quality-of-life improvement after PE repair. Results. Ninety-eight patients with a median age of 30.9 years (range, 21.8 to 55.1 years) at the time of repair were identified. One bar was placed in most patients
(89.7%). Four patients (4.1%) required reoperation for bar displacement. Results after bar removal were overall satisfactory in 94.4% of patients; 2 patients required reoperation for recurrence. Thirty-nine patients participated in the survey. Satisfaction with chest appearance was reported by 89.7% of responders. Seven patients reported dissatisfaction with the overall results; the most common complaints were severe postoperative chest pain and dissatisfaction with surgical scars. Conclusions. Favorable long-term results can be achieved with the Nuss procedure in adults. However, postoperative pain may require a more aggressive analgesic regimen, and it may be the overriding factor in the patient’s perception of the quality of the postoperative course.
S
This notion has been challenged by Coln and colleagues [5], who reported encouraging early results after Nuss repair in a series of 14 adults. Evidence of safety of the Nuss procedure in adults has been provided by other retrospective series [2, 6–9]; however, to date, limited data exist to support the improvement in cosmetic appearance persists after bar removal [7, 8, 10, 11]. Because the number of adults presenting for PE repair continues to increase, more robust evidence is needed about the safety and effectiveness of the Nuss procedure in this specific patient population to assist surgeons in counseling adults about its risks and benefits. The present study aims to report the results of a large single-institution experience in the management of PE with a modified Nuss procedure in adults and to evaluate long-term outcomes and overall patient satisfaction after bar removal.
ince its introduction to the American Pediatric Surgical Association by Dr Nuss in 1997, minimally invasive repair of pectus excavatum (MIRPE), also known as the Nuss procedure [1], has revolutionized the management of pectus excavatum (PE). Likely because of the perception of the procedure as less invasive, the technique quickly gained popularity among physicians and patients, leading to a dramatic increase in demand for surgical correction of this condition by patients of all ages [2, 3]. Because the Nuss procedure is based on the premise that cartilage is malleable and that reconfiguration of the chest wall can be obtained by applying force from a convex metal bar against the depressed sternum, children and adolescents are considered the ideal candidates for this approach [4]. In adults, the Ravitch repair has traditionally been favored, largely because of the belief that the rigidity of the adult chest wall may prevent successful remodeling.
(Ann Thorac Surg 2016;-:-–-) Ó 2016 by The Society of Thoracic Surgeons
Patients and Methods Accepted for publication Sept 24, 2015. Address correspondence to Dr Colombani, Division of Pediatric Surgery, All Children’s Hospital Johns Hopkins Medicine, 601 5th St S, Ste 501, St. Petersburg, FL 33701; email: [email protected].
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Study Population After institutional review board approval, a retrospective review was performed to identify patients who 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.09.102
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Preoperative evaluation included clinical examination, cardiac evaluation, static or dynamic pulmonary function tests, and computed tomography scan. The indication for PE repair was a severe pectus deformity as defined by a Haller index greater than 3 on computed tomography scan imaging associated with at least one of the following conditions: symptoms related to impairment of cardiopulmonary function or body image issues.
depression more than 2.5 cm was considered a recurrence with indication for surgical revision. PATIENT SATISFACTION AND QUALITY-OF-LIFE ASSESSMENT. For long-term evaluation we used the single-step questionnaire, introduced by Krasopoulos and colleagues [14], with modifications to focus on the assessment of patient satisfaction with operative results after bar removal. Patients were contacted by mail and were called by telephone when the letter was returned to sender as undeliverable or unable to forward. Telephone interviews were performed by a research fellow who was not part of the surgical team and was blinded to patient characteristics and prior course. All participants received written information about the study and the assurance of confidentiality. The questionnaire consisted of 11 items (Table 1) that measured the following domains: general health perception/physical functioning, social belonging, chest pain/discomfort, and satisfaction.
Surgical Technique
Statistical Analysis
A modified Nuss procedure as previously described is routinely performed at our institution [12]. Briefly, two transverse inframammary incisions are performed at the level of the midclavicular line and extended for 3 to 4 cm laterally. The intercostal space approximately 1 cm above the lower point of the sternum is opened. The pleural space is opened, and the dissector is introduced through the left incision and carried out to the right side, without thoracoscopy. A precurved bar is placed beneath the sternum at the level of the fifth intercostal space, and in situ bar benders are used to conform the bar to the sidewalls of the chest. The bar is then stabilized with two stabilizers and wired to the anterior arch of the adjacent ribs (Fig 1). Intraoperatively, if one bar does not satisfactorily correct the deformity, a second bar is placed superiorly. In situations in which asymmetry persists after bar placement, limited cartilage resections are performed. The bar is left in place for 2 to 4 years. Bar removal is performed under general anesthesia as an outpatient procedure. Both incisions are reopened, and stabilizers and wires are removed. With the use of the bar benders the two ends of the bar are straightened, and the bar is then slid out posterior to the sternum.
A descriptive analysis was performed to examine patient demographic characteristics, comorbid disease, operative characteristics, and clinical outcomes. Descriptive statistics are presented as mean and standard deviation or median and range. The Wilcoxon rank sum test was used to assess improvement in social life and chest pain perception after PE repair. Multivariate analysis was used to identify risk predictors for prolonged chest pain and early bar removal. Statistical analysis were performed with SPSS for Mac, version 20 (IBM Corporation, Armonk, NY). A p value less than 0.05 was considered statistically significant.
underwent PE repair by a modified Nuss procedure at the Johns Hopkins Hospital from January 1998 through June 2011. Included in the analysis were adult patients aged 21 years or older who underwent primary PE repair. Excluded from the analysis were patients with any history of connective tissue disorders and recurrent PE and patients who underwent combined cardiothoracic procedures.
Preoperative Workup and Surgical Indications
Assessment of Long-Term Results CLINICAL EVALUATION. Patients were followed in outpatient clinic at 3 and 6 weeks after the operation and then on an annual basis and 6 and 12 months after bar removal to assess the durability of the cosmetic result. Results after bar removal were defined as satisfactory if the sternum was symmetric and uniformly elevated in neutral position. Unsatisfactory results were defined as recurrence, protrusion of the sternum consistent with reactive carinatum deformity, or presence of asymmetry between the left and right sides of the thorax. The residual depression of the sternum was quantified with the use of caliper measurements [13]; more than 1.5 cm but less than 2.5 cm was considered a mild recurrence, whereas a residual
Results Demographic and Operative Characteristics During the study period a total of 132 patients (age >21 years) with PE underwent Nuss repair at our institution. Excluded from the analysis were 21 patients who had surgical repair for recurrent PE after a failed Ravitch procedure, 5 patients with acquired Jeune syndrome who had a complex chest wall reconstruction, and 8 patients with associated connective tissue disorders, 2 of whom had a combined major cardiac procedure. A total of 98 patients met inclusion criteria. The median age at operation was 30.9 years (range, 21.8 to 55.1 years). All patients had a severe defect with a mean Haller index of 4.3 1.3. Most patients seeking PE repair were symptomatic, whereas a minority (6.1%) were referred only for cosmetic reasons. Comorbid conditions and preoperative symptoms are summarized in Tables 2 and 3. Mean operative time was 62.9 24.9 minutes. One bar was used in most patients; two bars were required in 10 patients (10.2%). After bar placement, cartilage resection was performed in 2 patients (2%) with asymmetric deformity. Immediately after introduction of the dissector, 1 patient (1%) experienced a ventricular arrhythmia. Defibrillation restored sinus rhythm. The patient had a prompt recovery without any sequelae, and pectus repair was delayed a few days.
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Fig 1. Modified Nuss procedure without thoracoscopy. (A and B) Left-to-right retrosternal dissection, (C) bar placement, and (D) bar turned 180 and fixed in correct position with lateral stabilizers and wire sutures at the adjacent rib. (Reprinted with permission from Tim Phelps/JHU/AAAM 2015, Department of Art as Applied to Medicine, The John Hopkins University School of Medicine.)
Table 1. Modified Single-Step Questionnaire and Median Values per Question Obtained Question Stem 1. Health in general after operation 2. Exercise capacity after operation 3. Extent that chest appearance interfere with social life before operation 4. Extent that chest appearance interfere with social activity after operation 5. Overall satisfaction with postoperative chest appearance 6. Bothered by surgical scars 7. Pain during hospital stay 8. Chest pain with bar in place 9. Pain (now) without bar 10. Overall satisfaction (cosmetic and functional) with final result 11. Going back, would you have the operation again
Scoring
Median
Much better now, 5; somewhat better now, 4; about the same, 3; somewhat worse now, 2; much worse now, 1 Much better now, 5; somewhat better now, 4; about the same, 3; somewhat worse now, 2; Much worse now, 1 Extremely, 5; quite a bit, 4; moderately, 3; slightly, 2; not at all, 1
4
4
Not at all, 5; slightly, 4; moderately, 3; quite a bit, 2; extremely, 1
4
Extremely satisfied, 5; very satisfied, 4; satisfied, 3; dissatisfied, 2; very dissatisfied, 1 Not at all, 5; very slightly, 4; slightly, 3; a little bit, 2; a lot, 1 None, 5; very mild, 4; mild, 3; moderate/severe, 2; very severe, 1 None, 5; very mild, 4; mild, 3; moderate/severe, 2; very severe, 1 None, 5; very mild, 4; mild, 4; moderate/severe, 2; very severe, 1 Extremely satisfied, 5; very satisfied, 4; satisfied, 3; dissatisfied, 2; very dissatisfied, 1 Yes, 10; unsure, 5; no, 0
4
4
4 2 2 5 4 10
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Table 2. Preoperative Characteristics of Patients (n ¼ 98) Variable Family history of PE/PC, n (%) Male, n (%) Age, years, mean SD Haller index (CT scan), mean SD Depth of defect, cm, mean SD MVP, n (%) Aortic root dilatation, n (%) Electrocardiogram abnormalities, n (%) Atrial fibrillation Left atrial abnormal early repolarization RBBB Ventricular arrhythmia First degree AV block T-wave abnormality Sinus bradycardia CAD, n (%) Scoliosis, n (%) Severe scoliosis required spinal fusion, n (%) Asthma, n (%) Depression, n (%) Preoperative symptoms, n (%) Dyspnea on exertion Dyspnea at rest Chest paina Discomfort/chest pressure/paresthesia Fatigue, decreased energy Palpitations Dysphagia a
Value 4 (4.1) 73 (74.5) 32.3 7.9 4.3 1.7 3.6 0.9 11 (11.2) 1 (1) 16 (17.2) 1 2 5 2 2 1 3 2 (2.0) 10 (10.2) 2 (2.0) 11 (11.2) 4 (4.1)
Table 3. Preoperative Pulmonary Function Tests of Patients (n ¼ 55) Static PFT Normal, n (%) FEV1, mean SD FEV1/FVC ratio, mean SD Obstructive pattern, n (%) FEV1, mean SD FEV1/FVC ratio, mean SD Restrictive pattern, n (%) FEV1, mean SD FVC, mean SD FEV1/FVC ratio, mean SD Combined obstructive and restrictive disease, n (%) FEV1, mean SD FVC, mean SD FEV1/FVC ratio, mean SD CP stress test,a n (%) Normal study Cardiovascular limitation to exercise Pulmonary limitation to exercise a
63 1 28 9 44 3 2
(64.3) (1.0) (28.6) (9.2) (44.9) (3.1) (2.0)
One patient experienced chronic chest pain, requiring methadone.
AV ¼ artrioventricular; CAD ¼ coronary artery disease; CT ¼ computed tomography; MVP ¼ mitral valve prolapse; PC ¼ pectus carinatum; PE ¼ pectus excavatum; RBBB ¼ right bundle branch block; SD ¼ standard deviation.
No situations of cardiac perforation occurred during our entire experience.
Postoperative Course and Complications No patients were admitted to the intensive care unit for postoperative monitoring. Postoperative pain was managed with intravenous patient-controlled analgesia in 96.9% (n ¼ 95) and with epidural analgesia in 3.1% (n ¼ 3) of patients, for a mean of 3.2 2.1 days. The mean length of hospital stay was 3.6 1.2 days, and 60.2% of patients (n ¼ 59) were discharged home within the third postoperative day. Early and late postoperative complications are summarized in Table 4. Notable major early complications included pulmonary embolism (n ¼ 1; 1%), pleural effusion that required drainage (n ¼ 1; 1%), and hemothorax (n ¼ 2; 2%). Bar displacement occurred in 4 patients (4.1%); in 3 patients (3%) the bar was replaced with a new one, whereas in 1 patient (1%) it was only manipulated and fixed in correct position without reopening the pleural space. Finally, 1 patient (1%) required the placement of a second bar for depression of
Values 13 (23.6) 97.2 12.4 80.4 4.2 17 (30.9) 82.9 6.2 76.7 5.0 18 (32.7) 73.8 13.8 72.7 12.2 87.5 4.3 5 (9.0) 74.1 19.4 77.3 14.6 73.8 5.2 9 (52.9) 6 (35.3) 2 (11.8)
n ¼ 17 patients.
CP ¼ cardiopulmonary; FEV1 ¼ forced expiratory volume at 1 second; FVC ¼ forced vital capacity; PFT ¼ pulmonary function test; SD ¼ standard deviation.
the upper part of the sternum. A total of 12 patients (12.2%) experienced prolonged chest pain that required opioid medication for more than 8 weeks after operation (Fig 2). Bar removal was anticipated because of uncontrolled chest pain in 4 patients (4.7%) and bar infection in 1 patient (1%).
Patient Satisfaction At the time of the analysis, 89 patients (90.8%) had undergone bar removal after a mean period of 32.9 16.9 months (Table 5). Eight patients (8.1%) were lost at follow-up and are presumed to have undergone bar removal in outside hospitals. One patient (1%), who refused bar removal, currently has the bar still in place 11 years after the surgical procedure. From the surgical point of view, overall results were considered satisfactory in 94.4% of patients. Recurrence that required reoperation occurred in 2 patients (2.2%). Of the 89 patients who had undergone bar removal, 39 patients (43.8%) responded to the survey (Table 6). Most patients stated that general health and exercise tolerance were improved after the operation, and 89.7% (35 of 39 patients) noted a subjective improvement in their chest wall appearance, with improvement in social interaction reported by 84.6 % of responders (33 of 39). High levels of overall satisfaction were reported after Nuss repair, with 82% of patients (32 of 39) being either satisfied or very satisfied. Overall, 79.5% of patients (31 of 39) stated that they would have the operation again. Five patients (12.8%) would have chosen the Ravitch procedure instead, because of severe
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Table 4. Postoperative Complications of Patients (n ¼ 98) Complications, n (%) Pneumothorax Required chest tube Pleural effusion Required chest tube Pneumonia Hemothorax Pericarditis Pulmonary embolism Wound infection Wound drainage, noninfectious/seroma Allergic reaction Reoperation Bar displacement Placement of a second bar Prolonged chest paina
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SACCO CASAMASSIMA ET AL PATIENT SATISFACTION AFTER MIRPE IN ADULTS
Values 11 (11.2) . 8 (8.2) 1 (1.0) 2 (2.0) 2 (2.0) . 1 (1.0) 10 (10.2) 3 (3.1) 2 (2.0) 5 (5.1) 4 (4.1) 1 (1.0) 12 (12.2)
a
Defined as pain requiring narcotics for more than 8 weeks postoperatively.
chest pain that required analgesic medication for several months after the operation. One patient (1%) noted troublesome awareness of the bar for 2 years. In multivariate analysis female sex was identified as an independent predictor for prolonged chest pain, whereas no statistically significant patient or procedural factors predictive for need to anticipate bar removal were identified (Table 7).
Comment The present study is one of the largest single-institution experiences to investigate quality of life and patient satisfaction in adults after Nuss repair for PE. Our experience supports the contention that the Nuss procedure is effective in the adult population. The rate of recurrence reported herein is comparable with that reported in pediatric series [15, 16], and respondents to the survey expressed high levels of satisfaction in terms of self-image and quality of life. On the basis of their positive experience most patients felt confident in recommending this procedure to others. Our analysis has shown that
Fig 2. Postoperative need for pain medication. (NSAID ¼ nonsteroidal anti-inflammatory drug.)
Table 5. Follow-Up Information and Results After Bar Removal of Patients (n ¼ 98) Characteristic Bar removal, n (%) Bar removal <18 months, n (%) Persistent chest pain Bar infection Chronic wound infection Results after bar removal, n (%) Satisfactory cosmetic and functional results Recurrence requiring reoperation Mild recurrence (depth of defect >1.5 and <2.5 cm) Residual carinatum deformity (indication at external bracing)a a
Value 89 6 4 1 1
(90.8) (6.1) (4.15) (1.0) (1.0)
84 (94.4) 2 (2.2) 2 (2.2) 1 (1.1)
Asymmetric pectus excavatum.
indications for surgical repair of PE in adults are similar to those reported in pediatric patients [17, 18]. Because of differences in costal cartilage flexibility, there is a biomechanical disadvantage in performing the Nuss procedure in adults [19–21]. Previous studies have reported a linear relation between age-related rigidity and the elevating force needed to raise the depressed sternum. The estimated elevating force needed to elevate the sternum in children younger than 11 years is approximately 68 N and in adults is approximately 200 N [21–23]. The stress that occurs on the thorax after the Nuss procedure results in different patterns between children and adults in terms of intensity and distribution [20]. Although in children greater stress occurs on the rib supporting the bar, in adults, because of the costal cartilages are less likely to bend, the stress occurs over a wide range of ribs [20, 23]. As a consequence of differences in intensity and distribution of the mechanical forces that interact to reshape the chest wall, it is reasonable to expect less favorable outcomes in terms of operative time, rates of morbidity, postoperative pain control, and reconfiguration of the chest wall after the Nuss procedure in adults. In experienced hands, the modified Nuss technique without thoracoscopy can be safely accomplished in adults with operative time comparable with that in children [8]. In our series, the median duration of the Nuss procedure was 58 minutes (range, 31 to 150 minutes), which compares favorably with that reported in pediatric series [12, 16]. The use of the left-to-right approach without thoracoscopy allows us to shorten the operative time of approximately 20 minutes. However, for surgeons who are not familiar with this approach, the thoracoscopic visualization of the mediastinum or the use of the subxiphoid incision may help to improve safety during retrosternal dissection. Another factor that may affect the duration of the operation is the number of bars placed. Most surgeons who perform MIRPE in adults agree that the double-bar application in a lessflexible thorax would favor a more-effective remodeling of the chest wall. In adult series of MIRPE, two bars are
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Table 6. Impact of Operation on Quality of Life of Responders (n ¼ 39) Survey Question
Response
Change after operation Health in general Exercise capacity
Much worse
Worse
Same
Better
Much better
. .
2 (5.1) .
9 (23.0) 10 (25.6)
13 (33.3) 12 (30.8)
15 (38.5) 17 (43.6)
Impact of PE on social life
Not at all
Slightly
Moderately
Quite a bit
Extremely
Preoperative negative social impact Postoperative social impact
2 (5.1)
4 (10.3)
8 (20.5)
12 (30.8)
13 (33.3)
19 (48.7)
13 (33.3)
5 (12.8)
2 (5.1)
.
Pain after operation a
Pain in hospital Pain with bar place Persistent pain after bar removal
None
Mild
Moderate/severe
Very severe
2 (5.1) 2 (5.1) 33 (84.6)
4 (10.3) 12 (30.8) 5 (12.8)
23 (58.9) 21 (53.8) 2 (5.1)
10 (25.6) 4 (10.3) .
p Value .
<0.001
0.006 <0.001
Satisfaction with final results
Satisfied
Dissatisfied
Satisfaction with appearance Overall satisfaction
35 (89.7) 32 (82.0)
4 (10.3) 7 (17.9)
a
Pain during hospital stay at the time of Nuss operation.
Values are n (%) unless otherwise indicated. PE ¼ pectus excavatum.
used in 16% to 70% of patients [2, 6, 24]. Moreover, the double-bar application, which distributes the dynamic forces at multiple thoracic levels, has been proposed to be effective in reducing postoperative pain [25]. In contrast to this observation, in our experience patients in whom two bars were placed experienced more pain and wound troubles. We therefore believe that a satisfactory
remodeling of the chest wall can be achieved in most patients with a single bar. Intraoperative complications are not reported in adult series of PE repair [7, 8, 24]. In our experience we observed one intraoperative complication. Pulseless ventricular arrhythmia that required a single electrical cardioversion occurred during the operation in 1 patient
Table 7. Risk Factors Associated With Chest Pain and Need for Anticipated Bar Removal Prolonged Chest Pain Factors Preoperative chest pain No Yes Haller index 5 >5 No. of bars placed 1 2 Age Sex Male Female Scoliosis No Yes a
Odds ratio (CI)
Odds ratio (CI)
p Value
Ref 1.616 (0.554–4.718)
0.380
Ref 4.014 (0.269–59.978)
0.314
Ref 0.264 (0.025–2.800)
0.269
Ref 9.744 (0.363–261.366)
0.175
Ref 1.505 (0.322–7.039) 1.034 (0.975–1.097)
0.603 0.261
Ref 2.857 (0.164–49.693) 1.042 (0.900–1.206)
0.471 0.582
Ref 5.205 (1.786–15.172)
0.003
Ref 6.123 (0.462–81.210)
0.169
Ref 0.935 (0.174–5.000)
0.937
Dropped from the model because of collinearity.
CI ¼ confidence interval;
p Value
Intractable Pain That Required Early Bar Removal
Ref ¼ referent.
Refa
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without a past medical history of cardiovascular disease. Because sporadic cases of this complication are reported during both Ravitch and Nuss repairs [3, 26], whether this intraoperative ventricular arrhythmia is attributable to technical, patient, or anesthesia related factors remains unclear. Similar to previous studies [2, 5, 27, 28] we found an increased rate of early postoperative complications in adults compared with children and adolescents. Some of these complications, including pulmonary embolism, are generally not observed in pediatric patients and are not thought to be related to a specific procedure. One of the most common early complications reported in adult series of Nuss repair is pleural effusion [6, 7]. Cheng and colleagues [6] attribute the increased rate of pleural effusion to the presence of pleural and mediastinal adhesions and aberrant vessels detected during thoracoscopic Nuss in 9.4% of their adult patients. In our experience this complication occurred in 8.2% of patients; however, the effusion resolved in all but 1 patient spontaneously. An increased rate of bar displacement in adults has been reported by several investigators who compared results among age groups [10, 27–29]. In our experience bar displacement occurred in 4 patients (4.1%). Inadequate bar fixation contributed to bar shift in 2 patients, both of whom underwent repair during our early experience when no lateral stabilizers were used to secure the bar. The degree of postoperative pain after MIRPE has been shown to be the overriding factor in the patient’s perception of the quality of the postoperative course. A linear correlation between patient’s age and postoperative morphine consumption was reported in a study by Grosen and colleagues [30] that compared postoperative pain control in children and adults after MIRPE [30]. Moreover, the investigators found that 55% of patients older than 20 years complained of chest pain six months after the operation. Moderate-severe prolonged chest pain was the main complaint in this study. In our experience, we observed that a greater proportion of adults required prolonged use of oral narcotic medications than pediatric patients (12.2 % versus 3.6%, respectively) [12]. Although most patients were satisfied with the final cosmetic result, pain perception interfered with overall satisfaction and their willingness to undergo the operation again. Improvement in cosmetic appearance and health in general did not translate in all patients in an improvement in social life. This study is limited by its retrospective nature and by the small sample size, limiting our ability to draw generalized conclusions. Moreover, not all patients who underwent Nuss repair responded to the survey. Despite this limitation, this study is one of the largest experiences with the longest follow-up of adult patients who have undergone PE repair with the Nuss procedure and provides evidence of the durability of chest wall remodeling after bar removal in this specific population. In conclusion, although Nuss repair may be more challenging in adults in terms of postoperative pain
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control, the procedure ensures a satisfactory reconfiguration of the chest wall comparable with that achieved in pediatric patients.
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results in different patterns between adult and child patients. J Thorac Cardiovasc Surg 2007;134:1502–7. Weber PG, Huemmer HP, Reingruber B. Forces to be overcome in correction of pectus excavatum. J Thorac Cardiovasc Surg 2006;132:1369–73. Chang PY, Hsu ZY, Chen DP, Lai JY, Wang CJ. Preliminary analysis of the forces on the thoracic cage of patients with pectus excavatum after the Nuss procedure. Clin Biomech (Bristol, Avon) 2008;23:881–5. Nagasao T, Miyamoto J, Ichihara K, Jiang H, Jin H, Tamaki T. Age-related change of postoperative pain location after Nuss procedure for pectus excavatum. Eur J Cardiothorac Surg 2010;38:203–8. Hanna WC, Ko MA, Blitz M, Shargall Y, Compeau CG. Thoracoscopic Nuss procedure for young adults with pectus excavatum: excellent midterm results and patient satisfaction. Ann Thorac Surg 2013;96:1033–6; discussion 1037–8. Nagaso T, Miyamoto J, Kokaji K, et al. Double-bar application decreases postoperative pain after the Nuss procedure. J Thorac Cardiovasc Surg 2010;140:39–44; 44.e1–2.
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26. Redlinger RE Jr, Kelly RE Jr, 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. 27. 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. 28. 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. 29. Uemura S, Nakagawa Y, Yoshida A, Choda Y. Experience in 100 cases with the Nuss procedure using a technique for stabilization of the pectus bar. Pediatr Surg Int 2003;19:186–9. 30. Grosen K, Pfeiffer-Jensen M, Pilegaard HK. Postoperative consumption of opioid analgesics following correction of pectus excavatum is influenced by pectus severity: a singlecentre study of 236 patients undergoing minimally invasive correction of pectus excavatum. Eur J Cardiothorac Surg 2010;37:833–9.
Background. Extensive literature has proved that the Nuss procedure leads to permanent remodeling of the chest wall in pediatric patients with pectus excavatum (PE). However, limited long-term follow-up data are available for adults. Herein, we report a single-institution experience in the management of adult PE with the Nuss procedure, evaluating long-term outcomes and overall patient satisfaction after bar removal. Methods. Adult patients who underwent PE repair with a modified Nuss procedure between January 1998 and June 2011 were retrospectively identified. Outcomes of interest were postoperative pain, recurrence, and patient satisfaction. A modified single-step Nuss questionnaire was administered to evaluate patient satisfaction and quality-of-life improvement after PE repair. Results. Ninety-eight patients with a median age of 30.9 years (range, 21.8 to 55.1 years) at the time of repair were identified. One bar was placed in most patients
(89.7%). Four patients (4.1%) required reoperation for bar displacement. Results after bar removal were overall satisfactory in 94.4% of patients; 2 patients required reoperation for recurrence. Thirty-nine patients participated in the survey. Satisfaction with chest appearance was reported by 89.7% of responders. Seven patients reported dissatisfaction with the overall results; the most common complaints were severe postoperative chest pain and dissatisfaction with surgical scars. Conclusions. Favorable long-term results can be achieved with the Nuss procedure in adults. However, postoperative pain may require a more aggressive analgesic regimen, and it may be the overriding factor in the patient’s perception of the quality of the postoperative course.
S
This notion has been challenged by Coln and colleagues [5], who reported encouraging early results after Nuss repair in a series of 14 adults. Evidence of safety of the Nuss procedure in adults has been provided by other retrospective series [2, 6–9]; however, to date, limited data exist to support the improvement in cosmetic appearance persists after bar removal [7, 8, 10, 11]. Because the number of adults presenting for PE repair continues to increase, more robust evidence is needed about the safety and effectiveness of the Nuss procedure in this specific patient population to assist surgeons in counseling adults about its risks and benefits. The present study aims to report the results of a large single-institution experience in the management of PE with a modified Nuss procedure in adults and to evaluate long-term outcomes and overall patient satisfaction after bar removal.
ince its introduction to the American Pediatric Surgical Association by Dr Nuss in 1997, minimally invasive repair of pectus excavatum (MIRPE), also known as the Nuss procedure [1], has revolutionized the management of pectus excavatum (PE). Likely because of the perception of the procedure as less invasive, the technique quickly gained popularity among physicians and patients, leading to a dramatic increase in demand for surgical correction of this condition by patients of all ages [2, 3]. Because the Nuss procedure is based on the premise that cartilage is malleable and that reconfiguration of the chest wall can be obtained by applying force from a convex metal bar against the depressed sternum, children and adolescents are considered the ideal candidates for this approach [4]. In adults, the Ravitch repair has traditionally been favored, largely because of the belief that the rigidity of the adult chest wall may prevent successful remodeling.
(Ann Thorac Surg 2016;-:-–-) Ó 2016 by The Society of Thoracic Surgeons
Patients and Methods Accepted for publication Sept 24, 2015. Address correspondence to Dr Colombani, Division of Pediatric Surgery, All Children’s Hospital Johns Hopkins Medicine, 601 5th St S, Ste 501, St. Petersburg, FL 33701; email: [email protected].
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Study Population After institutional review board approval, a retrospective review was performed to identify patients who 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.09.102
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Preoperative evaluation included clinical examination, cardiac evaluation, static or dynamic pulmonary function tests, and computed tomography scan. The indication for PE repair was a severe pectus deformity as defined by a Haller index greater than 3 on computed tomography scan imaging associated with at least one of the following conditions: symptoms related to impairment of cardiopulmonary function or body image issues.
depression more than 2.5 cm was considered a recurrence with indication for surgical revision. PATIENT SATISFACTION AND QUALITY-OF-LIFE ASSESSMENT. For long-term evaluation we used the single-step questionnaire, introduced by Krasopoulos and colleagues [14], with modifications to focus on the assessment of patient satisfaction with operative results after bar removal. Patients were contacted by mail and were called by telephone when the letter was returned to sender as undeliverable or unable to forward. Telephone interviews were performed by a research fellow who was not part of the surgical team and was blinded to patient characteristics and prior course. All participants received written information about the study and the assurance of confidentiality. The questionnaire consisted of 11 items (Table 1) that measured the following domains: general health perception/physical functioning, social belonging, chest pain/discomfort, and satisfaction.
Surgical Technique
Statistical Analysis
A modified Nuss procedure as previously described is routinely performed at our institution [12]. Briefly, two transverse inframammary incisions are performed at the level of the midclavicular line and extended for 3 to 4 cm laterally. The intercostal space approximately 1 cm above the lower point of the sternum is opened. The pleural space is opened, and the dissector is introduced through the left incision and carried out to the right side, without thoracoscopy. A precurved bar is placed beneath the sternum at the level of the fifth intercostal space, and in situ bar benders are used to conform the bar to the sidewalls of the chest. The bar is then stabilized with two stabilizers and wired to the anterior arch of the adjacent ribs (Fig 1). Intraoperatively, if one bar does not satisfactorily correct the deformity, a second bar is placed superiorly. In situations in which asymmetry persists after bar placement, limited cartilage resections are performed. The bar is left in place for 2 to 4 years. Bar removal is performed under general anesthesia as an outpatient procedure. Both incisions are reopened, and stabilizers and wires are removed. With the use of the bar benders the two ends of the bar are straightened, and the bar is then slid out posterior to the sternum.
A descriptive analysis was performed to examine patient demographic characteristics, comorbid disease, operative characteristics, and clinical outcomes. Descriptive statistics are presented as mean and standard deviation or median and range. The Wilcoxon rank sum test was used to assess improvement in social life and chest pain perception after PE repair. Multivariate analysis was used to identify risk predictors for prolonged chest pain and early bar removal. Statistical analysis were performed with SPSS for Mac, version 20 (IBM Corporation, Armonk, NY). A p value less than 0.05 was considered statistically significant.
underwent PE repair by a modified Nuss procedure at the Johns Hopkins Hospital from January 1998 through June 2011. Included in the analysis were adult patients aged 21 years or older who underwent primary PE repair. Excluded from the analysis were patients with any history of connective tissue disorders and recurrent PE and patients who underwent combined cardiothoracic procedures.
Preoperative Workup and Surgical Indications
Assessment of Long-Term Results CLINICAL EVALUATION. Patients were followed in outpatient clinic at 3 and 6 weeks after the operation and then on an annual basis and 6 and 12 months after bar removal to assess the durability of the cosmetic result. Results after bar removal were defined as satisfactory if the sternum was symmetric and uniformly elevated in neutral position. Unsatisfactory results were defined as recurrence, protrusion of the sternum consistent with reactive carinatum deformity, or presence of asymmetry between the left and right sides of the thorax. The residual depression of the sternum was quantified with the use of caliper measurements [13]; more than 1.5 cm but less than 2.5 cm was considered a mild recurrence, whereas a residual
Results Demographic and Operative Characteristics During the study period a total of 132 patients (age >21 years) with PE underwent Nuss repair at our institution. Excluded from the analysis were 21 patients who had surgical repair for recurrent PE after a failed Ravitch procedure, 5 patients with acquired Jeune syndrome who had a complex chest wall reconstruction, and 8 patients with associated connective tissue disorders, 2 of whom had a combined major cardiac procedure. A total of 98 patients met inclusion criteria. The median age at operation was 30.9 years (range, 21.8 to 55.1 years). All patients had a severe defect with a mean Haller index of 4.3 1.3. Most patients seeking PE repair were symptomatic, whereas a minority (6.1%) were referred only for cosmetic reasons. Comorbid conditions and preoperative symptoms are summarized in Tables 2 and 3. Mean operative time was 62.9 24.9 minutes. One bar was used in most patients; two bars were required in 10 patients (10.2%). After bar placement, cartilage resection was performed in 2 patients (2%) with asymmetric deformity. Immediately after introduction of the dissector, 1 patient (1%) experienced a ventricular arrhythmia. Defibrillation restored sinus rhythm. The patient had a prompt recovery without any sequelae, and pectus repair was delayed a few days.
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SACCO CASAMASSIMA ET AL PATIENT SATISFACTION AFTER MIRPE IN ADULTS
Fig 1. Modified Nuss procedure without thoracoscopy. (A and B) Left-to-right retrosternal dissection, (C) bar placement, and (D) bar turned 180 and fixed in correct position with lateral stabilizers and wire sutures at the adjacent rib. (Reprinted with permission from Tim Phelps/JHU/AAAM 2015, Department of Art as Applied to Medicine, The John Hopkins University School of Medicine.)
Table 1. Modified Single-Step Questionnaire and Median Values per Question Obtained Question Stem 1. Health in general after operation 2. Exercise capacity after operation 3. Extent that chest appearance interfere with social life before operation 4. Extent that chest appearance interfere with social activity after operation 5. Overall satisfaction with postoperative chest appearance 6. Bothered by surgical scars 7. Pain during hospital stay 8. Chest pain with bar in place 9. Pain (now) without bar 10. Overall satisfaction (cosmetic and functional) with final result 11. Going back, would you have the operation again
Scoring
Median
Much better now, 5; somewhat better now, 4; about the same, 3; somewhat worse now, 2; much worse now, 1 Much better now, 5; somewhat better now, 4; about the same, 3; somewhat worse now, 2; Much worse now, 1 Extremely, 5; quite a bit, 4; moderately, 3; slightly, 2; not at all, 1
4
4
Not at all, 5; slightly, 4; moderately, 3; quite a bit, 2; extremely, 1
4
Extremely satisfied, 5; very satisfied, 4; satisfied, 3; dissatisfied, 2; very dissatisfied, 1 Not at all, 5; very slightly, 4; slightly, 3; a little bit, 2; a lot, 1 None, 5; very mild, 4; mild, 3; moderate/severe, 2; very severe, 1 None, 5; very mild, 4; mild, 3; moderate/severe, 2; very severe, 1 None, 5; very mild, 4; mild, 4; moderate/severe, 2; very severe, 1 Extremely satisfied, 5; very satisfied, 4; satisfied, 3; dissatisfied, 2; very dissatisfied, 1 Yes, 10; unsure, 5; no, 0
4
4
4 2 2 5 4 10
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Table 2. Preoperative Characteristics of Patients (n ¼ 98) Variable Family history of PE/PC, n (%) Male, n (%) Age, years, mean SD Haller index (CT scan), mean SD Depth of defect, cm, mean SD MVP, n (%) Aortic root dilatation, n (%) Electrocardiogram abnormalities, n (%) Atrial fibrillation Left atrial abnormal early repolarization RBBB Ventricular arrhythmia First degree AV block T-wave abnormality Sinus bradycardia CAD, n (%) Scoliosis, n (%) Severe scoliosis required spinal fusion, n (%) Asthma, n (%) Depression, n (%) Preoperative symptoms, n (%) Dyspnea on exertion Dyspnea at rest Chest paina Discomfort/chest pressure/paresthesia Fatigue, decreased energy Palpitations Dysphagia a
Value 4 (4.1) 73 (74.5) 32.3 7.9 4.3 1.7 3.6 0.9 11 (11.2) 1 (1) 16 (17.2) 1 2 5 2 2 1 3 2 (2.0) 10 (10.2) 2 (2.0) 11 (11.2) 4 (4.1)
Table 3. Preoperative Pulmonary Function Tests of Patients (n ¼ 55) Static PFT Normal, n (%) FEV1, mean SD FEV1/FVC ratio, mean SD Obstructive pattern, n (%) FEV1, mean SD FEV1/FVC ratio, mean SD Restrictive pattern, n (%) FEV1, mean SD FVC, mean SD FEV1/FVC ratio, mean SD Combined obstructive and restrictive disease, n (%) FEV1, mean SD FVC, mean SD FEV1/FVC ratio, mean SD CP stress test,a n (%) Normal study Cardiovascular limitation to exercise Pulmonary limitation to exercise a
63 1 28 9 44 3 2
(64.3) (1.0) (28.6) (9.2) (44.9) (3.1) (2.0)
One patient experienced chronic chest pain, requiring methadone.
AV ¼ artrioventricular; CAD ¼ coronary artery disease; CT ¼ computed tomography; MVP ¼ mitral valve prolapse; PC ¼ pectus carinatum; PE ¼ pectus excavatum; RBBB ¼ right bundle branch block; SD ¼ standard deviation.
No situations of cardiac perforation occurred during our entire experience.
Postoperative Course and Complications No patients were admitted to the intensive care unit for postoperative monitoring. Postoperative pain was managed with intravenous patient-controlled analgesia in 96.9% (n ¼ 95) and with epidural analgesia in 3.1% (n ¼ 3) of patients, for a mean of 3.2 2.1 days. The mean length of hospital stay was 3.6 1.2 days, and 60.2% of patients (n ¼ 59) were discharged home within the third postoperative day. Early and late postoperative complications are summarized in Table 4. Notable major early complications included pulmonary embolism (n ¼ 1; 1%), pleural effusion that required drainage (n ¼ 1; 1%), and hemothorax (n ¼ 2; 2%). Bar displacement occurred in 4 patients (4.1%); in 3 patients (3%) the bar was replaced with a new one, whereas in 1 patient (1%) it was only manipulated and fixed in correct position without reopening the pleural space. Finally, 1 patient (1%) required the placement of a second bar for depression of
Values 13 (23.6) 97.2 12.4 80.4 4.2 17 (30.9) 82.9 6.2 76.7 5.0 18 (32.7) 73.8 13.8 72.7 12.2 87.5 4.3 5 (9.0) 74.1 19.4 77.3 14.6 73.8 5.2 9 (52.9) 6 (35.3) 2 (11.8)
n ¼ 17 patients.
CP ¼ cardiopulmonary; FEV1 ¼ forced expiratory volume at 1 second; FVC ¼ forced vital capacity; PFT ¼ pulmonary function test; SD ¼ standard deviation.
the upper part of the sternum. A total of 12 patients (12.2%) experienced prolonged chest pain that required opioid medication for more than 8 weeks after operation (Fig 2). Bar removal was anticipated because of uncontrolled chest pain in 4 patients (4.7%) and bar infection in 1 patient (1%).
Patient Satisfaction At the time of the analysis, 89 patients (90.8%) had undergone bar removal after a mean period of 32.9 16.9 months (Table 5). Eight patients (8.1%) were lost at follow-up and are presumed to have undergone bar removal in outside hospitals. One patient (1%), who refused bar removal, currently has the bar still in place 11 years after the surgical procedure. From the surgical point of view, overall results were considered satisfactory in 94.4% of patients. Recurrence that required reoperation occurred in 2 patients (2.2%). Of the 89 patients who had undergone bar removal, 39 patients (43.8%) responded to the survey (Table 6). Most patients stated that general health and exercise tolerance were improved after the operation, and 89.7% (35 of 39 patients) noted a subjective improvement in their chest wall appearance, with improvement in social interaction reported by 84.6 % of responders (33 of 39). High levels of overall satisfaction were reported after Nuss repair, with 82% of patients (32 of 39) being either satisfied or very satisfied. Overall, 79.5% of patients (31 of 39) stated that they would have the operation again. Five patients (12.8%) would have chosen the Ravitch procedure instead, because of severe
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Table 4. Postoperative Complications of Patients (n ¼ 98) Complications, n (%) Pneumothorax Required chest tube Pleural effusion Required chest tube Pneumonia Hemothorax Pericarditis Pulmonary embolism Wound infection Wound drainage, noninfectious/seroma Allergic reaction Reoperation Bar displacement Placement of a second bar Prolonged chest paina
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SACCO CASAMASSIMA ET AL PATIENT SATISFACTION AFTER MIRPE IN ADULTS
Values 11 (11.2) . 8 (8.2) 1 (1.0) 2 (2.0) 2 (2.0) . 1 (1.0) 10 (10.2) 3 (3.1) 2 (2.0) 5 (5.1) 4 (4.1) 1 (1.0) 12 (12.2)
a
Defined as pain requiring narcotics for more than 8 weeks postoperatively.
chest pain that required analgesic medication for several months after the operation. One patient (1%) noted troublesome awareness of the bar for 2 years. In multivariate analysis female sex was identified as an independent predictor for prolonged chest pain, whereas no statistically significant patient or procedural factors predictive for need to anticipate bar removal were identified (Table 7).
Comment The present study is one of the largest single-institution experiences to investigate quality of life and patient satisfaction in adults after Nuss repair for PE. Our experience supports the contention that the Nuss procedure is effective in the adult population. The rate of recurrence reported herein is comparable with that reported in pediatric series [15, 16], and respondents to the survey expressed high levels of satisfaction in terms of self-image and quality of life. On the basis of their positive experience most patients felt confident in recommending this procedure to others. Our analysis has shown that
Fig 2. Postoperative need for pain medication. (NSAID ¼ nonsteroidal anti-inflammatory drug.)
Table 5. Follow-Up Information and Results After Bar Removal of Patients (n ¼ 98) Characteristic Bar removal, n (%) Bar removal <18 months, n (%) Persistent chest pain Bar infection Chronic wound infection Results after bar removal, n (%) Satisfactory cosmetic and functional results Recurrence requiring reoperation Mild recurrence (depth of defect >1.5 and <2.5 cm) Residual carinatum deformity (indication at external bracing)a a
Value 89 6 4 1 1
(90.8) (6.1) (4.15) (1.0) (1.0)
84 (94.4) 2 (2.2) 2 (2.2) 1 (1.1)
Asymmetric pectus excavatum.
indications for surgical repair of PE in adults are similar to those reported in pediatric patients [17, 18]. Because of differences in costal cartilage flexibility, there is a biomechanical disadvantage in performing the Nuss procedure in adults [19–21]. Previous studies have reported a linear relation between age-related rigidity and the elevating force needed to raise the depressed sternum. The estimated elevating force needed to elevate the sternum in children younger than 11 years is approximately 68 N and in adults is approximately 200 N [21–23]. The stress that occurs on the thorax after the Nuss procedure results in different patterns between children and adults in terms of intensity and distribution [20]. Although in children greater stress occurs on the rib supporting the bar, in adults, because of the costal cartilages are less likely to bend, the stress occurs over a wide range of ribs [20, 23]. As a consequence of differences in intensity and distribution of the mechanical forces that interact to reshape the chest wall, it is reasonable to expect less favorable outcomes in terms of operative time, rates of morbidity, postoperative pain control, and reconfiguration of the chest wall after the Nuss procedure in adults. In experienced hands, the modified Nuss technique without thoracoscopy can be safely accomplished in adults with operative time comparable with that in children [8]. In our series, the median duration of the Nuss procedure was 58 minutes (range, 31 to 150 minutes), which compares favorably with that reported in pediatric series [12, 16]. The use of the left-to-right approach without thoracoscopy allows us to shorten the operative time of approximately 20 minutes. However, for surgeons who are not familiar with this approach, the thoracoscopic visualization of the mediastinum or the use of the subxiphoid incision may help to improve safety during retrosternal dissection. Another factor that may affect the duration of the operation is the number of bars placed. Most surgeons who perform MIRPE in adults agree that the double-bar application in a lessflexible thorax would favor a more-effective remodeling of the chest wall. In adult series of MIRPE, two bars are
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Table 6. Impact of Operation on Quality of Life of Responders (n ¼ 39) Survey Question
Response
Change after operation Health in general Exercise capacity
Much worse
Worse
Same
Better
Much better
. .
2 (5.1) .
9 (23.0) 10 (25.6)
13 (33.3) 12 (30.8)
15 (38.5) 17 (43.6)
Impact of PE on social life
Not at all
Slightly
Moderately
Quite a bit
Extremely
Preoperative negative social impact Postoperative social impact
2 (5.1)
4 (10.3)
8 (20.5)
12 (30.8)
13 (33.3)
19 (48.7)
13 (33.3)
5 (12.8)
2 (5.1)
.
Pain after operation a
Pain in hospital Pain with bar place Persistent pain after bar removal
None
Mild
Moderate/severe
Very severe
2 (5.1) 2 (5.1) 33 (84.6)
4 (10.3) 12 (30.8) 5 (12.8)
23 (58.9) 21 (53.8) 2 (5.1)
10 (25.6) 4 (10.3) .
p Value .
<0.001
0.006 <0.001
Satisfaction with final results
Satisfied
Dissatisfied
Satisfaction with appearance Overall satisfaction
35 (89.7) 32 (82.0)
4 (10.3) 7 (17.9)
a
Pain during hospital stay at the time of Nuss operation.
Values are n (%) unless otherwise indicated. PE ¼ pectus excavatum.
used in 16% to 70% of patients [2, 6, 24]. Moreover, the double-bar application, which distributes the dynamic forces at multiple thoracic levels, has been proposed to be effective in reducing postoperative pain [25]. In contrast to this observation, in our experience patients in whom two bars were placed experienced more pain and wound troubles. We therefore believe that a satisfactory
remodeling of the chest wall can be achieved in most patients with a single bar. Intraoperative complications are not reported in adult series of PE repair [7, 8, 24]. In our experience we observed one intraoperative complication. Pulseless ventricular arrhythmia that required a single electrical cardioversion occurred during the operation in 1 patient
Table 7. Risk Factors Associated With Chest Pain and Need for Anticipated Bar Removal Prolonged Chest Pain Factors Preoperative chest pain No Yes Haller index 5 >5 No. of bars placed 1 2 Age Sex Male Female Scoliosis No Yes a
Odds ratio (CI)
Odds ratio (CI)
p Value
Ref 1.616 (0.554–4.718)
0.380
Ref 4.014 (0.269–59.978)
0.314
Ref 0.264 (0.025–2.800)
0.269
Ref 9.744 (0.363–261.366)
0.175
Ref 1.505 (0.322–7.039) 1.034 (0.975–1.097)
0.603 0.261
Ref 2.857 (0.164–49.693) 1.042 (0.900–1.206)
0.471 0.582
Ref 5.205 (1.786–15.172)
0.003
Ref 6.123 (0.462–81.210)
0.169
Ref 0.935 (0.174–5.000)
0.937
Dropped from the model because of collinearity.
CI ¼ confidence interval;
p Value
Intractable Pain That Required Early Bar Removal
Ref ¼ referent.
Refa
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without a past medical history of cardiovascular disease. Because sporadic cases of this complication are reported during both Ravitch and Nuss repairs [3, 26], whether this intraoperative ventricular arrhythmia is attributable to technical, patient, or anesthesia related factors remains unclear. Similar to previous studies [2, 5, 27, 28] we found an increased rate of early postoperative complications in adults compared with children and adolescents. Some of these complications, including pulmonary embolism, are generally not observed in pediatric patients and are not thought to be related to a specific procedure. One of the most common early complications reported in adult series of Nuss repair is pleural effusion [6, 7]. Cheng and colleagues [6] attribute the increased rate of pleural effusion to the presence of pleural and mediastinal adhesions and aberrant vessels detected during thoracoscopic Nuss in 9.4% of their adult patients. In our experience this complication occurred in 8.2% of patients; however, the effusion resolved in all but 1 patient spontaneously. An increased rate of bar displacement in adults has been reported by several investigators who compared results among age groups [10, 27–29]. In our experience bar displacement occurred in 4 patients (4.1%). Inadequate bar fixation contributed to bar shift in 2 patients, both of whom underwent repair during our early experience when no lateral stabilizers were used to secure the bar. The degree of postoperative pain after MIRPE has been shown to be the overriding factor in the patient’s perception of the quality of the postoperative course. A linear correlation between patient’s age and postoperative morphine consumption was reported in a study by Grosen and colleagues [30] that compared postoperative pain control in children and adults after MIRPE [30]. Moreover, the investigators found that 55% of patients older than 20 years complained of chest pain six months after the operation. Moderate-severe prolonged chest pain was the main complaint in this study. In our experience, we observed that a greater proportion of adults required prolonged use of oral narcotic medications than pediatric patients (12.2 % versus 3.6%, respectively) [12]. Although most patients were satisfied with the final cosmetic result, pain perception interfered with overall satisfaction and their willingness to undergo the operation again. Improvement in cosmetic appearance and health in general did not translate in all patients in an improvement in social life. This study is limited by its retrospective nature and by the small sample size, limiting our ability to draw generalized conclusions. Moreover, not all patients who underwent Nuss repair responded to the survey. Despite this limitation, this study is one of the largest experiences with the longest follow-up of adult patients who have undergone PE repair with the Nuss procedure and provides evidence of the durability of chest wall remodeling after bar removal in this specific population. In conclusion, although Nuss repair may be more challenging in adults in terms of postoperative pain
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control, the procedure ensures a satisfactory reconfiguration of the chest wall comparable with that achieved in pediatric patients.
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