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Eur J Pediatr Surg 2018; 28(04): 320-326
DOI: 10.1055/s-0038-1670690
Review Article
Georg Thieme Verlag KG Stuttgart · New York

Minor and Major Complications Related to Minimally Invasive Repair of Pectus Excavatum

Andre Hebra
1   Department of Surgery, Nemours Children's Hospital, Orlando, Florida, United States
› Author Affiliations
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Publication History

07 August 2018

13 August 2018

Publication Date:
18 September 2018 (online)

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Abstract

The technique for minimally invasive repair of pectus excavatum (MIRPE) has been adopted by most surgeons as the preferred method for treatment of this condition. However, there is limited awareness about the complications related to the procedure. Most importantly, the prevalence and potential for life-threatening complications have frequently been underestimated. The purpose of this communication is to increase awareness of the risk of minor and major (life-threatening) complications, as well as the operative steps and modifications which have been developed to prevent them. One of the most common complications reported in the early series of MIRPE cases was bar displacement, frequently requiring reoperation. Fortunately, technical modifications to the technique have resulted in a decrease in the incidence of such events from 10 to less than 2%. It is important for surgeons to have a good understanding of the potential complications, particularly the major type of complications post-MIRPE and postpectus bar removal. Although rare, the risk of mortality is real and it is the surgeon's responsibility to ensure optimal patient safety when performing this procedure. Factors such as operative technique, patient age, pectus severity and asymmetry, previous chest surgery, and the surgeon's experience play a role in the overall incidence of adverse events. These preventable events can be avoided with proper training, mentoring, and careful patient selection.

Keywords

pectus excavatum - mortality - morbidity - life-threatening complications - minimally invasive repair - Nuss procedure - cardiac injury - pectus bar removal - chest wall - deformity
 

  • References

  • 1 Nuss D, Kelly Jr RE, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998; 33 (04) 545-552
    CrossrefPubMedGoogle Scholar
  • 2 Nuss D. Minimally invasive surgical repair of pectus excavatum. Semin Pediatr Surg 2008; 17 (03) 209-217
    CrossrefPubMedGoogle Scholar
  • 3 Hebra A, Swoveland B, Egbert M. , et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg 2000; 35 (02) 252-257
    CrossrefPubMedGoogle Scholar
  • 4 Engum S, Rescorla F, West K, Rouse T, Scherer LR, Grosfeld J. Is the grass greener? Early results of the Nuss procedure. J Pediatr Surg 2000; 35 (02) 246-251
    CrossrefPubMedGoogle Scholar
  • 5 Kelly RE, Goretsky MJ, Obermeyer R. , et al. Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg 2010; 252 (06) 1072-1081
    CrossrefPubMedGoogle Scholar
  • 6 Park HJ, Jeong JY, Jo WM. , et al. Minimally invasive repair of pectus excavatum: a novel morphology-tailored, patient-specific approach. J Thorac Cardiovasc Surg 2010; 139 (02) 379-386
    CrossrefPubMedGoogle Scholar
  • 7 Pilegaard HK. Nuss technique in pectus excavatum: a mono-institutional experience. J Thorac Dis 2015; 7 (02) (Suppl. 02) S172-S176
    Google Scholar
  • 8 Nuss D, Croitoru DP, Kelly Jr RE, Goretsky MJ, Nuss KJ, Gustin TS. Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg 2002; 12 (04) 230-234
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Hebra A, Gauderer MW, Tagge EP, Adamson WT, Othersen Jr HB. A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum. J Pediatr Surg 2001; 36 (08) 1266-1268
    CrossrefPubMedGoogle Scholar
  • 10 Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: case reports. J Pediatr Surg 2001; 36 (01) 155-158
    CrossrefPubMedGoogle Scholar
  • 11 Hoel TN, Rein KA, Svennevig JL. A life-threatening complication of the Nuss procedure for pectus excavatum. Ann Thorac Surg 2006; 81 (01) 370-372
    CrossrefPubMedGoogle Scholar
  • 12 Marusch F, Gastinger I. Life-threatening complication of the Nuss-procedure for funnel chest. A case report [in German]. Zentralbl Chir 2003; 128 (11) 981-984
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Castellani C, Schalamon J, Saxena AK, Höellwarth ME. Early complications of the Nuss procedure for pectus excavatum: a prospective study. Pediatr Surg Int 2008; 24 (06) 659-666
    CrossrefPubMedGoogle Scholar
  • 14 Gips H, Zaitsev K, Hiss J. Cardiac perforation by a pectus bar after surgical correction of pectus excavatum: case report and review of the literature. Pediatr Surg Int 2008; 24 (05) 617-620
    CrossrefPubMedGoogle Scholar
  • 15 Alexander M. Night shift nightmare. Reader's digest. Available at: psnet.ahrq.gov/resources/5370/night.shift.nightmare . Accessed 2007
    PubMedGoogle Scholar
  • 16 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 (08) 757-761
    CrossrefPubMedGoogle Scholar
  • 17 Barber Jr J. Serious surgical mistakes: at least 4000 annually in US. Available at: Medscape: www.medscape.com/viewarticle/776573 . Accessed 2012
    PubMedGoogle Scholar
  • 18 Belcher E, Arora S, Samancilar O, Goldstraw P. Reducing cardiac injury during minimally invasive repair of pectus excavatum. Eur J Cardiothorac Surg 2008; 33 (05) 931-933
    CrossrefPubMedGoogle Scholar
  • 19 Park HJ, Lee SY, Lee CS. Complications associated with the Nuss procedure: analysis of risk factors and suggested measures for prevention of complications. J Pediatr Surg 2004; 39 (03) 391-395
    CrossrefPubMedGoogle Scholar
  • 20 Park HJ, Kim KS, Lee S, Jeon HW. A next-generation pectus excavatum repair technique: new devices make a difference. Ann Thorac Surg 2015; 99 (02) 455-461
    CrossrefPubMedGoogle Scholar
  • 21 Jaroszewski DE, Johnson K, McMahon L, Notrica D. Sternal elevation before passing bars: a technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients. J Thorac Cardiovasc Surg 2014; 147 (03) 1093-1095
    CrossrefPubMedGoogle Scholar
  • 22 Haecker FM, Sesia SB. Intraoperative use of the vacuum bell for elevating the sternum during the Nuss procedure. J Laparoendosc Adv Surg Tech A 2012; 22 (09) 934-936
    CrossrefPubMedGoogle Scholar
  • 23 Rygl M, Vyhnanek M, Kucera A, Mixa V, Kyncl M, Snajdauf J. Technical innovation in minimally invasive repair of pectus excavatum. Pediatr Surg Int 2014; 30 (01) 113-117
    CrossrefPubMedGoogle Scholar
  • 24 St Peter SD, Sharp SW, Ostlie DJ, Snyder CL, Holcomb III GW, Sharp RJ. Use of a subxiphoid incision for pectus bar placement in the repair of pectus excavatum. J Pediatr Surg 2010; 45 (06) 1361-1364
    CrossrefPubMedGoogle Scholar
  • 25 Sacco Casamassima MG, Goldstein SD, Salazar JH, McIltrot KH, Abdullah F, Colombani PM. Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume, single institution experience. J Pediatr Surg 2014; 49 (04) 575-582
    CrossrefPubMedGoogle Scholar
  • 26 de Campos JR, Das-Neves-Pereira JC, Lopes KM, Jatene FB. Technical modifications in stabilisers and in bar removal in the Nuss procedure. Eur J Cardiothorac Surg 2009; 36 (02) 410-412
    CrossrefPubMedGoogle Scholar
  • 27 Web based. 'Bullied teenager nearly died after steel bar inserted to disguise his sunken chest came within 1cm of his heart'. Available at: http://www.dailymail.co.uk/ health/article-2739727/Bullied-teenager-nearly-died-steel-barinserted-disguisesunken-chest-came-1cm-heart.html . Accessed 2016
    PubMedGoogle Scholar
  • 28 Haecker FM, Berberich T, Mayr J, Gambazzi F. Near-fatal bleeding after transmyocardial ventricle lesion during removal of the pectus bar after the Nuss procedure. J Thorac Cardiovasc Surg 2009; 138 (05) 1240-1241
    CrossrefPubMedGoogle Scholar
  • 29 Adam LA, Meehan J. Erosion of the Nuss bar into the internal mammary artery 4 months after minimally invasive repair of pectus excavatum. J Pediatr Surg 2008; 43 (02) 394-397
    CrossrefPubMedGoogle Scholar
  • 30 Barsness K, Bruny J, Janik JS, Partrick DA. Delayed near-fatal hemorrhage after Nuss bar displacement. J Pediatr Surg 2005; 40 (11) e5-e6
    PubMedGoogle Scholar
  • 31 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 (02) 66-72
    CrossrefPubMedGoogle Scholar
  • 32 Carlucci M, Torre M, Jasonni V. An uncommon complication of Nuss bar removal: is blind removal a safe procedure?. J Pediatr Surg Case Rep 2013; 1 (03) 34-35
    PubMedGoogle Scholar
  • 33 Jemielity M, Pawlak K, Piwkowski C, Dyszkiewicz W. Life-threatening aortic hemorrhage during pectus bar removal. Ann Thorac Surg 2011; 91 (02) 593-595
    CrossrefPubMedGoogle Scholar
  • 34 Leonhardt J, Kübler JF, Feiter J, Ure BM, Petersen C. Complications of the minimally invasive repair of pectus excavatum. J Pediatr Surg 2005; 40 (11) e7-e9
    PubMedGoogle Scholar
  • 35 Maagaard M, Udholm S, Hjortdal VE, Pilegaard HK. Right ventricular outflow tract obstruction caused by a displaced pectus bar 30 months following the Nuss procedure. Eur J Cardiothorac Surg 2015; 47 (01) e42-e43
    CrossrefPubMedGoogle Scholar
  • 36 Mazur L, de Ybarrondo L, Pickard L, Rao PS. Development of supravalvular pulmonary artery stenosis following a Nuss procedure. J Pediatr Surg 2012; 47 (12) e61-e64
    CrossrefPubMedGoogle Scholar
  • 37 Lin CW, Chen KC, Diau GY, Chu CC. Late-onset fatal complication after the Nuss procedure for pectus excavatum. Pediatr Surg Int 2012; 28 (01) 71-73
    CrossrefPubMedGoogle Scholar
  • 38 Notrica DM, McMahon LE, Johnson KN, Velez DA, McGill LC, Jaroszewski DE. Life-threatening hemorrhage during removal of a Nuss bar associated with sternal erosion. Ann Thorac Surg 2014; 98 (03) 1104-1106
    CrossrefPubMedGoogle Scholar
  • 39 Obert L, Munyon R, Choe A, Rubenstein J, Azizkhan R. Rare late complication of the Nuss procedure: a case report. J Pediatr Surg 2012; 47 (03) 593-597
    CrossrefPubMedGoogle Scholar
  • 40 Onursal E, Toker A, Bostanci K, Alpagut U, Tireli E. A complication of pectus excavatum operation: endomyocardial steel strut. Ann Thorac Surg 1999; 68 (03) 1082-1083
    CrossrefPubMedGoogle Scholar
  • 41 Raff GW, Wong MS. Sternal plating to correct an unusual complication of the Nuss procedure: erosion of a pectus bar through the sternum. Ann Thorac Surg 2008; 85 (03) 1100-1101
    CrossrefPubMedGoogle Scholar
  • 42 Sakakibara K, Kinoshita H, Ando K, Yasuda Y, Mori Y, Fujiwara Y. Right ventricular perforation due to a stabilizing bar installed for the Nuss procedure. Minerva Anestesiol 2013; 79 (07) 820-821
    PubMedGoogle Scholar
  • 43 Schaarschmidt K, Lempe M, Schlesinger F, Jaeschke U, Park W, Polleichtner S. Lessons learned from lethal cardiac injury by Nuss repair of pectus excavatum in a 16-year-old. Ann Thorac Surg 2013; 95 (05) 1793-1795
    CrossrefPubMedGoogle Scholar
  • 44 Umuroglu T, Bostancı K, Thomas DT, Yuksel M, Gogus FY. Perioperative anesthetic and surgical complications of the Nuss procedure. J Cardiothorac Vasc Anesth 2013; 27 (03) 436-440
    CrossrefPubMedGoogle Scholar
  • 45 Vegunta RK, Pacheco PE, Wallace LJ, Pearl RH. Complications associated with the Nuss procedure: continued evolution of the learning curve. Am J Surg 2008; 195 (03) 313-316
    CrossrefPubMedGoogle Scholar
  • 46 Kim KS, Hyun K, Kim DY, Choi K, Choi HJ, Park HJ. Lung entrapment between the pectus bar and chest wall after pectus surgery: an incidental finding during video assisted thoracoscopic surgery. Korean J Thorac Cardiovasc Surg 2015; 48 (05) 375-377
    CrossrefPubMedGoogle Scholar
  • 47 Nakahara O, Ohshima S, Baba H. Cardiopulmonary arrest during the Nuss procedure: case report and review. Acute Med Surg 2015; 2 (04) 250-252
    CrossrefPubMedGoogle Scholar
  • 48 Croitoru DP, Kelly Jr RE, Goretsky MJ, Lawson ML, Swoveland B, Nuss D. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002; 37 (03) 437-445
    CrossrefPubMedGoogle Scholar
  • 49 Harris B, Bushman GA, Hastings LA. Inferior vena cava obstruction after pectus excavatum repair. J Cardiothorac Vasc Anesth 2009; 23 (04) 515-517
    CrossrefPubMedGoogle Scholar
  • 50 Nuss D, Kelly R. The minimally invasive repair of pectus excavatum. Oper Tech Thorac Cardiovasc Surg 2014; 19 (03) 324-347
    CrossrefPubMedGoogle Scholar
  • 51 Sacco-Casamassima MG, Goldstein SD, Gause CD. , et al. Minimally invasive repair of pectus excavatum: analyzing contemporary practice in 50 ACS NSQIP-pediatric institutions. Pediatr Surg Int 2015; 31 (05) 493-499
    CrossrefPubMedGoogle Scholar
  • 52 Kelly Jr RE, Mellins RB, Shamberger RC. , et al. Multicenter study of pectus excavatum, final report: complications, static/exercise pulmonary function, and anatomic outcomes. J Am Coll Surg 2013; 217 (06) 1080-1089
    CrossrefPubMedGoogle Scholar