Objective To summarize the early experience of modified Nuss procedure with thoracoscope for repairing pectus excavatum in children. Methods Fiftythree pediatric pectus excavatum were treated by modified Nuss procedure with thoracoscope from June 2004 to July 2006, theage ranged from 2.4 to 16.0 years, the average age was 8.1 years. Thirtysix patients were symmetric pectus excavatum and 17 patients were asymmetric pectus excavatum. Results The operation in all patients were successful, the average blood loss was less than 10ml. Pericardium perforation occurred in 2 earlier patients during the operation, pneumothorax occurred in 6 patients postoperatively,pleural effusion occurred in 3 patients, and all resolved by corresponding treatments. The average hospital length of stay was 5.5 days. All patients had a satisfied deformity correction and no needs of transfusion. The depression was thoroughly corrected in 48 patients, residual depression was less than 20% of preoperative degrees in 5 patients. Therapeutic results evaluation showed excellent in 46 patients and good in 7 patients. All patients were followed up in 1-25 months without any complaints, the activity ability was same as normal children; there were no bar displacement and injury event occurred. The bar had been removed in 1 patient 24 months after surgery who still kept in excellent results. Conclusion Modified Nuss procedure is easy to be performed with minimal invasion and good shortterm results. Thoracoscopic visualization facilitates the safety of this technique. It is recommendable to be tried and extended applied.
ObjectiveTo summarize the clinical experience and investigate the safety and reliability of uniportal procedure for the correction of pectus excavatum (PE). MethodsFrom November 2010 to November 2015, 203 PE patients (164 males, 39 femalzs average age of 5.7±3.0 years, ranging from 2 to 19 years) underwent the correction operation with only single 2 cm incision on right lateral chest. There were 188 patients under 12 years of age and 15 patients above 12 years. According to Park classification, 176 patients were symmetric and 27 were asymmetric. ResultsAll operations were performed successfully. The average operating time was 16.1±5.2 min with a range of 4-65 min and the average postoperative hospital stay was 6.4±1.3 d, ranging from 4-14 d. A single incision was made on the right chest and only one bar was inserted in the patients. Postoperative follow-up was 1-56 months (mean, 27.6 months). There was no complication occurred such as bar turnover, displacement and redepressed sternum. Totally, 84 patients received bar removal procedure. ConclusionIn terms of operation time and surgical trauma, uniportal procedure for PE is superior to Nuss procedure. And there is no significant difference in the safety and effectiveness between two procedures. Uniportal procedure is especially suitable for the treatment of PE children under 12 years of age.
ObjectiveTo investigate the changes and clinical significance of cardiac structure and function evaluation by cardiac magnetic resonance imaging (CMR) for patients with pectus excavatum deformity at preoperation. MethodsWe retrospectively analyzed 54 patients (24 children and 30 adults) who underwent pectus excavatum surgery from June 2012 to June 2014. There were 48 males and 6 females at age of 7-33 (19.08±5.17) years. All the patients underwent CMR using 1.5 Tesla scanner for evaluation of compressing and displacement of the heart. The major and minor dimensions of right ventricle were measured. The right ventricle end-diastole volume (RVEDV), right ventricle end-systolic volume (RVESV), and right ventricle ejection fraction (RVEF) were also recorded and analyzed. ResultsThe heart compression and displacement occurred in 83.3% of the children group and 90.0% of the adults group. The extent of heart displacement in the adults was more serious than that in the children (76.86%±13.30% vs. 67.99%±8.15%, P<0.05). The structure of right ventricle were striking distorted because right atrum or right ventricule below valve ring was compressed locally, with the major dimension of right ventricle obviously increased, and the minor dimension of right ventricle obviously decreased. The indices of right ventricle major dimension and right ventricle minor dimension were 61.14±0.44 mm/m2 and 14.82±2.52 mm/m2 in the children, 49.54±15.40 mm/m2 and 18.90 ±3.14 mm/m2 in the adults. The RVEDV and RVESV were significantly higher in the adults than those in the children (139.09±29.08 ml vs. 121.50±31.27 ml; 73.61±16.05 ml vs. 64.92±19.28 ml; P<0.05). RVEF was similar between the children and the adults (45.29%±4.14% vs. 46.30±6.09%). The patients' symptoms disappeared after correction of pectus excavatum. ConclusionCMR is an useful method for evaluating right ventricular structure and functions in patients with cardiac compression and distortion by pectus excavatum before operation, which can bring strong indications for pectus excavatum repair surgery.
ObjectiveTo develop a symptom and function assessment scale for patients after Nuss procedure for pectus excavatum and to test its reliability and validity. MethodsFollowing the principles and procedures of patient-reported outcome (PRO) scale development stipulated by the U.S. Food and Drug Administration, an initial draft was formed through literature analysis, qualitative interviews, and Delphi expert consultation. The preliminary draft was used to conduct a pre-survey on patients who underwent Nuss procedure for pectus excavatum at Guangdong Provincial People's Hospital, and the reliability and validity of the scale were tested. ResultsA preliminary PRO-based symptom and function scale was constructed, covering two domains: symptoms and impact on daily functions. The symptom dimension includes six items: chest tightness, palpitations, pain, shortness of breath, foreign body sensation of the steel plate, and distress; while the impact on daily functions includes four items: difficulty in getting out of bed or lying down, raising arms, bending over, and standing or sitting for a long time. A total of 73 patients who underwent Nuss procedure for pectus excavatum were included in the questionnaire survey, with 70 valid questionnaires collected, including 64 males and 6 females, with 56 patients aged 12-17 years and 14 patients≥18 years. Through exploratory factor analysis, two common factors were extracted, with a cumulative variance contribution rate of 70%. The Cronbach's α coefficient of the scale is 0.917. ConclusionThe scale developed in this study has good reliability and validity, high reliability and stability, and can be used as an evaluation tool for the recovery status of patients after Nuss procedure for pectus excavatum.
Pectus excavatum is the most common chest wall deformity, and the Nuss procedure has become the most widely used surgical treatment owing to its minimally invasive nature and reliable corrective outcomes. However, during the critical step in which the introducer and corrective bar traverse the anterior mediastinum, rare but potentially fatal complications may occur, including injury to the lungs, heart, and great vessels. Although thoracoscopic assistance can reduce the incidence of these events to some extent, it cannot eliminate the risk entirely. To further enhance intraoperative safety, various sternal elevation techniques (SET) have been introduced in recent years and applied in combination with the Nuss procedure for the treatment of pectus excavatum. By temporarily elevating the sternum and anterior chest wall to enlarge the retrosternal space, SET may facilitate safer mediastinal passage and mitigate the risk of cardiopulmonary and major vascular injury. This review summarizes the technical characteristics and recent clinical advances of different SET modalities used in conjunction with the Nuss procedure, analyzes their advantages and limitations, and provides a reference for future research and clinical practice.
Objective To review and investigate the compl ication and the treatment in Nuss procedure for correction of pectus excavatum. Methods From September 2005 to March 2009, 221 patients with pectus excavatum were treated withNuss procedure, including 189 males and 32 females and aging 2 years old and 10 months to 25 years old (median 8 years and 7 months old). Of 18 patients with recurrent pectus excavatum, 12 patients underwent a Ravitch procedure and the recurrence time of the depression after the first operation was less than 1 year in 2 patients, 1-3 years in 3, 3-5 years in 5, and over 5 years in 2; 6 patients underwent a stemotumover operation and the recurrence time of the depression after the first operation was less than 1 year in 2 patients, 1-3 years in 1 and 3-5 years in 3. The other 203 patients had a primary Nuss procedure, and the course of disease was from 18 months to 24 years. The preoperative CT scan showed the Haller index was 4.36 ± 1.34. Results The operation in all the patients were performed successfully without compl ications of death, massive hemorrhage and intrathoracic organ injury. The time of operation was 25-80 minutes (mean 40 minutes). The bleeding volume during procedure was 5-25 mL, with an average of 10 mL. Local allergy occurred in 3 cases after 7-10 months of operation, wound reject reaction in 2 cases after 3 and 11 months respectively, and effusion in 3 cases after 6-10 months; incision healed after dressing change. Incision healed primarly in the other patients. Pneumothorax occurred in 3 cases when the operation finished and in 7 cases after 2-4 days, pleural effusion in 4 cases after 3-5 days of operation, Nuss plate displacement in 2 cases after 3 days and 9 months, respectively. The patients having compl ication recovered well after treatment. The compl ication rate was about 8.72% (17/195). The followupperiod was 2-37 months for 195 patients. The postoperative Haller index was 2.52 ± 0.32 after 3 months of operation, showing statistically significant difference when compared with that before operation (P lt; 0.05). Conclusion Nuss procedure with non-thoracoscopic assistance for correction of pectus excavatum is safe because of less trauma and compl ication.
The surgical treatment of pectus excavatum has a history of more than 100 years, which has gone through from traditional open surgery to the current popular minimally invasive surgery. Nuss procedure, as the most classic minimally invasive operation, has been improved in accordance with the clinical needs since its inception to achieve fewer complications and better results, but there are still limitations that are difficult to break through, attracting a large number of scholars to make continuous innovation and develop updated devices and operation methods. This article reviews the history of funnel chest surgery, application and improvement of Nuss operation, double compression and complete fixation bar system and Wang procedure.
ObjectiveTo summarize clinical experience of minimally invasive non-thoracoscopic Nuss procedure for the treatment of pectus excavatum (PE). MethodsFifty-one pediatric patients received minimally invasive nonthoracoscopic Nuss procedure for PE between July 2008 and February 2014 in Department of Thoracic Surgery, Jinan Military General Hospital. There were 32 males and 19 females with their average age of 8.32 (2.5-17.0) years. Transverse incisions were made in bilateral chest wall. Supporting plate was put to right chest wall through retrosternal approach, turned over and fastened onto the ribs. ResultsDeformity of all the patients was successfully corrected. Operation time was 30-52 (38±9) minutes. One patients had heart injury which was repair after open thoracotomy, and then supporting-plate was successfully secured. Postoperative complications included subcutaneous emphysema in 7 patients, pneumothorax in 3 patients and atelectasis in 3 patients, all of whom were cured by conservative treatment. Supportingplate transposition occurred in 1 patient and was corrected by reoperation. All the patients were followed up for 1-42 (21.6±7.6) months. According to Nuss standard, there were 39 patients with excellent results, 9 patients with good results, and 3 patients with fair results. ConclusionMinimally invasive Nuss procedure is an efficacious, easy, feasible and safe procedure for the treatment of PE with low morbidity.
Abstract： Objective To study thoracic bone remodeling and clinical effects after minimally invasive correctionfor pectus excavatum （PE） in children. Methods A retrospective review was conducted of a prospectively gathereddatabase of 74 child patients who underwent minimally invasive repair of PE at General Hospital of Beijing MilitaryDistrict between Apr. 2009 and Sept. 2010. Of the patients, 63 were males and 11 females; the age was（ 11.90±8.50）years, 11 patients ＜ 10-year-old among them. Under general anesthesia, two incisions were made at the side midaxillaryline, and the introducer created a tunnel at the trans-substernum and shaped the thoracic cavity. The bar was then insertedinto the retrosternum by video-assistant thoracoscopic monitoring. All patients were checked by chest computerizedtomography（CT） scan preoperatively and one week after operation, with three-dimensional reconstruction. The sagittalview was by means of the center line of the body of thoracic vertebrae. The distance between the sternum and the frontaledge of the body of thoracic vertebrae was measured and the return of displacement of the heart was observed. ResultsAll 74 operations were successful; there were no deaths. One bar was used for 66 patients （89.19%）, while two barswere used for the other 8 patients （10.81%）. Comparing the results of pre- with post-correction, for patients youngerthan 10 years（n=11） who had one bar placed, the inferior extremity of the manubrium and midsternum displacedforward to 3.76-22.92 mm. For 11-17 year-old patients（n=55） , anterior displacement of only the middle and lowerpart of the midsternum was 2.08-10.42 mm. There was a significant difference between the two groups in the inferiorextremity of the midsternum displaced（t=14.24, P ＜ 0.05）. For those patients with two bars, the inferior extremity ofthe manubrium and the midsternum were each displaced forward 4.19-15.03 mm at 7 d after operation. At 7 d after operation,the cardiac position in 65 patients（ 87.84%） of the all putted back by CT image. The chest shape of patients who received twobars was better than that of patients who received one bar. After 6-23 months of follow-up, it was pre-operative symptomsdisappeared in the patients, chest shape was satiation. Cardiac position in all patients was completely recovered. ConclusionThe thoracic bones of children with PE after minimally invasive repair have favorable remodeling. Older children requiregreater strength of support of the sternum during correction, but still realize a satisfactory therapeutic effect.
Pectus excavatum (PE) is a common congenital chest malformation in children, manifested by inward depression of the anteriorthorax wall, which can compress the normal tissues and organs in the chest and cause adverse effects on the physiology and psychology of patients. Surgery is the most important means of treating PE, and with the invention of Nuss surgery, the surgical treatment of PE has entered the minimally invasive era. At present, there are many indexes to evaluate the severity of thoracic malformations in PE patients, and selecting appropriate evaluation indexes is of great significance for the formulation of surgical protocols. As a physical and mental disease, PE's deformed thoracic appearance not only affects the function of thoracic organs, but also affects the psychological state of patients. Therefore, there is still controversy over whether the role of orthopedic surgery is to improve function or cosmetic plastic surgery. At the same time, the orthopedic efficacy and postoperative complications of the existing modified and novel surgical methods need to be further observed and evaluated. In addition, the design of surgical plan and the selection of surgical timing for PE combined with other diseases are also critical and controversial issues in clinical practice. Therefore, this article explores and reviews the controversial points in the current surgical treatment of PE.