EComment. Does pectus tunneloscopy make the Nuss repair for pectus excavatum safe?

Abstract

Darlong describes a new endoscopic technique known as pectus tunneloscopy to avoid cardiac injury at the time of the Nuss procedure for pectus excavatum [1]. As stated by the author, this is one of the major perioperative complications in minimally invasive repair. By studying literature data, we have, in fact, collected 16 cardiac injuries leading to death in two patients and severe hypoxic brain injury in one (in four articles, detailed outcomes were, however, not provided). Furthermore, in their landmark study in the field, Bouchard et al. stated: “Dr Nuss, in personal conversations with three of the authors, has noted other catastrophic outcomes in both placing the bars and removing them, yet these complications are rare but profound” [2]. We agree that pectus tunneloscopy as described by Darlong is a significant enhancement of the procedure, potentially minimizing the risk of cardiac, vascular (mainly internal thoracic artery) or pulmonary injury during the Nuss procedure. Delayed severe complications, however, could not be avoided, such as mechanical occlusion of the inferior vena cava requiring prompt bar removal [3], late-onset haemothorax, aortic cross or pulmonary artery injuries due to bar dislocation, and last but not least, catastrophic haemorrhage during bar removal due to transmyocardial migration, as observed in two patients and leading to death in one [2]. Besides these cardiovascular complications, postpericardiotomy syndrome, infection of the bar, metal allergy, mechanical conflicts and consecutive thoracic outlet syndrome or sternal erosion, and difficulties encountered at the time of bar removal due to neo-ossification are other causes for concern. Finally, a recent meta-analysis comparing both Nuss and Ravitch-type repair suggested no differences with respect to overall complications, but the rate of reoperation, postoperative haemothorax, and pneumothorax after the Nuss repair were significantly higher compared to the Ravitch-type repair [4]. Furthermore, in the real world, such a meta-analysis does not reflect well on the reality in terms of severe complications, since the majority of these, published in the form of case report/series, were excluded from this study. Thus, the acceptance of the Nuss procedure appears questionable to us. In our clinical practice since 2001, we perform a simplified pectus open repair (using an easily removable metallic strut under local anaesthesia) with no severe complications and favourable outcomes, and providing satisfactory long-term cosmetic results in 97.5% of patients (in line with prior published series) [5]. Conflict of interest: none declared