Editorial Comment: The Nuss operation for pectus carinatum

Abstract

The controversy regarding the wisdom of applying the Nuss operation for the repair of pectus excavatum (or PE, also known as ‘funnel chest’) is ongoing. The debate was further fuelled by Abramson, who also applied the method for the correction of carinatum deformities [2]. The article by Bostanci and co-workers ‘Quality of life of patients who have undergone the minimally-invasive repair of pectus carinatum’ joins the advocates of this approach [3]. To address the issue of Nuss repair of pectus carinatum (PC), one has to consider as a whole the state-of-the-art surgery available for anterior chest deformities. The introduction of the so-called ‘minimally-invasive repair’, developed by Donald Nuss in the mid-1990s, created turmoil in the seemingly quiet field of PE repair, not only by inserting the magic words ‘minimally-invasive’ into the field—thus tripling the number of patients requesting anterior chest wall repair—but also opened the door to other disciplines besides thoracic surgeons [4]. The fact that inserting up to three foot-long metal rods through double incisions, passing them through the narrow sternopericardial space and through both pleural cavities, leaving them in place for up to five years, then re-operating for removal apparently does not concern those who regard the operation as ‘minimally-invasive’. While the results of the Nuss procedure are comparable to modern, truly minimally-invasive modifications of the classic Ravitch operation, the potential for serious complications, including perforation of vital organs, is real and lasting postoperative pain and discomfort are common [5, 6]. The wisdom of applying the Nuss operation in patients with PC is even more dubious. These patients are different to those with excavatum deformity, not only because patients with PC of moderate-to-medium severity seldom, if ever, present themselves with cardiovascular impairment but also because, while severe cases of PE may benefit most from surgical correction, the physical status of far-advanced cases of carinatum—because of associated spinal deformities—can seldom be surgically alleviated. Thus, the open approach to correct PC is, for the majority of patients, purely cosmetic. To correct the anomaly with the minimally-invasive open method is simple. The surgeon has only to remove the protruding cartilages, perform a sternotomy, push the sternum down and close the pectoralis muscles over it [5]. The procedure may be performed through a 5–6 cm incision, the operative time is less than an hour and, if properly performed, it yields most satisfactory results. Considering this, one may rightly question why anybody would choose to apply a large metal bar and leave it place for up to five years to provide sternal compression, instead of performing a simple and low-risk open repair, discharging the patient from the hospital the next day and forgetting that he ever had a carinatum deformity. Bostanci and co-workers collected valuable information, coming from an institution with excellent and extensive experience with the Nuss procedure [3]. However, it must be emphasized that the information they provide is based on subjective data. It would also be of interest to know the ages of patients, as well as their anatomical and physiological parameters before and after the intervention, the number of peri-operative and late complications and, last, why only 30 out of their 40 operated patients were included in the study. Their conclusion that the patients’ quality of life improved after this largely cosmetic operation is certainly not surprising. The study did not intend to provide evidence of the superiority of the Nuss procedure over the minimally-invasive open approach; however, it does support the views of those who are, in general, in favour of interventional treatment of pectus carinatum.