Nuss Repair Of Pectus Excavatum Research Articles

Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive Nuss repair of pectus excavatum: a protocol for a randomised clinical trial (ICE trial)

IntroductionEpidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve...

Retrospectively analyze and compare the efficacy and safety of thoracoscopic-assisted Nuss repair of pectus excavatum under intubation anesthesia and non-intubation anesthesia

Thoracoscopic-assisted Nuss repair is a commonly used method for treating pectus excavatum, which has always been performed under tracheal intubation and general anesthesia. However, general anesthesia with endotracheal intubation can produce intubation and anesthetic drug related complications. In non-intubation anesthesia, laryngeal mask is used instead of tracheal intubation without muscle relaxants and small doses of sedative and analgesic drugs. Therefore, non-intubation anesthesia can reduce complications and speed up postoperative recovery. This study retrospectively analyzed the clinical impact of these two anesthesia methods on thoracoscopic-assisted Nuss repair for the treatment of pectus excavatum. A total of 115 pectus excavatum patients who underwent thoracoscopic-assisted Nuss procedure repair in the Department of Thoracic Surgery of Yunnan First People's Hospital from January 2017 to January 2022 were included. All subjects in this study underwent thoracoscopic assisted Nuss repair in the same thoracic surgical team. According to different anesthesia methods, they were divided into non-intubation anesthesia group (n=62) and intubation anesthesia group (n=53). The intubation time, intraoperative mean heart rate, postoperative complications, postoperative first oral food intake, water intake, ambulation, defecation time, postoperative blood drawing results, postoperative hospital stay and total hospitalization cost were compared between the two groups. There were no significant differences in clinical characteristics and preoperative examination indexes between the two groups, which were comparable. Compared with the intubation anesthesia group, the non-intubation anesthesia group had less anesthesia intubation time, lower intraoperative mean heart rate, less postoperative complications, such as pneumothorax, pleural effusion, and lung infection. In the non-intubation anesthesia group, the first time to eat, drink, get out of bed, and defecate were all earlier. Routine blood results 24 h after surgery indicated that the non-intubation anesthesia group had lower white blood cell, neutrophil and lymphocyte, an earlier postoperative discharge time, and lower total hospitalization expenses. Non-intubation anesthesia in thoracoscopic-assisted Nuss procedure for the repair of pectus excavatum can make the postoperative recovery of patients faster and has better safety and efficacy.

Same-day discharge following the Nuss repair: A comparison

PurposeIntercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB). MethodsIn June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017–2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR). ResultsThe characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation. ConclusionsThe majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital. Level-of-evidenceLevel II.

Thoracic epidural-based Enhanced Recovery After Surgery (ERAS) pathway for Nuss repair of pectus excavatum shortened length of stay and decreased rescue intravenous opiate use.

PCA- and block-based enhanced recovery after surgery (ERAS) pathways have been shown to decrease hospital length of stay (HLOS) and opiate use following Nuss Repair for Pectus Excavatum (NRPE). No thoracic epidural-based ERAS pathway has demonstrated similar benefits. In this pre-post single-center study, data were retrospectively collected for patients ≤ 21years undergoing NRPE from May 2015 to August 2019. Univariate and multivariate methods were used to evaluate whether implementation of a thoracic epidural-based ERAS in April 2017 was associated with HLOS, opiate use, or pain scores. There were 110 patients: 35 pre- and 75 post-ERAS. HLOS decreased from median 4.8 (1.1) to 3.3 (0.6) days with ERAS (p < 0.001). Use of rescue intravenous opiates decreased from 35.3% pre- to 9.3% with ERAS (p = 0.013). When adjusted for baseline characteristics, ERAS was associated with a 1.3 ± 0.2day decrease in HLOS and 0.188 times the odds of rescue intravenous opiate use (p = 0.011). Pain scores, ED visits, and readmissions did not change with ERAS (p > 0.05). Implementation of a thoracic epidural-based ERAS following NRPE was associated with decreased HLOS and need for any rescue intravenous opiates without a change in pain scores, ED visits, or readmission.

Continuous bilateral erector spinae plane analgesic block for an adolescent with Nuss repair of pectus excavatum

Abstract Thoracic epidural analgesia has been proven to be an effective method for pain management following Pectus excavatum repair. However, because of the accompanying thoracic spinal deformities, thoracic epidural analgesia may not always be a feasible option in all cases. If ineffective, there could be increased opioid administration in order to adequately manage any post operative pain. Studies have shown that early exposure of adolescents to opioids is associated with increased risk of persistent opioid use. This is because adolescents have larger reward centers and underdeveloped prefrontal cortex, hence an immature inhibitory system. An alternative regional technique for post operative pain management in these patients is thus valuable. Erector spinae plane (ESP) block has been explored and found to be a useful alternative for pain management in this group of patients. Although there are a few case reports showing the effectiveness of ESP blocks in Ravitch repair, we present, for the first time, the effectiveness of ESP in Nuss repair.

Use of a Capture-Guidance Surgical Instrument to Minimize Muscle Stripping During Nuss Repair of Pectus Excavatum.

Background: Pectus excavatum is an anomaly of chest wall development in which anterior ribs curve inward and the sternum is displaced toward the vertebral column. The Nuss procedure is a minimally invasive technique in which one or more metal bars are implanted to brace the sternum in a corrected position. Over time, the chest wall remodels into an anatomically corrected shape and the bar(s) are removed at a later date. During the procedure, passage of an introducer instrument and then the repair bar(s) may shear the intercostal muscles from the adjacent ribs. This creates larger than necessary defects in the chest wall, improper or unstable bar placement, and inadequate repair. Instrument Design: We report a new surgical instrument for guiding the introducer through the contralateral chest wall. This capture-guidance instrument (CGI) redirects and channels forces to keep the introducer true while preventing muscle stripping during passage of the introducer and repair bar(s). Instrument Use: The CGI has been piloted at two pectus centers with a notable decrease in intercostal muscle stripping. Conclusion: The CGI addresses the problem of shear and intercostal muscle stripping during traversal of the chest as part of Nuss repair of pectus excavatum.

Cryoanalgesia in Patients Undergoing Nuss Repair of Pectus Excavatum: Technique Modification and Early Results.

The Nuss procedure for surgical correction of pectus excavatum often causes severe postoperative pain. Cryoanalgesia of intercostal nerves is an alternative modality for pain control. We describe our modification of the cryoICE™ probe that allows for nerve ablation through the ipsilateral chest along with early results utilizing this technique. To allow for ipsilateral nerve ablation, a 20-French chest tube was cut and secured to the cryoICE probe, thus providing insulation for the malleable end of the probe. A 3-year retrospective review of patients undergoing Nuss repair at our institution was performed. Patients who received cryoanalgesia (cryo, n = 6) were compared with a historical control cohort who did not receive cryoanalgesia (nocryo, n = 13) during Nuss repair. Hospital length of stay, postoperative narcotic requirement (PNR), and highest postoperative pain score were collected. Both cohorts were similar regarding age, BMI, and pectus index. The cryo group had a significantly less PNR (6.4 versus 17.9 doses, P = .05) and was discharged on average >1 day earlier than nocryo patients (3.7 versus 2.2 days, P = .01). No complications occurred in either group. Our technique modification simplifies previously described approaches to intercostal nerve cryoablation. Patients undergoing this adjunct benefit with less PNR and a faster discharge time.

Cardiac arrest without physical cardiac injury during Nuss repair of pectus excavatum

BackgroundCardiac arrest is a lethal complication of Nuss repair of pectus excavatum which is strongly related to heart or big vessels injury. A rare case developed cardiac arrest without direct cardiac injury during Nuss procedure is presented in this article.Case PresentationIn July 2015, a previously healthy 18-year-old man undergoing Nuss repair for pectus excavatum developed cardiac arrest while the Nuss bar was being inserted into the chest. After successful resuscitation and exclusion of direct cardiac injury, the Nuss procedure was continued. The patient suffered a second cardiac arrest during rotation of the Nuss bar. This time, the patient had poor initial response to resuscitation and defibrillation until the retrosternal bar was removed. He ultimately recovered well from the episodes of cardiac arrest, but was unable to receive surgical correction of his pectus excavatum deformity.ConclusionsThe possible mechanisms of cardiac arrest and lessons we can learn from this complication are discussed.

Nuss repair of pectus excavatum after surgery for congenital heart disease: Experience from a single institution

Pectus excavatum developing after surgery for congenital heart disease has its own clinical characteristics. The present study aimed to present our technique and outcomes for the Nuss procedure in the repair of these cases. We conducted a retrospective study of all patients who had not been diagnosed as pectus excavatum preoperatively but subsequently had developed pectus excavatum after surgery for congenital heart disease from February 2005 to November 2012. The Nuss procedure was applied using a series of perioperative management techniques. The data relating to the surgical technique, complications, and outcomes were analyzed. The clinical evaluation was performed using the Nuss criteria. A total of 30 cases (14 boys and 16 girls) were included. The mean operative time was 73.5 minutes (range, 58-82). The mean length of hospital stay was 6.0 days. Complications occurred in 5 patients (16.7%), including asymptomatic pneumothorax, hematoma in the wound, pericardial penetration, and bar displacement. The mean follow-up period was 32 months (range, 9-60). Initially, 29 patients (96.7%) had excellent results, and 1 patient had a good result. The mean point of bar removal was 35.8 months (range, 30-39) after implantation. The postoperative results after bar removal in 17 patients were also recorded, including excellent results in 14 (82.4%), good results in 2 (11.7%), and a fair result in 1 patient. The Nuss procedure has been shown to be a safe and effective approach for the repair of pectus excavatum after surgery for congenital heart disease, although dissection of substernal adhesions can increase the risk of heart injury.

Lessons Learned From Lethal Cardiac Injury by Nuss Repair of Pectus Excavatum in a 16-Year-Old

This report investigates cardiac injury and arrest during a Nuss repair of severe pectus excavatum in a 16-year-old boy in 2006. The injuries of the right atrial auricle and the right ventricle were sutured, and the patient was resuscitated. Ultimately he died on the 11th day of progressive malignant cerebral edema and respiratory distress syndrome despite cerebral decompression and hypothermia. Typical morphologic features of cardiac injuries are demonstrated, and strategies to avoid inadvertent organ injury in pectus operations are discussed.

Infectious complications after the Nuss repair in a series of 863 patients

Purpose A nemesis of surgical implants is infection. We evaluated the various infectious complications after Nuss repair of pectus excavatum in 863 patients over 18 years. Methods After institutional review board approval, a retrospective review of a prospectively gathered database of patients was performed who underwent minimally invasive repair of pectus excavatum and developed an infection. All patients received intravenous antibiotics before surgery continuing until discharge. Patients with a persistent fever after operation were discharged with oral antibiotics. Results From January 1987 to September 2005, 863 patients underwent a minimally invasive pectus excavatum repair and 13 (1.5%) developed postoperative infections. These included 6 bar infections, 4 cases of cellulitis, and 3 stitch abscesses. Cellulitis was defined as erythema and warmth which responded to a single course of antibiotics. Bar infections were defined as an abscess in contact with the bar. Surgical drainage and long-term antibiotics resolved 3 of these abscesses, whereas 3 patients required early bar removal (1 after 3 months and 2 after 18 months). Cultures identified a single organism in each case and Staphylococcus aureus was the most common organism (83%) identified, and all being methicillin sensitive. All infections occurred on the side of the stabilizer if a stabilizer had been placed. Conclusions Infectious complications after Nuss repair are uncommon and occurred in 1.5% of our patients. Published rates of postoperative infection range from 1.0% to 6.8%. Superficial infections responded to antibiotics alone. Bar infection occurred in only 0.7% and required surgical drainage and long-term antibiotics. Only 3 of these (50% of bar infections and 0.34% overall) required early bar removal at 3 and 18 months because of recurring infections. Early bar removal should be a rare morbidity with the Nuss repair.

Cardiopulmonary effects of closed repair of pectus excavatum

Background/Purpose: Increasing numbers of patients with pectus excavatum defects are presenting for operative repair. Studies that follow-up with patients after open repair have found a decrease in pulmonary function with some improvement in cardiac output and exercise tolerance; however, these effects have not been examined systematically after closed or Nuss repair of pectus excavatum. This study examined the early postoperative effects of closed repair of pectus on pulmonary function, exercise tolerance, and cardiac function. Methods: Patients were followed up prospectively after initial evaluation for operation. All patients underwent preoperative computed tomography (CT) scan, and pre- and postoperative (3 months) pulmonary function studies, exercise tolerance, and echocardiographic evaluation of cardiac function. Results: Eleven patients underwent evaluation. Preoperative CT index was 4.1 ± 0.9. Patients reported an improvement in subjective postoperative exercise tolerance (4.1 ± 0.7; maximal, + 5). Pulmonary function studies (FVC and vital capacity) were significantly reduced at 3 months postsurgery: change in FVC, −0.67 ± 0.92 L and VC, −0.5 ± 0.72 L. Similarly, VO2 max was reduced: preoperative, 35.6 ± 1.5 versus postoperative, 29.1 ± 11.9 L/kg/min. Cardiac function was significantly improved postoperation (stroke volume preoperative, 61.6 ± 25 versus 77.5 ± 23 mL postoperative). All comparisons had a P value less than.05 by Student's paired t test. Conclusions: These results show that closed repair of pectus excavatum is associated with a subjective improvement in exercise tolerance, which is paralleled by an increase in cardiac function and a decline in pulmonary function. These findings support the use of closed repair of pectus excavatum in patients who complain of subjective shortness of breath; further study is required to delineate the long-term cardiopulmonary implications after closed repair. J Pediatr Surg 38:380-385. Copyright 2003, Elsevier Science (USA). All rights reserved.

Minimally invasive repair of pectus excavatum: A single institution's experience

Background. The Nuss repair of pectus excavatum is a relatively new, minimally invasive surgical (MIS) alternative to the traditional open “Ravitch-type” operation. We have one of the larger single-center experiences to date, and we conducted this clinical study to evaluate our early experience, emphasizing initial outcome and technical modifications designed to minimize complications. Methods. A retrospective chart review was performed on 112 patients who underwent 116 pectus excavatum repairs between January 1995 and January 2001. The Nuss procedure was performed in 80 patients, and open repair was performed in 32 patients. Information about demographics, deformity, operative course, complications, and early outcome was recorded. Results. Operative duration was 143 minutes for the open group and 53 minutes for the Nuss MIS group (P <.001). Blood loss was 6 mL/kg for the open group and 0.5 mL/kg for the MIS group (P <.001). Postoperative hospitalization was 3.2 days for the open group versus 3.7 days for the MIS group (P<.05). Conclusions. The MIS pectus repair can be performed safely with minimal blood loss and reduced operative time. Short-term analysis of the quality of repair, including absence of preoperative symptoms, patient satisfaction, and cosmetic appearance are encouraging. (Surgery 2001;130:652-9.)

A simple technique for preventing bar displacement with the nuss repair of pectus excavatum

Background/Purpose: The most common complication of the minimally invasive technique for repair of pectus excavatum (MIRPE) is bar displacement, which has been reported to occur in 9.5% of all cases, particularly in teenaged patients. The use of a lateral stabilizing bar has improved stability but has not eliminated the occurrence of this problem. The authors report a new technique added to the standard MIRPE that creates an additional third point of fixation of the pectus bar to prevent displacement. Methods: The technique requires the simple placement, via a spinal needle, of a nonabsorbable suture next to the sternum, encircling a rib and the bar, using a single 3-mm stab wound and thoracoscopic guidance. The suture simply is buried under the skin. Since 1998, this technique has been applied to 20 patients who underwent MIRPE. Results: The average age was 14 years; 80% were boys. Average operating time was 75 minutes, and all patients had thoracoscopy with the MIRPE. A lateral stabilizing bar also was used in 14 patients. Four patients had 2 struts placed. Average length of stay was 5.5 days. There were no early complications. Mean follow-up was 12 months. Bar displacement occurred in 1 patient early in the series in which an absorbable suture was used for fixation. One patient had a prolonged hospital stay of 7 days because of postoperative pain. Conclusions: This modification to the original technique of MIRPE creates a 3-point fixation system that minimizes the risk of bar shifting even in teenaged patients. It does not add any significant time or cost to the operation, and it is fairly simple to perform. The authors believe that this technique decreases the occurrence of bar displacement, and they recommend its use for all patients with pectus excavatum considered candidates for the Nuss repair. J Pediatr Surg 36:1266-1268. Copyright © 2001 by W.B. Saunders Company.