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The Nuss procedure for Pectus excavatum: Results from the last 10 years at CHKD

Robert E. Kelly, Jr., Frazier N. Frantz, Robert J. Obermeyer, M. Ann Kuhn, Michele Lombardo, Michael J. Goretsky, Donald Nuss

Children’s Hospital of the King’s Daughters and Eastern Virginia Medical School, Norfolk, Virginia, USA

 

Objective: To report the most recent results and complications of the Nuss procedure at Children’s Hospital of the King’s Daughters in Norfolk, Virginia, USA

Background Data:  In 1997, Donald Nuss reported a 10-year experience with a new minimally invasive procedure for surgical correction of Pectus excavatum in 42 children at CHKD.  Since then, we have treated an additional 2000 children.  In the intervening 19 years, many modifications to the original procedure have been made, and patient care has been improved.    In this report, we briefly summarize the results of previously published modifications by relating the results and complications in the most recent 10 years.

Methods:  From January 2006 to December 2016, we evaluated 1866 Pectus excavatum patients.  Following previously published criteria, they were evaluated by three-dimensional chest imaging, pulmonary function studies, and a cardiology evaluation which included echocardiogram and electrocardiogram.  Surgery was indicated if patients were symptomatic, had a severe pectus excavatum on a clinical basis, and had two or more of the following:  CT index greater than 3.25, evidence of cardiac or pulmonary compression on CT/MRI or echocardiogram, mitral valve prolapse, arrhythmia, or restrictive lung disease.  Data regarding evaluation, treatment and follow up have been prospectively recorded since 1994; only the most recent cases are reported here.  Surgical repair was performed in 1186 (63.5%) of 1866 pectus excavatum patients evaluated.  Of these, 1075 were primary repairs, and 56 were redo operations.  Bars have been removed from 1143 patients.

Results:  The mean Haller CT index was 5.36.  Mitral valve prolapse was present in 6.86 percent of 1006 patients studied with echocardiogram.  Complications continued to decrease in frequency in the last 10 years (the first such operation was perfomed by Dr. Nuss 29 years ago).  In primary operation patients, the bar displacement rate requiring surgical repositioning was 1.8%.  Allergy to metal was identified in 10 patients postoperation.  Since switching to a test which incorporates all of the elements in the 318 L stainless steel used (Allergease), only one patient has developed allergy postop.  Of the 10 with postop allergy, 2 required bar removal; the others were successfully treated medically.  Wound infection occurred in 18 (1.5%) patients, of whom 6 (0.5%) required surgical drainage.  Hemothorax occurred in 5 patients, 1 during the postoperative period and 4 occurred late.  A good or excellent anatomic surgical outcome was achieved in nearly all patients at the time of bar removal.  Recurrence of sufficient severity to require reoperation occurred in only 1 primary surgical patient.  The minimally invasive procedure has been successfully performed in 371 adult patients aged 18 to 46 years of age.