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Management of Life Threatening Major Bleed During Nuss Bar Removal

Mustafa Yüksel, Nezih Onur Ermerak, Zeynep Bilgi, Çağatay Çetinkaya, Bihter Sayan

Department of Thoracic Surgery, Marmara University Hospital, Istambul, Turkey


Objective: Nuss procedure is widely accepted as procedure of choice for repair of Pectus Excavatum and requires a bar removal operation approximately 2 years after the initial correction. While bar removal is generally believed to be safe, major bleeding can occur incidentally.

Methods: We report 3 cases of major hemorrhage occurred during bar removal and managed conservatively without needing thoracotomy, sternotomy or otherwise visualization of the bleeding source. Case 1: 24 years old male who was operated 2 years ago with two bars and 2 left stabilizers. Case 2: 20 years old female with a history of Nuss 3 years ago. She had 2 bars and 2 left stabilizers. Case 3: 32 years old male who was operated with double bars and two left stabilizers 4 years ago.

Results: 1300 cc was detected in the first case and 300cc and 400 cc in the other cases. Perioperative echocardiogram was performed in all cases. Pericaridal effusion was detected in 2 cases. Left videothoracoscopy was performed in the first case and only packing with gauzes was performed in the other two cases. Tube thoracostomy and blood transfusion was needed only in the third case. Postoperative period was uneventful in all cases. Fist case was discharged on postoperative 5th day, second case on 2nd day and third case on 4th day.

Conclusion: In terms of intraoperative management, it is very important to have multidisciplinary care available in short choice. It must be kept in mind that stable vitals are of paramount importance for decision to evaluate instead of surgical exploration. As long as the vitals of the patient permit, it is feasible to pack the bleeding, evaluate by noninvasive means (transesophageal ECHO, transthoracic ultrasound, C-arm and X-Ray etc.) to pinpoint the source and decide on a more invasive approach if necessary.

Keywords: Pectus, MIRPE, bar removal, bleeding