Pectus excavatum (PE) is one of the most common

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1 Analysis of the Nuss Procedure for Pectus Excavatum in Different Age Groups Do Hyung Kim, MD, Jung Joo Hwang, MD, Mi Kyeong Lee, RN, Doo Yun Lee, MD, and Hyo Chae Paik, MD Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital, Daejeon, and Department of Thoracic and Cardiovascular Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Background. The Nuss procedure is a newly developed operative method for minimally invasive repair of pectus excavatum in pediatric patients. However, the surgical indication for this procedure has been extended into adult patients. The aim of this study was to assess the surgical outcome of the Nuss procedure in different age groups and to analyze its feasibility in the adult population. Methods. From December 1999 to March 2003, 51 patients (40 males and 11 females) with pectus excavatum underwent the Nuss procedure. We classified patients into three groups based on age (pediatric, adolescent, and adult), retrospectively analyzed demographic, intraoperative and postoperative data, and compared outcomes among each group. Results. Mean operation time was minutes, minutes, and minutes in the pediatric, adolescent, and adult groups, respectively (p < 0.001). Postoperative complications occurred in 3 of 27 patients (11.1%) in the pediatric group and in 7 of 12 patients (58.3%) in both the adolescent and adult groups (p 0.002). Reoperations were performed due to complications in 1 of 27 patients (3.7%) in the pediatric group, 2 of 12 patients (16.6%) in the adolescent group, and 5 of 12 patients (41.7%) in the adult group (p 0.001). Conclusions. The Nuss procedure is highly recommended in pediatric patients with pectus excavatum. However, in adults it is necessary to select patients carefully because of the longer operation time and higher incidence of complications associated with the procedure in this population. (Ann Thorac Surg 2005;80:1073 7) 2005 by The Society of Thoracic Surgeons Pectus excavatum (PE) is one of the most common congenital chest wall anomalies and is first recognized primarily in infancy. The deformity becomes highly pronounced during the adolescent growth spurt, and most patients experience worsening of symptoms during this period; therefore, correction of PE in adolescents and adults is necessary in order to prevent and relieve aggravating symptoms [1]. The Nuss procedure is a minimally invasive procedure for correction of PE and has gained increasing acceptance worldwide. A recent survey reported that 31 of 74 responders (42%) use minimally invasive repair of PE as their procedure of choice [2]. However, the follow-up data regarding the Nuss procedure in the adult population is minimal [3], and thus the aim of this study was to compare outcomes of the Nuss procedure among pediatric, adolescent, and adult groups, as well as to analyze the feasibility of applying the procedure to adults and adolescents. Accepted for publication March 18, Address reprint requests to Dr Paik, Department of Thoracic & Cardiovascular Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine, Dogok-dong, Kangnam-gu, Seoul, , Korea; hcpaik@yumc.yonsei.ac.kr. Patients and Methods From December 1999 to March 2003, 51 patients with PE underwent the Nuss procedure. We classified patients into three age groups: children younger than 12 years old (pediatric group); patients between 12 and 20 years old (adolescent group); and patients older than 20 years of age (adult group). We analyzed each patient s demographics, and compared results of operation, length of hospital stay, and complication rate. We also compared the results of the Nuss procedure after the bar was removed in the pediatric group versus the adolescent and adult groups combined because the number of patients in the adult group was too small (n 4) to compare separately. Patients were followed up through outpatient clinic visits or with telephone calls. For all patients, the severity of PE was determined by computed tomographic scanning, in which the pectus index was calculated by dividing the width of the chest wall at the widest point by the distance between the posterior surface of the sternum and the anterior surface of the spine [4, 5]. A pectus index greater than 3.0 in a patient older than 3 years of age was determined as an indication for operation. We did not limit the upper age border for operation, and, if patients younger than 3 years old had recurrent pneumonia resulting in frequent hospital admissions, an operation was indicated in order to prevent the complications of pneumonia. The recom by The Society of Thoracic Surgeons /05/$30.00 Published by Elsevier Inc doi: /j.athoracsur

2 1074 KIM ET AL Ann Thorac Surg NUSS PROCEDURE IN DIFFERENT AGE GROUPS 2005;80: Table 1. Complications Among the Different Age Groups Pediatric Adolescent Adult p Value Incidence of complications 7.4% (2/27) 58.3% (7/12) 58.3% (7/12) Type of complications Bar displacement (1) Bar displacement (1) Bar displacement (3) Persistent pain (1) Persistent pain (1) Persistent pain (2) Pleural effusion (3) Pleural effusion (1) Incomplete correction (1) Wound problem due to stabilizer (3) Pneumothorax (1) mended time for removal of the bar was two years after the operation in the pediatric and adolescent groups, and between two and three years after the operation in the adult group. Operative Procedure Two small incisions were made in the right and left midaxillary lines at the level of deepest chest wall depression. With a long Kelly (forcep), a subcutaneous dissection was made until the pleural space was punctured near the midclavicular line. A Kelly was then passed underneath the sternum and into the contralateral side, out into the chest wall at the midclavicular line, and out through the previously made lateral skin incision. A long segment of umbilical tape was tied to a Kelly, which was then pulled out from the other side. A steel bar (Walter Lorenz Surgical, Jacksonville, FL), designed to conform to the chest wall deformity, was tied to the umbilical tape and was guided through the dissected plane, while pulling the umbilical tape from the contralateral side. After insertion, the bar was turned 180 degrees using a rotator until the chest wall was elevated. In order to stabilize the steel bar, both ends of the bar were suture-tied onto the rib using Nylon 1-0, or a stabilizer was used for fixation of the steel bar. Patients with inadequate chest wall elevation, which was most often noted in the adults, and patients with a focal remnant asymmetric deformity, had an additional bar inserted at one intercostal space above or below the original bar. The location and stability of the steel bar was assessed by a plain lateral chest roentgenogram, and intermittent intravenous analgesics were given to control postoperative pain. Statistical Analysis Data were analyzed with SPSS 11.0 statistical software (SPSS, Chicago, IL), and p values less than 0.05 were considered statistically significant. Discrete data were analyzed using the 2 test and continuous data were analyzed using the one-way analysis of variance test. Results Patient Demographics The mean age of patients was (range, 18 months to 51 years), and the ratio of men to women was 40 to 11. The pediatric group was composed of 27 patients, with a male to female ratio of 16 to 11, and ages ranged from 18 months to 12 years (mean, years). The adolescent group included 12 males, ranging in age from 13 to 19 years (mean, years). The twelve adults were all male, with ages ranging from 20 to 52 years old (mean, years). Common clinical symptoms were recurrent pneumonia in 19.6% (10 patients), arrhythmia in 3.9% (2 patients), and dyspnea on exertion in 5.9% (3 patients), and the mean pectus index was (range, 3.0 to 9.7). Three patients, who were younger than 3 years of age, underwent operation to relieve symptoms of recurrent pneumonia. Operation Results In the pediatric group, a single bar without a stabilizer was inserted in all patients. In the adolescent group, a single bar was inserted in three patients, while two bars were inserted in nine patients, and lateral stabilizers were used in 10 patients. In the adult group, two bars were inserted in all patients except one, who had only one bar inserted, and lateral stabilizers were used in all patients. Mean operation time was minutes (range, 25 to 140), minutes (range, 35 to 125), and minutes (range, 55 to 230) for the pediatric, adolescent, and adult groups, respectively (p 0.001). The mean duration of hospital stay was days (range, 2 to 8), days (range, 4 to 26), and days (range, 4 to 40) for the pediatric, adolescent, and adult groups, respectively (p 0.042). Focal asymmetry after operation was noted in 7.4% (2 out of 27) of the pediatric group, 25% (3 out of 12) of the adolescent group, and 25% (3 out of 12) of the adult group. The incidence of asymmetry after operation in the adolescent and adult groups was higher than in the pediatric group, but this difference was not statistically significant (p 0.085). The majority of patients (47 out of 51, 92.2%) had follow-up with a mean duration of months (range, 21 to 64). The rate of satisfaction was 88.0% (22 out of 25 patients) in the pediatric group, 72.7% (8 out of 11 patients) in the adolescent group, and 63.6% (7 out of 11 patients) in the adult group, with no statistically significant differences (p 0.221). The causes of dissatisfaction included insufficient elevation of the sternum to a desired level (five cases) and asymmetric correction (five cases). Although severity of pain was not found to be a cause of

3 Ann Thorac Surg KIM ET AL 2005;80: NUSS PROCEDURE IN DIFFERENT AGE GROUPS 1075 dissatisfaction, chest pain for more than six months after operation was present in 4% (1 out of 25) of pediatric patients and 54.5% (6 out of 11) of adults (p 0.001). Complications Postoperative complications occurred in three patients (11.1%) in the pediatric group, seven patients (58.3%) in the adolescent group, and seven patients (58.3%) in the adult group, which shows statistically significant differences between the pediatric group versus the adolescent and adult groups (p 0.002) (Table 1). The incidence of major complications requiring surgical intervention was 3.7% (bar rotation, one case) in the pediatric group, 16.6% (bar rotation, one case; incomplete correction, one case) in the adolescent group, and 50% (bar rotation, four cases; uncontrolled persistent pain necessitating bar removal, one case; stabilizer-induced wound problem, one case) in the adult group (p 0.001). The most common complication was bar displacement, with an incidence of 3.7% in pediatric patients, 8.3% in adolescents, and 33.3% in adults (p 0.027). In the adult group, three patients developed wound infections near the stabilizer, two cases of which were associated with bar displacement where the infection disseminated from the vicinity of the bar into the thoracic cavity causing empyema thoracis, thereby requiring removal of the bar. In the remaining patient, the infection did not disseminate, but wide muscle and skin defects occurred due to the severity of the infection near the stabilizer, necessitating a musculocutaneous flap and bar repositioning. One patient, who had a severe asymmetric deformity, experienced bar displacement on the third postoperative day, although two bars and two stabilizers were used, and had to undergo a Ravitch operation. Results of Bar Removal The bars were removed from 36 patients (23 pediatrics, 9 adolescents, and 4 adults) after a mean duration of months (range, 15.6 to 31.2) in the pediatric group and months (range, 19.6 to 51.2) in the combined adolescent and adult group (p 0.483). The mean operation time for bar removal was minutes (range, 20 to 150) and minutes (range, 35 to 120), in the pediatric and combined group, respectively (p 0.082). The mean duration of hospital stay for bar removal was days (range, 1 to 6) in the pediatric group and days (range, 1 to 7 days) in the combined adolescent and adult group (p 0.013). Hemothorax developed in one adolescent after bar removal and the patient subsequently received a closed thoracostomy. Follow-Up After Bar Removal The majority of patients (94.4%, 34 out of 36) were followed after the bar removal with a mean duration of months (range, 1 to 37). Two of the pediatric patients complained of mild depression of the sternum after bar removal, but all of the adults sustained contour of the chest wall. Comment The Ravitch operation has provided the best long-term results with the least discomfort and fewest complications [6] for treatment of pectus excavatum and thus the procedure has been the treatment of choice. However, chest wall instability may occur after the surgery due to aggressive dissection of the perichondrium, which results in growth retardation of the chest wall [7], and the procedure also requires a large skin incision into the anterior chest wall. Nuss [8] originally presented a technique of minimally invasive repair of PE at the American Pediatric Surgery Association in 1997, and a further update to the technique was presented by Croitoru and colleagues [9]. Compared to the Ravitch procedure, the Nuss technique offers several advantages, such as a shorter operation time, avoidance of instability of the chest wall, maintenance of chest wall elasticity, and absence of a large surgical incision [10]. This is a relatively new procedure and long-term follow-up results have not been reported; therefore, determining the surgical method of choice for different age groups is controversial. In an earlier report of the Nuss procedure, a higher complication rate and a longer hospital stay, in addition to more severe postoperative pain, was associated with the Nuss procedure compared with the Ravitch operation [10]. However, recent reports suggest that the Nuss procedure is associated with a shorter hospital stay and a lower incidence of major complications because the learning curve in the manipulation, insertion, and fixation of the pectus bar has been accomplished [11, 12]. The recommended optimal age for the Nuss procedure is between 6 and 12 years and it is generally not recommended for adults [9]. In a survey by the American Pediatric Surgical Association, most surgeons who responded to a questionnaire indicated that patients greater than 15 years old were at higher risk for complications, particularly the pectus bar displacement [2]. However, even without the publication of a feasibility study of the Nuss procedure in adults, application of this method in adolescents and adults has been steadily increasing, with a 21.2% procedure rate in PE patients older than 15 years of age reported in the recent literature [8, 13]. The outcomes of the Ravitch procedure in adults are satisfactory both from a cosmetic and from a physiologic point of view [14]. On the other hand, because there are only a few reports available regarding the Nuss procedure in adults, it is difficult to evaluate the feasibility of the Nuss procedure in this population. Fonkalsrud and colleagues [1] analyzed 116 adults with PE who underwent the Nuss procedure and concluded that, although the procedure is technically more difficult in adults, good physiologic and cosmetic effects with low morbidity and shorter hospital stays are possible in adults with the Nuss procedure. A long-term follow-up study showed a reoperation rate of 1.3% and an excellent satisfaction rate [15]. Coln and colleagues [3] also concluded that the Nuss

4 1076 KIM ET AL Ann Thorac Surg NUSS PROCEDURE IN DIFFERENT AGE GROUPS 2005;80: procedure was feasible to relieve symptoms and correct deformity in adults with PE. The force necessary to elevate the sternum to the desired level in children under 10 years old is reported to be 15 lbs, whereas for adolescents and adults, the mean force required is approximately 32 lbs and 41 lbs, respectively [16]. This higher force against the sternum not only causes considerable pain but also increases the likelihood of bar displacement. Ohno and colleagues [17] compared the results of the Nuss procedure by different ages, and concluded that patients older than 13 years of age experienced more complications and had poorer cosmetic results than did younger patients. In our study, the incidence of complications in older patients was also significantly higher than in younger patients. Additionally, the incidence of bar displacement, persistent pain, and reoperation rate due to the complications was also higher. Most of the complications we experienced with the Nuss procedure were related to extending the procedure into the adult population. The reported incidence of bar displacement is from 4% to 8%, and efforts have been made by many groups to reduce this complication. The use of a bar stabilizer, introduced by Nuss, has been shown to reduce the incidence of bar displacement from 15.7% to 5.4%. By using a combined technique of wiring the bar and the stabilizer, the incidence decreased even further [18] although the technique caused wound problems in the proximity of the stabilizer due to pressure damage. Hebra and colleagues [12] reported a 5% incidence of bar displacement by using a three-point fixation technique where the bar was secured by placing sutures at both ends of the bar in addition to placing sutures at the lateral margin of sternum at a point where the pectus bar crosses the cartilaginous rib. Park and colleagues [13], who modified a three-point fixation technique by adding two more fixations on the lateral rib with steel wires encircling the ribs above and below, reported a 3.4% incidence of bar rotation, and thus proposed that using a stabilizer has no advantage over this five-point fixation technique. Complications associated with the use of a stabilizer may be severe and disastrous. Wide and aggressive dissection during stabilizer insertion may result in a large amount of seroma formation postoperatively and thus increase the chance of wound infections around the bar [19]. Bar displacement in patients who received stabilizers seemed to result in more severe tissue destruction. In our cases, refixating the bar was not difficult, and the outcome of reoperation was good in patients who did not receive a stabilizer. However, patients who received stabilizers have experienced poor outcomes eventually necessitating the removal of the bar. The best candidates for the Nuss operation are young patients who have a symmetrical deformity [20]. However, most patients with an asymmetrical deformity seemed to prefer having minimal residual asymmetry rather than having a large scar on the chest associated with the Ravitch operation. However, in our study 15.7% of patients who underwent the Nuss procedure were asymmetrically corrected and 63% of these patients were dissatisfied with the results. In patients with severe asymmetrical deformity, especially in adults, the possibility of bar rotation and persistent pain is increased. According to Park and colleagues [21], the major complications after the Nuss procedure were associated with the severity of asymmetricity (eccentric long canal type) and the lack of experience of the surgeons. In adults with severe asymmetrical deformity, the Ravitch procedure may be a better initial choice than the obstinate application of the Nuss procedure because of the high probability of bar displacement and associated complications seen in this population. The outcomes after the bar removal reported by Nuss include cosmetic and functional results in which 71.8% were excellent, 10.7% were good, and 8.5% had failed [9]. Another report concluded that of 42 patients who underwent bar removal, all maintained initial contour [15]. In our cases, 34 of 36 patients who underwent bar removal maintained the same contour, and only two patients complained of mild depression of the sternum. However, in our study, the mean follow-up duration was short and the number of patients was small, and therefore it is difficult to conclude long-term outcomes after the bar removal in adults. In conclusion, the Nuss operation is highly recommended in the pediatric population due to lower complication and reoperation rates. In adolescents, although the complication rate was higher than in the pediatric group, the incidence of late complications such as bar displacement and persistent pain is acceptable. In adults, however, the incidence of reoperation due to bar displacement or stabilizer-related wound infection is high; therefore, the Nuss procedure is not recommended for correction of PE, especially when the PE is associated with a severe asymmetrical deformity. References 1. Fonkalsrud EW, DeUgarte D, Choi E. Repair of pectus excavatum and carinatum deformities in 116 adults. Ann Surg 2002;236: Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg 2000;35: Coln D, Gunning T, Ramsay M, Swygert T, Vera R. Early experience with the Nuss minimally invasive correction of pectus excavatum in adults. World J Surg. 2002;26: Haller JA, Kramer SS, Lietman SA. Use of CT scans in selection of patients of pectus excavatum surgery: a preliminary report. J Pediatr Surg 1987;22: Nakahara K, Ohno K, Miyoshi S, Maeda H, Monden Y, Kawashima Y. An evaluation of operative outcome in patients with funnel chest diagnosed by means of the computed tomogram. J Thorac Cardiovasc Surg 1987;93: Fonkalsrud EW, Dunn JCY, Atkinson JB. Repair of pectus excavatum deformities: 30 years experience with 375 patients. Ann Surg 2000;231: Haller JA, Colombani PM, Humphries CT, Azizkhan RG, Loughlin. Chest wall constriction after too extensive and too early operations for pectus excavatum. Ann Thorac Surg 1996;61:

5 Ann Thorac Surg KIM ET AL 2005;80: NUSS PROCEDURE IN DIFFERENT AGE GROUPS Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33: Croitoru DP, Kelly RE Jr, Goretsky MJ, Lawson ML, Swoveland B, Nuss D. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37: Molik KA, Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL. Pectus excavatum repair: experience with standard and minimal invasive techniques. J Pediatr Surg 2001; 36: Uemura S, Nakagawa Y, Yoshida A, Choda Y. Experience in 100 cases with the Nuss procedure using a technique for stabilization of the pectus bar. Pediatr Surg Int 2003;19: Hebra A, Gauderer MW, Tagge EP, Adamson WT, Othersen HB Jr. A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum. J Pediatr Surg 2001;36: Park HJ, Lee SY, Lee CS, Youm W, Lee KR. The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients. Ann Thoracic Surg 2004; 77: Fonkalsrud EW. Current management of pectus excavatum. World J Surg 2003;27: Mansour KA, Thourani VH, Odessey EA, Durham MM, Miller JI, Miller DL. Thirty-year experience with repair of pectus deformities in adults. Ann Thorac Surg 2003;76: Fonkalsrud EW, Reemtsen B. Force required to elevate the sternum of pectus excavatum patients. J Am Coll Surg 2002;195: Ohno K, Morotomi Y, Ueda M, et al. Comparison of the Nuss procedure for pectus excavatum by ages and uncommon complications. Osaka City Med J 2003;49: Nuss D, Croitoru DP, Kelly RE Jr, Goretsky MJ, Nuss KJ, Gustin TS. Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg 2002;2: Watanabe A, Watanabe T, Obama T, et al. The use of lateral stabilizer increases the incidence of wound trouble following the Nuss procedure. Ann Thorac Surg 2004;77: Jacobs JP, Quintessenza JA, Morell VO, Botero LM, van Gelder HM, Tchervenkov CI. Minimally invasive endoscopic repair of pectus excavatum. Eur J Cardiothorac Surg 2002; 21: Park HJ, Lee SY, Lee CS. Complications associated with the Nuss procedure: analysis of risk factors and suggested measures for prevention of complications. J Pediatr Surg 2004;39:391 5.