Pectus excavatum is a chest wall deformity characterized

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1 Minimally Invasive Repair for Pectus Excavatum in Adults Swee H. Teh, MD, Angela M. Hanna, MD, Tuan H. Pham, MD, PhD, Adriana Lee, MD, Claude Deschamps, MD, Penny Stavlo, RN, and Christopher Moir, MD Divisions of Pediatric Surgery and Thoracic Surgery, Mayo Clinic, Rochester, Minnesota Background. The purpose of this study is to review the minimally invasive pectus excavatum repair in adults to determine the safety and effectiveness. Methods. An Institutional Review Board approved chart review identified patients 17 years or older who underwent minimally invasive pectus excavatum repair (MIPER) between January 1999 and January Results. Nineteen patients underwent MIPER. Indications for surgery were reduced exercise tolerance (13), dyspnea on exertion (17), improve self-perception (10), and chest pain (6). There were no intraoperative complications or conversions to open repair. Twelve patients (63%) required one strut and seven patients (37%) required two struts. Postoperative complications included self-resolving asymptomatic pneumothorax in six patients and pneumonia in one. Pain at six weeks postoperatively was mild to none in most patients and all had no pain at three months postoperatively except one patient with strut displacement. Two patients required removal of one of two struts due to displacement. The mean postoperative pectus index was significantly lower than preoperative value: 2.5 versus 4.6, p Among six patients with strut removal at two years postoperatively, two patients had mild recurrence of their deformity. Conclusions. Minimally invasive pectus excavatum repair can be performed safely in adults. This approach is technically more challenging in adults with one-third of the patients requiring two struts for optimal repair. The risk of strut displacement is higher than in the pediatric population. The long-term effectiveness and durability of this procedure in adults is still unknown. (Ann Thorac Surg 2008;85:1914 8) 2008 by The Society of Thoracic Surgeons Pectus excavatum is a chest wall deformity characterized by posterior displacement of the sternum. The etiology of this deformity is poorly understood. Most patients have the deformity throughout their childhood life and it worsens during the teenage growth spurt. Surgical correction offers a favorable outcome. Among the surgical approaches described, the minimally invasive pectus excavatum repair (MIPER) has recently received much attention, especially in children [1]. Many patients, however, enter into adulthood with persistence of their pectus excavatum deformity. There are limited reports on the suitability of this minimally invasive repair technique for young adults. The aim of this study is to review a single institution experience with adult repair to determine the safety and effectiveness of the minimally invasive approach. Material and Methods Patients and Data An Institutional Review Board approved retrospective review was performed to identify patients who were 17 years old or greater and underwent MIPER between January 1999 and January Individual consent for the Accepted for publication March 5, Address correspondence to Dr Moir, Mayo Clinic Rochester, Division of Pediatric Surgery, 200 Second Street SW, Rochester, MN 55905; moir.christopher@mayo.edu. study was waived because it was a retrospective review. Data on general demographics, clinical presentation, radiologic studies, severity of the deformity, surgical procedure, perioperative morbidity and mortality, and success of pectus repair were tabulated from detailed chart review. The severity of the deformity was assessed by the pectus index, the ratio of transverse diameter of the chest to the anteroposterior distance as measured from the anterior border of the vertebral body to the posterior border of the sternum [2]. This was assessed either by chest X-ray or computed tomographic computed tomographic scan. Pectus index of greater than 3 is classified as severe deformity. Indications for surgery were reduced exercise tolerance, dyspnea on exertion, poor self-perception, and chest pain (6). Operative Technique Preoperatively, thoracic epidural catheter was inserted for pain management. After induction of general anesthesia, a transverse skin marking was made outlining the anticipated placement of the strut bar to correct the pectus deformity. At the midclavicular point of the skin marking, a3to4cmtransverse skin incision was made bilaterally. Using electrocautery and blunt dissection, subcutaneous pockets around the incision were created just above the chest wall musculature. A trocar fitting a 5-mm thorascopic camera was inserted into the right hemithorax through the right inferolateral chest wall incision. Carbon 2008 by The Society of Thoracic Surgeons /08/$34.00 Published by Elsevier Inc doi: /j.athoracsur

2 Ann Thorac Surg TEH ET AL 2008;85: MIPER IN ADULTS dioxide insufflation to 6 mm Hg was administered through the trocar to partially deflate the right lung. Through the midclavicular transverse incision, and under direct thorascopic camera visualization, the right thoracic cavity was entered bluntly using either a large aortic aneurysmal clamp or pectus dissector instrument (Walter Lorenz Surgical, Jacksonville, FL). Again under direct vision from the thorascopic camera, the aneurysmal clamp or pectus dissector was tunneled across the sternum to the left hemithorax, and its tip bluntly exited the left hemithorax through the left midclavicular incision. An umbilical tape was secured to the aneurysmal clamp or pectus dissector. The clamp or dissector was withdrawn, and this resulted in tunneling of the umbilical tape from left to right. A strut, which was custom fashioned by hand intraoperatively to fit each individual s chest conformation and pectus defect, was secured to the right end of the umbilical tape. Guided by the umbilical tape, the strut was passed through the thorax from the right to the left incision in a concave-up position. The strut was flipped to a concave-down position to buttress the sternum and correct the pectus deformity. Once the strut is positioned to properly correct the deformity, it is secured to the chest wall with 0-prolene or wire sutures tied around the rib to anchor the bar to the rib. Many patients were identified preoperatively for two struts based on the severity of their deformity in addition to their age. Intraoperatively, if one strut did not correct the deformity satisfactorily then a second strut was placed either superior or inferior to the first bar in an identical fashion. Air in the chest cavity was evacuated by applying suction through the trocar as well as by giving the patient a few large tidal breaths. An immediate postoperative chest X-ray was performed to ascertain proper strut position as well as residual pneumothorax. Postoperative pain management was achieved through a combination of epidural, intravenous, and oral analgesics. Epidural was continued for the first 72 hours. Patient control analgesia was started when deemed necessary. Patients were dismissed from hospital when they were able to tolerate postoperative pain with oral analgesia, including nonsteroidal antiinflammatory drugs (ie, ibuprofen), acetaminophen, and oxycodone. Statistical Method Statistical analyses were performed using the JMP statistical package (JMP Software, Cary, NC). The paired Student t test was used to evaluate for statistical difference between groups, where a p value less than 0.05 was considered statistically significant. Standard error of the mean ( SE) is used to express value uncertainty, unless specified otherwise. Results Nineteen patients underwent minimally invasive pectus excavatum repair during the study period. There were 11 men and 8 women presenting at a mean age of 19.5 years (age 17, n 9; 18, n 3; 19, n 2; 20, n 1; 21, n 3; 42, 1915 Fig 1. Severity of pain at six weeks after minimally invasive repair of pectus excavatum in 19 adults. n 1.) The mean preoperative pectus index was (range, 3.2 to 15). The indications for surgery were reduced exercise tolerance (13), dyspnea on exertion (17), poor self-perception (10), and chest pain (6). Preoperative workup included pulmonary function tests in 12 patients, which revealed mild restrictive patterns but no major abnormalities, and echocardiogram in 4 patients, which were all normal. No patients had signs or symptoms of Marfan syndrome or other connective tissue disorders. Two patients had recurrence of the deformity after open repair elsewhere. One patient had an open repair at the age of 9 and developed relapse one year later with worsening chest pain. The other patient had open repair of his pectus excavatum at age 5 but had a recurrent deformity several years later with associated symptoms of dyspnea on exertion and chest pain. Both patients underwent minimally invasive repair for the excavatum at age 17 at our institution. Minimally invasive pectus excavatum repair was successfully performed in all patients. There were no intraoperative complications, and no patient required conversion to an open repair or blood transfusion. The mean operative time was hours (range, 1.0 to 5.16 hours), 63% (12 patients) required one strut and 37% (7 patients) required two struts in order to properly correct for the deformity. There were no perioperative deaths. One patient developed pneumonia and six patients were noted to have asymptomatic residual pneumothorax that resolved without chest tube placement. Thoracic epidural and oral analgesia, as described above satisfactorily controlled immediate postoperative pain. All patients reached satisfactory pain relief by oral analgesia prior to hospital dismissal. The mean hospital stay was 5.8 days (range, 4 to 8 days). At six weeks after surgery, all patients were evaluated with clinical exam and chest X-ray. Pain at six weeks postoperative was significant in four, moderate in four, mild in six, and none in five patients (Fig 1). Two of the GENERAL THORACIC

3 1916 TEH ET AL Ann Thorac Surg MIPER IN ADULTS 2008;85: Fig 2. Plot of the mean preoperative versus mean postoperative pectus index in all 19 adult patients who underwent minimally invasive pectus excavatum repair. four patients with significant pain were due to strut displacement. These two patients required premature removal of one of the two struts at one and seven months postoperatively. At three months postoperatively, all patients were pain free except one whose pain was secondary to strut displacement. Based on self-reporting, patients were satisfied with the results, where all the repairs were evaluated as good to excellent at mean follow-up of 27 months (range, 3 to 71 months). All 13 patients who had reduced exercise tolerance preoperatively reported improvement of the cardiorespiratory symptoms postoperatively. By objective measure, the mean postoperative pectus index was significantly lower as compared with the mean preoperative value: 2.5 versus 4.58, p (Fig 2). Six of the nineteen patients had their bar removed at the end of two years. Among these, 33% (two patients) were noted to have a mild recurrence of their pectus deformity. The first patient was an 18-year-old symptomatic female with a preoperative pectus index of 3.3 that improved postoperatively to 2.7. On follow-up at 13 months after strut removal, her pectus index had progressed from 2.7 to 2.9. This patient did opt for a redo repair, which due to adhesions and difficulty was converted to an open procedure. The second patient was a 19-year-old male whose preoperative pectus index was 3.9 and his postoperative pectus index was improved to 2.5. He had a progression of his pectus index to 2.68 at 16 months after strut removal. The other four patients were followed for a mean of six months without evidence of recurrence. Comment Pectus excavatum is often associated with children. When repair is not pursued or failed during childhood, the deformity persists into adulthood. Surgical repair is frequently delayed until after the teenage growth spurt when the chest wall growth decreases and the risk of recurrence is minimized. The deformity may cause several clinical symptoms that range from chest discomfort and reduced exercise tolerance to social withdrawal due to poor self-perception [3, 4]. Surgical repair of this deformity in early adulthood may offer the best corrective measure and has a lower hypothetical risk of recurrence because chest wall growth is minimal during this period. The surgical treatment of pectus excavatum has changed considerably in the last several decades, ranging from the open repair to the recently described minimally invasive technique known as the Nuss procedure [5]. The effectiveness of this procedure is based on the premise that the chest wall possesses the capability of remodeling and reconfiguration. The Nuss procedure has received much attention as it is minimally invasive, safe, avoids cartilage resection, has a shorter operating time, is highly effective in children, and offers excellent results in more than 90% of patients [5 7]. This procedure also improves the patient s self-perception and quality of life [4]. There are limited data to support the role of this repair in early adult patients with pectus excavatum. In one report by Coln and colleagues [8], eight patients aged 19 to 32 years underwent the Nuss procedure based on a chest wall index greater 3.25 or cardiac abnormalities identified on echocardiography. Only one bar was used in these patients with one to two lateral stabilizing bars. Mean operative time was 1.32 hours, mean hospital stay was four days, and pain medication was stopped between two and four weeks postoperatively in all patients except two who continued narcotics for two and four months. Late complications included one separation of a stabilizer bar requiring reoperation, and one bar displacement requiring reoperation. Follow-up was a mean of 22.1 months, and only four patients had undergone bar removal after one to two years. In these patients there was a good result with no loss of correction in a mean follow-up of 9.7 months after bar removal. The series is small with a short follow-up but shows good early results using only one bar that is removed after one to two years. Another series by Kim and colleagues [9] compared the results of the Nuss procedure in three different age groups: pediatrics less than 12 years (n 27), adolescents 12 to 20 years (n 12), and adults greater than 20 years (n 12). A pectus index greater than 3.0 was an indication for operation, in addition to recurrent pneumonia, arrhythmia, and dyspnea on exertion. In adolescents, three patients had one bar placed while nine had two bars and lateral stabilizers were used in ten patients. In adults, all patients but one had two bars placed and all had lateral stabilizers. Mean operative times were longer in the adolescent, and more so in the adult populations where the mean operative time was minutes. Additionally, mean hospital stay was increased, at days for adolescents and days for adults. In adults, 54.5% had chest pain for more than six months after the operation, one of whom ultimately underwent bar removal due to pain. Postoperative complications in the adolescent and adult groups were 58.3% in each

4 Ann Thorac Surg TEH ET AL 2008;85: MIPER IN ADULTS group, with bar rotation in 8.3% of adolescents and 33.3% of adults, one of whom ultimately underwent a Ravitch procedure for correction. There were three wound infections, where two patients developed empyema as a result necessitating bar removal, and one who required bar repositioning and musculocutaneous flap. Nine adolescents and four adults had bars removed at a mean of months. After bar removal, a follow up of months showed that all adolescents and adults had sustained results. The authors concluded that the bar displacement in adolescents is acceptable; however, in adults, even though post bar removal results are good, due to a high incidence of complications and reoperation the procedure is not recommended. Our series has demonstrated that this minimally invasive repair is indeed safe in adult patients without major operative morbidity. The operative duration is longer compared with children [6, 7]. Our mean operative time was 2.1 hours, mildly increased compared with the other reports in adults [9, 10]; however, there were two patients whose operative times were 5.07 and 5.16 hours. The first patient had undergone a previous open Ravitch repair, making dissection tedious and difficult. The second patient had a severe and lengthy deformity eventually requiring intraoperative placement of two struts to correct the angulation. The common immediate postoperative complications encountered in children were similarly seen in the adult population [1, 9, 10]. In our population, all pneumothoraces were small, limited, and resolved without chest tube placement. Postoperative pain could be managed effectively with epidural analgesia and subsequently with the combination of opiate and nonsteroidal antiinflammatory drugs. Of note, the postoperative pain was more marked in our adult patients as compared with children, where 21.1% of the patients still experienced a significant amount of intermittent pain at six weeks postoperative. This range is consistent with the previous reports in the adult population [9, 10]. The etiology of the continued pain in two of the four patients was secondary to strut displacement. The pain resolved when one of their two struts was removed surgically. It is also likely that in adults the chest wall is stiffer, harder to reconfigure by the strut, and therefore results in more pain. We also demonstrated that the pectus excavatum was successfully corrected in all patients with the minimally invasive technique, including two patients who had a recurrence from a failed open repair [10]. Seven of 19 patients (37%) required two struts for optimal correction. Many patients were considered to be candidates preoperatively for two struts based on the severity of their deformity in addition to their age. However, the final decision for two struts was made intraoperatively if one strut did not correct the deformity satisfactorily. Two of the seven patients experienced the complication of strut displacement causing significant pain and in these cases one strut was removed prematurely. We hypothesize that the higher complication rate encountered in patients who had two struts might be due to selection bias as these patients have a greater cephalocaudal axis extent of their 1917 deformity. The insertion of the second strut increased the risk of suboptimal contact of one of the bars to the undersurface of the sternum. This allowed some degree of mobility in the strut that has a suboptimal strut-sternal contact. Nuss and colleagues [5] also note that strut displacement occurs in 15% of patients without a stabilizer, 6% of patients with a stabilizer but without wiring, and only in 5% of patients with wiring of the stabilizer [1, 5]. Therefore, stabilizing techniques used in adults must be reinforced with wiring of the stabilizer. We used a technique similar to the wire-fixation technique where we tied the bar around the rib without a stabilizer. This was done in all but two patients, one who was early on in our experience before we incorporated this technique, and the other had undergone previous open Ravitch repair and we felt the bar had better stabilization with a stabilizer bar. The wire-fixation technique may be less costly, more time efficient, safer, and more effective to perform in children; however, it may not be suitable for adults with a stronger physique and severe pectus deformity. Typically bars have been left in place for two years. Among our patients, six of nineteen have had their bars removed, all as completion of the operation. Two of these patients have been noted to have a mild recurrence, one at one week and one at 16 months post strut removal. The first patient eventually underwent a redo repair that converted to an open procedure secondary to adhesions. The second patient had remained asymptomatic and has not required reoperation. As the result of this finding, we now have been opting to leave the strut in longer, up to three years. Most patients with severe pectus excavatum experience reduced exercise tolerance, dyspnea on exertion with shifting of the cardiac chambers, and compression of the heart marked radiologically [11]. It has been postulated that the respiratory symptoms seen in patients with pectus excavatum are secondary from alteration of the cardiac physiology during exercise. Zhao and colleagues [12] demonstrated that the exercise capacity during an upright position in these patients is affected by reduced venous filling of the heart and therefore results in reduction of stroke volume and peak oxygen uptake. Our series had 13 patients who reported reduced exercise tolerance, 17 reported dyspnea on exertion, and 6 complained of chest pain. Twelve patients underwent standard pulmonary function tests, which some reported mild restrictive patterns but did not reveal significant abnormality. Four patients were evaluated with an echocardiogram, all of which were normal. All of our 13 patients with reduced exercise tolerance preoperatively had resolved cardiopulmonary symptoms postoperatively, which is corroborated by other studies [9 11, 13, 14]. Minimally invasive pectus excavatum repair can be performed safely in adult patients. The operative and recovery time is longer and up to one third of adult patients may need a second strut to optimize the repair. The risk of strut displacement is higher than in children especially when a second strut is placed. We observed significant recurrence rate of the deformity in adults if the strut was removed in two years. Therefore, in this GENERAL THORACIC

5 1918 TEH ET AL Ann Thorac Surg MIPER IN ADULTS 2008;85: patient population, we are now leaving struts in for three years. Overall, the long-term effectiveness and durability of this procedure in adults is still unknown and longer follow-up is needed. References 1. 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;12: Daunt SW, Cohen JH, Miller SF. Age-related normal ranges for the Haller index in children. Pediatr Radiol 2004;34: 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: Lawson ML, Cash TF, Akers R, et al. A pilot study of the impact of surgical repair on disease-specific quality of life among patients with pectus excavatum. J Pediatr Surg 2003; 38: 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: Hosie S, Sitkiewicz T, Petersen C, et al. Minimally invasive repair of pectus excavatum--the Nuss procedure. A European multicentre experience. Eur J Pediatr Surg 2002;12: Miller KA, Woods RK, Sharp RJ, et al. Minimally invasive repair of pectus excavatum: a single institution s experience. Surgery 2001;130: 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: Kim do H, Hwang JJ, Lee MK, Lee DY, Paik HC. Analysis of the Nuss procedure for pectus excavatum in different age groups. Ann Thorac Surg 2005;80: Miller KA, Ostlie DJ, Wade K, et al. Minimally invasive bar repair for redo correction of pectus excavatum. J Pediatr Surg 2002;37: Beiser GD, Epstein SE, Stampfer M, Goldstein RE, Noland SP, Levitsky S. Impairment of cardiac function in patients with pectus excavatum, with improvement after operative correction. N Engl J Med 1972;287: Zhao L, Feniberg MS, Gaides M, Ben-Dov I. Why is exercise capacity reduced in subjects with pectus excavatum? J Pediatr 2000;136: Quigley PM, Haller JA Jr, Jelus KL, Loughlin GM, Marcus CL. Cardiorespiratory function before and after corrective surgery in pectus excavatum. J Pediatr 1996;128(5 Pt 1): Haller JA Jr, Loughlin GM. Cardiorespiratory function is significantly improved following corrective surgery for severe pectus excavatum. Proposed treatment guidelines. J Cardiovasc Surg (Torino) 2000;41: Notice From the American Board of Thoracic Surgery Regarding Trainees and Candidates for Certification Who Are Called to Military Service Related to the War on Terrorism The Board appreciates the concern of those who have received emergency calls to military service. They may be assured that the Board will exercise the same sympathetic consideration as was given to candidates in recognition of their special contributions to their country during the Vietnam conflict and the Persian Gulf conflict with regard to applications, examinations, and interruption of training. If you have any questions about how this might affect you, please call the Board office at (312) Richard H. Feins, MD Chair The American Board of Thoracic Surgery 2008 by The Society of Thoracic Surgeons Ann Thorac Surg 2008;85: /08/$34.00 Published by Elsevier Inc