Early Experience with the Nuss Minimally Invasive Correction of Pectus Excavatum in Adults

Abstract

Nuss described a minimally invasive technique for correcting pectus excavatum in children. A curved stainless-steel bar is inserted behind the sternum through the chest cavity with the convex surface face down, then rotated 180 degrees to elevate the sternum and correct the deformity. The procedure gained wide acceptance in children. The purpose of this study was to determine if the procedure is effective in adults. Only patients with symptoms limiting lifestyle, chest wall indices higher than 3.25, and demonstrable cardiac compression on echocardiography were accepted. Between April 1998 and January 2001, 14 adults aged 19 to 46 underwent assessment for the Nuss minimally invasive technique for correction of pectus excavatum. Eight patients, 19 to 32 years of age, met the stated criteria for acceptance. The comorbidities were 2 asymmetrical deformities, 2 scolioses, 1 previous pectus repair, and 1 previous breast augmentation. The patients were informed of the benefits and disadvantages of both the Ravitch and the Nuss procedures. All patients except the first had talked to one or more adults who previously had the procedure. Follow-up was 7 to 37 months (mean 22.1 months). Four patients have had their bars removed and maintained correction. Success of the operation was based on relief of cardiac compression, alleviation of symptoms, and adequate pain control. Operating time was 1 to 2:05 hours (mean 1:32 hours). Complications were pneumothorax in one patient, urinary retention in 2, and left lower lobe atelectasis in 5. Complications did not prolong hospitalization. Postoperative epidural analgesia was discontinued after 2 to 4 days (mean 2.8 days). Average daily pain scores were between 1.6 and 3.7 on a scale of 0 to 10. Hospital stay was 3 to 5 days (mean 4 days). Relief of symptoms and increase in activity were obtained in all patients. Relief of cardiac compression was demonstrated in the 6 patients who have had postoperative echocardiograms. Patients returned to normal activity 2 to 4 weeks postoperatively (mean 2.3 weeks). Duration of pain medicine was 2 to 4 weeks in 6 patients and 2 and 4 months for the other 2 (mean 5.5 weeks). There were 2 late complications related to the bar, but without loss of correction. The early experience with the Nuss minimally invasive pectus excavatum repair in adults is encouraging. The procedure is effective for correcting pectus excavatum in selected patients. Early results are dependent upon adequate bar stabilization and pain control. The long-term results in adults are unknown.

Current Management of Pectus Excavatum: A Review and Update of Therapy and Treatment Recommendations

“…In adults the loss of elasticity and flexibility of the chest can lead to cardiac symptoms with only moderate exertion. 8,26 A similar phenomena is also seen in patients with scoliosis as they age. 6,7 Publications regarding the surgical management of adult patients with pectus deformities are few, but have increased significantly during the past few years with greater recognition of the physiologic and psychologic impact of the disease.…”

“…Cosmetic results are reported as good to excellent in Ͼ85% of patients, and the operation has rapidly gained popularity because of the small skin incisions and shorter operative time. 20,25,26,47,50 In recent years the operation has been successfully used to repair PE in adults, although higher rates of complications and postoperative pain have been reported. 26,29,32,53 The advantages of the Nuss approach include avoiding an anterior chest wall incision, resection of rib cartilages, and no sternal osteotomy.…”

“…20,25,26,47,50 In recent years the operation has been successfully used to repair PE in adults, although higher rates of complications and postoperative pain have been reported. 26,29,32,53 The advantages of the Nuss approach include avoiding an anterior chest wall incision, resection of rib cartilages, and no sternal osteotomy. Incorporation of thoracoscopic techniques has made the Abnormal cardiopulmonary testing operation safer, allowing for visualization of the heart when the bar is passed retrosternal.…”

“…3,29,30,36,49 Adult repair is also feasible and has been reported in patients as old as 78 years. 18,19,24,26,29,30,32,50 In general, referral to a surgeon for consultation should occur when a patient demonstrates any of the criteria listed in Table 2. Most patients will be considered for surgical correction if they demonstrate at least 2 of the listed criteria.…”

The Nuss Procedure for the Correction of Pectus Excavatum

“…Because of its simplicity the procedure has been introduced also for only cosmetic indications. The operation has been also performed in adults (12,13).…”