Selective use of sternal elevation before substernal dissection in more than 2000 Nuss repairs at a single institution

Obermeyer, Robert J.; Goretsky, Michael J.; Kelly, Robert E.; Frantz, Frazier W.; Kuhn, M. Ann; McGuire, Margaret; Duke, Duane S.; Paulson, James F.

doi:10.1016/j.jpedsurg.2020.07.005

Cited by 5 publications

(6 citation statements)

References 30 publications

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“…More than half of the cases (11/16), including ours, happened during initial PE repair and 3/16 during bar removal procedures. Out of 16, 1 had a previous Ravitch repair, whereas 3 had a history of open cardiac surgery [ 6 , 13 ]. The most frequent injury sites (12/16 cases) were the right atrium or ventricle, or both.…”

Section: Discussionmentioning

confidence: 99%

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Cardiac perforation during minimally invasive repair of pectus excavatum: a rare complication

Senica

Gasparella

Soldatenkova

et al. 2022

Journal of Surgical Case Reports

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Life-threatening complications (LTCs) and negative results of surgical treatments often go unreported. Minimally invasive repair of pectus excavatum (MIRPE) represents a procedure with a low incidence of adverse outcomes. However, 15 potentially fatal cases of MIRPE-related heart injury have been published. We report a case of cardiac perforation (CP) during MIRPE. A 12-year-old female was admitted for elective repair of a severe asymmetric pectus excavatum. Preoperative computed tomography showed a Haller index of 4.9. MIRPE was performed under bilateral video-assisted thoracoscopy. After the placement of the pectus bar, cardiac arrhythmias, hypotension and bilateral hemothorax occurred. Emergency thoracotomy without pectus bar removal showed CP. The wound sites were repaired and the pectus bar was eventually successfully implanted. The patient was discharged on postoperative day 11. After 10 months, she remains asymptomatic. Reporting rare complications is essential for accurate calculations of the true prevalence of LTCs, maintaining high alertness in pediatric surgeons.

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Section: Discussionmentioning

confidence: 99%

“…Over the years, several modifications have improved results and reduced the risk of LTCs, such as sternal elevation, vacuum bell and subxiphoid handheld hook [ 13 ]. In our case, bilateral thoracoscopy allowed visualization of the introducer’s tip throughout the procedure.…”

Section: Discussionmentioning

confidence: 99%

Cardiac perforation during minimally invasive repair of pectus excavatum: a rare complication

Senica

Gasparella

Soldatenkova

et al. 2022

Journal of Surgical Case Reports

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“…There are multiple methods by which sternal elevation can be performed, including off-label use of a vacuum bell applied externally to the sternum (12)(13)(14), various methods of crane elevation first described by Park (15), and by use of a subxiphoid incision for manual elevation of the sternum (16,17). In patients without prior sternotomy, selective sternal elevation has been demonstrated to be safe (10). However, in cases of prior sternotomy, routine sternal elevation was frequently used but alone was inadequate to prevent iatrogenic cardiac injury.…”

Section: Review Of Mirpe Procedures After Previous Sternotomymentioning

confidence: 99%

“…Using thoracoscopy, the surgeon maintains direct visualization of the tip of the dissecting instrument at all times, keeps a clear view of the pericardial sac away from the sternum, and sees the contralateral exit site during passage of the introducer. This is described as the “critical view” for performing MIRPE safely ( 9 , 10 ). In cases of prior sternotomy, it is important to note that thoracoscopy alone is not adequate to maintain the “critical view”.…”

Section: Review Of Mirpe Procedures After Previous Sternotomymentioning

confidence: 99%

Pectus repair after prior sternotomy: clinical practice review and practice recommendations based on a 2,200-patient database

Kenney¹,

Obermeyer²

2023

J Thorac Dis

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The minimally invasive repair of pectus excavatum (MIRPE) is widely accepted as a method of pectus excavatum (PE) repair. Repair is rarely performed in patients with a history of median sternotomy.A feared complication of this procedure is iatrogenic cardiac injury; the risk of injury in patients with prior sternotomy is especially high due to the development of post-surgical retrosternal adhesions, which obscures the "critical view" during MIRPE. A 14-center review reported the incidence to be as high as 7% after analyzing 75 patients with history of sternotomy who underwent MIRPE. Little literature exists on how to best prepare for MIRPE in patients with prior sternotomy. A review of the literature and a retrospective review of over 2,200 patients who underwent MIRPE at our institution was performed to analyze 9 patients who underwent MIRPE after prior sternotomy. Iatrogenic cardiac injury occurred in 2 patients. Given the infrequency in our experience and the low numbers reported in the literature, statistical conclusions cannot be drawn. However, prudent strategies based on this experience include thoracoscopy, routine sternal elevation, direct sub-xiphoid retrosternal dissection, coordination with cardio-thoracic surgeons, preparation for cardio-pulmonary bypass, and massive transfusion protocol availability to optimize surgical outcomes in patients undergoing MIRPE with a history of sternotomy.

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“… 3 To reduce the risks of potentially fatal complications, it is imperative to maximize the substernal space for better visualization while performing dissection and to lessen the risk of intercostal stripping during the implantation of the Nuss bar. 4 …”

mentioning

confidence: 99%

Commentary: How best to quantify an uplifting pectus operation?

Chang

Hsin

2021

JTCVS Techniques

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Selective use of sternal elevation before substernal dissection in more than 2000 Nuss repairs at a single institution

Cited by 5 publications

References 30 publications

Cardiac perforation during minimally invasive repair of pectus excavatum: a rare complication

Cardiac perforation during minimally invasive repair of pectus excavatum: a rare complication

Pectus repair after prior sternotomy: clinical practice review and practice recommendations based on a 2,200-patient database

Commentary: How best to quantify an uplifting pectus operation?

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