Pediatric Surgery International

, Volume 31, Issue 5, pp 493–499 | Cite as

Minimally invasive repair of pectus excavatum: analyzing contemporary practice in 50 ACS NSQIP-pediatric institutions

  • Maria G. Sacco-Casamassima
  • Seth D. Goldstein
  • Colin D. Gause
  • Omar Karim
  • Maria Michailidou
  • Dylan Stewart
  • Paul M. Colombani
  • Fizan Abdullah
Original Article

Abstract

Background

Minimally invasive repair of pectus excavatum (MIRPE) is a well-established procedure. However, morbidity rate varies widely among institutions, and the incidence of major complications remains unknown.

Study design

The American College of Surgeons 2012 National Surgical Quality Improvement Program-Pediatric (NSQIP-P) participant user file was utilized to identify patients who underwent MIRPE at 50 participant institutions. Outcomes of interest were overall 30-day morbidity, hospital readmission, and reoperation.

Results

Chest wall repair designated MIRPE accounted for 0.6 % (n = 264) of all surgical cases included in the NSQIP-P database in 2012. The median age at surgical repair was 15.2 years. Thoracoscopy was used in 83.7 % of cases. No mediastinal injuries or perioperative blood transfusions were identified. The 30-day readmission rate was 3.8 %. Three patients (1.1 %) required re-operation due to the following complications: superficial site infection, bar displacement and pneumothorax. The overall morbidity was 3.8 % with no incidences of mortality.

Conclusions

This analysis of a large prospective multicenter dataset demonstrates that major complications following MIRPE are uncommon in contemporary practice. Wound infection is the most common complication and the main cause of hospital readmission. Targeted quality improvement initiative should be focused on perioperative strategy to further reduce wound occurrences and hospital readmission.

Keywords

Pectus excavatum MIRPE NSQIP-Pediatric Outcomes 

Abbreviations

PE

Pectus excavatum

MIRPE

Minimally invasive repair of pectus excavatum

NSQIP-P

National Surgical Quality Improvement Program-Pediatric

ICD-9

International Classification of Diseases

CPT

Current procedural terminology

BMI

Body mass index

CDC

Centers for disease control

SD

Standard deviation

IQR

Interquartile range

CTD

Connective tissue disorder

References

  1. 1.
    Nuss D, Kelly RE Jr, Croitoru DP, Katz ME (1998) A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 33(4):545–552CrossRefPubMedGoogle Scholar
  2. 2.
    Protopapas AD, Athanasiou T (2008) Peri-operative data on the Nuss procedure in children with pectus excavatum: independent survey of the first 20 years’ data. J Cardiothorac Surg 4(3):40CrossRefGoogle Scholar
  3. 3.
    Castellani C, Schalamon J, Saxena AK, Hoellwarth ME (2008) Early complications of the Nuss procedure for pectus excavatum: a prospective study. Pediatr Surg Int 24(6):659–666CrossRefPubMedGoogle Scholar
  4. 4.
    Fallon SC, Slater BJ, Nuchtern JG, Cass DL, Kim ES, Lopez ME et al (2013) Complications related to the Nuss procedure: minimizing risk with operative technique. J Pediatr Surg 48(5):1044–1048CrossRefPubMedGoogle Scholar
  5. 5.
    Kelly RE, Goretsky MJ, Obermeyer R, Kuhn MA, Redlinger R, Haney TS et al (2010) Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg 252(6):1072–1081CrossRefPubMedGoogle Scholar
  6. 6.
    Johnson WR, Fedor D, Singhal S (2014) Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum. J Cardiothorac Surg 9(1):25 (8090-9-25)CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Kelly RE Jr, Mellins RB, Shamberger RC, Mitchell KK, Lawson ML, Oldham KT et al (2013) Multicenter study of pectus excavatum, final report: complications, static/exercise pulmonary function, and anatomic outcomes. J Am Coll Surg 217(6):1080–1089CrossRefPubMedGoogle Scholar
  8. 8.
    Hebra A, Swoveland B, Egbert M, Tagge EP, Georgeson K, Othersen HB Jr et al (2000) Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg 35(2):252–257 (discussion 257–258)CrossRefPubMedGoogle Scholar
  9. 9.
    Leonhardt J, Kubler JF, Feiter J, Ure BM, Petersen C (2005) Complications of the minimally invasive repair of pectus excavatum. J Pediatr Surg 40(11):e7–e9CrossRefPubMedGoogle Scholar
  10. 10.
    Gips H, Zaitsev K, Hiss J (2008) Cardiac perforation by a pectus bar after surgical correction of pectus excavatum: case report and review of the literature. Pediatr Surg Int 24(5):617–620CrossRefPubMedGoogle Scholar
  11. 11.
    Becmeur F, Ferreira CG, Haecker FM, Schneider A, Lacreuse I (2011) Pectus excavatum repair according to Nuss: is it safe to place a retrosternal bar by a transpleural approach, under thoracoscopic vision? J Laparoendosc Adv Surg Tech A 21(8):757–761. doi: 10.1089/lap.2011.0035 CrossRefPubMedGoogle Scholar
  12. 12.
    Nuss D, Croitoru DP, Kelly RE Jr, Goretsky MJ, Nuss KJ, Gustin TS (2002) Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg 12(4):230–234CrossRefPubMedGoogle Scholar
  13. 13.
    Palmer B, Yedlin S, Kim S (2007) Decreased risk of complications with bilateral thoracoscopy and left-to-right mediastinal dissection during minimally invasive repair of pectus excavatum. Eur J Pediatr Surg 17(2):81–83CrossRefPubMedGoogle Scholar
  14. 14.
    Tedde ML, de Campos JR, Wihlm JM, Jatene FB (2012) The Nuss procedure made safer: an effective and simple sternal elevation manoeuvre. Eur J Cardiothorac Surg 42(5):890–891CrossRefPubMedGoogle Scholar
  15. 15.
    Tedde ML, Campos JR, Das-Neves-Pereira JC, Abrao FC, Jatene FB (2011) The search for stability: bar displacement in three series of pectus excavatum patients treated with the Nuss technique. Clinics (Sao Paulo) 66(10):1743–1746CrossRefGoogle Scholar
  16. 16.
    Casamassima MGS, Goldstein SD, Salazar JH, McIltrot KH, Abdullah F, Colombani PM (2014) Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume, single institution experience. J Pediatr Surg 49(4):575–582CrossRefGoogle Scholar
  17. 17.
    Bouchard S, Hong AR, Gilchrist BF, Kuenzler KA (2009) Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum. Semin Pediatr Surg 18(2):66–72CrossRefPubMedGoogle Scholar
  18. 18.
    Robicsek F, Hebra A (2009) To Nuss or not to Nuss? Two opposing views. Semin Thorac Cardiovasc Surg 21(1):85–88 (Spring)CrossRefPubMedGoogle Scholar
  19. 19.
    Raval MV, Dillon PW, Bruny JL, Ko CY, Hall BL, Moss RL et al (2011) Pediatric American College of Surgeons National Surgical Quality Improvement Program: feasibility of a novel, prospective assessment of surgical outcomes. J Pediatr Surg 46(1):115–121CrossRefPubMedGoogle Scholar
  20. 20.
    Bruny JL, Hall BL, Barnhart DC, Billmire DF, Dias MS, Dillon PW et al (2013) American College of Surgeons National Surgical Quality Improvement Program Pediatric: a beta phase report. J Pediatr Surg 48(1):74–80CrossRefPubMedGoogle Scholar
  21. 21.
    Dillon P, Hammermeister K, Morrato E, Kempe A, Oldham K, Moss L et al (2008) Developing a NSQIP module to measure outcomes in children’s surgical care: opportunity and challenge. Semin Pediatr Surg 17(2):131–140CrossRefPubMedGoogle Scholar
  22. 22.
    Defining childhood obesity and overweight for professionals. Center for disease Control and Prevention [Internet]. http://www.cdc.gov/obesity/childhood/defining.html
  23. 23.
    Horan TC, Andrus M, Dudeck MA (2008) CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 36(5):309–332CrossRefPubMedGoogle Scholar
  24. 24.
    Hosie S, Sitkiewicz T, Petersen C, Gobel P, Schaarschmidt K, Till H et al (2002) Minimally invasive repair of pectus excavatum–the Nuss procedure. A European multicentre experience. Eur J Pediatr Surg 12(4):235–238CrossRefPubMedGoogle Scholar
  25. 25.
    Kelly RE Jr, Shamberger RC, Mellins RB, Mitchell KK, Lawson ML, Oldham K et al (2007) Prospective multicenter study of surgical correction of pectus excavatum: design, perioperative complications, pain, and baseline pulmonary function facilitated by internet-based data collection. J Am Coll Surg 205(2):205–216CrossRefPubMedGoogle Scholar
  26. 26.
    Nasr A, Fecteau A, Wales PW (2010) Comparison of the Nuss and the Ravitch procedure for pectus excavatum repair: a meta-analysis. J Pediatr Surg 45(5):880–886CrossRefPubMedGoogle Scholar
  27. 27.
    Molik KA, Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL (2001) Pectus excavatum repair: experience with standard and minimal invasive techniques. J Pediatr Surg 36(2):324–328CrossRefPubMedGoogle Scholar
  28. 28.
    Boehm RA, Muensterer OJ, Till H (2004) Comparing minimally invasive funnel chest repair versus the conventional technique: an outcome analysis in children. Plast Reconstr Surg 114(3):668–673 (discussion 674–675)CrossRefPubMedGoogle Scholar
  29. 29.
    Park HJ, Sung SW, Park JK, Kim JJ, Jeon HW, Wang YP (2012) How early can we repair pectus excavatum: the earlier the better? Eur J Cardiothorac Surg 42(4):667–672CrossRefPubMedGoogle Scholar
  30. 30.
    Adams HD (1951) Costosternoplasty with rib strut support for funnel chest in adults. Lahey Clin bull. 7:111–116PubMedGoogle Scholar
  31. 31.
    Raff GW, Wong MS (2008) Sternal plating to correct an unusual complication of the Nuss procedure: erosion of a pectus bar through the sternum. Ann Thorac Surg 85(3):1100–1101CrossRefPubMedGoogle Scholar
  32. 32.
    Hoel TN, Rein KA, Svennevig JL (2006) A life-threatening complication of the Nuss procedure for pectus excavatum. Ann Thorac Surg 81(1):370–372CrossRefPubMedGoogle Scholar
  33. 33.
    Belcher E, Arora S, Samancilar O, Goldstraw P (2008) Reducing cardiac injury during minimally invasive repair of pectus excavatum. Eur J Cardiothorac Surg 33(5):931–933CrossRefPubMedGoogle Scholar
  34. 34.
    Hebra A (2000) Minimally invasive pectus surgery. Chest Surg Clin N Am 10(2):329–339 (vii)PubMedGoogle Scholar
  35. 35.
    Umuroglu T, Bostanci K, Thomas DT, Yuksel M, Gogus FY (2013) Perioperative anesthetic and surgical complications of the nuss procedure. J Cardiothorac Vasc Anesth 27(3):436–440CrossRefPubMedGoogle Scholar
  36. 36.
    Rygl M, Vyhnanek M, Kucera A, Mixa V, Kyncl M, Snajdauf J (2014) Technical innovation in minimally invasive repair of pectus excavatum. Pediatr Surg Int 30(1):113–117CrossRefPubMedGoogle Scholar
  37. 37.
    St Peter SD, Sharp SW, Ostlie DJ, Snyder CL, Holcomb GW 3rd, Sharp RJ (2010) Use of a subxiphoid incision for pectus bar placement in the repair of pectus excavatum. J Pediatr Surg 45(6):1361–1364CrossRefPubMedGoogle Scholar
  38. 38.
    Fox ME, Bensard DD, Roaten JB, Hendrickson RJ (2005) Positioning for the Nuss procedure: avoiding brachial plexus injury. Paediatr Anaesth 15(12):1067–1071PubMedGoogle Scholar
  39. 39.
    Lee SH, Ryu SM, Cho SJ (2011) Thoracic outlet syndrome after the Nuss procedure for the correction of extreme pectus excavatum. Ann Thorac Surg 91(6):1975–1977CrossRefPubMedGoogle Scholar
  40. 40.
    Miller KA, Woods RK, Sharp RJ, Gittes GK, Wade K, Ashcraft KW et al (2001) Minimally invasive repair of pectus excavatum: a single institution’s experience. Surgery 130(4):652–657 (discussion 657–659)CrossRefPubMedGoogle Scholar
  41. 41.
    Nuss D (2008) Minimally invasive surgical repair of pectus excavatum. Semin Pediatr Surg 17(3):209–217CrossRefPubMedGoogle Scholar
  42. 42.
    Van Renterghem KM, von Bismarck S, Bax NM, Fleer A, Hollwarth ME (2005) Should an infected Nuss bar be removed? J Pediatr Surg 40(4):670–673CrossRefPubMedGoogle Scholar
  43. 43.
    Shin S, Goretsky MJ, Kelly RE Jr, Gustin T, Nuss D (2007) Infectious complications after the Nuss repair in a series of 863 patients. J Pediatr Surg 42(1):87–92CrossRefPubMedGoogle Scholar
  44. 44.
    Papandria D, Arlikar J, Sacco Casamassima M, Ortega G, Salazar J, Zhang Y et al (2013) Increasing age at time of pectus excavatum repair in children: emerging consensus? J Pediatr Surg 48(1):191–196CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Maria G. Sacco-Casamassima
    • 1
  • Seth D. Goldstein
    • 1
  • Colin D. Gause
    • 1
  • Omar Karim
    • 1
  • Maria Michailidou
    • 1
  • Dylan Stewart
    • 1
  • Paul M. Colombani
    • 2
  • Fizan Abdullah
    • 1
  1. 1.Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric SurgeryJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Department of Pediatric SurgeryAll Children’s Hospital Johns HopkinsFloridaUSA

Personalised recommendations