Nuss Procedure for Pectus Excavatum

Nuss Procedure for Pectus Excavatum

No Results

No Results


Pectus excavatum, also known as sunken or funnel chest, is a congenital chest wall malformation in which several ribs and the sternum grow abnormally, producing a concave or caved-in appearance of the anterior chest wall and sternum. (See the image below.)

Pectus excavatum occurs in an estimated 1 in 300-500 births, with a 3:1 male predominance. The condition is typically noticed at birth, and more than two thirds of cases are diagnosed within the first year of life. Worsening of the chest’s appearance and the onset of symptoms are usually reported during rapid bone growth seen in puberty and early teenage years. [1] Many patients are not brought to the attention of a pediatric surgeon until the patient and the family have noticed such changes. Despite the lack of an identifiable genetic marker, the familial occurrence of pectus deformity is reported in 35% of cases. [2]

This topic focuses on the operative technique known as minimally invasive repair of pectus excavatum (MIRPE). It was originally described by Donald Nuss and thus is also known as the Nuss technique or pectus bar procedure. Nuss performed the first minimally invasive operation for the correction of pectus excavatum in the 1980s, but it was not until 1997 that this innovative technique was introduced to the American Pediatric Surgical Association and subsequently published in the Journal of Pediatric Surgery. [3]

Because of the early excellent results of the Nuss procedure and because of its less radical nature (as compared with the open Ravitch technique), [4, 5, 6, 7] the popularity of this operation has grown dramatically. [8]  (See the image below.)

Pectus excavatum patients are considered candidates for corrective surgery on the basis of the following criteria:

The chest Haller index is a measurement taken from a noncontrast compuited tomography (CT) scan of the chest in which a ratio is obtained between the lateral and the anterior-posterior diameter of the chest wall at the point of maximal depression of the sternum (see the image below). A normal chest index is around 2.5. Patients with an index greater than 3.2 have a fairly pronounced and severe pectus excavatum and will typically benefit from operative correction. [9] Even if asymptomatic, those patients usually benefit from the corrective surgery.

Of note, obtaining a chest Haller index in a young patient (see the image below) with pectus excavatum is not necessary. The Haller index should be obtained before corrective surgery (within months and not years) so that it can provide information helpful to the surgeon in planning the operative correction of the pectus. [10, 11]

Symptomatic patients with pectus excavatum typically experience occasional episodes of chest pain, shortness of breath with exertion, and decreased exercise tolerance. Such patients usually have abnormal pulmonary function test results, and echocardiography may demonstrate mitral and tricuspid valve regurgitation. Mitral valve prolapse is also commonly seen on the echocardiogram. [12, 13]

Many patients with mild-to-moderate pectus excavatum do not report any significant shortness of breath. Upon further questioning, however, one may find that the child is unable to keep up with their peers during play and physical activity. [14] They usually report getting tired more easily.

Another common observation in children with pectus excavatum is that they are very shy and reserved about their physical appearance. Frequently, as summer comes around, they are unwilling to take their shirt off for sports, swimming, or around other children. The psychosocial stress caused by the abnormal chest can be quite severe and can result in a major adjustment disorder, depression, and even suicide ideation later in life. [15, 16]

The most common goal in operative repair of pectus excavatum is to correct the chest deformity. As noted above, this is particularly important in teenagers, in whom the abnormal appearance of the chest can result in significant problems related to body image and self-esteem. Thus, the desire to improve the appearance of the chest is considered an appropriate medical indication for surgery. [17]

The current recommendations support the use of MIRPE in patients aged 5-20 years. The ideal age for undergoing this operation has been established at 8-12 years because in this age range, the chest wall is still very malleable, stabilization of the bar is easily achieved, thoracic epidural can be safely placed, and the child is mature enough to understand the operation and postoperative instructions, particularly incentive spirometry, which is essential for minimizing pulmonary problems after surgery. [18]

Of note, operative correction of pectus excavatum should not be viewed as an operation limited exclusively to pediatric patients. Indeed, the open technique has been used in adult patients with excellent results. Although experience with MIRPE in adult patients has been relatively limited, [19]  there is increasing evidence to suggest that similar principles apply to adult patients and that operative correction using MIRPE can be achieved in this population. [20, 21]

Limiting factors for MIRPE in adults include a larger chest wall and poor malleability of the ribs, cartilage, and sternum. A surgeon experienced in the field of chest-wall malformations must carefully evaluate adult patients to determine which operation would best correct the anatomic deformity. [22]

Moreover, adult patients with pectus excavatum who undergo open heart surgery have significant displacement and rotation of the heart to the left chest. This can make the operative approach to the heart at the time of open heart surgery very challenging. With this in mind, elective repair of the pectus deformity prior to open heart surgery may be indicated in selected adult cases.

In a retrospective multicenter study of 20 adult patients with recurrent pectus excavatum, Kocher et al found MIRPE to be safe and effective for repairing the recurrences after a failed Ravitch procedure. [23] The results were good to excellent in the majority of adults, and there were no major complications or further recurrences. Another study found that a modified MIRPE could be successfully used in most adults to revise a failed prior Nuss procedure. [24]

Patients with other associated complex congenital anomalies, neurodevelopmental delay, congenital heart disease with primary cardiac dysfunction, and chronic immunosuppression are not considered good candidates for corrective surgery for pectus excavatum. A comprehensive preoperative evaluation, including cardiology consultation and echocardiography, must be completed in order to determine the patient’s level of risk.

Not all patients with pectus excavatum are considered candidates for corrective surgery. The decision to undergo surgery is based on clinical symptoms and the severity of the deformity. The surgeon, patient, and immediate family must reach a consensus as to the benefits of operative repair for the child with pectus excavatum. The morbidity and mortality of the surgical intervention must be taken into consideration.

Patients must be selected carefully for the procedure. Preoperative assessment may include pulmonary function testing (PFT) and noncontrast CT of the chest. CT allows determination of the preoperative Haller index (as previously described). Patients with a Haller index higher than 3.2 are considered candidates for MIRPE. PFT typically demonstrates mild changes in pulmonary volumes (restrictive pattern). [25] Echocardiography is performed selectively in patients with clinical evidence of Marfan syndrome or with any cardiac symptoms or murmurs.

Appropriate patient selection and careful attention to operative and technical details minimize the risk of complications. [26] Moreover, recognizing that the ideal age for operative repair is between 8 and 12 years of age is important. [27] Prepubertal patients have a more flexible rib cage, which facilitates reconstruction and remodeling of the ribs and sternum. Younger patients typically experience less postoperative pain and discomfort than teenagers and young adults do. [18]

Several studies have been published that evaluate the short and long-term outcomes of patients following minimally invasive repair of pectus excavatum. The overall patient and family satisfaction has been considered very good, with excellent and good results reported in more than 90% of cases. [28, 29, 26]

In 2000, a multi-institutional study that reviewed 251 MIRPE cases demonstrated a significant complication rate (overall incidence of complications was almost 20%). [26] The most common complication necessitating reoperation was displacement of the retrosternal stainless steel support bar (reported to occur in 9.5% of all patients). Such displacement can include a 90° rotation, a 180° rotation, or a lateral migration. Teenaged patients are at higher risk for complications, particularly pectus bar displacement, probably because of the increased pressure on the bar generated by a larger chest and a more rigid chest cage.

The rate of complications was found to be relatively high when many different surgeons performed the operation. [28, 26] This probably reflects the learning curve associated with the introduction of MIRPE. Since the first such procedure was performed, the bar has been modified four times; current bars are strong enough to withstand the pressure of even the most severe deformity.

Factors contributing to the suboptimal results reported include the softness of the bars initially used, the premature removal of the bar, and the failure to stabilize the bar adequately. [30] Experience has shown that stabilization of the bar is absolutely essential for success and that the use of a lateral stabilizing bar and the third point of fixation (when appropriate) can minimize the occurrence of bar displacement. [31]

The spectrum of adverse outcomes is variable, and most complications are considered rare and unusual. [28, 26, 32, 33, 34, 27] The following is a list of reported complications after MIRPE (and their estimated incidence):

With respect to cardiopulmonary outcomes after MIRPE, one study demonstrated that objective measures of forced expiratory volume in 1 second (FEV1), total lung capacity, diffusing lung capacity, and respiratory quotient all showed significant improvement (after bar removal) in comparison with preoperative values, whereas normalized values of cardiac index at rest did not. [25]

It should be noted that this improvement in cardiopulmonary function is not necessarily seen during the time that the support bar is still in place. For that reason, functional outcomes should not be evaluated until the patient has completed treatment with bar removal. Of note, the dreaded complication of chest wall constriction after Ravitch repair of pectus excavatum has never been reported with the Nuss procedure.

Attempts have been made to determine which technique (ie, MIRPE or open surgery) provides the better outcome in patients with pectus excavatum. [36]  Although many surgeons with expertise in the management of children with chest-wall deformities have shown some bias toward the use of the Nuss technique, this bias is not strongly supported by prospective randomized published data.

A systematic review by Johnson et al compared outcome measures for Nuss and Ravitch procedures (as well as other, less common approaches) in both pediatric and adult patients. [37] The results indicated slightly better outcomes with the Nuss procedure than with any other approach in children; in adults, the results did not lead to a preference for the Nuss procedure over the Ravitch procedure or vice versa, though both were preferred over the less common approaches.

Since the introduction of thoracoscopy and lateral stabilizers, as well as the third point of fixation technique, bar displacement has become quite unlikely, with an estimated incidence of less than 2.5%. [18]

Another significant advantage of MIRPE over the open surgical procedure is that the dreaded complication of “thoracic constriction” (Jeune syndrome) does not seem to occur with this new technique. [38]  Chest-wall constriction has been described in a few patients following extensive open pectus excavatum operations. Apparently, the bone growth center can be affected, which results in restriction of chest-wall growth with marked limitation of ventilatory function. Such patients are very symptomatic and cannot compete in running games. The forced vital capacity (FVC) and FEV1 are typically decreased by more than 50% of predicted reference range levels.

With MIRPE, because no resection or incision is made on ribs or cartilages, such a complication does not appear to be a problem. [8]  Once the cartilage and bony structures are remodeled, normal or improved pulmonary function is established and the flexibility and malleability of the chest remains unaffected.

Critics of MIRPE claim that it is too invasive, poses substantial risks, and is not pain-free. Proponents argue that MIRPE, compared with open surgery (modified Ravitch operation), eliminates the need for an anterior chest-wall incision with creation of pectoralis muscle flaps, resection of several ribs and cartilages, and sternal osteotomies. MIRPE allows a much shorter operating time, causes minimal blood loss, and results in minimal surgical chest wall scarring. Moreover, the stability and strength of the chest wall are not compromised, as is sometimes the case with open repair.

Data published in 2011 by the multicenter study group evaluating the pulmonary functional outcome of pediatric patients with pectus excavatum treated with MIRPE clearly demonstrated that the increasing severity of pectus excavatum is associated with reduced pulmonary function and that the Nuss operation can effectively reverse that process. [39]

Final data analysis generated by the multicenter study and published in 2013 clearly demonstrated that there is significant improvement in lung function at rest and in VO2 max and O2 pulse oximetry after surgical correction of pectus excavatum with a Haller index greater than 3.2. The study concluded that operative correction significantly reduces the Haller index and markedly improves the shape of the entire chest and cardiopulmonary function. [40]

The Nuss procedure has been associated with a greater degree of postoperative pain than the Ravitch procedure. However, a meta-analysis of 19 studies (N = 1731) found that the postoperative length of stay was similar for the two procedures and that the Nuss procedure (n = 989) was associated with shorter operating times and less blood loss than the Ravitch procedure (n = 742). [41]

It is important to note that there is a risk of significant complications with both the open and the minimally invasive approach to repair of pectus excavatum. A 2018 study reported the types of life-threatening complications related to minimally invasive repair. [42] As expected, the overall incidence of such complications was quite low (< 0.1%) and was not dissimilar to that associated with the open repair. Surgeons performing minimally invasive repairs must familiarize themselves with the potential complications in order to minimize the risk of unfavorable outcomes.

Tsirikos AI, McMaster MJ. Congenital anomalies of the ribs and chest wall associated with congenital deformities of the spine. J Bone Joint Surg Am. 2005 Nov. 87 (11):2523-36. [Medline].

Shamberger RC. Congenital chest wall deformities. Curr Probl Surg. 1996 Jun. 33 (6):469-542. [Medline].

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 Apr. 33 (4):545-52. [Medline].

Ravitch MM. The Operative Treatment of Pectus Excavatum. Ann Surg. 1949 Apr. 129 (4):429-44. [Medline]. [Full Text].

Ravitch MM. Pectus excavatum. Congenital Deformities of the Chest Wall and Their Operative Correction. WB Saunders: Philadelphia; 1977.

Robicsek F. Surgical treatment of pectus excavatum. Chest Surg Clin N Am. 2000 May. 10 (2):277-96. [Medline].

Haller JA Jr, Scherer LR, Turner CS, Colombani PM. Evolving management of pectus excavatum based on a single institutional experience of 664 patients. Ann Surg. 1989 May. 209 (5):578-82; discussion 582-3. [Medline].

Robicsek F, Hebra A. To Nuss or not to Nuss? Two opposing views. Semin Thorac Cardiovasc Surg. 2009 Spring. 21 (1):85-8. [Medline].

Haller JA Jr, Kramer SS, Lietman SA. Use of CT scans in selection of patients for pectus excavatum surgery: a preliminary report. J Pediatr Surg. 1987 Oct. 22 (10):904-6. [Medline].

Daunt SW, Cohen JH, Miller SF. Age-related normal ranges for the Haller index in children. Pediatr Radiol. 2004 Apr. 34 (4):326-30. [Medline].

Fefferman NR, Pinkney LP. Imaging evaluation of chest wall disorders in children. Radiol Clin North Am. 2005 Mar. 43 (2):355-70. [Medline].

Quigley PM, Haller JA Jr, Jelus KL, Loughlin GM, Marcus CL. Cardiorespiratory function before and after corrective surgery in pectus excavatum. J Pediatr. 1996 May. 128 (5 Pt 1):638-43. [Medline].

Peterson RJ, Young WG Jr, Godwin JD, Sabiston DC Jr, Jones RH. Noninvasive assessment of exercise cardiac function before and after pectus excavatum repair. J Thorac Cardiovasc Surg. 1985 Aug. 90 (2):251-60. [Medline].

Weg JG, Krumholz RA, Harkleroad LE. Pulmonary dysfunction in pectus excavatum. Am Rev Respir Dis. 1967 Nov. 96 (5):936-45. [Medline].

Ohno K, Morotomi Y, Nakahira M, Takeuchi S, Shiokawa C, Moriuchi T, et al. Indications for surgical repair of funnel chest based on indices of chest wall deformity and psychological state. Surg Today. 2003. 33 (9):662-5. [Medline].

Cahill JL, Lees GM, Robertson HT. A summary of preoperative and postoperative cardiorespiratory performance in patients undergoing pectus excavatum and carinatum repair. J Pediatr Surg. 1984 Aug. 19 (4):430-3. [Medline].

Goretsky MJ, Kelly RE Jr, Croitoru D, Nuss D. Chest wall anomalies: pectus excavatum and pectus carinatum. Adolesc Med Clin. 2004 Oct. 15 (3):455-71. [Medline].

Hebra A. Minimally invasive repair of pectus excavatum. Semin Thorac Cardiovasc Surg. 2009 Spring. 21 (1):76-84. [Medline].

Hebra A, Jacobs JP, Feliz A, Arenas J, Moore CB, Larson S. Minimally invasive repair of pectus excavatum in adult patients. Am Surg. 2006 Sep. 72 (9):837-42. [Medline].

Jaroszewski DE, Ewais MM, Chao CJ, Gotway MB, Lackey JJ, Myers KM, et al. Success of Minimally Invasive Pectus Excavatum Procedures (Modified Nuss) in Adult Patients (≥30 Years). Ann Thorac Surg. 2016 Sep. 102 (3):993-1003. [Medline].

Velazco CS, Arsanjani R, Jaroszewski DE. Nuss procedure in the adult population for correction of pectus excavatum. Semin Pediatr Surg. 2018 Jun. 27 (3):161-169. [Medline].

Fonkalsrud EW, Bustorff-Silva J. Repair of pectus excavatum and carinatum in adults. Am J Surg. 1999 Feb. 177 (2):121-4. [Medline].

Kocher GJ, Gstrein N, Jaroszewski DE, Ewais MM, Schmid RA. Nuss procedure for repair of pectus excavatum after failed Ravitch procedure in adults: indications and caveats. J Thorac Dis. 2016 Aug. 8 (8):1981-5. [Medline].

Ashfaq A, Beamer S, Ewais MM, Lackey J, Jaroszewski D. Revision of Failed Prior Nuss in Adult Patients With Pectus Excavatum. Ann Thorac Surg. 2018 Feb. 105 (2):371-378. [Medline].

Lawson ML, Mellins RB, Paulson JF, Shamberger RC, Oldham K, Azizkhan RG, et al. Increasing severity of pectus excavatum is associated with reduced pulmonary function. J Pediatr. 2011 Aug. 159 (2):256-61.e2. [Medline].

Hebra A, Swoveland B, Egbert M, Tagge EP, Georgeson K, Othersen HB Jr, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg. 2000 Feb. 35 (2):252-7; discussion 257-8. [Medline].

Hebra A. Minimally invasive pectus surgery. Chest Surg Clin N Am. 2000 May. 10 (2):329-39, vii. [Medline].

Engum S, Rescorla F, West K, Rouse T, Scherer LR, Grosfeld J. Is the grass greener? Early results of the Nuss procedure. J Pediatr Surg. 2000 Feb. 35 (2):246-51; discussion 257-8. [Medline].

Nuss D. Recent experiences with minimally invasive pectus excavatum repair “Nuss procedure”. Jpn J Thorac Cardiovasc Surg. 2005 Jul. 53 (7):338-44. [Medline].

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 Aug. 12 (4):230-4. [Medline].

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 Aug. 36 (8):1266-8. [Medline].

Marusch F, Gastinger I. [Life-threatening complication of the Nuss-procedure for funnel chest. A case report]. Zentralbl Chir. 2003 Nov. 128 (11):981-4. [Medline].

Rushing GD, Goretsky MJ, Gustin T, Morales M, Kelly RE Jr, Nuss D. When it is not an infection: metal allergy after the Nuss procedure for repair of pectus excavatum. J Pediatr Surg. 2007 Jan. 42 (1):93-7. [Medline].

Shin S, Goretsky MJ, Kelly RE Jr, Gustin T, Nuss D. Infectious complications after the Nuss repair in a series of 863 patients. J Pediatr Surg. 2007 Jan. 42 (1):87-92. [Medline].

Binkovitz LE, Zendejas B, Moir CR, Binkovitz LA. Nuss bar migrations: occurrence and classification. Pediatr Radiol. 2016 Dec. 46 (13):1797-1803. [Medline].

Fonkalsrud EW, Beanes S, Hebra A, Adamson W, Tagge E. Comparison of minimally invasive and modified Ravitch pectus excavatum repair. J Pediatr Surg. 2002 Mar. 37 (3):413-7. [Medline].

Johnson WR, Fedor D, Singhal S. Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum. J Cardiothorac Surg. 2014 Feb 7. 9:25. [Medline]. [Full Text].

Haller JA Jr, Colombani PM, Humphries CT, Azizkhan RG, Loughlin GM. Chest wall constriction after too extensive and too early operations for pectus excavatum. Ann Thorac Surg. 1996 Jun. 61 (6):1618-24; discussion 1625. [Medline].

Lawson ML, Mellins RB, Paulson JF, Shamberger RC, Oldham K, Azizkhan RG, et al. Increasing severity of pectus excavatum is associated with reduced pulmonary function. J Pediatr. 2011 Aug. 159 (2):256-61.e2. [Medline].

Kelly RE Jr, Mellins RB, Shamberger RC, Mitchell KK, Lawson ML, Oldham KT, et al. Multicenter study of pectus excavatum, final report: complications, static/exercise pulmonary function, and anatomic outcomes. J Am Coll Surg. 2013 Dec. 217 (6):1080-9. [Medline]. [Full Text].

Mao YZ, Tang S, Li S. Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis. J Pediatr Surg. 2017 Oct. 52 (10):1545-1552. [Medline].

Hebra A, Kelly RE, Ferro MM, Yüksel M, Campos JRM, Nuss D. Life-threatening complications and mortality of minimally invasive pectus surgery. J Pediatr Surg. 2018 Apr. 53 (4):728-732. [Medline].

Frick SL. Scoliosis in children with anterior chest wall deformities. Chest Surg Clin N Am. 2000 May. 10 (2):427-36. [Medline].

Grimes SJ, Acheson LS, Matthews AL, Wiesner GL. Clinical consult: Marfan syndrome. Prim Care. 2004 Sep. 31 (3):739-42, xii. [Medline].

Fokin AA. Pouter pigeon breast. Chest Surg Clin N Am. 2000 May. 10(2):377-91. [Medline].

Fokin AA, Robicsek F. Poland’s syndrome revisited. Ann Thorac Surg. 2002 Dec. 74 (6):2218-25. [Medline].

Seyfer AE, Icochea R, Graeber GM. Poland’s anomaly. Natural history and long-term results of chest wall reconstruction in 33 patients. Ann Surg. 1988 Dec. 208 (6):776-82. [Medline].

Kelly RE Jr, Shamberger RC, Mellins RB, Mitchell KK, Lawson ML, Oldham K, et al. 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. 2007 Aug. 205 (2):205-16. [Medline].

Frawley G, Frawley J, Crameri J. A review of anesthetic techniques and outcomes following minimally invasive repair of pectus excavatum (Nuss procedure). Paediatr Anaesth. 2016 Nov. 26 (11):1082-1090. [Medline].

Oswald N, Jalal Z, Kadiri S, Naidu B. Changes in chest wall motion with removal of Nuss bar in repaired pectus excavatum – a cohort study. J Cardiothorac Surg. 2019 Jan 8. 14 (1):4. [Medline]. [Full Text].

Andre Hebra, MD Chief Medical Officer, Nemours Children’s Hospital; Professor of Surgery, University of Central Florida College of Medicine

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children’s Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association

Disclosure: Nothing to disclose.

Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society

Disclosure: Received consulting fee from Provation Medical for writing.

Nuss Procedure for Pectus Excavatum

Research & References of Nuss Procedure for Pectus Excavatum|A&C Accounting And Tax Services