Pectus Excavatum Follow-up

The typical follow-up postoperative repair of pectus excavatum involves outpatient visits with the pediatric surgeon 2-3 weeks after surgery and at regular intervals after that for the next 2 years. Monitoring patients at least every 3-6 months is recommended to ensure that they are not developing an anterior protrusion of the chest due to excessive pressure from the pectus bar. Pectus carinatum as a sequela of MIRPE has been reported.

Following surgery, patients are reminded that good posture with a straight back is very important. Bending at the hip and slouching are not allowed in the first 1-2 months following repair. Regular activity is permitted as postoperative pain decreases and mobility increases. Heavy lifting is not permitted for 1 month following surgery, and contact sports are to be avoided. Heavy lifting can be defined as anything greater than 10 lb, and patients are not allowed to carry heavy book bags for at least 4 weeks.

The bar generally remains implanted for 2 years and is removed in an outpatient procedure under anesthesia. ^[21]  Nuss bar removal has been shown to have small but detectable effects on diaphragmatic ribcage motion; these effects are unlikely to be of clinical significance. ^[22]  No change in exercise capacity should be anticipated. The main complication reported after removal of the pectus bar in adults is surgical bleeding. ^[23]

During the patient's hospital stay following corrective surgery for pectus excavatum, the author strongly recommends consultation with the anesthesia pain team. With intravenous narcotics and epidural analgesia, the pain that follows surgery can be controlled fairly well.

Typically, the thoracic epidural is removed 3-4 days after surgery, and most patients are discharged after 5-7 days. At the time of discharge, pain should be controlled with oral narcotics. NSAIDs, such as ibuprofen or ketorolac tromethamine (Toradol), are frequently added to the postoperative drug regimen. When using NSAIDs, consider adding histamine 2 (H2) blockers to prevent ulcer-related complications.

Refer patients with pectus excavatum to a pediatric surgeon experienced in the field of congenital chest wall deformities.

Physical fitness and development of strong anterior chest musculature may improve the appearance of pectus excavatum. However, clinical experience has demonstrated that only mild cases of pectus may benefit from this technique. The deformity worsens in most patients with moderate or severe pectus excavatum, particularly during the physiologic rapid growth of puberty.

There are few large series that examined complications and outcomes of the minimally invasive technique for repair of pectus excavatum (MIRPE). ^{[24, 25]} In those reports, patient and family satisfaction were found to be very good, with excellent and good results reported at 93% and 96%, respectively. However, one multi-institutional study, which reviewed 251 cases of MIRPE, demonstrated a significant rate of complications (the overall incidence rate of complications was almost 20%). ^[25]

By far, the most common complication reported requiring reoperation was displacement of the retrosternal stainless steel support bar (initially 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 more rigid chest cage. Today, the risk of bar displacement has been reduced to approximately 2.5% owing to new techniques of bar stabilization (described under Surgical technique in Surgical Care).

The acceptance and popularity of MIRPE developed quickly since its introduction in 1997. The principal advantages of this new technique are based on the fact that incising the anterior chest wall, raising the pectoralis muscle flaps, resecting the rib cartilages, and performing a sternal osteotomy are not needed. This leads to a much shorter operating time, minimal blood loss, and early return to full activity because the stability and strength of the chest wall is not compromised. The apparent simplicity of the technique, combined with the early good results reported, contributed to the enthusiastic widespread use of this operation by many pediatric surgeons.

Unfortunately, a relatively high rate of complications was reported when many different surgeons performed the operation, probably reflecting the learning curve associated with the introduction of this new technique. Since the first MIRPE was performed, the bar has been modified 4 times and is now strong enough to withstand the pressure of even the most severe deformity. The poor results likely occurred early in the reported series because the bar was too soft, was removed too soon, or was not stabilized adequately. Experience has shown that stabilization of the bar is absolutely essential for success, and the use of a lateral stabilizing bar and the third point of fixation (when appropriate) minimizes the occurrence of bar displacement.

An interesting observation has been that complications, mainly bar displacement, have appeared to be more common in teenaged patients. Initially, the MIRPE was limited to the younger prepubertal patients (aged 3-12 y), which probably accounted for the rare occurrence of bar displacement in the first report by Nuss. ^[13] Older patients were offered the procedure because of the success of the procedure in young patients. Only later was the importance of proper stabilization of the bar identified and the lateral stabilizing bar was introduced (in 1998), followed by the addition of the third point of fixation technique (in 2000) to provide additional support and stability for the bar. The results seemed to have improved so much that the operation is now considered in adult patients with pectus excavatum.

Fortunately, most factors that may lead to complications and poor results were related to early inexperience, and these factors have been corrected. Moreover, the introduction of thoracoscopy when performing MIRPE has significantly enhanced the surgeon's ability to pass the bar precisely behind the sternum, avoiding the risk of cardiac or vascular injury. Reassuringly, one reported case of cardiac perforation occurred prior to the routine use of thoracoscopy.

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. 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 and forced expiratory volume in one second is typically decreased by more than 50% of predicted reference range levels. With the MIRPE, because no resection or incision is made on ribs or cartilages, such a complication does not appear to be a problem. 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 the MIRPE claim that the Nuss procedure is too invasive, too risky, and not pain free. Proponents argue that this new approach, compared with the open surgery (modified Ravitch operation), eliminates the need for a large anterior chest wall incision with creation of pectoralis muscle flaps, resection of several ribs and cartilages, and sternal osteotomies. The MIRPE allows for a much shorter operating time, minimal blood loss, and minimal anterior chest wall scar. Moreover, the stability and strength of the chest wall is not compromised as it is with the open repair. For a more detailed review of the pros and cons of both approaches, please refer to the article "To Nuss or Not to Nuss? Two Opposing Views" in the Spring 2009 edition of Seminars of Thoracic and Cardiovascular Surgery. ^[19]

Mortality of surgery

There have been at least 2 reported cases of cardiac injury and death following the Nuss procedure. The retrosternal dissection during the MIRPE and the placement of the bar can certainly cause a life-threatening complication such as cardiac injury. Becmeur et al have published a retrospective review of 16 cases of cardiac lacerations. ^[26] It is important for surgeons, patients, and their families to be aware of this risk. Meticulous attention to surgical technique as outlined in this article is important to minimize the risk of cardiac injury.

Because of the recent advances in the operative repair of pectus excavatum, education of medical professionals and the public is important. Again, patients with pectus excavatum should be referred to a surgeon experienced in the field of congenital chest wall malformations. Early assessment and follow-up is essential to maximize good outcomes.

After operative repair of the pectus excavatum, instruct patients on correct posture to eliminate musculoskeletal pain and to prevent worsening of the spinal deformity. Emphasize that repair of the pectus in itself does not result in correction of any associated spinal deformity or problems related to poor posture.