Department of Biosurgery & Surgical Technology, Imperial College London, St. Mary's Hospital, London, W2 1NY, UK
Abstract
Objective
To review the literature and assess the cumulative data on the Nuss operation in children on its twenty years' anniversary: The Nuss procedure corrects the pectus excavatum by minimal access semi-permanent insertion of metal bars in order to reduce the deformity and refashion the contour of the growing thorax. The advantage over previous techniques is avoidance of osteochondrotomies and thence allowance for normal growth of the thorax.
Study design
PubMed search was performed. Primary outcomes were mortality, morbidity and individual complications. Secondary outcomes were procedure time and hospital stay.
Results
We merged the data from 19 reports comprising 1949 children of mean age 10.6 years.
No mortality was observed and the procedure was associated with morbidity of 15.4%. The commonest complications are bar-related adverse events (5.7%) and pneumothorax (3.5%). The average procedure time and the average hospital stay were 68 minutes and 5.5 days respectively.
Conclusion
20 years of initial evidence suggests that the Nuss group of procedures is a safe minimal access option for correction of pectus excavatum in childhood.
Introduction
The cardiothoracic surgeons are moving towards minimally invasive techniques. Such a technique is the Nuss repair (alias Minimally Invasive Repair of Pectus Excavatum or Miniature Access Pectus Excavatum Repair) for pectus excavatum (funnel chest)
The original Nuss technique has being previously described
Advantages and disadvantages of the Nuss in relation to open techniques (such as Ravitch
Perceived advantages and disadvantages of minimal access strategy for correction of pectus in childhood in comparison to pre-existing conventional techniques
Advantages
Disadvantages
Short hospital stay
Cost of thoracoscopy and equipment
Minimal trauma
Second procedure for bar removal
Allowance for skeletal growth
Capnothorax in thoracoscopy
The principal advantage over these techniques is avoidance of osteochondrotomies and thence allowance for normal growth of the thorax, as subperichondral resection of the costal cartilages may halt the growth of the thoracic cage in toddlers and adolescents.
The metalwork is later removed as a day-case operation (nor requiring overnight stay in hospital) under general anaesthesia.
The Nuss operation can be performed with or without use of thoracoscopy. The selection of age for the Nuss varies with clinical, personal and socio-economical reasons (such as change of school and fear of intimidation by new peers), while removal of bars is scheduled within two to three years from the insertion. In Britain, some surgeons prefer to perform Nuss around the age of 10, before the child changes schools and thence is exposed to new peers. Some other surgeons will perform Nuss earlier, deciding on parental preference and individual clinical circumstances.
Materials and methods
We searched the literature with a simple strategy :
PubMed search
Last Date performed: 31 December 2006
Search keyword ‘Nuss’, language English, Humans, children
Cross-validation by hand search to identify case series and exclude isolated case reports.
Primary outcomes: Mortality, morbidity, individual complications
Secondary outcomes: Procedure time and hospital stay.
Descriptive and summary statistics were performed. Denominators were related to actual data. Missing data were not defaulted.
Results
Selection of reports
18 series of Nuss on children were identified (Table
The series merged, 20 years of Nuss operations in children 1987–2006
Reference
number
Patients
operated
Type of study
Number of
centres
Comment
1
329
Retrospective
One
Series update on ref. 24
3
21
Comparative
One
4
52
Retrospective
One
5
335
Retrospective
One
Encompasses ref. 19
6
53
Retrospective
One
10
22
Retrospective
One
11
40
Retrospective
Not reported
12
172
Retrospective
Eight
13
31
Retrospective
One
15
20
Retrospective
One
Modified technique
16
36
Comparative
One
23
27
Retrospective
One
Subgroup of all-age cohort
8*
107
Comparative
One
Similar data to ref. 9
9*
107
Retrospective
Not reported
Similar data to ref. 8
14
80
Comparative
One
17**
35
Comparative
One
Same centre as ref. 18
18**
21
Retrospective
One
Same centre as ref. 17
22
461
Retrospective
One
Total
1949
Of these, there were at least three reports preceded by others with apparently overlapping cohorts,
Interestingly, two reports from neighbouring countries [Japan, South Korea,
Demographics (Table
Cumulative perioperative data on 20 years of Nuss operations in children 1987–2006
Reference
number
Patient
number
Average Age
Average
Operating
Time
Average
Hospital Stay
1
329
11 years
Not reported
5 days
3
21
14.4 years
53'
Not reported
4
52
Unknown
106'
3.9 days
5
335
8 years
Not reported
Not reported
6
53
9 years
76'
8.9 days
10
22
15.5 years
Not reported
13.4 days
11
40
17.6 years
126'
Not reported
12
172
15.1 years
76'
Not reported
13
31
14.5 years
Not reported
4 days
15
20
14 years
75'
5.5 days
16
36
12.3 years
96'
5.5 days
8
107
7.9 years
67'
8 days
9
107
7.5 years
48'
Not reported
14
80
11.5 years
53'
3.7 days
17
35
9.5 years
198'
4.8 days
18
21
8.2 years
Not reported
4.9 days
22
461
15.2 years
52'
5.3 days
23
27
5.9 years
52'
4.9 days
Total
1949
10.6 years
68'
5.5 days
1949 children have had Nuss operations. Mean age was 10.6 years, ratio male: female 77:23.
Morbidity and Mortality
No mortality was observed and the incidence of morbidity was 15.4%. The most commonly reported complications were:
1.
2.
The incidence of wound infection was 2.2%, the incidence of other pleuropulmonary complications including effusions and atelectasis/pneumonia was 2%. Other complications were less common (Table
Complications of 20 years of Nuss operations in children 1987–2006
Complication
Cumulative
Bar-related adverse events
111 (37%)
Pneumothorax
68(23%)
Other Pleuropulmonary, except pneumothorax
39(13%)
Wound infection
43(14%)
Pericardial effusion
28(9%)
Hemothorax
12(4%)
Total
301
Other Perioperative Data
The average length of operation in minutes was 68 minutes (range 28–200).
Average Hospital stay was 5.5 days (range 2–27 days).
Conclusion
We hope that this brief independent survey will offer the necessary peri-operative data on this now well-established cosmetic intervention in children: The Nuss procedure has been performed all around the world with no reported mortality for 20 years (1987–2007), indicated primarily for cosmesis in the paediatric sufferer of pectus excavatum. Potential cardiorespiratory improvement is not as yet confirmed, whilst the co-existence of Marfan's syndrome can be ruled out by pre-operative echocardiography.
The variations of the Nuss procedure stem from thoracoscopic or open, and then thoracoscopy with single or double-lumen ventilation (in toddlers double lumen ventilation may be cumbersome given their tracheal size). Bar stabilisers have evolved as a valid addition to the technique
Pneumothorax and bar-related events (pain, dislocation or infection) may complicate the procedure and are the primary post operative points of concern. Pneumothorax is as expected, commoner with thoracoscopy: the technique may involve carbon dioxide insufflation (capnothorax
Our observations reinforce these of a previous smaller multi-centre cumulative report on 251 cases 7 years ago
The advantages of this procedure include the following: the short hospital stay and limited invasion surgery which allows for growth in the skeleton as opposed to the ostochondrectomies (Table
We have now reached the point of adequate experience with Nuss that the purchasers may decide on strategies after careful individual cost-effectiveness assessment. Most workers timed the operation at an age appropriate to the cosmetic expectations of the patient and family considering the growth spurt of teenagers, namely prior to the early teens. It is not unusual to perform Nuss in young adults as a matter of surgeon's and patient's preference, where care should be exercised for the bar recipient not to be exposed to vigorous activity prior to removal of the bar as displacement is a recognised complication associated with contact sports, trauma or intense manual labour
Limitations of the study and future research
Not all reported series include the data for the variables studied, the length of postoperative in-hospital stay being one important one. This might have an impact on the results. Post operative hospital stay is a surrogate index of performance, especially in paediatric populations. It is evident in the literature that the available data have not been based in comparative high quality studies and patient based outcomes such as Health Related Quality of life and patient satisfaction which are important considerations in therapeutic decision making. Also the long-term results of the procedure are not being discussed in this paper.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AP conceived the research idea and drafted the manuscript. TA corrected the manuscript. Both authors read and approved the final manuscript.