Ann Thorac Surg 2006;81:370-372
© 2006 The Society of Thoracic Surgeons
Case report
A Life-Threatening Complication of the Nuss-Procedure for Pectus Excavatum
Tom N. Hoel, MD
*
,
Kjell Arne Rein, MD, PhD,
Jan L. Svennevig, MD, PhD
Department of Thoracic and Cardiovascular Surgery, Rikshospitalet University Hospital, Oslo, Norway
Accepted for publication September 7, 2004.
* Address correspondence to Dr Hoel, Department of Thoracic and Cardiovascular Surgery, Rikshospitalet, Sognsvannsveien 20, Oslo, N-0027 Norway (Email: tom.nilsen.hoel{at}rikshospitalet.no).
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Abstract
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We describe a delayed, life-threatening complication in a boy operated on using the Nuss-procedure 2 months earlier. On admittance he was in shock with cardiac tamponade. An immediate needle aspiration of blood from the pericardium was done before a median sternotomy. The Nuss-bar was removed, and we identified a 1.5-cm laceration in the adventitial layer of the ascending aorta as the source of bleeding. The tear was closed, and the patient had an uneventful recovery. Careful positioning of the bar is necessary to avoid complications. Measures must be taken postoperatively to confirm that the steel bar does not rotate.
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Introduction
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Pectus excavatum is a common congenital anomaly. However, most thoracic units observe a small number of cases each year. Our preferred method of repair has been a modification of the technique originally described by Ravitch [1], postponing the operation until after the patient's final growth period; with most patients this period ranges from 16 to 19 years of age. During the last years a new technique described by Nuss and colleagues [2] has gained increasing popularity. This method is applicable primarily on smaller children with several studies showing good results [3, 4]. However, in some series the rate of complication is high. Park and colleagues [5] had a complication rate of 16%, and in a European multicenter study [6] a complication rate of 19% was reported. Even though most of the complications are minor and easily dealt with, some major complications are of concern. In one publication, perforation of the heart [5] has been described and Marusch and Gastinger [7] reported on a life-threatening complication after the Nuss procedure due to perforation of the diaphragm.
Encouraged by the report of Jacobs and Quintessenza [8], we were considering the Nuss method before we experienced a serious complication in a 17-year-old boy.
The patient was first admitted to our department at the age of 14. He presented with an asymmetric pectus excavatum, but was still not in his final growth period and the operation was postponed. At the age of 17 years he was scheduled for surgery with the modified Ravitch procedure. However, he and his family insisted on the Nuss method and consulted another Scandinavian center. Shortly thereafter he was operated on with video assisted thoracoscopic implantation of a steel bar to correct the deformity. Due to displacement of the steel bar he had to undergo a reoperation on the postoperative day 3 with reimplantation of a new and stronger bar. During the rest of the stay he suffered severe pain and needed epidural analgesia and ketobemidon hydrochlorid intravenously. A chest roentgenogram before leaving the hospital 6 days after the initial procedure showed good position of the implanted steel bar.
Two months later, the day before admission to our hospital, the patient suffered pain in the neck and abdomen. On the day of admittance he suddenly experienced pain and lost consciousness and was brought to the local hospital as an emergency case. Suspecting complications from the implanted steel bar, the patient was immediately referred to the department of cardiothoracic surgery at Rikshospitalet University Hospital. Two more episodes with loss of consciousness and a systolic blood pressure of <60 mm Hg was noted. On arrival in the emergency room he was obviously in shock and had signs of cardiac tamponade. A transthoracic echocardiography was performed immediately and showed large amounts of fluid in the pericardial sac with compression of the right atrium and right ventricle. A needle puncture of the pericardium through a subxiphoid approach with aspiration of 60 mL of blood relieved the situation. The right side of the heart then began functioning, and systolic blood pressure returned to nearly normal values. An emergency thoracic computed tomographic scan and chest roentgenogram were performed. The steel bar was obviously displaced with a 90° rotation, the convexity pointing cranially. The rotation was due to insufficient fixation of the lateral stabilizing bars to the chest wall. The curvature was lying right in front of the ascending aorta (Figs 1A, 1B and Fig 2). There were large amounts of blood in the pericardial cavity. Due to reduced blood pressure and obvious tamponade the patient was brought to the operation room. A subxiphoid pericardial window was established and the pericardium was emptied of blood. There was still continuos arterial bleeding, and a median sternotomy was made before careful removal of the steel bar under direct vision. The pericardium was opened in the midline, and traces of the bar with a 1.5-cm tear in the adventitial layer of the ascending aorta were visualized. At a small point under this tear there was pulsatile bleeding. The tear was closed with two mattress sutures of Prolene 4-0 (Ethicon, Somerville, NJ), with the last one pledgetted. There were no other injuries, and after standard closure of the sternotomy with mediastinal drainage, the patient had an uneventful recovery. Eight days later he was discharged from the hospital without any signs of neurologic deficiency, and he was in good shape.
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Fig 1. (A) Scout view from the computed tomographic scan on arrival showing the steel bar with dislocation (anteroposterior view). (B) Scout view from the computed tomographic scan, again showing the dislocation of the steel bar (lateral view).
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Fig 2. Computed tomographic scan at the level of the most cranial part of the displaced steel bar. Arrow pointing at the uppermost part of the bar. Note the proximity of the bar and the ascending aorta. The malformation of the thoracic wall is also depicted.
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Comment
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We report a case of potentially life-threatening complication of the Nuss procedure for correction of pectus excavatum. Quite special attention to the position of the steel bar must be taken postoperatively. Every patient should have a routine chest roentgenogram performed before being admitted home to verify a good position of the steel bar. If the patient has any unusual symptoms or signs during the postoperative period, a routine thoracic computed tomographic scan must be performed. If the patient shows any cardiac symptoms, a transthoracic echocardiography is also indispensable.
Even though there are a large number of complications reported in other series, several authors have a reduced number of complications after an initial learning curve [3]. The method is fast, minimally invasive, and technically easy to learn [9]. There are also good early cosmetic results. Further assessment of patient selection regarding age and the degree of chest wall asymmetry are needed. Close follow-up is necessary to provide good long-term results, and special precautions must be taken to prevent complications due to loss of position. Therefore we advocate a more rigid fixation of the lateral stabilizing bars to the chest wall by means of steel wires instead of nonresorbable sutures that can be stretched or disrupted.
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References
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- Ravitch MM. Operative technique of pectus excavatum repair Ann Surg 1949;129:429-444.[Medline]
- Nuss D, Kelly Jr RE, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum J Pediatr Surg 1998;33(4):545-552.[Medline]
- Nuss D, Croitoru DP, Kelly Jr RE, Goretsky MJ, Nuss KJ, Gustin TS. Review and discussion of the complications of minimally invasive pectus excavatum repair Eur J Pediatr Surg 2002;12(4):230-234.[Medline]
- Zallen GS, Glick PL. Miniature access pectus excavatum repairlessons we have learned. J Pediatr Surg 2004;39(5):685-689.[Medline]
- Park HJ, Lee SY, Lee CS. Complications associated with the Nuss procedureanalysis of risk factors and suggested measures for prevention of complications. J Pediatr Surg 2004;39(3):391-395.[Medline]
- Hosie S, Sitkiewicz T, Petersen C, et al. Minimally invasive repair of pectus excavatum–the Nuss procedureA European multicentre experience. Eur J Pediatr Surg 2002;12(4):235-238.[Medline]
- Marusch F, Gastinger I. Life-threatening complication of the Nuss-procedure for funnel chesta case report. Zentralbl Chir 2003;128(11):981-984.[Medline]
- Jacobs JP, Quintessenza JA, Morell VO, Botero LM, van Gelder HM, Tchervenkov CI. Minimally invasive endoscopic repair of pectus excavatum Eur J Cardiothorac Surg 2002;21(5):869-873.[Abstract/Free Full Text]
- 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;35(2):246-251.[Medline]
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Abstract
Introduction
