Ann Thorac Surg 2008;86:957. doi:10.1016/j.athoracsur.2008.05.069
© 2008 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
Dawn Jaroszewski, MD
Department of Cardiothoracic Surgery, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
(Email: jaroszewski.dawn{at}mayo.edu).
Despite many years of successful surgical repair, the field of pectus deformity remains controversial. Notwithstanding the argument as to whether or not the repair improves a patient's cardiopulmonary function, how the repair is done has divided surgeons into two camps: (1) the open modified Ravitch with minimal cartilage resection camp and (2) the minimally invasive Nuss repair camp. The Nuss procedure was introduced in 1998, and its proponents cite the benefits of a small incision and shorter operation time [1]. Opponents who favor the open procedure have published data that conclude longer hospitalization, higher pain levels, and more frequent recurrences with the Nuss procedure [2–4].
Multiple articles have been published on the Nuss technique in younger patients, but for some time the adult population has been treated almost solely with the open procedure. Many believe the ideal age for the Nuss procedure is less than 12 years [5]. Others have completely discouraged the use of the Nuss procedure in teenagers and older patients because of an increased rate of complication or lack of efficacy [2, 3]. Despite this, the Nuss procedure has been increasingly used in the adult population during the past few years with the publication of some case reports and small series of adult patients [6–8].
This article [9] represents the largest published experience of minimally invasive correction of pectus excavatum in adults older than 18 years of age. It is noteworthy not only because of its large number of treated adults (180 patients) ranging from 18 to 43 years, but for the seemingly effortless repair that is performed. Interestingly the majority of patients only required one bar. The mean operating time was significantly longer than that of pediatric cases, especially when multiple bars were required. It is exceptional in that "excellent" results were obtained when previous Nuss proponents have concluded that additional procedures are required to achieve a comprehensive correction of the deformity in patients older than 15 years of age [2, 3, 5]. A definition for qualifying "excellent" was not provided.
The biggest criticism of the study is that follow-up in the patients was short and few patients had their bars removed. The stress factors on the ribs following the Nuss procedure must be significantly high and recurrences would be expected on removal of the bars [3, 8, 10, 11]. Until follow-up can be obtained from patients who have been shown not to have any recurrence after removal of their supporting bar, judgment as the adequacy of this procedure in adults needs to be reserved.
 |
References
|
|---|
- Nuss D, Kelly Jr RE, Croitoru DP, Karz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum J Pediatr Surg 1998;33:545-552.[Medline]
- Molik KA, Engum SA, Rescorla FJ, et al. Pectus excavatum repair: experience with standard and minimal invasive techniques J Pediatr Surg 2001;36:324-328.[Medline]
- Fonkalsrud EW, Beanes S, Hebra A, et al. Comparison of minimally invasive and modified Ravitch pectus excavatum repair J Pediatr Surg 2002;37:413-417.[Medline]
- Wu PC, Knauer EM, McGowan GE, et al. Repair of pectus excavatum deformities in children: a new perspective of treatment using minimal access surgical technique Arch Surg 2001;136:419-424.[Abstract/Free Full Text]
- Hebra A. Minimally invasive pectus surgery Chest Surg Clin N Am 2000;10:329-339.[Medline]
- Schalamon J, Pokall S, Windhaber J, Hoellwarth ME. Minimally invasive correction of pectus excavatum in adult patients J Thorac Cardiovasc Surg 2006;132:524-529.[Abstract/Free Full Text]
- Aronson D, Bosgreaaf RP, van der HC, Ekkelkamp S. Nuss procedure: pediatric surgical solution for adults with pectus excavatum World J Surg 2007;31:26-29.[Medline]
- Coln D, Gunning T, Ramsay M, Swygert T, Vera R. Early experience with the Nuss minimally invasive correction of pectus excavatum in adults World J Surg 2002;26:1217-1221.[Medline]
- Pilegaard HK, Licht PB. Routine use of minimally invasive surgery for pectus excavatum in adults Ann Thorac Surg 2008;86:952-957.[Abstract/Free Full Text]
- Nagasao T, Miyamoto J, Tamaki T, et al. Stress distribution on the thorax after the Nuss procedure for pectus excavatum results in different patterns between adult and child patients J Thorac Cardiovasc Surg 2007;134:1502-1507.[Abstract/Free Full Text]
- Rodgers B. Nuss procedure of pediatric surgical solution for adults with pectus excavatum World J Surg 2007;31:30.
Top
References