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Ann Thorac Surg 2009;88:1773-1779. doi:10.1016/j.athoracsur.2009.07.051
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Pectus Excavatum Surgery: Sternochondroplasty Versus Nuss Procedure

Marlos de Souza Coelho, MD, PhD*, Ruy Fernando Kuenzer Caetano Silva, MD, Nelson Bergonse Neto, MD, Wilson de Souza Stori, Jr, MD, Anna Flávia Ribeiro dos Santos, MD, Rafael Garbelotto Mendes, MD, Lucas de Matos Fernandes, MD

Thoracic Surgical Department, Hospital Universitário Cajuru and Santa Casa de Misericórdia, Pontificial Catholic University of Paraná, Curitiba, Brazil

Accepted for publication July 28, 2009.

* Address correspondence to Dr de Souza Coelho, Rua Dep. Leoberto Leal, 187 Guabirotuba, Curitiba, Paraná, 81 510 090, Brazil (Email: clinicadotorax{at}marloscoelho.com.br).

Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: The repair of pectus excavatum (PE) by minimally invasive Nuss surgery is well established, but its complication rate is high and its indication is indiscriminate. Sternochondroplasty (SCP) provides good results with a low complication rate but requires a small transverse incision.

Methods: To compare SCP and Nuss, we analyzed 40 patients with PE who underwent surgery (SCP, n = 20; Nuss, n = 20). Thirty subjects (75.0%) were male and 10 (25.0%) were female. In the SCP group, 9 (45.0%) had symmetric PE, and 11 (55.0%) had asymmetric PE. In the Nuss group, 17 (85%) had symmetric PE, and 3 (15%) had asymmetric PE (p = 0.020).

Results: The mean duration of SCP was 229.5 minutes, and the mean duration of Nuss was 54.3 minutes. The average length of hospital stay was 4 days with SCP and 6.3 days with Nuss (p = 0.172). The SCP results were favorable in 18 subjects (90%) and fair in 2 subjects (10%). In the Nuss group, we observed 17 patients (85.0%) with favorable results and 3 (15.0%) with poor results. Patients with asymmetric PE exhibited severe pectus carinatum. No complications were found in 17 patients (85%) in the SCP group. In the Nuss group, 9 patients (45.0%) had 13 complications (65.0%; p = 0.004).

Conclusions: Sternochondroplasty surgery yielded better results than the Nuss procedure and more patients with asymmetric PE, less pain, and fewer complications. Nuss surgery had shorter operating times than SCP, younger patients, more symmetric PE, and 3 patients who experienced severe postoperative asymmetric pectus carinatum. In summary, for asymmetric PE the best indication is SCP.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Pectus excavatum (PE) is not an uncommon disease, with an incidence ranging from 0.58 to 3 per 1,000 [1, 2]. To choose the appropriate treatment, determining the disease type, indications, surgical techniques, and results is essential [3]. The most widely used technique is Ravitch, whose principles include subperichondrial resection, separation of the intercostal muscle bundle and perichondrals of the sternum, sternal transverse osteotomy, and no sternum support [4]. Modifications have been introduced to include chondrotomies [5, 6], changes in osteotomy [7], no separation of muscle bands and cartilage from sternum [8], sternal support using mainly a polypropylene screen [9], metal plate [10], and steel wire of Kirchner and Steimann [11], autologous perichondrium [12], Dacron vascular graft [13], vascularized rib graft [14], and "gull wing" metallic stent [15].

The Ravitch technique received the stigma of being an extensive surgery with little aesthetic result, but excellent results were obtained with open surgery for correction of PE. Better would be to designate these techniques as sternochondroplasties (SCP), which are implemented in accordance with the principles followed by each author [3].

Nuss developed a technique that uses a metal bar assembly that is introduced on the side of the hemithorax through a 5-cm incision and pulled through the anterior mediastinum and retro sternum, with the concave side up [16]. The plate is rotated so that the convex side of the bar is up and then is attached to the ribs. Although the results have been encouraging, the high complication rate, such as rotation and bar displacement, yielded fair results of 13.3% [17] and intense chest pain and discouraged more widespread use of the technique [6]. Subsequently, the pain could be eased with the use of epidural analgesia and the use of thoracoscopy for viewing the passage of the plate. The increase in technical modifications meant that a larger number of surgeons began to use it, but the number of complications is still high, and the indications for using this method have been indiscriminate by not always considering the patient's age, the type and degree of deformity, and the presence of lower costal protrusion [18]. Sternochondroplasty, in contrast, provides favorable results with a low complication rate, but this technique requires a transverse incision in the anterior chest wall.

The purpose of the present study was to compare SCP and Nuss with regard to indications, performance, duration of hospitalization, surgical time, and complications and to propose an organizational chart for the treatment of PE.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patients underwent treatment following institutional protocol in accordance with the ethical standards of the Ethics Committee for Analysis of Research Projects on Human Experimentation. All patients gave informed consent for the procedure and the retrospective study.

We evaluated 40 patients, with the last 20 consecutive patients undergoing SCP and the first 20 consecutive patients undergoing minimally invasive Nuss surgery in the Department of Thoracic Surgery, Hospital Universitario Cajuru, and Santa Casa de Misericordia de Curitiba, Pontificial Catholic University of Parana, by the same surgeon (C.M.S.) from January 2003 to July 2008.

Thirty patients (75.0%) were male, and 10 patients (25.0%) were female. The mean age was 18.1 years (range, 10 to 38 years). In the SCP group, 9 patients (45.0%) had symmetric PE, and 11 patients (55.0%) had asymmetric PE. In the Nuss group, 17 patients (85%) had symmetric PE, and 3 patients (15%) had asymmetric PE (p = 0.020; Table 1).


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  		Table 1 Demographic Data
 
The surgical indication was the presence of deformity, the will of the patient or family to undergo surgery, and the presence of cardiac or pulmonary symptoms. No severity index was used to indicate surgery. All patients had complaints regarding the bad image of the chest and avoided sports or situations in which they had to expose their chest.

The patient and family received information about the surgery and postoperative care. Routine examinations included blood, blood glucose, coagulation, chest roentgenogram, computed tomography chest scan, electrocardiogram, echocardiogram, and pulmonary function tests. All patients were recorded prospectively with preoperative and postoperative photographs, thoracic molds, and computed tomographic scans.

The Coelho SCP modification was used in compliance with the following principles. Subperichondrial resection of the cartilage involved in the defect was performed. Intercostal muscle bundles and longitudinal perichondrials were not dissected but were cut bilaterally or separated from the sternum. Osteotomy was performed in the anterior surface of the sternum after blunt retrosternal dissection of mediastinal fat, pericardium, and pleura. A metal plate was placed to support the sternum. Wrinkling of the beams from the muscle or cartilage subperichondrial resection was performed. Meticulous care was taken in the reconstruction of pectoral and abdominal muscles [8].

The Nuss technique began with bilateral incisions. A 5-mm endoscope, at an angle of 30 degrees, was introduced in the right hemithorax, two spaces below the intercostal incision, to visualize the passage through the mediastinum. The preshaped bar was drawn through with the convex side down. The bar was then rotated. We used one lateral stabilizer on the left side that was attached to the bar with steel wires. We pulled through an absorbable suture string with the intermediate portion of the bar in the left hemithorax and another three points up under endoscopic visualization around the bar and the corresponding rib in the right hemithorax so that the bar did not rotate.

Postoperative care was similar for the modified SCP and the Nuss technique. Radiography of the chest was performed in the operating room (Nuss) and on the second postoperative day (both). Epidural analgesia was administered for 48 to 72 hours. Patients slept in the supine position for the first 15 days after surgery. Patients are usually discharged on the fourth postoperative day and prescribed oral analgesics, with the recommendation of not engaging in physical activities for 3 months, after which they can lead a normal life.

Follow-ups occurred 1 week, 1 month, and every 3 months for 1 year, and then once a year until bar removal. At 6 months, the patients underwent a chest roentgenogram, computed tomographic scan of the chest, and echocardiogram. The Nuss and SCP bar remained implanted for 3 years and then was removed under general anesthesia. Surgical outcome was classified by direct examination as good (functional outcome including a perfectly contoured chest as regarded by the surgical team and the patients and families), fair (when patients or family did not completely like the results, such as unsatisfactory chest contour, the presence of sternal projections, or bony costal chondral protrusions, although the functional outcome was achieved), and poor (when the correction was partial, with a recurrence of deformity or the presence of hypertrophic or unaesthetic scars). To determine intergroup significance, nonparametric Mann-Whitney U test, {chi}2 test, and Fisher's exact test were used (Epi-Info, Version 6.04b, January 1997; Centers for Disease Control & Prevention, US; World Health Organization, Geneva, Switzerland). Values of probability of less than 0.05 were considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The presence of a family history of PE was higher in the SCP group than in the Nuss group. Patients who underwent SCP were older than Nuss patients. No significant difference was found with regard to sex, onset of disease (median, 5.5 years; range, 0 to 17 years), the presence of symptoms, disease, the presence of mitral valve prolapse, and the Haller index (Table 1).

More positive results were observed in the SCP group, but the difference with the Nuss group did not achieve statistical significance. Most patients in both groups had favorable results and were very satisfied with the aesthetic results achieved. In the Nuss group, we found a longer duration of epidural analgesia (Table 2).


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  		Table 2 Results
 
No significant differences were found when comparing the number of patients who had complications between the two groups. However, when comparing the number of complications in each group, more complications were found in the Nuss group. In the SCP group, one case of hypertrophic scar was found that was subjected to resection and beta therapy 8 months after surgery with good results. Beta therapy follows the same principles of radiation and provides a better result of healing. A case of displacement of the bar in the Nuss group was subjected to repositioning with good results. One case of exteriorization of the lateral stabilizing steel wire was treated with antibiotics and controlled until 2 years after surgery; when the bar was removed, the patient experienced an excellent outcome. One patient with repeated syncope and paroxysmal supraventricular tachycardia became asymptomatic after SCP. Three patients in the Nuss group exhibited postoperative pectus carinatum (PC). One 13-year-old patient with moderate PE at the third postoperative month had a slightly inflexible PC that progressed until the eighth postoperative month to become severe asymmetric PC (Fig 1).


Figure 1
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  		Fig 1. Pectus carinatum resulting from Nuss procedure shown 24 months postoperative.

 
In the review of the preoperative computed tomographic scans, we found discrete sternal asymmetry. The sternum was in the central position, and the surgeon proposed waiting for 2 years before performing SCP. The computed tomographic scan of the chest showed asymmetry of the right hemithorax, cartilage hypertrophy on the right side, and sternal rotation. Sternochondroplasty was performed with the removal of the Nuss bar with excellent aesthetic results (Fig 2). Two patients with moderate slightly asymmetrical PE exhibited asymmetric PC. The surgeon waited for 2 years before subjecting the patients to SCP, with excellent aesthetic results.


Figure 2
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  		Fig 2. Asymmetric pectus excavatum shown 12 months postoperative of sternochondroplasty with removal of the Nuss bar, obtaining excellent aesthetic result.

 
The time of surgery was greater with SCP than with Nuss. There was no difference in relation to duration of hospital stay and follow-up (Table 3).


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  		Table 3 Time of Surgery, Hospital Stay, and Follow-Up
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Patients and family members should be fully informed about each type of deformity and the limitations of each treatment so that they can make the appropriate treatment decision in view of the success rates [19]. The surgical indication is based on the presence of deformity with or without psychological, heart, lung, or postural considerations and the wishes of patients or family [8]. Numeric severity indices, such as those of Welch and Wada, have little practical usefulness in surgery indication [10]. Some authors, however, have used the Haller index for surgical indication [16, 17]. In our institution we do not use any severity index; instead, the surgical indication is based on the algorithm proposed by our group [3].

Pectus excavatum is classified as symmetric, in which sternal depression is present to a greater or lesser degree, with both sides nearly equal, and asymmetric, in which a difference is present between the two halves of the chest and the sternum, which, in addition to being depressed, is turned [8]. Pectus excavatum can be classified into acute PE and wide PE [3, 9]. The diagnosis is visual and classified empirically and subjectively as mild, moderate, and severe. Surgical correction of PE is possible at any age, even in adulthood, when using SCP, although the surgery is faster and easier for children and teenagers. Most surgeons prefer to operate on teenagers unless they have symptoms or associated physiologic effects [9]. The Nuss procedure was initially used in children or adolescents because of chondrosternal elasticity, but reports in adults have focused mainly on intense pain and prolonged postoperative care, bar displacement, and the recurrence of deformity, which is dependent on the rigidity of the chest wall [14, 16]. Schalamon and colleagues [20] achieved excellent results in 91% of patients between 18 and 39 years of age, unsatisfactory results in 9%, and a complication rate of 26% for Nuss surgery. In this series, 3 patients older than 28 years of age underwent Nuss surgery with good results with only one bar, but patients older than 30 years required two or more bars in 50% of cases [18].

The correction of the asymmetric form of mild and moderate PE with the Nuss technique is not aesthetically perfect, although it is functionally acceptable with only mild PE. The risk of small asymmetries are accentuated after Nuss surgery and may progressively increase because of hypergrowth of costal cartilage in the hemithorax, which can later develop into asymmetric PC. Three patients in this series exhibited PC after the Nuss procedure for symmetric moderate PE in 15-year-old patients. No patients had Marfan syndrome. The decision was made to monitor the Nuss bar for 2 years despite presenting with a grotesque form of PC. The 3 patients at the end of 2 years with the bar at the site underwent SCP with excellent aesthetic results. Reactive PC was reported in 2 patients who underwent Nuss surgery and 1 patient who underwent Ravitch surgery [21]. Until recently, no descriptions of PC have been made after Nuss because the outcomes have been considered to be good, with relief of cardiac compression. However, some reports have found hypercorrection of PE in 3.2% of patients with Marfan syndrome who underwent Nuss surgery [18].

The rate of surgical complications with Nuss has been high (10.1% early and 14% late) and includes liver damage, pericardial effusion, pericarditis, pleural effusion, atelectasis, bar infection, pneumonia, upper limb paralysis, pneumothorax requiring drainage, wound infection, pseudoaneurysm of the thoracic aorta, costal and sternal erosion, allergic reactions to the bar, persistent cardiac arrhythmia [16, 18, 22, 23], cardiac tamponade by laceration of the ascending aorta, erosion of the right lower lobe artery, and cardiac injury from passing the bar [21, 24]. Extrapleural and submuscular passage of the bar, a firm grip of the bar, pleural effusion, and pericardial effusion reduced the incidence of secondary pneumothorax [25].

The addition of lateral stabilizers has reduced the displacement of the bar (5% to 8.8%) [18, 22, 24]. Most surgeons now use a lateral thoracic incision to place the suture around the bar and rib under thoracoscopic control [18, 26]. Some surgical centers use wire and others use absorbable sutures. A new absorbable stabilizer recently became available [18]. Currently, we use a lateral stabilizer on the left side and absorbable sutures around the bar under endoscopic visualization at three different points in the right hemithorax to prevent bar movement [27].

Two patients in the Nuss group had severe pain that was considered to be a complication that did not occur in the SCP group. Generally, other authors have not considered pain to be a complication [18]. In this series of patients, the SCP group required a shorter time of epidural analgesia and a reduced need for analgesics [3].

The mortality rate of SCP is between 0% and 0.5% [9], and complications occur in 7.6% to 22.9% [8, 9]. Several complications have been reported, including hemopericardium [1], cardiac tamponade [12], "floating sternum" [28], and Jeune syndrome [29]. In this series, the number of complications was significantly lower with SCP than with Nuss.

The bars of Nuss and SCP need to be removed within 3 years because of the impossibility of external cardiac massage by the rigidity of the chest wall caused by the presence of the bar. One case of death was reported under these circumstances [30]. Cardiac arrest and pulmonary hemorrhage have been reported with removal of the bar [18]. The removal of the bar is done under general anesthesia, with patients properly monitored, and has generally not been associated with difficulties or complications. However, we found difficulty in removing the bar in 3 patients in the Nuss group because of bone involvement around the bar and stabilizer.

Difficulty has been experienced in analyzing and comparing the results in the literature between the different SCP techniques in the treatment of PE. Good aesthetic results have been obtained, ranging from 54% [1, 4] to 80% to 94% [8, 9]. The rates of excellent and good results with the Nuss procedure have improved from 86.6% [16] to 92.2% [18]. The improvement in results reflects better patient selection with regard to mean age and PE type. A multicenter European study of Nuss surgery found excellent and good results in 81.5% of patients and poor results in 18.5% of patients, which can be explained by the high number of patients with asymmetric deformities and the higher average age [22].

Sternochondroplasty, when performed by surgeons who have acquired familiarity with the technique, has also achieved good results. The Nuss technique requires a smaller incision, little blood loss, good aesthetic results, and less operative time but a higher rate of revision surgeries, a higher rate of complications, a greater need for epidural analgesia and analgesics after hospital discharge, a higher rate of rehospitalization for pain, and a longer hospital stay [17, 21, 31]. The difference in surgical time between Nuss and SCP should not be used alone when choosing which surgery to perform [3].

Although Nuss and his supporters have used his procedure for all forms of PE, even asymmetric PE and lower costal protrusion, its best indication is for symmetric moderate PE and symmetric mild PE. Patients with severe PE should undergo the modified SCP technique because PC cases can occur after surgery when undergoing the Nuss technique. Patients undergoing modified SCP for asymmetric PE should be informed of the Nuss technique as a possible option, but they and their families should also be informed about the outcome and the possibility of exhibiting asymmetric PC postoperatively. When presenting with unilateral or bilateral chondrocostal protrusions associated with PE, SCP is indicated. However, Nuss may be an option for patients provided that they and their families are prepared to accept aesthetic results that might be below their expectations. The best indication for the Nuss technique is symmetric acute to moderate PE without chondrocostal protrusion in adolescents and young adults, although patients older than 30 years of age who have undergone Nuss have also achieved excellent results [20].

In this series, no significant difference was found between SCP and Nuss with regard to aesthetic results. However, patients undergoing SCP had less pain and fewer complications, and despite the large absolute number of patients with asymmetric PE, no case of postoperative PC was reported in the SCP group. Nuss surgery had shorter operating times than SCP, younger patients, more symmetric PE, and 3 patients with severe postoperative asymmetric PC. In summary, for asymmetric PE the best indication is SCP.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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