In 1998 a minimally invasive repair of pectus excavatum

Routine Use of Minimally Invasive Surgery for Pectus Excavatum in Adults Hans K. Pilegaard, MD, and Peter B. Licht, MD, PhD Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby Aarhus; and Department of Cardiothoracic Surgery, Odense University Hospital Odense, Denmark Background. The Nuss operation, a minimally invasive repair of pectus excavatum, is considered the treatment of choice in children. It is controversial in adults, but smaller series have been published. We have used the Nuss operation routinely in adults since 2003. Methods. The indication for operation was a patientdescribed disabling cosmetic appearance. We modified the operation by using a shorter pectus bar, which appears to be more stable. All patient records were available and analyzed retrospectively. Results. Operations for pectus excavatum were done in 475 patients (89% men) at Aarhus University Hospital. 180 patients (38%) were aged 18 years or older, median patient age was 22 years (range, 18 to 43 years). All but one patient achieved an excellent cosmetic result. Two pectus bars were required in 57 patients (32%), and 2 patients required 3 pectus bars. The median duration of the procedure was 41 minutes (range, 16 to 119 minutes), which was significantly longer compared with younger patients, but the difference was not clinically relevant (6 minutes). Pneumothorax occurred in 86 patients (48%), but only 4 (2%) required chest tube drainage. In 3 patients the pectus bar dislocated during follow-up. Conclusions. Minimally invasive repair for pectus excavatum can be performed safely in adults, with excellent immediate cosmetic results. Adults often require more than 1 pectus bar. From the results of this large series, we conclude that patients aged younger than 50 years are eligible for minimally invasive surgical correction of pectus excavatum. (Ann Thorac Surg 2008;86:952 7) 2008 by The Society of Thoracic Surgeons Accepted for publication April 23, 2008. Presented at the Poster Session of the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28 30, 2008. Address correspondence to Dr Pilegaard, Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby, Brendstrupgaardsvej 100, Aarhus, 8200, Denmark; e-mail: pilegaard@dadlnet.dk. In 1998 a minimally invasive repair of pectus excavatum was reported by Nuss and colleagues [1]. It involves remodeling of the anterior chest wall by using a retrosternal metal bar with avoidance of cartilage resection. The Nuss operation has since rapidly gained acceptance as the preferred method in children and young adolescents because the procedure is associated with small skin incisions, shorter operation time, minimal blood loss, and early return to full activity. Several articles have been published on this technique in younger patients, but there is much controversy in the literature about the ideal age for minimally invasive surgical repair. Most authors recommend surgical intervention between age 5 and 20 years, and some believe that the ideal age is 8 to 12 years because the chest wall is still very malleable [2 4]. Others discourage the use of Nuss operations in teenagers because of an increased rate of complications or lack of efficacy [5]. Nevertheless, in recent years the indication for operation has been extended to adults [6 11] even though higher rates of complications and postoperative pain have been reported [5, 7, 9, 12]. Its application has since been steadily increasing, and from 2003, we have used the Nuss operation in adults with disabling pectus excavatum. The aim of this study was to report our experience and demonstrate that it can be used routinely in adults. Material and Methods From 2001 to 2007, 475 patients underwent minimally invasive repair of pectus excavatum at Aarhus University Hospital. We began to use this technique in adults in 2003 and have operated on 180 patients who were aged 18 years or older, which is 38% of all our patients. The indication for operation was disabling cosmetic appearance, as described by the patient (Fig 1). All patients were seen preoperatively for a clinical examination. If the pectus excavatum was evaluated to be less than 2.5 cm deep, the patient was not considered for operation. In the beginning we only operated on patients with symmetric deformities, but since 2004, we have also admitted patients with an asymmetric pectus excavatum. This group constitutes approximately 10% of our patients, and we believe there is no limit to the extent of asymmetry that excludes patients for the minimally invasive approach. From 2001 through 2005, our patients were routinely scheduled for a computed tomography scan, but we never used the Haller index as a reason to exclude the patient from an operation, and consequently, we stopped these investigations. Preoperative echocardiography was only performed in 9 patients who were thought to have Marfan syndrome. In accordance with Danish law, the 2008 by The Society of Thoracic Surgeons 0003-4975/08/$34.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2008.04.078

Ann Thorac Surg PILEGAARD AND LICHT 2008;86:952 7 PECTUS EXCAVATUM IN ADULTS 953 Fig 1. A typical case of pectus excavatum in an adult before minimally invasive correction. Fig 2. A typical patient with moderate pectus excavatum and a pectus bar shaped like the expected new anterior chest wall. The 5-mm port for the thoracoscope is shown. local ethics committee waived review and consent requirements for retrospective follow-up studies where individual patients are not identified. All operations were performed by the same surgeon. All hospital records were retrieved. The data recorded included length of hospital stay, postoperative complications, duration of the surgical procedure, and signs of pneumothorax on the routine postoperative chest roentgenogram. Statistical analysis included cross-tabulation and univariate analysis implemented in SPSS 15.0 software (SPSS Inc, Chicago, IL). Values of p 0.05 were considered statistically significant. Surgical Technique From 2001 to 2004, all patients underwent operation in the supine position, with abduction of both arms. Double-lumen intubated anesthesia was used. Since 2004, all patients aged younger than 25 were intubated with single-lumen tracheal tube, and the operations were performed with brief periods of apnea. A 5-mm blunt-tip trocar was introduced into the chest for the use of a 30 videothoracoscope (Olympus Winter & Ibe, Hamburg, Germany) to define the deepest point under the funnel chest and allow safe retrosternal instrumentation. A template was shaped as the expected new form of the anterior chest wall and a Pectus Support Bar (Lorenz Surgical Inc, Jacksonville, FL) was bent to match the template (Fig 2). We routinely used bars that were 5 to 8 cm shorter than originally described by Nuss because this facilitated placement of the stabilizer close to the entry of the pectus bar into the thoracic cavity. A subcutaneous tunnel was created by blunt dissection to the highest point of the funnel (thoracic entry and exit points). A long steel rod (introducer) was inserted into the chest and pushed behind the sternum anterior to the pericardium (Fig 3). A 0-0 Ethibond suture (Ethicon, Somerville, NJ) was tied to the eyelet at the end of the introducer, which was then pulled back, guiding the suture through the thoracic cavity. The pectus bar was attached to the suture and pulled through the tunnel with the convex side facing down (Fig 4). Finally, the bar was rotated 180, and the sternum was tilted upward. A stabilizer was placed on the left side of the bar as close as possible to the entry into the chest to avoid rotation. In addition, the pectus bar was secured on the right side by two or three 0-0 polydioxanone (PDS) sutures around the ribs. An additional bar was introduced if the cosmetic result was unacceptable with a single pectus bar (Fig 5). If the patient presented with an asymmetric pectus excavatum, the metal bar was bent asymmetrically according to the method described by Park and colleagues [8]. It was never necessary to resect cartilage, but in patients with a severe protrusion of the costal cartilage, which is sometimes associated with pectus excavatum, Fig 3. Same patient as Figure 2 with the introducer in place before introduction of the metal pectus bar.

954 PILEGAARD AND LICHT Ann Thorac Surg PECTUS EXCAVATUM IN ADULTS 2008;86:952 7 Fig 4. Same patient as Figure 2 just before the metal pectus bar is turned. this protrusion was acceptable but still evident after the operation. All patients received an epidural catheter for postoperative pain control. This was removed on postoperative day 3 or 4, and the patient was treated with oral opioids, nonsteroidal anti-inflammatory drugs, and acetaminophen for an additional 4 to 6 weeks. Patients were not advised to wear protective thoracic gear but were always advised to refrain from contact sports during the full 3-year period with the pectus bar in place. All pectus bars were left for a minimum of 3 years before they were removed under general anesthesia. Results The median age of the 180 patients was 22 years (range, 18 to 43 years), and 160 (89%) were men. No operative Fig 5. A roentgenogram of patient in Figure 1 with 2 pectus bars. Fig 6. Photograph shows the patient in Figure 1 six weeks after surgery. deaths occurred. All but one patient achieved an excellent cosmetic result (Fig 6). Two pectus bars were required in 57 patients (32%), and 2 patients required 3 pectus bars. The use of several pectus bars was significantly more common (p 0.01) in adults compared with younger patients, where 254 patients (86%) received 1 pectus bar and 41 patients (14%) needed 2 pectus bars. The median duration of the surgical procedure was 41 minutes (range, 16 to 119 minutes) in adults, which was significantly longer (p 0.01) compared with 35 minutes (range, 17 to 180 minutes) in the 295 younger patients, but the difference was just 6 minutes. This duration remained significantly longer in adults even after adjustment for the number of inserted pectus bars (p 0.01). The median postoperative length of hospital stay was 5 days (range, 3 to 29 days), which was not significantly longer compared with younger patients. The hospital stay was significantly shorter in both adults and children in the last half of the study period (p 0.01). Information on the postoperative chest roentgenogram was available from all charts: a pneumothorax was visible in 86 cases (48%), but only 4 patients (2%) required chest tube drainage. In the remaining 82 patients, all of whom were asymptomatic, the pneumothorax was treated conservatively, and on the day of discharge it had resolved completely. Other postoperative complications included pneumonia in 4 patients, pleural effusion in 4, empyema in 1, seroma in 1 and deep infection in 5. Three patients (2%) underwent reoperation because the bar dislocated. In another 13 patients (7%), the stabilizer was removed early because of intolerable pain. At present, the bars have been removed in 46 patients (26%), and their final results were excellent at the time of discharge and at routine follow-up after 1 month. Unfortunately, we do not yet have any long-term follow-up data on these patients.

Ann Thorac Surg PILEGAARD AND LICHT 2008;86:952 7 PECTUS EXCAVATUM IN ADULTS 955 Comment In 1998 Nuss and colleagues [1] introduced a minimally invasive alternative to the standard open Ravitch technique for the correction of pectus excavatum. The rationale was that it seemed unnecessary to perform an extensive and radical resection when the malleability of the thoracic cage was well demonstrated clinically by the observation that a characteristic barrel chest develops even in adult patients with chronic obstructive pulmonary disease long after their bones have matured and calcified. The advantages of this minimally invasive approach are obvious: 1. no anterior chest wall incision, no need to raise pectoralis muscle flaps, and no need to resect rib cartilages or perform sternal osteotomy; 2. shorter operating time, minimal blood loss, and early return to full activity; 3. normal long-term chest strength, expansion, flexibility, and elasticity; and 4. excellent long-term cosmetic result in children [1]. Incorporation of thoracoscopic techniques and small but important modifications to the technique originally described have made this operation very effective and safe, and several studies have since been published in children and adolescents. Most are small in numbers, but some report extensive experience [2, 8, 12 16]. Patient and physician acceptance have since been growing steadily, and it is likely that the Nuss operation will become the gold standard for the operative management of pectus excavatum if long-term cosmetic results after removal of the pectus bar remain excellent. Treatment of pectus excavatum in adults is more controversial. The open repair as described by Ravitch [17] has been used for decades and is still used routinely [18 25]. Minimally invasive repair of pectus excavatum in adults has been used since 1998 [11], and a few smaller studies have been published [6 10, 16]. One larger study included 461 children and adult patients, and the authors concluded that additional procedures were required to achieve a comprehensive correction of the deformity in patients aged older than 15 years [16]. We have used the minimally invasive approach in adults routinely since 2003, and the number of referred adult patients seems to increase year after year. In our experience it is not necessary to add any additional procedures to achieve a comprehensive correction of the deformity in adults. All but one patient achieved an excellent immediate cosmetic result after final rotation of the pectus bar, but we did find that a significantly higher proportion of adults required more that 1 pectus bar before the result was satisfactory. Although the present study represents a large published experience of minimally invasive correction of pectus excavatum in adults, there is no consensus in the literature on pectus excavatum of when a patient is considered an adult. Different authors define adults from age 14 [10], 16[18], 18[6, 7, 22], or 20 years [9]. Asin most of these studies, we defined patients as adults if they were 18 years or older, and found 180 such patients, which were 38% of all patients treated by this operation at our institution. Our oldest patient was 43 years old, but we would not hesitate to perform the Nuss operation in patients up to 50 years old. Our results demonstrate that the operation may be done safely in adults with excellent immediate results, few complications, and a short hospital stay, which was not significantly longer than in younger patients. The duration of surgery was significantly longer in adults compared with children and remained so after adjusting for the number of pectus bars inserted. However, the mean difference was just 6 minutes, which we do not consider clinically relevant. Our results confirm previous reports that complications occur frequently after the Nuss operation and that intolerable pain led to early removal of the stabilizer in 7% of our adult patients. Reported complications include pneumothorax, wound seroma, bar displacement, pericarditis, pericardial effusion, pleural effusion, and hemothorax [26]. However, one reason that complications are frequent is because even the smallest pneumothorax, which is seen in almost half of all patients, is considered a complication. Nearly all of these cases were asymptomatic and resolved spontaneously during the hospital stay without chest drainage, and it is indeed questionable if they should be considered real complications. Other complications were infrequent in our patients. This may be secondary to the high volume of operations at our institution, but is more likely to reflect that we avoided many of the early pitfalls with this technique because we first started out late in 2001. In addition, just like others surgeons who have made modifications [8], we modified the original technique by shortening the pectus bar approximately 5 to 8 cm, which may have reduced the incidence of bar displacement and wound seromas. The rationale was that the stabilizer is placed closer to the entrance of the bar into the thoracic cavity, thereby decreasing the risk of rotation or displacement because the point where the stabilizer is attached may function as a hinge. The closer this point is to the center of the pectus bar, the less likely it will rotate. In contrast, if a longer pectus bar is used, the stabilizer is inevitably placed more laterally on the chest because it cannot be pushed medially on the curved pectus bar. Further, we believe it is possible that shortening the pectus bar decreases its movement in the tunnel created in the anterior part of the thoracic cavity, which leads to less inflammation and reduced problems with seroma at the ends of the pectus bar. It appears that these theoretic considerations may have some importance, because the incidence of bar displacement or rotation was less than 2%, and seroma only occurred in 1 patient. Previous studies have reported bar displacement in up to 12% to 13% of patients [7, 27] and seroma in up to 9% [4]. Most patients who undergo surgical repair for pectus excavatum are asymptomatic children and adolescents. Symptoms are infrequent during early childhood, apart from a shy awareness of the abnormality and a typical unwillingness to expose the chest while taking part in

956 PILEGAARD AND LICHT Ann Thorac Surg PECTUS EXCAVATUM IN ADULTS 2008;86:952 7 social or athletic activities. In the absence of objectively proven cardiorespiratory problems, the principal indication for operation in our patients was for cosmetic improvement. Others have also operated on patients whose only indication was an unacceptable chest wall deformity [6]. Our results demonstrate that the immediate result of intervention with the Nuss technique was excellent in almost all patients. We acknowledge that it may be premature to claim that the Nuss procedure is the method of choice for correction of pectus excavatum, particularly in adults, because relatively few patients had the bar removed and the follow-up period in that subset was short. Computer model simulation recently suggested that stress factors on the ribs after the Nuss procedure are higher in adults compared with children [28]. In addition, with the decreased compliance of the adult chest wall, some authors claim it would be logical to expect a greater incidence of recurrent pectus excavatum anomalies in this population than that experienced with children [29]. This may be true; but so far it is speculative, and we must await results from long-term follow-up studies. In fact, we do not suspect that recurrence of pectus excavatum is a major problem after removal of the pectus bar because we have not yet experienced a single case at our institution and we have not seen any such case reports in the literature. However, we recognize that it may be too early to estimate the true incidence of recurrence after bar removal, and this should always be mentioned to patients who consider surgical intervention. In any case, many adult patients have become aware that their deformities can be corrected with a high degree of immediate success, and the number of adult patients referred for operation in Denmark continues to increase. References 1. Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545 52. 2. Croitoru DP, Kelly RE Jr, Goretsky MJ, Lawson ML, Swoveland B, Nuss D. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37:437 45. 3. Hebra A. Minimally invasive pectus surgery. Chest Surg Clin N Am 2000;10:329 39, vii. 4. Watanabe A, Watanabe T, Obama T, et al. The use of a lateral stabilizer increases the incidence of wound trouble following the Nuss procedure. Ann Thorac Surg 2004;77: 296 300. 5. Molik KA, Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL. 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