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Life-threatening complications and mortality of minimally invasive pectus surgery

      Abstract

      The prevalence and type of life-threatening complications related to the minimally invasive repair of pectus excavatum (MIRPE) and bar removal are unknown and underreported. The purpose of this communication is to make surgeons aware of the risk of these life threatening complications as well as the modifications which have been developed to prevent them.

      Methods

      Data related to life-threatening complications of Pectus Excavatum (PE) patients was obtained from four sources: 1. A survey of Chest Wall International Group (CWIG) surgeons who specialize in repairing congenital chest wall malformations, 2. Papers and case reports presented at CWIG meetings, 3. Review of medico-legal cases from the USA and 4. A systematic review of the literature related to major complications post MIRPE.

      Results

      From 1998 to 2016, we identified 27 published cases and 32 unreported life-threatening complications including: cardiac perforation, hemothorax, major vessel injury, lung injury, liver injury, gastrointestinal problems, and diaphragm injury. There were seven cases of major complications with bar removal (reported and non-reported) with two lethal outcomes. Mortality data with bar placement surgery: Four published death cases and seven unpublished death cases. The overall incidence of minor & major complications post MIRPE has been reported in the literature to be 2–20%. The true incidence of life-threatening complications and mortality is not known as we do not know the overall number of procedures performed worldwide. However, based on data extrapolated from survey information, the pectus bar manufacturer in the USA, literature reports, and data presented at CWIG meetings as to the number of cases performed we estimated that approximately fifty thousand cases have been performed and that the incidence of life-threatening complications is less than 0.1% with many occurring during the learning curve. Analysis of the cases identified in our survey revealed that previous chest surgery, pectus severity and inexperience were noted to be significant risk factors for mortality.

      Conclusions

      Published reports support the safety and efficacy of MIRPE; however major adverse outcomes are underreported. Although major complications with MIRPE and pectus bar removal surgery are very rare, awareness of the risk and mortality of life-threatening complications is essential to ensure optimal safety. Factors such as operative technique, patient age, pectus severity and asymmetry, previous chest surgery, and the surgeon's experience play a role in the overall incidence of such events. These preventable events can be avoided with proper training, mentoring, and the use of sternal elevation techniques.

      Type of study

      Treatment Study.

      Level of evidence

      Level IV.

      Key words

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      References

        • Nuss D.
        • Kelly R.
        • Croitoru D.
        A 10-year review of a minimally invasive technique for the correction of pectus excavatum.
        J Pediatr Surg. 1998; 33: 545-552
        • Nuss D.
        Minimally invasive surgical repair of pectus excavatum.
        Semin Pediatr Surg. 2008; 17: 209-217
        • Hebra A.
        • Swoveland B.
        • Egbert M.
        • et al.
        Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases.
        J Pediatr Surg. 2000; 35: 252-258
        • Engum S.
        • Rescorla F.
        • West K.
        • et al.
        Is the grass greener? Early results of the Nuss procedure.
        J Pediatr Surg. 2000; 35: 246-251
        • Web based
        (n.d.) Retrieved from CWIG
        • Adam L.
        • Lawrence J.
        • Meehan J.
        Erosion of the Nuss bar into the internal mammary artery 4 months after the minimally invasive repair of pectus excavatum.
        J Pediatr Surg. 2008; 43: 394-397
        • Barsness K.
        • Bruny P.
        • Janik J.
        • et al.
        Delayed near-fatal hemorrhage after Nuss bar displacement.
        J Pediatr Surg. 2005; 40: e5-6
        • Bouchard S.
        • Hong A.
        • Gilchrist B.
        • et al.
        Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum.
        Semin Pediatr Surg. 2009; 18: 66-72
        • Carlucci M.
        • Torre M.
        • Jasonni V.
        An uncommon complication of Nuss bar removal: is blind removal a safe procedure?.
        J Pediatr Surg Case Rep. 2013; 1: 34-35
        • Castellani C.
        • Schalamon J.
        • Saxena A.
        • et al.
        Early complications of the Nuss procedure for pectus excavatum: a prospective study.
        Pediatr Surg Int. 2008; 24: 659-666
        • Gips H.
        • Zaitsev K.
        • Hiss J.
        Cardiac perforation by a pectus bar after surgical correction of pectus excavatum: case report and review of the literature.
        Pediatr Surg Int. 2008; 24: 617-620
        • Haecker F.
        • Berberich T.
        • Mayr J.
        • et al.
        Near-fatal bleeding after the transmyocardial ventricle lesion during removal of the pectus bar after the Nuss procedure.
        J Thorac Cardiovasc Surg. 2009; 138: 1240-1241
        • Harris B.
        • Bushman G.
        • Hastings L.
        Inferior vena cava obstruction after pectus excavatum repair.
        J Cardiovasc Surg. 2009; 23: 515-517
        • Jemielity M.
        • Pawlak K.
        • Piwkowski C.
        • et al.
        Life-threatening aortic hemorrhage during pectus bar removal.
        Ann Thorac Surg. 2011; 91: 593-595
        • Leonhardt J.
        • Kubler J.F.
        • Feiter J.
        • et al.
        Complications of the minimally invasive repair of pectus excavatum.
        J Pediatr Surg. 2005; 40: e7-9
        • Maagaard M.
        • Udholm S.
        • Hjordtal V.
        • et al.
        Right ventricular outflow tract obstruction caused by a displaced pectus bar 30 months following the Nuss procedure.
        Eur J Cardiothorac Surg. 2015; 47: e42-e43
        • Marusch F.
        • Gastinger I.
        Life threatening complications of the Nuss-procedure for funnel chest: a case report.
        Zentralbl Chir. 2003; 128: 981-984
        • Mazur L.
        • Ybarondo L.
        • Pickard L.
        • et al.
        Development of supra-valvular pulmonary artery stenosis following a Nuss procedure.
        J Pediatr Surg. 2012; 47: E61-E64
        • Moss R.L.
        • Albanese C.T.
        • Reynolds M.
        Major Complications after minimally invasive repair of pectus excavatum: case reports.
        J Pediatr Surg. 2001; 36: 155-158
        • Lin C.W.
        • Chen K.C.
        • Diau G.Y.
        • et al.
        Late onset vital complication after flu Nuss procedure for pectus excavatum.
        Pediatr Surg Int. 2012; 28: 71-73
        • Notrica D.
        • McMahon L.
        • Johnson K.
        • et al.
        Life-threatening hemorrhage during removal of a Nuss bar associated with sternal erosion.
        Ann Thorac Surg. 2014; 98: 1104-1106
        • Obert L.
        • Munyon R.
        • Choe A.
        • et al.
        Rare late complications of the Nuss procedure: a case report.
        J Pediatr Surg. 2012; 47: 593-597
        • Onursal E.
        • Toker A.
        • Bostanci K.
        • et al.
        A complication of pectus excavatum operation: endomyocardial steel strut.
        Ann Thorac Surg. 1999; 68: 1082-1083
        • Raff G.
        • Wong M.
        Sternal plating to correct an unusual complication of the Nuss procedure: erosion of a pectus bar through the sternum.
        Ann Thorac Surg. 2008; 85: 1100-1101
        • Sakakibara K.
        • Kinoshita H.
        • Ando K.
        • et al.
        Right ventricular perforation due to stabilizing bar installed for the Nuss procedure.
        Minerva Anestesiol. 2013; 79: 820-821
        • Schaarschmidt K.
        • Lempe M.
        • Schlesinger F.
        • et al.
        Lessons learned from lethal cardiac injury by Nuss repair of pectus excavatum in a 16-year-old.
        Ann Thorac Surg. 2013; 95: 1793-1795
        • Umuroglu T.
        • Bostanc K.
        • Thomas D.
        • et al.
        Perioperative anesthetic and surgical complications of the Nuss procedure.
        J Cardiothorac Vasc Anesth. 2013; 27: 436-440
        • Vegunta R.
        • Pacheco P.
        • Wallace L.
        • et al.
        Complications associated with the Nuss procedure: continued evolution of the learning curve.
        Am J Surg. 2008; 195: 313-317
        • Kim K.S.
        • Hyun K.
        • Kim D.Y.
        • et al.
        Lung entrapment between the pectus bar and chest wall after pectus surgery: an incidental finding during video assisted thoracoscopic surgery.
        Korean J Thorac Cardiovasc Surg. 2015; 48: 375-377
        • Nakahara O.
        • Ohshima S.
        • Baba H.
        Cardiopulmonary arrest during the Nuss procedure: case report and review.
        Acute Med Surg. 2015; 2: 250-252
        • Croitoru D.
        • Kelly R.
        • Goretsky M.
        • et al.
        Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients.
        J Pediatr Surg. 2002; 37: 437-445
        • Kelly R.E.
        • Goretsky M.J.
        • Obermeyer R.
        • et al.
        21 years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients.
        Ann Surg. 2010; 252: 1072-1081
        • Park H.J.
        • Jeong J.Y.
        • Jo W.M.
        • et al.
        Minimally invasive repair of pectus excavatum: a novel mophology tailored, patient specific approach.
        J Thorac Cardiovasc Surg. 2010; 139: 379-386
        • Pilegaard H.K.
        Nuss technique in pectus excavatum; A mono institutional experience.
        J Thorac Dis. 2015; 7: 5172-5176
        • Nuss D.
        • Croitoru D.
        • Kelly Jr., R.
        • et al.
        Review and discussion of the complications of minimally invasive pectus excavatum repair.
        Eur J Pediatr Surg. 2002; 12: 230-234
        • Hebra A.
        • Gauderer M.W.
        • Tagge E.P.
        • et al.
        A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum.
        J Pediatr Surg. 2001; 36: 1266-1268
        • Hoel T.N.
        • Rein K.A.
        • Svennevig J.L.
        A life threatening complication of the Nuss procedure for pectus excavatum.
        Ann Thorac Surg. 2006; 81: 370-372
        • Alexander M.
        Night shift nightmare. Reader's digest.
        (available at:)
        • Becmeur F.
        • Gomes Ferreira C.
        • Haecker F.
        • et al.
        Pectus excavatum repair according to Nuss: is it safe to place a retrosternal bar by a Transpleural approach, under Thoracoscopic vision?.
        J Laparoendosc Adv Surg Tech A. 2011; 21: 1-5
        • Barber Jr., J.
        Serious surgical mistakes: at least 4000 annually in US.
        (Retrieved from Medscape)
        • Belcher E.
        • Arora S.
        • Samancilar O.
        • et al.
        Reducing cardiac injury during minimally invasive repair of pectus excavatum.
        Eur J Cardiothorac Surg. 2008; 33: 931-933
        • Park H.L.
        • Lee C.
        Complications associated with the Nuss procedure: analysis of risk factors and suggested measures for prevention of complications.
        J Pediatr Surg. 2004; 39: 391-395
        • Park H.J.
        • Kim K.S.
        • Lee S.
        • et al.
        A next generation pectus excavatum repair technique: new devices make a difference.
        Ann Thorac Surg. 2013; 99: 455-461
        • Jaroszewski D.E.
        • Johnson K.N.
        • McMahon L.E.
        • et al.
        Sternal elevation before passing bars: technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients.
        J Thorac Cardiovasc Surg. 2014; 147: 1093-1095
        • Haecker F.M.
        • Sesia S.B.
        Intraoperative use of vaccum bell for elevating the sternum during the Nuss procedure.
        J Laparoendosc Adv Surg Tech A. 2012; 22: 934-936
        • Rygl M.
        • Vyhnanek M.
        • Kucera A.
        • et al.
        Technical innovation in minimally invasive repair of pectus excavatum.
        Pediatr Surg Int. 2014; 30: 113-117
        • St Peter S.D.
        • Sharp S.W.
        • Ostlie D.J.
        • et al.
        Use of subxiphoid incision for pectus bar placement in the repair of pectus excavatum.
        J Pediatr Surg. 2010; 45: 1361-1364
        • Sacco Casamassima M.G.
        • Goldstein S.G.
        • Salazar J.H.
        • et al.
        Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume single instritution experience.
        J Pediatr Surg. 2014; 49: 572-582
        • Milanez de Campos J.R.
        • Pereira J.C.N.
        • Lopes K.M.
        • et al.
        Technical modifications in stabilisers and in bar removal in the Nuss procedure.
        Eur J Cardiothorac Surg. 2009; 36: 410-412
        • Web based
        'Bullied teenager nearly died after steel bar inserted to disguise his sunken chest came within 1cm of his heart'.
        (Retrieved from)
        • Web based
        'She just wanted to fill a bra like her friends but paid with her life': teenager, 17, dies after surgery to correct sunken hollow in her chest.
        (n.d.) Retrieved from
        • Kelly R.E.
        • Mellins R.B.
        • Shamberger R.C.
        • et al.
        Multicenter study of pectus excavatum final report: complications, static exercise pulmonary function, and anatomic outcomes.
        J Am Coll Surg. 2013; 217: 1080-1089
        • Sacco-Casamassima M.
        • Goldstein S.
        • Gause C.
        • et al.
        Minimally invasive repair of pectus excavatum: analyzing contemporary practice in 50 ACS NSQIP-pediatric institutions.
        Pediatr Surg Int. 2015; 31: 493-499