Outcome analysis of minimally invasive repair of pectus excavatum: Review of 251 cases

Presented at the 30th Annual Meeting of the American Pediatric Surgical Association, Rancho Mirage, California, May 16-19, 1999.
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Abstract

Background/Purpose: Since the first report in 1997 by Dr Nuss of the technique for minimally invasive repair of pectus excavatum (MIRPE), the popularity and demand for this operation has increased dramatically. Many pediatric surgeons became familiarized with MIRPE and have applied it to a large number of patients. Outcomes and complications have not yet been defined. Methods: A comprehensive survey of APSA members was conducted to review technical problems, complications, and outcomes of this new technique. Results: Of the 74 survey responders, 31 (42%) currently use the MIRPE as their procedure of choice, and 251 cases were reviewed. A total of 74.2% of surgeons relied on direct observation and written documentation to obtain training in MIRPE. Less than 60% used the chest index in the preoperative assessment. A total of 98% used the Walter Lorenz bar for the MIRPE. The most common complication was bar displacement or rotation requiring reoperation (9.2%). Pneumothorax requiring tube thoracostomy was reported in 4.8%. Less common problems included infectious complications (2%), pleural effusion (2%), thoracic outlet obstruction (0.8%), cardiac injury (0.4%), sternal erosion (0.4%), pericarditis (0.4%), and anterior thoracic artery pseudoaneurysm (0.4%). Three patients (1.2%) required early strut removal. Reoperation using the open modified Ravitch approach was performed in 2 patients (0.8%). Most surgeons indicated that teenaged patients (>15 years old) were at higher risk for complications. Thoracoscopy in combination with MIRPE was used by 61% of the surgeons. Overall patient satisfaction was rated as excellent or good (96.5%). Conclusions: The relatively high incidence of problems with MIRPE is probably related to the learning curve associated with the introduction of this new technique. Awareness of technical details, careful patient selection, use of a stabilizing bar, and thoracoscopy likely will result in decreased complications. Long-term results are yet to be determined. The development of a national registry is of great importance for further outcome analysis of MIRPE. J Pediatr Surg 35:252-258. Copyright © 2000 by W.B. Saunders Company.

Section snippets

Materials and methods

To obtain information from pediatric surgeons who have performed the MIRPE, a comprehensive survey was sent out to all members of APSA. The questionnaire was designed to allow the easy reporting of technical information and problems or complications related to the technique of MIRPE as illustrated in Table 1.Note that Table 1 is not a reprint of the survey but only an outline of the key points that are the focus of this report.

Because the survey focused on the technique and results of the

Results

Of the 74 survey responders, 31 (42%) currently use the MIRPE as their procedure of choice for repair of pectus excavatum. A total of 251 cases were collected and reviewed for the purpose of this study. Seventy-four percent of the pediatric surgeons that have performed the MIRPE relied on direct observation of an experienced surgeon performing the operation to obtain training in performing the procedure, whereas 26% used only written or verbal description of the operation before performing it

Discussion

The technique for minimally invasive repair of pectus excavatum was introduced to APSA in 1997, and the first report describing the experience and results with 42 patients was published in 1998 by the senior author in the Journal of Pediatric Surgery.7 The acceptance and popularity of this technique developed quickly among patients and surgeons mainly because of its less radical approach and excellent cosmetic results. The principal advantages of the MIRPE technique were based on the fact that

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Address reprint requests to André Hebra, MD, Assistant Professor of Surgery and Pediatrics, Medical University of South Carolina, Department of Surgery, 171 Ashley Ave, Charleston, SC 29425.

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