Comparison of minimally invasive and modified Ravitch pectus excavatum repair
Abstract
Background/Purpose: Minimally invasive repair of pectus excavatum (MIRPE) has gained wide acceptance during the last 4 years. This study compares, retrospectively, the experience at 2 large hospitals, 1 using MIRPE and the other a modified Ravitch repair (MRR). Methods: From 1996 to 2000, 68 PE patients underwent MIRPE at one hospital, and 139 underwent MRR at another hospital. Ages ranged from 5 to 19 years (mean, 12) for MIRPE, and 3 to 51 years (mean, 17.3) for MRR. The mean pectus severity index was 4.2 for MIRPE and 4.9 for MRR (normal, 2.5). Results: There were no deaths after MIRPE or MRR. Complications included 6 reoperations for MIRPE and none for MRR. There were 8 rehospitalizations for MIRPE and none for MRR. Ninety percent of MIRPE complications occurred in the first 25 cases. The mean blood loss was under 90 mL for both MIRPE and MRR. Mean operating time was 75 minutes for MIRPE and 212 minutes for MRR. Ninety-six percent of MIRPE patients and no MRR patients had epidurals. Intravenous analgesics averaged 5 days for MIRPE and 1.7 days for MRR. Mean hospitalization was 6.5 days for MIRPE and 2.9 days for MRR. Mean time before return to work or school was 18 days for MIRPE and 12 days for MRR. The sternal bar was removed from 107 of 139 MRR patients (mean time, 19 minutes) and 18 of 68 MIRPE patients (mean time, 25 minutes). Conclusions: Both MIRPE and MRR provide excellent clinical results. MRR has a longer operating time but decreased hospital stay, complication rate, and use of pain medications. Attention to technical operative details and surgeon's experience are essential for optimal results using both techniques.
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Complications after Ravitch versus Nuss repair of pectus excavatum: A Society of Thoracic Surgeons (STS) General Thoracic Surgery Database analysis
2021, Surgery (United States)There are conflicting reports in the literature comparing outcomes after open Ravitch and minimally invasive Nuss procedures for pectus excavatum repair, and there is relatively little data available comparing the outcomes of these procedures performed by thoracic surgeons.
The 2010 to 2018 Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients age 12 or greater undergoing open or minimally invasive repair of pectus excavatum. Patients were stratified by operative approach. Multivariable logistic regression was performed with a composite outcome of 30-day complications.
A total of 1,767 patients met inclusion criteria, including 1,017 and 750 patients who underwent minimally invasive pectus repair and open repair, respectively. Open repair patients were more likely to be American Society of Anesthesiologists (ASA) class III or greater (24% vs 14%; P < .001), have a history of prior cardiothoracic surgery (26% vs 14%; P < .001), and require longer operations (median 268 vs 185 minutes; P < .001). Open repair patients were more likely to require greater than 6 days of hospitalization (18% vs 7%; P < .001), undergo transfusion (7% vs 2%; P < .001), and be readmitted (8% vs 5%; P = .004). After adjustment, open repair was not associated with an increased risk of a composite of postoperative complications (odds ratio 0.99, 95% confidence interval 0.67–1.46). This finding persisted after propensity score matching (odds ratio 1.11, 95% confidence interval 0.74–1.67).
Pectus excavatum repair procedure type was not associated with the risk of postoperative complications after adjustment. Further investigation is necessary to determine the impact of pectus excavatum repair type on recurrence and patient reported outcomes, including satisfaction, quality of life, and pain control.
Surgical Outcomes of Double Compression and Complete Fixation Bar System in Pectus Excavatum
2018, Annals of Thoracic SurgeryMinimally invasive repair of pectus excavatum is a widely used technique for correction of pectus excavatum. Yet despite the advancement in the surgical techniques, it is still associated with various complications, including bar displacement leading to reoperation. To overcome this problem, we developed the double compression and complete fixation bar (DCCF) system that consists of 2 metal bars that are inserted above and below the sternum and compressed to correct pectus excavatum.
Patients who underwent pectus excavatum correction surgery at this center between April 2006 and March 2017 were divided into a DCCF system group and a conventional Nuss procedure group and their demographic, clinical, and surgical characteristics were compared.
A total of 220 patients underwent the DCCF system procedure and 306 patients underwent the conventional Nuss procedure. The DCCF system group had significantly shorter operation time (p < 0.001) and postoperative hospital admission time (p < 0.001) compared with the conventional Nuss procedure group. There were only 2 cases (0.9%) of postoperative complications in the DCCF system group, which was significantly less than that of the conventional Nuss procedure group (n = 64, 20.9%; p < 0.001). In particular, there were no cases of bar displacement in the DCCF system group.
The DCCF system was applied to surgical correction of pectus excavatum, which led to significant reduction in the operation time and postoperative hospital admission period, as well as reduced minimally invasive repair of pectus excavatum complication and bar displacement rates. Therefore, we recommend the application of the DCCF system to the surgical correction of pectus excavatum.
Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis
2017, Journal of Pediatric SurgeryCitation Excerpt :Post-surgical analgesic is an important factor to be evaluated with respect to repair of pectus excavatum. Seven studies included in the current analysis reported analgesic use following surgery [27,30,33,36,38,40,42]. Analgesics used included epidurals, patient-controlled analgesia (PCA), opioids, and other drugs such as ketoprofen, valium (administered intravenously), and non-steroid anti-inflammatory drugs (NSAIDs).
To evaluate surgical outcomes of Nuss versus Ravitch repair of pectus excavatum via a systematic review and meta-analysis.
Medline, PubMed, Cochrane, EMBASE, and Google Scholar databases were searched up to September 5, 2016 using the following search terms: pectus excavatum, funnel chest, Nuss; Ravitch, minimally invasive, and open surgery. Randomized controlled trials, two-arm prospective, and two-arm retrospective studies were eligible for inclusion.
Nineteen studies were included with a total of 1731 patients: 989 treated with Nuss and 742 treated with Ravitch. The overall analysis revealed that patients in the Nuss group had significantly shorter operation time (pooled SMD = − 2.83, 95% CI = − 3.76 to − 1.90, p < 0.001) and less blood loss (pooled SMD = − 1.68, 95% CI = − 2.28 to − 1.09, P < 0.001) than the Ravitch group. However, the length of hospital stay was similar between groups (pooled SMD = − 0.55, 95% CI = − 1.44 to 0.35, p = 0.230). These findings were similar in the subgroup analysis for randomized and non-randomized controlled studies. Complications were not assessed due to inconsistent reporting across the included studies.
Our meta-analysis demonstrate that the Nuss procedure has a shorter operative time and less operative blood loss than the Ravitch procedure while the postoperative length of stay was similar.
Level III.
Postoperative opioid analgesic use after Nuss versus Ravitch pectus excavatum repair
2014, Journal of Pediatric SurgeryAnticipated postoperative pain may affect procedure choice in patients with pectus excavatum. This study aims to compare postoperative pain in patients undergoing Nuss and Ravitch procedures.
A 5 year retrospective review was performed. Data on age, gender, Haller index, procedure, pain scores, pain medications, and length of hospital stay were collected. Total inpatient opioid administration was converted to morphine equivalent daily dose per kilogram (MEDD/kg) and compared between procedures.
One hundred eighty-one patients underwent 125 (69%) Nuss and 56 (31%) Ravitch procedures. Ravitch patients were older (15.7 yo vs 14.6 yo, p = 0.004) and had a higher Haller index (5.21 vs 4.10, p = < 0.001). Nuss patients had higher average daily pain scores, received 25% more opioids (MEDD/kg 0.66 vs. 0.49, p = < 0.001), and received twice as much IV diazepam/kg. In the multivariate analysis, higher MEDD/kg correlated with both the Nuss procedure and older age in the Nuss group. Opioid administration did not correlate with Haller index or Nuss bar fixation technique. Increased NSAID administration did not correlate with lower use of opioids.
The Nuss procedure is associated with greater postoperative pain compared to the Ravitch procedure. Opioid use is higher in older patients undergoing the Nuss procedure, but is not associated with severity of deformity.
Increasing age at time of pectus excavatum repair in children: Emerging consensus?
2013, Journal of Pediatric SurgeryAdvances in surgical technique for pectus excavatum repair continue to change practice patterns. The present study examines trends in operative age in a nationwide administrative database.
A cross-sectional descriptive analysis was performed using the Nationwide Inpatient Sample (NIS) and Kids’ Inpatient Database (KID) data from 1998 to 2009. Pediatric discharges involving surgical repair of pectus excavatum were selected. Patients were sub-grouped by age at operation and calendar year of repair for further comparison.
A total of 5830 elective admissions were identified that met inclusion criteria. Mean age at operation was 13.5 years, and this increased from 11.8 years to 14.4 years over the period studied and was accompanied by narrowing of the interquartile range. Examined over groups of four calendar years, patient age at the time of repair was significantly higher in more recent years in both unadjusted and multivariate analyses (P < .001).
The age at operation in this sample has steadily increased, with an accompanying decrease in variability. This is consistent with previous findings and with overall trends in patient selection reported in the literature. This selection pattern may reflect evolving consensus regarding optimal management of pectus excavatum and provide clinical guidance regarding appropriate referral and intervention.
Current readings: Surgical repair experience of congenital chest wall Deformities
2013, Seminars in Thoracic and Cardiovascular SurgeryMajor advancements have been made in the surgical repair of congential chest wall deformities. This review highlights selected readings of the experience in correction of pectus excavatum and pectus carinatum. In particular, it summarizes the current standard of care and outcomes of new and modified procedures for patients with chest wall deformities.