Progress in surgical treatment of pectus excavatum_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

SHANG Hongwei ,  LI Qiang

Department of Thoracic Surgery, The 983^rd Hospital, Joint Service Support Force, PLA, Tianjin, 300142, P.R.China;

Corresponding author：

LI Qiang, Email: anna197957@126.com

Keywords：

Pectus excavatum; modified Nuss operation; double compression and complete fixation bar system; Wang procedure; review

DOI：

10.7507/1007-4848.202006072

Video：

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The surgical treatment of pectus excavatum has a history of more than 100 years, which has gone through from traditional open surgery to the current popular minimally invasive surgery. Nuss procedure, as the most classic minimally invasive operation, has been improved in accordance with the clinical needs since its inception to achieve fewer complications and better results, but there are still limitations that are difficult to break through, attracting a large number of scholars to make continuous innovation and develop updated devices and operation methods. This article reviews the history of funnel chest surgery, application and improvement of Nuss operation, double compression and complete fixation bar system and Wang procedure.

Citation： SHANG Hongwei, LI Qiang. Progress in surgical treatment of pectus excavatum. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2021, 28(9): 1119-1124. doi: 10.7507/1007-4848.202006072 Copy

1.	Kelly RE, Lawson ML, Paidas CN, et al. Pectus excavatum in a 112-year autopsy series: Anatomic findings and the effect on survival. J Pediatr Surg, 2005, 40(8): 1275-1278.
2.	Meyer L. Zur chirurgischen Behandlung der angeborenen Trichterbrust. Berl Kiln Wschr, 1911, 48: 1563-1566.
3.	Sauerbruch F. Operative Beseitigung der angeborenen Trichterbrust. Deutsche Zeitschrift Für Chirurgie, 1931, 234: 760-764.
4.	Ravitch MM. The operative treatment of pectus excavatum. Ann Surg, 1949, 129(4): 429-444.
5.	Nuss D, Kelly RE, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg, 1998, 33(4): 545-552.
6.	Nuss D, Kelly Jr RE. Chest wall deformities. Preface. Semin Pediatr Surg, 2008, 17(3): 153.
7.	Papandria D, Arlikar J, Sacco Casamassima MG, et al. Increasing age at time of pectus excavatum repair in children: Emerging consensus? J Pediatr Surg, 2013, 48(1): 191-196.
8.	Jaroszewski DE, Ewais MM, Chao CJ, et al. Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (≥30 years). Ann Thorac Surg, 2016, 102(3): 993-1003.
9.	Park HJ, Sung SW, Park JK, et al. How early can we repair pectus excavatum: The earlier the better? Eur J Cardiothorac Surg, 2012, 42(4): 667-672.
10.	Fox ME, Bensard DD, Roaten JB, et al. Positioning for the Nuss procedure: Avoiding brachial plexus injury. Paediatr Anaesth, 2005, 15(12): 1067-1071.
11.	de Campos JR, Fonseca MH, Werebe Ede C, et al. Technical modification of the Nuss operation for the correction of pectus excavatum. Clinics (Sao Paulo), 2006, 61(2): 185-186.
12.	Kimura H, Yasuoka T, Nagao M, et al. Oblique lateral incision and subpectoral dissection in modified Nuss procedure minimize future breast deformity. J Plast Reconstr Aesthet Surg, 2015, 68(5): 692-697.
13.	Clark JJ, Johnson SM. Single incision Nuss procedure for pectus excavatum. Pediatr Surg Int, 2011, 27(7): 733-736.
14.	Kasagi Y, Kasagi M, Matsuoka A. Submuscular Nuss procedure using mammary areola incision for adult pectus excavatum with significant upper chest depression. Kyobu Geka, 2008, 61(13): 1126-1129.
15.	Deng X, Liu P, Wang J, et al. An auxiliary subxiphoid incision in nuss procedure for the treatment of complex pectus excavatum. J Coll Physicians Surg Pak, 2020, 30(3): 335-337.
16.	Jacobs JP, Quintessenza JA, Morell VO, et al. Minimally invasive endoscopic repair of pectus excavatum. Eur J Cardiothorac Surg, 2002, 21(5): 869-873.
17.	Darlong LM. Pectus tunneloscopy: Making Nuss procedure for pectus excavatum safe. Interact Cardiovasc Thorac Surg, 2013, 17(2): 233-236.
18.	St Peter SD, Sharp SW, Ostlie DJ, et al. Use of a subxiphoid incision for pectus bar placement in the repair of pectus excavatum. J Pediatr Surg, 2010, 45(6): 1361-1364.
19.	Zhao J, Ma N, Yuan L, et al. Ultrasound-guided extrapleural Nuss procedure for pectus excavatum repair. Ann Thorac Surg, 2014, 98(5): 1863-1864.
20.	Hendrickson RJ, Bensard DD, Janik JS, et al. Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum. J Pediatr Surg, 2005, 40(8): 1312-1314.
21.	Park HJ, Chung WJ, Lee IS, et al. Mechanism of bar displacement and corresponding bar fixation techniques in minimally invasive repair of pectus excavatum. J Pediatr Surg, 2008, 43(1): 74-78.
22.	Belcher E, Arora S, Samancilar O, et al. Reducing cardiac injury during minimally invasive repair of pectus excavatum. Eur J Cardiothorac Surg, 2008, 33(5): 931-933.
23.	Tedde ML, de Campos JR, Wihlm JM, et al. The Nuss procedure made safer: An effective and simple sternal elevation manoeuvre. Eur J Cardiothorac Surg, 2012, 42(5): 890-891.
24.	Takahashi T, Okazaki T, Yamataka A, et al. Usefulness of Kent retractor and lifting hook for Nuss procedure. Pediatr Surg Int, 2015, 31(11): 1103-1105.
25.	Takagi S, Oyama T, Tomokazu N, et al. A new sternum elevator reduces severe complications during minimally invasive repair of the pectus excavatum. Pediatr Surg Int, 2012, 28(6): 623-626.
26.	Obermeyer RJ. Incorporating vacuum bell therapy into pectus excavatum treatment. J Vis Surg, 2016, 2: 99.
27.	Noguchi M, Kondoh S, Fujita K. A simple and safe technique for manipulation of retrosternal dissection in the nuss procedure. Eplasty, 2014, 14: e8.
28.	Ohno K, Nakamura T, Azuma T, et al. Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation. J Pediatr Surg, 2009, 44(12): 2426-2430.
29.	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(5): 1793-1795.
30.	Pilegaard HK, Licht PB. Early results following the Nuss operation for pectus excavatum—a single-institution experience of 383 patients. Interact Cardiovasc Thorac Surg, 2008, 7(1): 54-57.
31.	Park HJ. A technique for complex pectus excavatum repair: The cross-bar technique for grand canyon type deformity (Park classification). Ann Cardiothorac Surg, 2016, 5(5): 526-527.
32.	Pilegaard HK. Short Nuss bar procedure. Ann Cardiothorac Surg, 2016, 5(5): 513-518.
33.	Ghionzoli M, Ciuti G, Ricotti L, et al. Is a shorter bar an effective solution to avoid bar dislocation in a Nuss procedure? Ann Thorac Surg, 2014, 97(3): 1022-1027.
34.	Pio L, Carlucci M, Leonelli L, et al. Minimally invasive repair of pectus excavatum without bar stabilizers using Endo close. J Laparoendosc Adv Surg Tech A, 2016, 26(2): 148-152.
35.	Hebra A, Gauderer MW, Tagge EP, et al. A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum. J Pediatr Surg, 2001, 36(8): 1266-1268.
36.	Pilegaard HK. Single centre experience on short bar technique for pectus excavatum. Ann Cardiothorac Surg, 2016, 5(5): 450-455.
37.	Park HJ, Lee SY, Lee CS, et al. The Nuss procedure for pectus excavatum: Evolution of techniques and early results on 322 patients. Ann Thorac Surg, 2004, 77(1): 289-295.
38.	Park HJ, Kim KS, Lee S, et al. A next-generation pectus excavatum repair technique: New devices make a difference. Ann Thorac Surg, 2015, 99(2): 455-461.
39.	Park HJ, Kim KS, Moon YK, et al. The bridge technique for pectus bar fixation: A method to make the bar un-rotatable. J Pediatr Surg, 2015, 50(8): 1320-1322.
40.	Park HJ, Jeong JY, Kim KT, et al. Hinge reinforcement plate for adult pectus excavatum repair: A novel tool for the prevention of intercostal muscle strip. Interact Cardiovasc Thorac Surg, 2011, 12(5): 687-691.
41.	Yoon YS, Kim HK, Choi YS, et al. A modified Nuss procedure for late adolescent and adult pectus excavatum. World J Surg, 2010, 34(7): 1475-1480.
42.	Jaroszewski DE, Johnson K, McMahon L, et al. Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients. J Thorac Cardiovasc Surg, 2014, 147(3): 1093-1095.
43.	Notrica DM. Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review. Semin Pediatr Surg, 2018, 27(3): 133-150.
44.	Song IH, Lee SJ, Kim SS, et al. Surgical outcomes of double compression and complete fixation bar system in pectus excavatum. Ann Thorac Surg, 2018, 106(4): 1025-1031.
45.	Wang WL, Chen CM, Long WG, et al. Wang procedure: Novel minimally invasive procedure for pectus excavatum children with low age. Case Rep Imag Surg, 2018, 1(1): 1-2.
46.	Tanaka Y, Matsumoto I, Saito D, et al. Surgical treatment of pectus excavatum in patients with Marfan syndrome associated with vertebral or cardiovascular disease. Kyobu Geka, 2020, 73(3): 163-168.
47.	Yang G, Deng X, Yang Y, et al. Simultaneous operative repair of pectus excavatum and concurrent congenital heart defects. Interact Cardiovasc Thorac Surg, 2019, 28(5): 783-788.
48.	Media AS, Pilegaard HK, de Paoli FV. Combining correction of pectus excavatum and open heart surgery in a single-stage procedure. Ann Thorac Surg, 2020, 109(1): e71-e74.
49.	Muhammad MI. Thoracoscopic repair of pectus excavatum using different bar stabilizers versus open repair. Asian Cardiovasc Thorac Ann, 2014, 22(2): 187-192.
50.	Sujka JA, St Peter SD. Quantification of pectus excavatum: Anatomic indices. Semin Pediatr Surg, 2018, 27(3): 122-126.
51.	Harrison MR, Gonzales KD, Bratton BJ, et al. Magnetic mini-mover procedure for pectus excavatum Ⅲ: Safety and efficacy in a Food and Drug Administration-sponsored clinical trial. J Pediatr Surg, 2012, 47(1): 154-159.

1. Kelly RE, Lawson ML, Paidas CN, et al. Pectus excavatum in a 112-year autopsy series: Anatomic findings and the effect on survival. J Pediatr Surg, 2005, 40(8): 1275-1278.
2. Meyer L. Zur chirurgischen Behandlung der angeborenen Trichterbrust. Berl Kiln Wschr, 1911, 48: 1563-1566.
3. Sauerbruch F. Operative Beseitigung der angeborenen Trichterbrust. Deutsche Zeitschrift Für Chirurgie, 1931, 234: 760-764.
4. Ravitch MM. The operative treatment of pectus excavatum. Ann Surg, 1949, 129(4): 429-444.
5. Nuss D, Kelly RE, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg, 1998, 33(4): 545-552.
6. Nuss D, Kelly Jr RE. Chest wall deformities. Preface. Semin Pediatr Surg, 2008, 17(3): 153.
7. Papandria D, Arlikar J, Sacco Casamassima MG, et al. Increasing age at time of pectus excavatum repair in children: Emerging consensus? J Pediatr Surg, 2013, 48(1): 191-196.
8. Jaroszewski DE, Ewais MM, Chao CJ, et al. Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (≥30 years). Ann Thorac Surg, 2016, 102(3): 993-1003.
9. Park HJ, Sung SW, Park JK, et al. How early can we repair pectus excavatum: The earlier the better? Eur J Cardiothorac Surg, 2012, 42(4): 667-672.
10. Fox ME, Bensard DD, Roaten JB, et al. Positioning for the Nuss procedure: Avoiding brachial plexus injury. Paediatr Anaesth, 2005, 15(12): 1067-1071.
11. de Campos JR, Fonseca MH, Werebe Ede C, et al. Technical modification of the Nuss operation for the correction of pectus excavatum. Clinics (Sao Paulo), 2006, 61(2): 185-186.
12. Kimura H, Yasuoka T, Nagao M, et al. Oblique lateral incision and subpectoral dissection in modified Nuss procedure minimize future breast deformity. J Plast Reconstr Aesthet Surg, 2015, 68(5): 692-697.
13. Clark JJ, Johnson SM. Single incision Nuss procedure for pectus excavatum. Pediatr Surg Int, 2011, 27(7): 733-736.
14. Kasagi Y, Kasagi M, Matsuoka A. Submuscular Nuss procedure using mammary areola incision for adult pectus excavatum with significant upper chest depression. Kyobu Geka, 2008, 61(13): 1126-1129.
15. Deng X, Liu P, Wang J, et al. An auxiliary subxiphoid incision in nuss procedure for the treatment of complex pectus excavatum. J Coll Physicians Surg Pak, 2020, 30(3): 335-337.
16. Jacobs JP, Quintessenza JA, Morell VO, et al. Minimally invasive endoscopic repair of pectus excavatum. Eur J Cardiothorac Surg, 2002, 21(5): 869-873.
17. Darlong LM. Pectus tunneloscopy: Making Nuss procedure for pectus excavatum safe. Interact Cardiovasc Thorac Surg, 2013, 17(2): 233-236.
18. St Peter SD, Sharp SW, Ostlie DJ, et al. Use of a subxiphoid incision for pectus bar placement in the repair of pectus excavatum. J Pediatr Surg, 2010, 45(6): 1361-1364.
19. Zhao J, Ma N, Yuan L, et al. Ultrasound-guided extrapleural Nuss procedure for pectus excavatum repair. Ann Thorac Surg, 2014, 98(5): 1863-1864.
20. Hendrickson RJ, Bensard DD, Janik JS, et al. Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum. J Pediatr Surg, 2005, 40(8): 1312-1314.
21. Park HJ, Chung WJ, Lee IS, et al. Mechanism of bar displacement and corresponding bar fixation techniques in minimally invasive repair of pectus excavatum. J Pediatr Surg, 2008, 43(1): 74-78.
22. Belcher E, Arora S, Samancilar O, et al. Reducing cardiac injury during minimally invasive repair of pectus excavatum. Eur J Cardiothorac Surg, 2008, 33(5): 931-933.
23. Tedde ML, de Campos JR, Wihlm JM, et al. The Nuss procedure made safer: An effective and simple sternal elevation manoeuvre. Eur J Cardiothorac Surg, 2012, 42(5): 890-891.
24. Takahashi T, Okazaki T, Yamataka A, et al. Usefulness of Kent retractor and lifting hook for Nuss procedure. Pediatr Surg Int, 2015, 31(11): 1103-1105.
25. Takagi S, Oyama T, Tomokazu N, et al. A new sternum elevator reduces severe complications during minimally invasive repair of the pectus excavatum. Pediatr Surg Int, 2012, 28(6): 623-626.
26. Obermeyer RJ. Incorporating vacuum bell therapy into pectus excavatum treatment. J Vis Surg, 2016, 2: 99.
27. Noguchi M, Kondoh S, Fujita K. A simple and safe technique for manipulation of retrosternal dissection in the nuss procedure. Eplasty, 2014, 14: e8.
28. Ohno K, Nakamura T, Azuma T, et al. Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation. J Pediatr Surg, 2009, 44(12): 2426-2430.
29. 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(5): 1793-1795.
30. Pilegaard HK, Licht PB. Early results following the Nuss operation for pectus excavatum—a single-institution experience of 383 patients. Interact Cardiovasc Thorac Surg, 2008, 7(1): 54-57.
31. Park HJ. A technique for complex pectus excavatum repair: The cross-bar technique for grand canyon type deformity (Park classification). Ann Cardiothorac Surg, 2016, 5(5): 526-527.
32. Pilegaard HK. Short Nuss bar procedure. Ann Cardiothorac Surg, 2016, 5(5): 513-518.
33. Ghionzoli M, Ciuti G, Ricotti L, et al. Is a shorter bar an effective solution to avoid bar dislocation in a Nuss procedure? Ann Thorac Surg, 2014, 97(3): 1022-1027.
34. Pio L, Carlucci M, Leonelli L, et al. Minimally invasive repair of pectus excavatum without bar stabilizers using Endo close. J Laparoendosc Adv Surg Tech A, 2016, 26(2): 148-152.
35. Hebra A, Gauderer MW, Tagge EP, et al. A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum. J Pediatr Surg, 2001, 36(8): 1266-1268.
36. Pilegaard HK. Single centre experience on short bar technique for pectus excavatum. Ann Cardiothorac Surg, 2016, 5(5): 450-455.
37. Park HJ, Lee SY, Lee CS, et al. The Nuss procedure for pectus excavatum: Evolution of techniques and early results on 322 patients. Ann Thorac Surg, 2004, 77(1): 289-295.
38. Park HJ, Kim KS, Lee S, et al. A next-generation pectus excavatum repair technique: New devices make a difference. Ann Thorac Surg, 2015, 99(2): 455-461.
39. Park HJ, Kim KS, Moon YK, et al. The bridge technique for pectus bar fixation: A method to make the bar un-rotatable. J Pediatr Surg, 2015, 50(8): 1320-1322.
40. Park HJ, Jeong JY, Kim KT, et al. Hinge reinforcement plate for adult pectus excavatum repair: A novel tool for the prevention of intercostal muscle strip. Interact Cardiovasc Thorac Surg, 2011, 12(5): 687-691.
41. Yoon YS, Kim HK, Choi YS, et al. A modified Nuss procedure for late adolescent and adult pectus excavatum. World J Surg, 2010, 34(7): 1475-1480.
42. Jaroszewski DE, Johnson K, McMahon L, et al. Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients. J Thorac Cardiovasc Surg, 2014, 147(3): 1093-1095.
43. Notrica DM. Modifications to the Nuss procedure for pectus excavatum repair: A 20-year review. Semin Pediatr Surg, 2018, 27(3): 133-150.
44. Song IH, Lee SJ, Kim SS, et al. Surgical outcomes of double compression and complete fixation bar system in pectus excavatum. Ann Thorac Surg, 2018, 106(4): 1025-1031.
45. Wang WL, Chen CM, Long WG, et al. Wang procedure: Novel minimally invasive procedure for pectus excavatum children with low age. Case Rep Imag Surg, 2018, 1(1): 1-2.
46. Tanaka Y, Matsumoto I, Saito D, et al. Surgical treatment of pectus excavatum in patients with Marfan syndrome associated with vertebral or cardiovascular disease. Kyobu Geka, 2020, 73(3): 163-168.
47. Yang G, Deng X, Yang Y, et al. Simultaneous operative repair of pectus excavatum and concurrent congenital heart defects. Interact Cardiovasc Thorac Surg, 2019, 28(5): 783-788.
48. Media AS, Pilegaard HK, de Paoli FV. Combining correction of pectus excavatum and open heart surgery in a single-stage procedure. Ann Thorac Surg, 2020, 109(1): e71-e74.
49. Muhammad MI. Thoracoscopic repair of pectus excavatum using different bar stabilizers versus open repair. Asian Cardiovasc Thorac Ann, 2014, 22(2): 187-192.
50. Sujka JA, St Peter SD. Quantification of pectus excavatum: Anatomic indices. Semin Pediatr Surg, 2018, 27(3): 122-126.
51. Harrison MR, Gonzales KD, Bratton BJ, et al. Magnetic mini-mover procedure for pectus excavatum Ⅲ: Safety and efficacy in a Food and Drug Administration-sponsored clinical trial. J Pediatr Surg, 2012, 47(1): 154-159.

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