title: The minimally invasive Nuss technique for recurrent or failed pectus excavatum repair in 50 patients.
abstract: OBJECTIVE
  The aim of this study was to demonstrate the efficacy of the minimally invasive technique for recurrent pectus excavatum.
  
  
  METHODS
  Fifty patients with recurrent pectus excavatum underwent a secondary repair using the minimally invasive technique. Data were reviewed for preoperative symptomatology, surgical data, and postoperative results.
  
  
  RESULTS
  Prior repairs included 27 open Ravitch procedures, 23 minimally invasive (Nuss) procedures, and 2 Leonard procedures. The prior Leonard patients were also prior Ravitches and are therefore counted only once in the analyses. The median age was 16.0 years (range, 3-25 years). The median computed tomography index was 5.3 (range, 2.9-20). Presenting symptoms included shortness of breath (80%), chest pain (70%), asthma or asthma symptoms (26%), and frequent upper respiratory tract infections (14%). Both computed tomography scan and physical exam confirmed cardiac compression and cardiac displacement. Cardiology evaluations confirmed cardiac compression (62%), cardiac displacement (72%), mitral valve prolapse (22%), murmurs (24%), and other cardiac abnormalities (30%). Preoperative pulmonary function tests demonstrated values below 80% normal in more than 50% of patients. Pectus repair was done using a single pectus bar (66%), 2 bars (32%), or 3 bars (2%). Stabilizers were used in 88% of the patients. Median length of surgical time did not significantly differ from that of primary surgeries. Complications were slightly higher than those in primary repairs and included pneumothorax requiring chest tube (14%), hemothorax (8%), pleural effusion requiring drainage (8%), pericarditis (4%), pneumonia (4%), and wound infection (2%). There were no deaths or cardiac perforations. Initial postoperative results were excellent in 70%, good in 28%, and fair in 2%. Late complications of bar shift requiring revision occurred in 8%. Seventeen patients have had bar removals with 9 patients being more than 1 year postremoval. For the 17 patients who are postremoval, excellent results have been maintained in 8 (47%), good in 7 (41%), fair in 1 (6%), and failed in 1 (6%). There have been no recurrences postremoval.
  
  
  CONCLUSIONS
  Although failed or recurrent pectus excavatum repairs are technically more challenging, reoperative correction by the Nuss procedure has met with excellent success.
authors.affiliation: Division of Pediatric Surgery, Children's Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Dartmouth Medical School, Lebanon, NH 03766, USA. dcroitor@chkd.org
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Croitoru
authors.forename: Robert E
authors.initials: RE
authors.lastname: Kelly
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Goretsky
authors.forename: Tina
authors.initials: T
authors.lastname: Gustin
authors.forename: Rebecca
authors.initials: R
authors.lastname: Keever
authors.forename: Donald
authors.initials: D
authors.lastname: Nuss
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D005260:Female; D005660:Funnel Chest / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D006331:Heart Diseases / Q000209:etiology; D006801:Humans; D016268:Internal Fixators; D008171:Lung Diseases / Q000209:etiology; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D012008:Recurrence; D012086:Reoperation; D019616:Thoracic Surgical Procedures / Q000295:instrumentation*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome