title: The learning curve in learning the curve: a review of Nuss procedure in teenagers.
abstract: BACKGROUND
  The Nuss procedure is a new minimally invasive repair for pectus excavatum that was first published in 1998. Modifications in technique are constantly evolving to minimize complications, especially bar displacement, which are higher in adolescents and adults. The present study reviews our early experience with this procedure in a much older group of children than previously reported and suggests an alternative method of avoiding bar displacement.
  
  
  METHODS
  Retrospective chart review was carried out on 78 consecutive patients who underwent the Nuss procedure between December 1999 and January 2004. All patients underwent a uniform technique using bilateral lateral stabilisers and thoracoscopy was not used. Operative details, subjective cosmetic results and complication rates were assessed.
  
  
  RESULTS
  The mean age was 15.4 +/- 3.2 years. Single bars were used in 95%, double bars in 5%. The defect was asymmetrical in 26%. The defect was mild in 7%, moderate in 59% and severe in 34%. The median length of stay was 6.0 days (range 4-11). Total operating time was 58 min (range 35-95). Patient controlled analgesia (morphine) for pain relief was used for 105 h (range 61-169) or 4.4 days; the epidural infusion was stopped 1 day earlier. Cosmetic results were excellent in 80.3%. There was residual asymmetry in 75% of the asymmetrical defects although all were improved. Complications included eight (10%) reoperations for bar displacement. This was related to the learning curve as seven of these occurred in the first 2 years of the series. Removal of the bar has been accomplished in 31 (40%) patients. This was elective in all but four patients (three early removals for pain and one for infection).
  
  
  CONCLUSIONS
  The Nuss procedure gives good results even in teenagers. Modification of technique and increased experience has reduced complications. The use of bilateral lateral stabilisers without additional wire fixation is an alternative method to avoid bar displacement.
authors.affiliation: General Surgery Department, Royal Children's Hospital, Melbourne, Victoria, Australia. carolineong@mac.com
authors.forename: Caroline C P
authors.initials: CC
authors.lastname: Ong
authors.forename: Kelvin
authors.initials: K
authors.lastname: Choo
authors.forename: Philip
authors.initials: P
authors.lastname: Morreau
authors.forename: Alex
authors.initials: A
authors.lastname: Auldist
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002983:Clinical Competence; D005260:Female; D005660:Funnel Chest / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome