title: Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume, single institution experience.
abstract: BACKGROUND
  The safety and efficacy of minimally invasive pectus excavatum repair have been demonstrated over the last twenty years. However, technical details and perioperative management strategies continue to be debated. The aim of the present study is to review a large single-institution experience with the modified Nuss procedure.
  
  
  METHODS
  A retrospective review was performed of patients who underwent primary pectus excavatum repair at a single tertiary hospital via a modified Nuss procedure that included: no thoracoscopy, retrosternal dissection achieved via a left-to-right thoracic approach, four-point stabilization of the bar, and no routine epidural analgesia. Data collected included demographics, preoperative symptoms, operative characteristics, hospital charges and postoperative outcomes.
  
  
  RESULTS
  A total of 336 pediatric patients were identified. No cardiac perforations occurred and the rate of pericarditis was 0.6%. Contemporary rates of bar displacement have fallen to 1.2%. Routine use of chlorhexidine scrub reduced superficial site infections to 0.7%. Two patients (0.6%) with severe recurrence required reoperation. Bars were removed after an average period of 31.7(SD 13.2) months, with satisfactory cosmetic and functional results in 94.9% of cases.
  
  
  CONCLUSIONS
  We report here a single-institution large volume experience, including modifications to the Nuss procedure that make the technique simpler and safer, improve results, and minimize hospital charges.
authors.affiliation: Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Sacco Casamassima
authors.affiliation: Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: sgoldstein@jhmi.edu.
authors.forename: Seth D
authors.initials: SD
authors.lastname: Goldstein
authors.affiliation: Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Jose H
authors.initials: JH
authors.lastname: Salazar
authors.affiliation: Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Kimberly H
authors.initials: KH
authors.lastname: McIltrot
authors.affiliation: Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Fizan
authors.initials: F
authors.lastname: Abdullah
authors.affiliation: Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: pc@jhmi.edu.
authors.forename: Paul M
authors.initials: PM
authors.lastname: Colombani
mesh_terms: D000293:Adolescent; D015142:Baltimore; D005260:Female; D005660:Funnel Chest / Q000191:economics / Q000601:surgery*; D017722:Hospital Charges / Q000706:statistics & numerical data; D061847:Hospitals, High-Volume; D006801:Humans; D016268:Internal Fixators; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D019637:Orthopedic Procedures / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D019990:Perioperative Care / Q000191:economics / Q000379:methods*; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Chest wall deformities; Invasive repair; Minimally; Nuss procedure; Pectus excavatum