The cardiothoracic surgeons are moving towards minimally invasive techniques. Such a technique is the Nuss repair (alias Minimally Invasive Repair of Pectus Excavatum or Miniature Access Pectus Excavatum Repair) for pectus excavatum (funnel chest) 1, the commonest chest wall anomaly in humans 2, first described in 1594 by Johannes Schenk, occurring in approximately 1 in every 400 births, males being afflicted 5 times more often than females. The indication for correction is primarily cosmetic, although the potential for cardiorespiratory improvement can be considered.
The original Nuss technique has being previously described 1,24. Its principle is the permanent reduction of the bone deformity by insertion of one (or more) malleable metal bars in order to refashion the contour of the growing thorax.
Advantages and disadvantages of the Nuss in relation to open techniques (such as Ravitch 2 and Willital-Hegemann that include extensive thoracic incisions and multiple thoracic osteochondrectomies (resections of ribs and cartilage) are presented in Table 1.
The principal advantage over these techniques is avoidance of osteochondrotomies and thence allowance for normal growth of the thorax, as subperichondral resection of the costal cartilages may halt the growth of the thoracic cage in toddlers and adolescents.
The metalwork is later removed as a day-case operation (nor requiring overnight stay in hospital) under general anaesthesia.
The Nuss operation can be performed with or without use of thoracoscopy. The selection of age for the Nuss varies with clinical, personal and socio-economical reasons (such as change of school and fear of intimidation by new peers), while removal of bars is scheduled within two to three years from the insertion. In Britain, some surgeons prefer to perform Nuss around the age of 10, before the child changes schools and thence is exposed to new peers. Some other surgeons will perform Nuss earlier, deciding on parental preference and individual clinical circumstances.
Materials and methods
We searched the literature with a simple strategy:
- PubMed search
- Last Date performed: 31 December 2006
- Search keyword ├óÔé¼´åİNuss™, language English, Humans, children
- Cross-validation by hand search to identify case series and exclude isolated case reports.
- Primary outcomes: Mortality, morbidity, individual complications
- Secondary outcomes: Procedure time and hospital stay.
- Descriptive and summary statistics were performed.
- Denominators were related to actual data. Missing data were not defaulted.
- Nuss D, Croitoru DP, Kelly RE Jr, Goretsky MJ, Nuss KJ, Gustin TS: Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg 2002, 12(4):230-4.
- Huddleston CB: Pectus excavatum. Semin Thorac Cardiovasc Surg 2004, 16:225-32.
- Boehm RA, Muensterer OJ, Till H: Comparing minimally invasive funnel chest repair versus the conventional technique: an outcome analysis in children. Plast Reconstr Surg 2004, 114(3):668-73. discussion 674├óÔé¼ÔÇ£5.
- Zallen GS, Glick PL: Miniature access pectus excavatum repair: Lessons we have learned. J Pediatr Surg 2004, 39(5):685-9.
- Park HJ, Lee SY, Lee CS: Complications associated with the Nuss procedure: analysis of risk factors and suggested measures for prevention of complications. J Pediatr Surg 2004, 39:391-5.
- Watanabe A, Watanabe T, Obama T, Ohsawa H, Mawatari T, Ichimiya Y, et al.: The use of a lateral stabilizer increases the incidence of wound trouble following the Nuss procedure. Ann Thorac Surg 2004, 77(1):296-300.
- Ohno K, Morotomi Y, Ueda M, Yamada H, Shiokawa C, Nakaoka T, et al.: Comparison of the Nuss procedure for pectus excavatum by age and uncommon complications. Osaka City Med J 2003, 49(2):71-6.
- Jo WM, Choi YH, Sohn YS, Kim HJ, Hwang JJ, Cho SJ: Surgical treatment for pectus excavatum. J Korean Med Sci 2003, 18:360-4.
- Uemura S, Nakagawa Y, Yoshida A, Choda Y: Experience in 100 cases with the Nuss procedure using a technique for stabilization of the pectus bar. Pediatr Surg Int 2003, 19(3):186-9.
- Haecker FM, Bielek J, von Schweinitz D: Minimally invasive repair of pectus excavatum (MIRPE) ├óÔé¼ÔÇ£ the Basel experience. Swiss Surg 2003, 9(6):289-95.
- Schaarschmidt K, Kolberg-Schwerdt A, Dimitrov G, Straubeta J: Submuscular bar, multiple pericostal bar fixation, bilateral thoracoscopy: A modified Nuss repair in adolescents. J Pediatr Surg 2002, 37(9):1276-80.
- Hosie S, Sitkiewicz T, Petersen C, Gobel P, Schaarschmidt K, Till H, et al.: Minimally invasive repair of pectus excavatum ├óÔé¼ÔÇ£ the Nuss procedure. A European multicentre experience. Eur J Pediatr Surg 2002, 12(4):235-8.
- Jacobs JP, Quintessenza JA, Morell VO, Botero LM, van Gelder HM, Tchervenkov CI: Minimally invasive endoscopic repair of pectus excavatum. Eur J Cardiothorac Surg 2002, 21(5):869-73.
- Miller KA, Woods RK, Sharp RJ, Gittes GK, Wade K, Ashcraft KW, et al.: Minimally invasive repair of pectus excavatum: a single institution's experience. Surgery 2001, 130(4):652-7. discussion 657├óÔé¼ÔÇ£9.
- Hebra A, Gauderer MW, Tagge EP, Adamson WT, Othersen HB Jr: A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum. J Pediatr Surg 2001, 36(8):1266-8.
- Wu PC, Knauer EM, McGowan GE, Hight DW: Repair of Pectus Excavatum Deformities in Children: A New Perspective of Treatment Using Minimal Access Surgical Technique. Arch Surg 2001, 136(4):419-424.
- Molik KA, Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL: Pectus excavatum repair: experience with standard and minimal invasive techniques. J Pediatr Surg 2001, 36(2):324-8.
- Engum S, Rescorla F, West K, Rouse T, Scherer LR, Grosfeld J: Is the grass greener? Early results of the Nuss procedure. J Pediatr Surg 2000, 35(2):246-51.
- Park HJ, Lee SY, Lee CS, Youm W, Lee KR: The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients. Ann Thorac Surg 2004, 77(1):289-95.
- Croitoru DP, Kelly RE Jr, Goretsky MJ, Lawson ML, Swoveland B, Nuss D: Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002, 37(3):437-45.
- Hebra A, Swoveland B, Egbert M, Tagge EP, Georgeson K, Othersen HB Jr, et al.: Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg 2000, 35(2):252-7.
- Dzielicki J, Korlacki W, Janicka I, Dzielicka E: Difficulties and limitations in minimally invasive repair of pectus excavatum-6 years experiences with Nuss technique. Eur J Cardiothorac Surg 2006, 30(5):801-4.
- Kim DH, Hwang JJ, Lee MK, Lee DY, Paik HC: Analysis of the Nuss Procedure for Pectus Excavatum in Different Age Groups. Ann Thorac Surg 2005, 80(3):1073-7.
- Nuss D: Recent experiences with minimally invasive pectus excavatum repair Nuss procedure". Jpn J Thorac Cardiovasc Surg 2005, 53:338-44.
- Peden CJ, Prys-Roberts C: Capnothorax: Implications for the anaesthetist. Anaesthesia 1991, 48:664-6.
- Schalamon J, Pokall S, Windhaber J, Hoellwarth M: Minimally invasive correction of pectus excavatum in adult patients. J Thorac Cardiovasc Surg 2006, 132(3):524-9.