The Nuss procedure is a minimally-invasive procedure, invented
in 1987 by Dr. Donald Nuss for treating pectus excavatum. He developed it at
Children's Hospital of The King's Daughters, in Norfolk, Virginia. The
operation typically takes approximately two hours.
Through two small incisions in the side of the chest, an introducer is pushed
along posterior to the sternum and ribs, and anterior to the heart and lungs.
Then a concave stainless steel bar is slipped under the sternum, through the
incisions in the side of the chest. A third, smaller incision is made to
insert a thoracoscope used to help guide the bar. Taller patients, older
patients, or patients requiring extensive correction may receive two or
more bars. All bars may be placed through two incisions or additional
incisions may be made. The bar is then flipped, and the sternum pops out. To
support the bar and keep it in place, a metal plate called a stabilizer may be
inserted with the bar on one side of the torso. PDS sutures may also be used in
addition to the stabilizer. The stabilizer fits around the bar and into
the ribcage. The bar and stabilizer are secured with sutures that dissolve in
about six months. Some surgeons have achieved excellent
results using only pericostal sutures, without the use of stabilizers. For
older children who have more ossified bones, an additional option the surgeon
has is to make an incision across the sternum so the bar is attached with a
wire to the sternum to avoid bar displacement. Older children's bones do
not conform as easily to the bar, thus increasing the risk of bar displacement,
so the wire attaching the bar directly to the sternum may help avoid a second
surgery to correct bar displacement. Eventually, the bar is secured with
muscle tissue that regrows during the recovery time. Although initially
recommended only for younger patients, the Nuss procedure is now commonly used
on patients in their thirties and forties with excellent results.
Postoperative evaluation indicates a significant improvement in pulmonary
function studies and a high proportion of patients report improvements in well
being and an increase in exercise tolerance.
Although this procedure is categorized as "minimally invasive", one must not
infer that recovery from this procedure is minimal. Post-operative pain control
can be quite challenging, thus requiring multi-modal pain management such as
epidural. Nurses who attend these patients post operation generally concur
that this operation is one of the more difficult recoveries of any operations
for children. Recovery
Recovery time is generally four to five days as an in-patient, depending on the
patient age, activity level, co-morbidities and post-operative
complications, followed by time at home to overcome the pain and to let the bar
settle into place. Sleep will be hampered because of the pain, discomfort
and inability to sleep on either side of the body. Breathing can be difficult
because of the stiffness of the bar and post-operative pain, but this generally
improves within a few weeks to a month. Patients younger than fifteen often
require only two to four weeks at home after being discharged from the hospital
for recovery. However, older children and adults typically require a greater
recovery time due to the increased ossification of their bones.
In this case, the difficulty and length of recovery should be carefully
considered prior to making the decision to undergo the operation, as the
limitations to lifestyle, functionality and comfort can be dramatic for many
months. This cannot be understated for older children, which is why many
doctors do not recommend this procedure unless medically necessary. Fully grown
adults may require from four weeks to many months before they can resume
normal activities, including work. For six to twenty-four hours after the
operation, the patient generally will have a Foley catheter to minimize risk
of movement that could displace bar, and because the epidural can interfere with
normal urination. The patient may also receive thoracic epidural analgesia in
the back for two to five days depending on patient recovery.
For six weeks, physical activity should be limited. Walking for exercise and
breathing exercises aid in recovery. It is sometimes suggested that
weight-training should be limited or eliminated for up to three months. It is
also recommended that any sports where contact may occur should be avoided.
However, aerobic sports are, in fact, encouraged, as results after bar removal
are best maintained in patients who have stimulated their cardiopulmonary systems
whilst the bar was in place The restoration of the patients physical
abilities can take up to ten months. However, in the majority of cases,
patients report a return to their preoperative physical state after
roughly six months. Many patients choose to return to work at this point. Despite
this physical recovery, patients are recommended to avoid more physical
situations such as contact sports until after the bar has been removed.
Many Pectus Excavatum patients exhibit psychological symptoms associated with
the cosmetic appearance of their disorder . For many, it is the driving
force behind undergoing the Nuss procedure. The recovery from these
psychological symptoms can also take some time, though many patients report
improvements in confidence and self-esteem after only a few weeks, once
the effects of the surgery can be noticed. Ultimately, almost all patients
report a noticeable improvement in their confidence and body image after they
have completely recovered from the operation.
Bar removal After a period of two to four years, the
surgical stainless steel bar is removed from the patient's chest. This procedure
lasts approximately ninety minutes. The length of time that the patient stays at
the hospital following the bar removal procedure varies, depending on the
amount of new bone growth surrounding the bar. Accordingly, the length of time
may range from a few hours to several days, or up to one week.
Complications Iatrogenic damage to the heart and lungs
during the procedure is a concern. Scopes are often utilized by the
surgical team to minimize this risk. There is still an extremely minor risk
of abrasion or puncture. Air in the chest is one of the more
frequent complications. A chest tube may be required or aggressive breathing
exercises and close monitoring may be adequate.
With the use of stabilizers and PDS sutures, bar displacement rarely occurs.
If these methods of bar fixation are not used, bar displacement may occur. This
can be quite painful and requires some sort of intervention: either bar
removal, or repositioning of the bar with some sort of bar fixation. Patients
should understand prior to the surgery that if bar displacement occurs soon
after surgery, a second surgery will be immediately required which is even a
more difficult recovery as the patient is already weakened and in pain. High
impact trauma, such as car accidents can dislodge the bars, causing extreme pain.
This is the reason for the restriction on driving, because a sudden defensive
maneuver, such as a jerk of the steering wheel, could dislodge the bar up to six
weeks directly after the surgery. Other complications which may occur
include hemothorax, pleural effusion, pericarditis, wound infection and
pneumonia and acquired scoliosis. Vigorous incentive spirometry is used to
prevent pneumonia. Some patients are allergic to one of the components of
stainless steel. As a result, allergy testing is now routinely done prior to
surgery. In the event of an allergy, a titanium bar will be used.
Older children may also struggle with adjusting to living in their changed
bodies during the several months of healing due to the pain and limitations.
References Protopapas, Aristotle D.; Athanasiou,
Thanos. "Peri-operative data on the Nuss procedure in children with pectus
excavatum: independent survey of the first 20 years' data". J Cardiothorac
Surg 3. doi:10.1186/1749-8090-3-40. PMC 2474598. PMID 18601720.
External links Nuss procedure at DMOZ