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CASE REPORT
Year : 2019  |  Volume : 14  |  Issue : 3  |  Page : 216-219
Successful management for repeated bar displacements after Nuss method by two bars connected by a stabilizer


Department of Plastic and Reconstructive Surgery, Nihon University School of Medicine, Tokyo, Japan

Date of Submission06-Mar-2019
Date of Acceptance28-Apr-2019
Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Tsutomu Kashimura
Department of Plastic and Reconstructive Surgery, Nihon University School of Medicine, 30-1 Ooyaguchikami-cho, Itabashi-ku, Tokyo 1738610
Japan
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DOI: 10.4103/atm.ATM_84_19

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   Abstract 

The Nuss method has become the standard surgery for the treatment of funnel chest, and good therapeutic results have been reported. Among the complications of the Nuss method, displacement of the bar is the most frequent, and there are cases in which reoperation is necessary. In this case report, we have devised a new stabilizer that connects and fixes two bars as bar displacement occurred following each of the two prior Nuss procedures, and the outcome of our procedure was evaluated.


Keywords: Bar displacement, Nuss method, stabilizer


How to cite this article:
Yoshida K, Kashimura T, Kikuchi Y, Nakazawa H. Successful management for repeated bar displacements after Nuss method by two bars connected by a stabilizer. Ann Thorac Med 2019;14:216-9

How to cite this URL:
Yoshida K, Kashimura T, Kikuchi Y, Nakazawa H. Successful management for repeated bar displacements after Nuss method by two bars connected by a stabilizer. Ann Thorac Med [serial online] 2019 [cited 2019 Dec 11];14:216-9. Available from: http://www.thoracicmedicine.org/text.asp?2019/14/3/216/261456




The Nuss method was reported by Nuss et al. in 1998 as a minimally invasive treatment for funnel chest, and it has become the standard surgery for the treatment of funnel chest.[1],[2] Among the complications of the Nuss method, displacement of the bar is the most frequent, and there are cases in which reoperation is necessary.[1],[3],[4]

In this case report, a new stabilizer was developed as bar displacement occurred following each of the two prior Nuss procedures, and the outcome of our procedure was evaluated.


   Case Report Top


A 7-year-old boy underwent the Nuss procedure at the age of 5 years for funnel chest wherein bar displacement occurred, and the Nuss method was performed a second time at the age of 6 years at the same hospital. However, even after the second surgery, the bar displaced, and he visited our hospital. The preoperative photograph showed strong depression on the left, centering on the solar plexus from the lower end of the sternum, and the ends on both sides of the bar protruded subcutaneously [Figure 1]a and [Figure 1]c. The pretreatment radiograph taken at the previous hospital showed a depression below the sternum [Figure 2]a. The bar was placed horizontally immediately after the first surgery [Figure 2]b. In the radiograph obtained 5 months after the first surgery, there was displacement toward the foot side [Figure 2]c. The angle of the bar relative to the sternum was 23°. The second surgery was performed 1½ years after the first operation. However, the reinserted bar caused displacement to the head side. The patient visited our hospital 2 years after the initial surgery. During radiography at our hospital, the central part of the bar rotated toward the head side, and the displacement of the bar with respect to the sternum was 27° [Figure 2]d. The computed tomography (CT) index was 4.1 [Figure 3]a and [Figure 3]c.
Figure 1: (a and c) Radiograph of the 7-year-old boy at the first visit, (b and d) radiograph at 3 months after the operation

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Figure 2: (a) Preoperative radiograph, (b) radiograph at the first Nuss repair, (c) radiograph 5 months after the first Nuss repair, (d) radiograph at the first visit to our hospital

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Figure 3: (a and c) Computed tomography image obtained at the first visit (b and d) computed tomography image obtained 1 month after the Nuss method, with a stabilizer

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In this case, we considered that double bars should be used because the chest deformity is extensive depression and performed the third Nuss procedure using a new stabilizer. The new stabilizer was constructed based on the conventional stabilizer developed by Lorentz, and the stabilizers were fixed by connecting the two bars [Figure 4]. We planned to insert bars in the fourth and fifth intercostal spaces and set the interval between the two bars to 3 cm. Lifting of the sternum by the Nuss method was carried out as expected. We confirmed that the morphology of the thorax was corrected adequately. A new stabilizer was placed under the skin of the right chest on the surface of the ribs, and the bar was fixed. The stabilizer and thorax were fixed with sutures.
Figure 4: (a) Stabilizer: front, (b) Stabilizer: side, (c) the two bars with the stabilizer

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The postoperative course was good, and no bar displacement occurred [Figure 1]b and [Figure 1]d. On the postoperative radiograph, the two bars were connected and fixed, retaining a stable shape [Figure 5]. The CT index, which was 4.1 at our hospital, improved to 2.7 after the surgery [Figure 3]b and [Figure 3]d.
Figure 5: Radiograph obtained 3 months after the operation, (a) frontal view, (b) lateral view

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   Discussion Top


The Nuss method has been rapidly accepted in the last 20 years as a minimally invasive treatment for thoracic deformity. However, displacement of the bars remains a challenge as a relatively frequent complication.[1],[3],[4] Displacement of the bars has been reported to lead to not only inadequate correction of the chest morphology but also serious complications, such as shock due to cardiac tamponade.[5]

The displacement of the bar could be in several directions. Park et al. examined 725 patients after Nuss repair and classified the bar displacement into three types.[6] Among these, bar flipping is the most frequent; even in the patient in the present study, the two Nuss repairs caused upward and downward bar flipping.

In addition, the degree of displacement of the bar has been studied. Del Frari and Schwabegger similarly measured the angle of the sternum and bar and defined it as excellent at a displacement of 15° or less, incomplete at 15–45°, and poor at 45° or higher.[7] In this study, the displacements of the bars inserted by the two surgeries were 23° and 27°, respectively, both of which were evaluated as incomplete, and it was expected that a recessed deformation would be left behind.

There are several reports on the fixed method for prevention of bar displacement.[4],[8],[9] After the correction of the sternum, the bar is pressed toward the dorsal side with the intercostal penetrating part as the fulcrum. It is thought that upward and downward bar flipping will occur by the application of rotational movement because of the shape of the sternum or xiphoid process. To prevent bar flipping, it is necessary to fix the bars so that they resist force from above and below. In the conventional method of fixing both ends and a point of bar, a three-point fixation, fulcrum to resist the force of the vertical direction is small and the fixed becomes insufficient.

In addition, in recent years, there have been many reports on insertion methods wherein two or more bars are used.[8],[9] In this case, it was thought that correction by insertion of two bars was necessary because there was extensive depression in the chest. Furthermore, by connecting and fixing the two bars, it was possible to sufficiently resist the force in the vertical direction. We have devised a new stabilizer that connects and fixes the two bars, and good results were obtained. Park et al. reported a method of connecting and fixing both ends of two bars similar to that in this case.[10] In this case, only one side was connected by a stabilizer and fixed. Even with the connection on only one side, there was sufficient fixation for upward and downward forces, and the range of undermine where the stabilizer is inserted is also on only one side, which is thus considered to be less invasive. In addition, as the bar and stabilizer are fixed without using bolts and nuts and the subcutaneous part implanted is compact, the surgical procedure is simple and the protrusion of the stabilizer after the operation is not conspicuous.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Nuss D, Kelly RE Jr., Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-52.  Back to cited text no. 1
    
2.
Kelly RE, Goretsky MJ, Obermeyer R, Kuhn MA, Redlinger R, Haney TS, et al. Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg 2010;252:1072-81.  Back to cited text no. 2
    
3.
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;77:289-95.  Back to cited text no. 3
    
4.
Pilegaard HK, Licht PB. Early results following the Nuss operation for pectus excavatum – A single-institution experience of 383 patients. Interact Cardiovasc Thorac Surg 2008;7:54-7.  Back to cited text no. 4
    
5.
Hoel TN, Rein KA, Svennevig JL. A life-threatening complication of the Nuss procedure for pectus excavatum. Ann Thorac Surg 2006;81:370-2.  Back to cited text no. 5
    
6.
Park HJ, Chung WJ, Lee IS, Kim KT. Mechanism of bar displacement and corresponding bar fixation techniques in minimally invasive repair of pectus excavatum. J Pediatr Surg 2008;43:74-8.  Back to cited text no. 6
    
7.
Del Frari B, Schwabegger AH. How to avoid pectus bar dislocation in the MIRPE or MOVARPE technique: Results of 12 years' experience. Ann Plast Surg 2014;72:75-9.  Back to cited text no. 7
    
8.
Nuss D, Croitoru DP, Kelly RE Jr., Goretsky MJ, Nuss KJ, Gustin TS, et al. Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg 2002;12:230-4.  Back to cited text no. 8
    
9.
Yoo G, Rha EY, Jeong JY, Lee J, Sim SB, Jo KH, et al. Emerging fixation technique to prevent pectus bar displacement: Needlescope-assisted 3-point fixation. Thorac Cardiovasc Surg 2016;64:78-82.  Back to cited text no. 9
    
10.
Park HJ, Kim KS, Moon YK, Lee S. The bridge technique for pectus bar fixation: A method to make the bar un-rotatable. J Pediatr Surg 2015;50:1320-2.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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