The Nuss Procedure is often referred to as a minimally invasive repair of Pectus Excavatum. Let me make this very clear. There is nothing minimally invasive about the Nuss Procedure from the patient’s perspective. It invades like the Trojans invaded Troy. It invades with steel ripping through muscles, tissue, and nerves. It invades with pain. Trust me, it invades like hell. The scars may be minimal, hence this seemingly odd moniker of minimalism, but when all is said and done, the Nuss Procedure is a very serious operation and not one to be undertaken without thoughtful consideration.
WHAT’S HAPPENS DURING SURGERY?
Let me briefly describe, in non-medical terms, what will happen to you as you lay anesthetized upon the operating table. For those of you who may be interested in a more precise medical description of the procedure, take a look at the Medical Research links in the sidebar.
Your surgeons (yes, there will be two) will make two incisions on either side of your chest, generally at the point where the dent is at its deepest. An “introducer” is pushed along under the sternum and ribs, basically to make a tunnel for the introduction of the concave Pectus Bar. Once the tunnel is created, the surgeons will insert the Pectus Bar through the two incisions. A third, smaller incision is made to insert a thoracoscope (small camera), which is essential to help guide the Pectus Bar along its journey from one side of your chest to the other side. Patients have died from the Pectus Bar piercing the heart, so the thoracoscope is an invaluable tool used to help prevent such accidents.
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. The popping out, I think, is reserved for younger patients whose bones are very pliable. My sternum is old and calcified, so it put up a bit of a fight, so my surgeon tells me. My sternum, rather than being “popped out” was brutally forced into submission.
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. Absorbable sutures may also be used in addition to the stabilizer. The stabilizer fits around the bar and into the ribcage. Some surgeons, such as Professor Schaarschmidt, have achieved excellent results using only peri costal sutures, without the use of stabilizers. Eventually, the bar is secured with muscle tissue that regrows during the recovery time.
WHAT’S THE BEST AGE TO GET NUSSED?
Although initially recommended only for younger patients, the Nuss procedure is now commonly used on patients in their thirties and forties with excellent results. The best age to get Nussed is between 16 and 18 years old. Any earlier and there is a good chance of regression due to the fact that the bones have not stopped growing. It’s best to time the surgery such that the bars are taken out just when bone growth has stopped, so that is why 16 to 19 years is optimal.
Younger patients also experience far less post operative pain because their bones are very supple and the sternum is easily pushed out into the correct position. Older patients have less supple bones. Accordingly, more force is required to push the sternum into the correct position. Older bones equals more pain. That does not mean, however, that older patients cannot achieve excellent results! I hope to prove that to be the case!
HOW MANY BARS WILL I GET?
Younger patients usually end up with a single pectus bar, unless their PE is very severe. A single bar usually does the trick when the bones are still pliable. Older patients, on the other hand, or those with significant upper PE, ought to have two pectus bars implanted. Many surgeons fail to correct upper-PE with the use of a second pectus bar. This is a result of inexperience. An experienced surgeon is perfectly capable of placing a second bar. In fact, all older patients with moderate to severe PE should ideally have two pectus bars implanted. The additional support of a second bar makes for a much better correction and less chance of regression at bar removal. If you are an older patient, or someone with severe PE or significant PE, ask your surgeon about having two pectus bars. If he or she avoids the question or says that it is too difficult to place a second bar, then it’s time to consider changing surgeons!
When I was in Berlin, I met a young German guy who had extremely severe PE, as well as significant upper PE. He showed me his pre-surgery photographs and his PE was probably the most severe that I have ever seen. How many bars do you think he had implanted? Three!! Professor Schaarschmidt implanted three pectus bars into this guy and his chest result was absolutely extraordinary. His chest was flat and just perfect. And all of these bars were inserted into the same incision. So, even though he had three bars, he had exactly the same incision as someone who had a single bar implanted. I am quite sure that no other surgeon in the world would be capable of such wonders!!
IS THE NUSS PROCEDURE RISKY?
Any surgical procedure carries a degree of risk. The Nuss Procedure is no different. People have died during and after the Nuss Procedure. Deaths during the operation usually result from the pectus bar puncturing one of your vital organs, such as your heart. Deaths following surgery usually result from infection. The mortality rate for the Nuss Procedure is very small, but it is not zero. The statistics that I have seen indicate that it is less than 1%. That means that you have a greater than 99% chance of survival – excellent odds by any standard.
I am not writing this to frighten anyone. However, I would be remiss in neglecting to inform people that the Nuss Procedure does carry with it the risk of death, albeit a very small risk. It is always good to have all the facts at your disposal before making a decision to go ahead with the surgery.
BAR REMOVAL AND REGRESSION
Every Nuss patient is concerned about the possibility of a return of their PE once the bars are removed, also known as regression. Obviously, this is an extremely important issue. To endure the pain of recovery from the Nuss Procedure and then have the PE return once that bars are removed would devastating.
There are a number of factors which will have an impact on the likelihood of regression. The first and most important is your choice of surgeon. Chances of regression are significantly reduced with an experienced surgeon on your side. An experienced surgeon will ensure the bars are placed in the optimal position for correction of your deformity. Poor bar placement, or poor bar fixation, may contribute to regression at a later time, even before bar removal. Younger patients and their parents need to be particularly cautious and concerned about regression. Insertion of the bars too early can be a mistake. If the bars are inserted too early and removed before the child has stopped growing, the possibility of regression is increased. As mentioned earlier, 16 to 18 is the optimal age for the Nuss Procedure.
Another factor which has an impact on regression is the length of fixation, that is, the length of time that the bars are inside your body. Generally, bars remain in place for between two and three years. More aggressive surgeons will advocate a three year minimum. Older patients should certainly not have their bars removed before three years, unless there is a compelling reason to do so. On the other hand, leaving the bars in for too long is also not good because the bars will become too entangled in the tissue and bone and may prove very difficult to remove. I understand that 5 years is the absolute maximum length of time that the bars should remain in place.
So, although regression is a possibility following bar removal, it is fairly remote. If you are concerned about the possibility of regression, you should discuss the matter with your surgeon.
Bar removal is a relatively simple procedure when compared to the initial surgery. Your original incisions will be re-opened, the bar located, and then basically pulled out. The procedure usually last from 45 to 90 minutes and recovery and hospitalization times are significantly less than those for bar insertion. There are some excellent photographs of a bar removal procedure here.