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Pleural Effusion Complicating After Nuss Procedure for Pectus Excavatum

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Pleural Effusion Complicating After Nuss Procedure for Pectus Excavatum Ann Thorac Cardiovasc Surg Advance Published Date: February 15, 2013 doi: 10.5761/atcs.oa.12.02067 Original Article Pleural Effusion Complicating after Nuss Procedure for Pectus Excavatum Yeung-Leung Cheng, MD, PhD,1 Chin-Ta Lin, MD,1 Han-Bin Wang, MD,2 and Huang Chang, MD, PhD1 Purpose: The Nuss procedure is a minimally invasive method for the correction of pectus excavatum (PE). Pleural effusion complicating following the Nuss procedure was uncom- mon but may be critical. We evaluated the risk factors of postoperative pleural effusion after Nuss repair. Methods: We included all patients with PE primarily corrected by Nuss procedure from July 2005 to December 2011. The clinical features, treatment and outcomes of these patients with pleural effusion were analyzed retrospectively. Results: 390 patients (338 men, 52 women) with a mean age of 23.9 years (5-44 years) were included. Postoperative pleural effusion occurred in 10 patients (2.6%). The time of occurrence of pleural effusion was on a mean of 16.6 days (8-32 days) after operation presenting with progressive dyspnea. All of these patients were adults, and 9 patients (90%) were repaired by two pectus bars (p <0.001). Six patients with massive pleural effusion received thoracocentesis (400 ml-1000 ml). All of the effusions were exudative. These patients took short-term indomethacin or steroids without removal of bars and all recov- ered well after a mean of 40 months (12-72 months) follow-up. Conclusions: Pleural effusion complicating after Nuss procedure was uncommon. It occurred most on adult patients with placement of double bars. Close follow-up in adults after more than one bar insertion is recommended. Administration of tempo- rary medications of indomethacin/steroid and/or thoracocentesis could obtain a satisfy- ing result. Early administration of indomethacin/steroid in adult patients repaired by two bars with mild pleural effusion for preventing pooling of effusion could also be considered. Keywords: Pectus excavatum, Nuss procedure, pleural effusion, NSAID, steroid 1Division of Thoracic Surgery, Department of Surgery, Tri-Service Introduction General Hospital, National Defense Medical Center, Taipei, Taiwan Pectus excavatum is the most frequent congenital chest 2Division of Chest Medicine, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, wall deformity mostly presenting since neonate and might Taiwan be sunken after adolescence.1) In 1998, Nuss and associ- ates documented a minimally invasive method for cor- Received: June 13, 2012; Accepted: August 8, 2012 1,2) Corresponding author: Yeung-Leung Cheng, MD, PhD. Division rection of pectus excavatum with a good result. This of Thoracic Surgery, Department of Surgery, Tri-Service procedure remodels the anterior chest wall employing General Hospital, 325, Section 2, Cheng-Kung Road, Taipei 114, a metal bar without resection of cartilage. This new Taiwan approach is expected to have better functional and cos- Email: [email protected] ©2013 The Editorial Committee of Annals of Thoracic and Car- metic outcomes than invasive repairs for symmetrical diovascular Surgery. All rights reserved. pectus excavatum.1,2) 1 Ann Thorac Cardiovasc Surg Advance Published Date: February 15, 2013 Cheng YL, et al. Although this procedure was accepted near-universally, 10-mm, 0 degree scope entering the pleural cavity via the complications and learning curve were discussed in the right surgical wound for direct inspection of the the recent issue.3,4) The postoperative complications after mediastinal structures was done fi rst. A left thoracos- Nuss procedure, including pneumothorax, pleural effusion, copy was performed via the left surgical wound later. hemothorax, empyema, pneumonia, pericardial effusion, A right-to-left mediastinal dissection by the introducer cardiac injury and dislocated bar, were reported.5–8) The under direct left thoracoscopic visualization and was complications of pleural effusion could give rise to respi- undergone. After the substernal tunnel achieved, a 28 Fr ratory distress or compromised vital signs. The compli- chest tube was connected on the introducer and retained cation rate of pleural effusion was reported with a wide in the thorax after the introducer was pulled back. A range in different groups (0.3%–17%),3–6) and the associ- pre-bent Lorenz pectus bar (Lorenz Surgical, Inc., ated factors, treatment and outcome were not analyzed Jacksonville, FL, USA) was connected to the chest tube in detail. and advanced across the mediastinum. After the pectus The aim of this study was to analyze and discuss the bar was rotated and anchored into the position, the bar clinical features, associated factors, treatment and out- was fi xed with either a 1.0-mm stainless wire or heavy comes of pleural effusion complicating after Nuss repair nonabsorbing sutures at the end holes of the pectus bar for pectus excavatum in our experience. and the right hinge point3). In patients with very long and severe deformity, an additional substernal tunnel was Materials and methods made under the direct left thoracoscopic viewing and another pectus bar was introduced and fi xed. Two We included all patients with pectus excavatum who small-caliber close drainage tubes were inserted to the had a Nuss procedure as their fi rst repair at the Division pleural spaces for drainage of air and fl uid. After extuba- of Thoracic Surgery, Tri-Service General Hospital, tion, all patients were taken a postoperative radiograph Taipei, Taiwan, from July 2005 to December 2011. Eval- and intensive monitored for 24 hours. uation by complete history, physical examination, chest Postoperative pain was controlled epidural patient radiographs, electrocardiogram, pulmonary function test, controlled analgesics by administration of fentanyl. echocardiogram, and computerized tomography (CT) of Nonsteroidal anti-infl ammatory drugs (NSAIDs) were the chest were performed. The indications for surgical provided in patients of severe pain episodes. The patients repair were 2 or more of the following criteria demon- were discharged from the hospital when pain control was strated by Dr. Nuss: (1) progression of the deformity; replaced by oral analgesics. (2) exercise intolerance; (3) progressive chest pain or Most of our patients were regularly monitored by dyspnea; (4) restrictive ventilatory impairment; (5) Haller chest plain fi lm at 2 weeks, 1 month, 3 months after index >3.25; (6) cardiac compression (7) mitral valve operation, and then twice annually. If patients with pro- prolapsed.9,10) The demographic data, clinical data, com- gressive dyspnea and the followed chest plain fi lm plications, and surgical outcome were collected. showed pleural effusion, the choice of management for This study was approved by the Ethics Committee procedures of aspiration or drainage, or medication with and the Institutional Review Board of the Tri-Service oral indomethacin or prednisolone (if patients had General Hospital, National Defense Medical Center, allergy to NSAIDs) was made depended on the condition Taipei, Taiwan, ROC (TSGH-IRB No: 098-05-244). of patients.11) Surgical preparation and technique Statistical analysis A bilateral thoracoscopy-assisted Nuss procedure was Descriptive data are expressed as mean ± SD or median according to our description before.10) In brief, all patients (interquartile range [IQR]) for normally or non-normally had a thoracic epidural for intraoperative anesthesia and distributed continuous variables. The Student t test postoperative pain control. The patient was placed in the was used for normally distributed continuous data, and supine position after general anesthesia. One small verti- the nonparametric Spearman R test for non- normally cal skin incision was made in the midaxillary line each distributed continuous data. Chi-square or Fisher exact side. After subcutaneous or submuscular dissections test were used for comparison of categorical variables were performed, the pleural cavities were entered at the between groups. A signifi cant p value was defi ned highest point of the funnel. A right thoracoscopy with a less than 0.05. Statistical software (Stata 10; StataCorp 2 Ann Thorac Cardiovasc Surg Advance Published Date: February 15, 2013 Pleural Effusion After Nuss Procedure Table 1 Demographic variables and surgical characteristics persistent air leakage or massive effusion. The mean of 342 patients with pectus excavatum corrected by length of hospital stay was 6.8 days (rage 4–14 days). Nuss procedure Our patients had been followed with a mean of 48 months All patients Characteristics (6–78 months) after operation. (n = 390) Age, years, mean (IQR) * 23.9 (5–44) Surgical complications Gender (M: F) 342:48 Body mass index, kg/m2 (IQR) 19.2 ± 2.3 No mortality, mediastinal injury, active bleeding or (16.5–25.2) life-threatening complication occurred after operation. Family history, No. (%) 102 (26.2) Only two patients with pneumothorax (0.5%) were iden- Scoliosis, No. (%) 91 (23.3) tifi ed after operation, but did not require chest tube inser- Haller index, mean (IQR) 5.2 (2.6–75) Restrictive pulmonary function, No. (%) 55 (14.1) tion. Two patients (0.5%) with postoperative pericardial Mitral valve prolapse, No. (%) 40 (10.3) effusion. There were 6 patients (1.5%) bar displacements Operative time, min, mean (IQR) 70.5 (40–125) requiring surgical revision. Double bars placed, No. (%) 154 (39.5) Ten patients (2.6%) presenting dyspnea diagnosed Estimated blood loss, ml, mean (IQR) 14.6 (10–35) with pleural effusion after Nuss procedure. All of these Blood transfusion, No. (%) 0 (0.0) Mortality, No. (%) 0 (0.0) patients with postoperative effusion were adults with Length of stay, days, mean (IQR) 6.8 (4–14) mean age of 27.8 (range 22 to 36 years). We divided all Complications, No. (%) 25 (6.4) of the patients into two groups with Group I (without Pneumothorax (drainage required) 2 (0.5) pleural effusion after Nuss procedure, n = 380) and Bar infection 1 (0.3) Pleural effusion 10 (2.6) Group II (with pleural effusion after Nuss procedure, Pericardial effusion 2 (0.5) n = 10) in Table 2.
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