Ann Thorac Surg 2004;77:296-300
© 2004 The Society of Thoracic Surgeons
Original article: general thoracic
The use of a lateral stabilizer increases the incidence of wound trouble following the Nuss procedure
Atsushi Watanabe, MDa*,
Toshiaki Watanabe, MDa,
Takuro Obama, MDa,
Hisayoshi Ohsawa, MDa,
Tooru Mawatari, MDa,
Yasunori Ichimiya, MDa,
Tomio Abe, MDa
a Department of Cardiothoracic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
Accepted for publication July 17, 2003.
* Address reprint requests to Dr Atsushi Watanabe, Department of Cardiothoracic Surgery, Sapporo Medical University School of Medicine, Sapporo, South 1, West 16, Chuo-ku, Sapporo 060-8543, Japan.
e-mail: atsushiw{at}sapmed.ac.jp
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Abstract
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BACKGROUND: A lateral stabilizer has been used to prevent bar displacement during the Nuss procedure for pectus excavatum repair in pediatric patients. We experienced wound troubles in patients who had a stabilizer placed within them. The aim of this study was to examine the effect of a lateral stabilizer and other clinical factors on wound troubles after the Nuss procedure.
METHODS: 53 patients with pectus excavatum underwent repair by the Nuss procedure. Preoperative clinical data, operative data, and postoperative complications were examined in all patients.
RESULTS: A lateral stabilizer was placed in 29 of the 53 patients. Short-term results were excellent in 42 patients (79.2%). Postoperative complications involved pneumothorax requiring drainage in two patients, atelectasis in one patient, pleural effusion in three patients, deterioration of scoliosis in one patient, erythema in one patient, persistent pain in two patients, bar displacement in four patients, and local wound complications (Seroma with dermatitis due to pressure damage) in five patients. All seromas with dermatitis due to pressure damage were initially aseptic around lateral stabilizers and became infected in four patients after resection of the seroma or spontaneous perforation. Removal of both the pectus bar and lateral stabilizer was performed in two of those four patients and the lateral stabilizer was removed in the other two patients to prevent catastrophic infection such as empyema or mediastinitis. The use of a lateral stabilizer increases the incidence of wound trouble (p = 0.041).
CONCLUSIONS: Although the Nuss procedure has evolved into an effective method for pectus excavatum repair, the use of a lateral stabilizer increases the incidence of wound difficulties.
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Introduction
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Repair of pectus excavatum in childhood is a well-established procedure, and the outcome is excellent. Sternal elevation [1, 2], sternal turnover [3], and other modifications [4, 5] have been introduced. A minimally invasive operation using a pectus bar for correction of the pectus excavatum with excellent results was reported by Nuss et al [6]. The procedure reported does not require an anterior chest wall incision, raising of the pectoralis muscle flaps, resection of costal cartilage, or a sternal osteotomy. The Nuss operation is rapidly gaining acceptance as the preferred method for pectus excavatum repair because the procedure is associated with a small skin incision, a shorter operation time, minimal blood loss, and early return to full activity [7]. However, drawbacks of the Nuss procedure include high postoperative complications [8] such as pectus bar displacement, pneumothorax, infectious complications, pleural effusion, pericarditis, persistent pain, and skin erosion, etc. The purpose of this report is to review special and severe complications of seroma with dermatitis due to pressure damage, which probably resulted from the use of a lateral stabilizer.
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Patients and methods
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From July 1999 to January 2003, 53 patients with pectus excavatum underwent minimal invasive repair using the Nuss procedure in our hospital. The 53 patients included 38 boys and 15 girls with a mean age of 9 ± 4 years (range of ages, 4 to 18 years). The distribution of the patients' ages is shown in Figure 1. Twenty-two patients were 6 years of age or less. Haller's pectus index (width of chest divided by the distance between the sternum and spine: 2.56 for a normal chest) [9] has a mean index of 4.96 ± 1.43 (range of index, 2.72 to 9.86). None of the patients had associated cardiopulmonary anomalies. The short-term results from 3 to 6 months after the operation were classified into four groups as described previously [10].
Indications for the Nuss procedure
Our eligible criteria for the Nuss operation was as follows: 1) Haller's pectus index was more than 3.0. 2) A patient or patient's parents hoped to receive the operation and the patient was hesitant to expose their chest due to the deformity, even if the pectus index of the patient was less than 3.0. 3) There were subjective symptoms such as easy fatigability, increased frequency of upper respiratory infection, and/or decreased stamina compared with their peers.
Operative technique
The Nuss procedure was performed as described previously [6]. A thoracoscope of 3 or 5 mm in diameter was introduced into the right pleural space through a thoracoport placed in the 6 or 7 intercostal space on an anterior auxillary line to observe the right pleural space and anterior mediastinum. A lateral stabilizer (Walter Lorenz Surgical, Jacksonville, FL) was used to prevent bar displacement for 29 of the 53 patients and bilateral stabilizers were used in 1 patient. The indications for placement of the stabilizer have changed since we began the procedure. Before November 2000 the stabilizer was used only if we could not confirm the bar's stability during the intraoperative evaluation, so we only used a stabilizer in one of eight patients. In December 2000, a patient's bar was found to be displaced, so thereafter, the stabilizer was used for all 21 patients who underwent the Nuss procedure between December 2000 and February 2002. During the period, a complication, seroma with dermatitis due to pressure damage, developed in 5 of the 21 patients. After that period, the stabilizer was used if they were older than 10 years of age and if the bar's stability could not be confirmed in intraoperative evaluation. Only 7 of the 24 patients undergoing the Nuss procedure after March 2002 received the stabilizer.
The bar was fixed to the serratus anterior muscle using about ten nonabsorbable sutures (braided nylon suture: 1 to 0 Surgilon, United States Surgical, Norwalk, CT) on the right side and the same number of absorbable polydioxanone sutures (1 PDS, Ethicon, Edinburgh, UK) on the left side. The reason why different suture material was used on the left versus the right is that only the wound on the right will be opened when the bar is removed, and we think that the nonabsorbable sutures have longer durability to prevent bar dislocation than absorbable sutures. Our methods of stabilization were unified throughout the series.
Postoperative management
A chest X-p was taken in the operating room before each patient was transported to the recovery room. A thoracic epidural catheter was left in place for 1 to 10 days (mean duration, 4.3 ± 2.1 days). None of the patients stayed in the intensive care unit after the operation. Perioperative antibiotics were administrated intravenously for 24 hours and then orally for 4 or 5 days. Each patient had strict bed rest on a ward bed for the first 2 days after the operation to prevent bar displacement. Patients were discharged from the hospital when they felt no chest pain at rest with a nonnarcotic analgesic. Full activities, which meant that patients could play contact sports, were permitted 3 months after the operation. The removal of the bar is scheduled about 3 years after the operation if there are no troubles.
Measurement of physical factors
The body mass index (BMI) was calculated by using the following formula: BMI = weight (kg) · height (m)-2. The thickness of the subcutaneous fatty layer and muscle thickness were measured at the slice level in which a right lower pulmonary vein was shown on a chest tomographic scan as a factor of physique. The thickness of the fatty layer in presternal site was measured by the distance between the skin and anterior surface of the sternum in a midsternal line. The thickness of the fatty layer in the right lateral chest was measured by the distance between skin and anterior surface of the serratus anterior muscle. Furthermore, the thickness of the right serratus anterior muscle indicated the thickness in the site of the anterior border of the latissimus dorsi muscle.
Statistical analysis
Statistical analyses were performed using SPSS 10.0 software (SPSS, Chicago, IL). All continuous data are expressed as a mean ± standard deviation of the mean. Categorical and continuous variables were analyzed by the 
-square test or Fisher's exact test as appropriate and by an unpaired Student's t test, respectively. A p value less than 0.05 was considered significant. Furthermore, continuous variables were converted into categorical variables using each cutoff level and the ratio of the patients with a converted variable was compared in the two groups.
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Results
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Operative and postoperative course
Operation time averaged 76 ± 25 minutes and ranged from 42 to 155 minutes. Amount of intraoperative blood loss averaged 4 mL and ranged from 0 to 50 ml. No chest tube drainage was required immediately after operation. A thoracic epidural catheter was placed in 39 (73.6%) of the patients for postoperative pain control. The duration of hospital stay ranged from 5 to 27 days (mean duration, 8.9 ± 3.8 days).
Postoperative complications
Postoperative
complications (Table 1) occurred during hospitalization in 7 (13.2%) of 53 patients: pneumothorax in 2 patients, atelectasis in 1 patient, pleural effusion in 3 patients (one being the patient with pneumothorax), deterioration of scoliosis in 1 patient, and linear erythema in the skin lying over an implanted pectus bar in 1 patient. Late postoperative complications after discharge occurred in 9 (17.0%) of the 53 patients: bar displacement occurred in 4 patients (2 patients with the stabilizer and 2 patients without the stabilizer) within 1 month after discharge (two of these 4 patients required a reoperation to reposition and refix a pectus bar 2 months and 10 months after the first operation), persistent chest pain continuing for more than 2 months in 2 patients, and seroma with dermatitis due to pressure damage on the side on which a lateral stabilizer had been placed to prevent bar displacement (right side in 4 patients and left side in 1 patient) in 5 patients 2 to 6 months after the Nuss procedure. Three patients had two or more postoperative complications, therefore, postoperative complications occurred in 12 (22.6%) of the 53 patients.
Seroma with dermatitis due to pressure damage
Five patients who developed seroma with dermatitis due to pressure damage are summarized in Table 2
and a photograph of the typical seroma with dermatitis due to pressure damage (case 3) is shown in Figure 2.
Needle aspiration was performed on all of these patients. The aspirated fluid was clear and was found to be aseptic by bacterial analysis. The volume of fluid collected ranged from 3 to 10 mL during each aspiration. Only one patient, who was a 15-year-old boy, recovered from seroma with dermatitis due to pressure damage after five needle aspirations. Seromas with dermatitis due to pressure damage in the other four patients developed 2 to 6 months after the first operation. The seromas with dermatitis due to dermatitis in three of four patients were removed before perforation because the skin lying over the seroma gradually got weak and fragile, and the wounds were reclosed without removal of the lateral stabilizer. However, these four patients suffered recurrence of seroma with dermatitis due to pressure damage, and the seromas perforated and became infected. In two of those, both pectus bar and lateral stabilizer were removed and chest wall drainage was performed. In the other two patients, the seroma with dermatitis due to pressure damage and the lateral stabilizer were removed, leaving the pectus bar in place because the seromas with dermatitis due to pressure damage were determined to be aseptic immediately before the operation.
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Fig 2. Seroma with dermatitis due to pressure damage developing in a 5-year-old boy 2 months after the Nuss procedure.
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Analysis of risk factors in relation to seroma with dermatitis due to pressure damage
There
were no significant differences between patients without the seroma and patients with the seroma in terms of age, BMI, operative time, thickness of fatty tissue layer in the chest wall or serratus anterior muscle, and Haller's pectus index (Table 3). The rate of the use of a lateral stabilizer was higher in patients with the seroma than in patients without it. The rate of BMI 
15 kg · m-2, the thickness of subcutaneous fatty layer in lateral chest wall 
4 mm, the thickness of serratus anterior muscle 4 mm, and Haller's pectus index were higher in patients with the seroma than in patients without the seroma, but did not reach a statistically significant level (0.05 < p < 0.20).
Short-term results
Short-term results were excellent in 42 patients (79.2%), good in 6 patients (11.3%), fair in 4 patients (7.6%), and poor in 1 patient (1.9%).
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Comment
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The technique of minimally invasive repair of pectus excavatum was first reported by Nuss [6] in 1997. Minimally invasive surgery for the repair of pectus excavatum in young patients has been accepted by patients and surgeons because of its minimal invasiveness and excellent cosmetic results. The best time for the operation is when children are between the ages of five to ten because ribs are still soft and most deformities remain symmetric, consequently the deformity is easily corrected and postoperative pain is mild, so patients who were less than 4 years old or more than 18 years old were excluded from the eligible criteria. Unfortunately, the long-term results and complications are still not clearly documented. It has been reported that the most common complication requiring reoperation was displacement of the pectus bar (23/251 cases, 9.2%), 90° rotation in 13 cases, 180° rotation in 2 cases, and lateral displacement in 8 cases [10]. It is absolutely essential to stabilize the pectus bar at the time of operation in order to prevent bar displacement. The following five steps are important for minimizing the risk of bar displacement. 1) An appropriate bar for each patient must be selected at the time of surgery. 2) The lateral thoracic incisions must be made in the midauxillary line, and the tunnel created should allow for placement of the bar at the deepest point of the excavatum deformity, with the bar crossing the sternum in the anterior mediastinum at a 90 degree angle. 3) Older, larger, or more active patients or patients with a severe deformity may require placement of an additional bar. 4) Stability of the bar should be evaluated intraoperatively before closing. The bar should be secured with heavy sutures to the lateral chest wall muscles. 5) The transition from general anesthesia to conscious sedation should be smooth [8]. Nuss et al recommend the routine use of a lateral stabilizer to minimize the risk of bar displacement after the operation. On the other hand, the use of a wire stabilizer and a three-point fixation system to prevent a bar displacement have been reported by Nuss et al [11] and Hebra et al [12]. The former is a technique by which a rib and the bar are encircled with a wire. The latter is a technique requiring simple placement, via a spinal needle, of a nonabsorbable suture next to the sternum, encircling a rib and the bar, using a single 3 mm stab wound and thoracoscopic guidance. In our series, incidence of wound trouble after the Nuss operation is 9.4%, which is very high compared with previous reports [8, 13]. This study indicated that the use of a lateral stabilizer increases the incidence of seroma with dermatitis due to pressure damage. Generally, children with pectus excavatum are more slender compared with their peers. A lateral stabilizer is 60 by 16 mm with a maximum thickness of 5 mm. There is only one size for all patients, which is inappropriate because the patients' physique is never confined within a narrow range. We think that the stabilizer is too large to be placed in the subcutaneous layer of a small or very slender patient with pectus excavatum. In this study, there were no significant relationships between each physical parameter and the incidence of seroma with dermatitis due to pressure damage; we think that is because the subjective patient number was small (total number = 53 and number of patients developing seroma with dermatitis due to pressure damage = 5). Seroma with dermatitis due to pressure damage was very difficult to cure. Inflammation of the skin and subcutaneous tissue around a lateral stabilizer occurs due to the volume effect of the stabilizer and infection develops after resection of seroma with dermatitis due to pressure damage because the volume effect of the stabilizer on the skin and subcutaneous tissue layer continues and prevents the wound from healing if the stabilizer is not removed during the resection. Furthermore, infections develop after spontaneous skin ulceration or perforation, which results in seroma with dermatitis, unless a surgical procedure is used to remove the seroma. A pectus bar should be removed if there is wound infection around a pectus bar. It must be emphasized that placement of a lateral stabilizer is very risky for small or very slender patients with pectus excavatum because it can cause seroma with dermatitis due to pressure damage and infection around the pectus bar. We always consider this when the Nuss procedure is performed: The complications occurred in patients undergoing elective surgery in the pediatric age group for, at least in some cases, predominantly cosmetic reasons. It caused disaster, considering the incidence of infection, the use of third generation antibiotics, long hospital stay, and the expectation of bar removal in the future, which may add more complications.
A lateral stabilizer is not always necessary to prevent bar displacement in small patients whose rib and rib cartilage is still soft. Furthermore, the lateral stabilizer should not be used as a first choice of material to prevent bar displacement and another method such as a wire stabilizer or three-point fixation should be used if stabilization of a pectus bar is necessary. A lateral stabilizer should be simultaneously removed in a second operation for removal of seroma with dermatitis due to pressure damage if the seroma has occurred after the Nuss procedure.
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References
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Abstract
Introduction
