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Ann Thorac Surg 2007;83:1844-1849
© 2007 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Self and Parental Assessment After Minimally Invasive Repair of Pectus Excavatum: Lasting Satisfaction After Bar Removal

Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany

Accepted for publication December 27, 2006.

^_* Address correspondence to Dr Metzelder, Department of Pediatric Surgery, Hannover Medical School, Carl-Neuberg-Str 1, 30625 Hannover, Germany (Email: mmetzelder{at}yahoo.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background: Improvement of quality of life by minimally invasive repair of pectus excavatum (MIRPE) has been demonstrated only for the period with implanted pectus bar. The aim of this study was to demonstrate the effects of MIRPE on psychosocial and physical well-being after removal of the pectus bar.

Methods: Forty patients (26 boys and 14 girls; mean age, 17 years; range, 10 to 24 years) were assessed. Follow-up was performed for a mean of 54 months after pectus repair (range, 25 to 73 months). Patients were interviewed at 6 months after MIRPE with the bar in place, and patients and parents were assessed a mean of 23 months after bar removal (range, 2 to 48 months). A single-step questionnaire that evaluates psychosocial and physical well-being was independently used by patients and their parents.

Results: There was a high level of persistent satisfaction with MIRPE after bar removal (mean total score = 67; maximal score = 80) and a highly significant correlation between self and external assessment (p < 0.001; Spearman correlation coefficient = 0.77). Analysis of specific and total scores revealed a significant improvement of psychosocial and physical well-being after bar implantation, which persisted up to 4 years after bar removal (p < 0.001). Age and sex had no significant impact on the mean specific and total scores either in patients or in parents. Persistent pectus excavatum was noticed in 1 patient after bar removal (2.5%) as a result of treatment failure.

Conclusions: The positive impact of MIRPE on psychosocial and physical well-being in children and adolescents persists after bar removal. Thus we consider MIRPE to be justified for cosmetic reasons.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Minimally invasive repair of pectus excavatum (MIRPE), a procedure introduced by Nuss and colleagues [1] and modified by numerous others [2–4], has gained worldwide acceptance as a new standard technique [5]. The majority of patients undergo the procedure for cosmetic reasons and to stop the progression of the chest deformity [6]. Patients are routinely screened for associated cardiorespiratory disease [3]. However, the impact of pectus repair on cardiopulmonary impairment remains controversial [7].

The impact of MIRPE on the physical and psychosocial well-being and the quality of life was investigated by several authors [8, 9], but the series were small and the pectus bar was still in place. Krasopoulos and colleagues [6] analyzed the quality of life in 20 male adolescents after Nuss procedure, also before pectus bar removal. A significant quality-of-life improvement was confirmed in all these reports.

The long-term satisfaction of the patients after removal of the pectus bar has not yet been investigated. This is of particular interest because the improvement of self-assessed quality of life in children and adolescents may be temporary [6, 9, 10]. Moreover, changes in body image and self-esteem have been shown to be sex-related [11], but no study exists comparing the impact of MIRPE in boys and girls. Parental assessment has been reported to correlate with patient assessment while the pectus bar was implanted [8], but this has not been assessed after bar removal.

Therefore, the aim of our study was to investigate the outcome after MIRPE with removal of the pectus bar by self and parental assessment according to sex and age.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Patients
In 45 patients, who had undergone former MIRPE in our institution, a planned bar removal was performed between February 2002 and February 2006. These patients had been seen at follow-up 6 months after the operation with the pectus bar still in place. In February 2006, the patients and their parents were contacted for follow-up evaluation. Forty patients and 39 parents agreed to participate in the study, which was approved by the Hannover Medical School Ethics Committee, with waiver of informed consent.

All patients had undergone MIRPE for cosmetic reasons. Lung function tests, chest radiographs, electrocardiograms, and echocardiography were routinely undertaken. There was no preoperative computed tomography as we do not use the sternum-vertebral ratio indices either for preoperative or postoperative assessment. The indication for operation in all patients was the persistent request for the procedure, despite extensive information on risks and potential complications. There was no preoperative selection concerning different degrees of chest wall depression and of asymmetry.

Minimally invasive repair of pectus excavatum repair was performed as originally described by Nuss and associates [1, 10] using a one-bar technique under thoracoscopic guidance. We used the same skin incision for the thoracoscope and implantation of the pectus bar. The trocar entered the thorax in the intercostal space cranial to the tunneling instrument, providing the surgeon with an optimal view during the entire operation. No chest drain was used, and patients left the operating room breathing spontaneously. Postoperatively, we used patient-controlled analgesia and nonsteroidal analgesics as required. Hospital stay was scheduled for 1 week, depending on the subjective preference of the patients. The removal of the pectus bar was scheduled for 2 to 3 years after MIRPE according to the recommendations of Nuss and associates [1].

Six months after MIRPE, all patients were interviewed during a follow-up examination using standardized questionnaires to document impairment caused by the implanted bar, and psychosocial and physical well-being. The questionnaire also contained various items of the Krasopoulos questionnaire [6]. All events and complications related to MIRPE were listed in a prospectively collected database.

Method of Follow-Up
Patient data and data of the postoperative period, including complications, were documented prospectively using standardized questionnaires. For follow-up evaluations, we used the single-step questionnaire (SSQ) introduced by Krasopoulos and coworkers [6] with modifications to focus on the assessment of satisfaction with the operative result after pectus bar removal. This questionnaire was translated into the German language and was separately completed by the patients and their parents to obtain internal as well as external assessment. The questionnaire consisted of 16 items (Table 1). Results of questions 1, 2, 5 through 7, and 14 through 16 after bar removal were compared with results obtained at follow-up interviews 6 months after MIRPE, when the pectus bar was still in place. The evaluation at 6 months postoperatively included a follow-up examination by a pediatric surgeon and an interview by a research person not belonging to the pediatric surgical team. The follow-up evaluation after pectus bar removal was performed by posted questionnaires.

The Wilcoxon rank sum test was used to test for differences between boys and girls and different age groups, as well as differences at various time points up to 4 years concerning satisfaction after bar removal. The Friedman repeated-measures analysis of variance on ranks with Tukey test was used to compare the assessment of pain at different points.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Patients and Complications
The mean age of the 40 patients at the time of pectus bar implantation was 13.5 years (range, 6 to 20 years) and 17 years (range, 10 to 24 years) when the questionnaire was completed. The mean time with implanted pectus bar was 31 months (range, 23 to 39 months). The mean follow-up after pectus repair was 54 months (range, 25 to 73 months) and 23 months (range, 2 to 48 months) after bar removal.

No major complications, such as bar dislocation, injury of intrathoracic organs, and bleeding, were seen. Minor complications occurred in 8 of 40 (20%) patients, in 4 without need of surgical intervention (wound infection in 3, seroma in 1). Two patients required revision of a subcutaneous hematoma. Refixation of a dislocated pectus bar stabilizer was required in 1 patient; removal of a stabilizer, which caused local discomfort, in another.

Patients and Parental Satisfaction After Bar Removal
Thirty-nine of the 40 patients (97.5%) and 38 of 39 parents (97.4%) were satisfied with the overall result after pectus bar removal at the time of assessment by questionnaires. The median, mean (± standard deviation), and the range of the score of each SSQ question are shown in Table 1, including the correlation coefficient for self and parental assessment. After removal of the pectus bar, the total mean score of the patients was 67 (median, 67.5; range, 53 to 80), and a mean score of 65 was obtained from their parents (median, 66; range, 41 to 79). There was a highly significant correlation between self and parental assessment for each question (p < 0.001; Spearman correlation coefficient = 0.77).

The vast majority of patients stated that general health (question 1) and exercise capacity (question 2) were improved after the operation. Two patients felt somewhat impaired while the bar was implanted, but both stated overall improvement after bar removal. The extent to which chest looks interfered with preoperative (question 3) compared with postoperative (question 4) social activity was similar in patients’ and parents’ assessments. One patient and his parents were dissatisfied with the overall postoperative appearance (question 5) while the bar was implanted (score = 2), as well as after bar removal (score = 2). According to our criteria, the dissatisfaction of the patient and his parents with the initial procedure, as well as with the final result after bar removal, constitutes treatment failure.

With regard to the impairment by surgical scars (question 6), most of the patients (37 of 40) and most of the parents (38 of 39) were at least satisfied with the outcome. Two boys and 1 girl were dissatisfied with their scars. All but 3 patients communicated improvement of their social life after MIRPE (question 7). The patient with treatment failure stated that the operation had a negative impact on his social life. The changes in self-esteem before pectus repair and after bar removal (questions 8 and 9) were confirmed by a median increase of 1 point in patients’ scores, as well as in parents’ scores (p < 0.001).

Apart from the above-mentioned patient, all patients stated that they were satisfied (n = 9), very satisfied (n = 19), or extremely satisfied with the final result (n = 11; question 14), and that their chest look was improved (question 15). All but 4 patients would choose to undergo the operation again (question 16). One male patient was not decided, and 2 boys and 1 girl would choose not to undergo the operation again. The parents of these patients also stated they would not choose the operation again, although both patients and parents were satisfied with the result of the procedure. Overall, a high level of satisfaction after removal of the pectus bar was detected (median scoring for question 14 = 4; overall mean total score = 67; limits, 53 to 80).

Pain
Thirteen patients (10 boys, 3 girls) and 10 of their parents (8 male, 2 female children) considered postoperative pain after MIRPE to be severe (scoring 1 or 2, question 10), although the median score was 3 in both groups (Table 1). In contrast, median pain with implanted pectus bar beyond the postoperative period (question 11) was less (median score, 4), and there was no pain after bar removal (question 12, median score, 5). The significance of changes in pain assessment was retrospectively analyzed, and patients observed a significant decrease in pain for each time (p < 0.05). Most patients had some degree of consciousness (question 13) of the pectus bar, but only 3 patients felt impaired in their daily routine. Postoperative pain did not interfere with overall satisfaction or the willingness to have the operation again.

Satisfaction at 6 Months Versus After Bar Removal
The satisfaction after 6 months was excellent. The correlation between individual answers of each patient (questions 1, 2, 5, 6, 7, 14, 15, and 16) at follow-up 6 months after MIRPE and after pectus bar removal was highly significant (p < 0.001; Fig 1). We compared the post–bar removal results of patient and parental assessment in 1-year intervals (<1year, n = 13; 1 to 2 years, n = 8; 2 to 3 years, n = 10; 3 to 4 years,: n = 9; Fig 2). Similar results were found for the different periods.

View larger version (39K): [in this window] [in a new window]   Fig 1. Patient satisfaction with minimally invasive repair of pectus excavatum repair before and after bar removal. Mean score distribution according to analogous questions used in personal patient interviews 6 months postoperatively (light gray bars) and after (dark gray bars) pectus bar removal (single-step questionnaire [SSQ] questions 1, 2, 5, 6, 7, 14, 15, and 16 from the questionnaire shown in Table 1). According to Krasopoulos and coworkers [6], values for single-step questionnaire questions 1 through 15 were scored 1 for extremely negative or dissatisfied to 5 for extremely positive or satisfied. Single-step questionnaire question 16 was analogously scored: yes = 10; unsure = 5; no = 0.

View larger version (20K): [in this window] [in a new window]   Fig 2. Total mean single-step questionnaire (SSQ) scores of patient versus parental assessment with regard to time after bar removal. Mean single-step questionnaire score distribution according to four time intervals (<1 year, n = 13; 1–2 years, n = 8; 2–3 years, n = 10; 3–4 years, n = 9) after pectus bar removal comparing self-assessment (light gray plots) and parental assessment (dark gray plots), showing no significant differences. Boxes represent the mean and 25th to 75th percentile range; bars represent the 10th to 90th percentile range.

View larger version (18K): [in this window] [in a new window]   Fig 3. Total mean single-step questionnaire (SSQ) scores of patient versus parental assessment for different age groups. Mean single-step questionnaire score distribution according to three age groups (10–14 years, n = 10; 14–18 years, n = 16; 19–24 years, n = 14) comparing patient assessment (light gray plots) and parental assessment (dark gray plots), showing no significant differences. Boxes represent the mean and 25th to 75th percentile range, bars represent the 10th to 90th percentile range.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

Using validated questionnaires, Lawson and colleagues [8] reported on a significant improvement of life quality in 19 children with implanted bars and reported on its high correlation with parental assessment. Krasopoulos and associates [6] presented an excellent improvement of quality of life after MIRPE assessed from 20 young male patients. However, these investigations concerned only patients before removal of the pectus bar. Our results confirm a high patient satisfaction after pectus bar removal, which is underlined by highly correlating parental assessment.

Although some concerns exist that in the developing chest of children and adolescents the positive effects may be temporary [6, 9, 10], only one report on long-term observations of patients after the Nuss procedure suggests that there is only a small percentage of recurrence [3]. Similar to this study, we noticed 1 patient with persisting pectus excavatum (2.5%) as a result of treatment failure.

Similar to other reports [6], minor complications occurred in 20% of our patients and had no effect on overall satisfaction. Although the total score of each patient would indicate an acceptable result, 4 would not choose to undergo MIRPE again. In 3 of these patients, however, this was not associated with complications, lack of satisfaction with the operative result, or the amount of postoperative pain. The patient with treatment failure and persisting pectus excavatum scored worst in our questionnaire and regretted having the procedure done.

We noticed a high postoperative pain score in one third of our patients, although this did not interfere with overall satisfaction or willingness of the patient to undergo the operation again. Although some studies suggest the use of epidural anesthesia for postoperative pain management [18], we were concerned about the potentially associated risks of neurologic complications, which we considered not acceptable for a cosmetic procedure. In light of the results of this study, however, this regimen will be reconsidered. Pain was irrelevant after pectus bar removal in our series.

Our results of midterm improvement of life satisfaction were similar to the short-term effects reported by Krasopoulos and coworkers [6], with a mean total SSQ score of 67 in our series and 65 in their study [6].

We also demonstrated that MIRPE significantly improved patient self-esteem, which was supported by the external parental assessment. Moreover, we noticed that high satisfaction of our patients remained unchanged for the follow-up period of up to 4 years after bar removal.

Although adolescents and children have been compared concerning the feasibility of MIRPE [19], effects of age and sex on the satisfaction after MIRPE have not yet been investigated. In our series, there was no significant difference between different age groups or sex with regard to mean total SSQ scores, as well as scores for each question.

In conclusion, we demonstrate a lasting satisfaction with the results of MIRPE after removal of the pectus bar, justifying MIRPE for cosmetic reasons.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The authors thank Svetlana Gerbel for her technical assistance.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Metzelder, M. L. Articles by Petersen, C. Search for Related Content PubMed PubMed Citation Articles by Metzelder, M. L. Articles by Petersen, C. Related Collections Chest wall Related Article