The Nuss Procedure: Balance the Risks against Benefits

Objective: The Nuss technique is a minimally invasive repair of pectus excavatum with intrathoracic placement of metal bar(s) allowing permanent remodeling of the anterior chest wall. Given severe complications reported so far, one must balance the risks against benefits of this procedure.Material and methods: Publication searches through electronic bibliographic databases. Severe complications were selected according to Castellani’s criteria.Results: Twenty-eight patients sustained procedural complications, mainly hemorrhages, including 18 cardiac injuries; and 3 cases of mechanical occlusion of the inferior vena cava, which required prompt bar removal. The most common delayed complications were: (1) Bar displacement (5.7-to-18%), leading to late-onset hemothorax in 15 patients, aortic-cross injury in 2 and pulmonary injury in 2; (2) Infection of the bar; (3) Postpericardiotomy syndrome; (4) Metal allergy; (5) Mechanical conflicts and consecutive thoracic outlet syndrome or sternal erosion. Last, hemothorax or catastrophic hemorrhages due to cardiac laceration and difficulties due to neo-ossification were encountered during bar removal. Finally, 8 patients experienced per operative cardiac arrest leading to death in 3 or severe hypoxic brain injury in 2.Conclusions: Besides the fact that the Nuss technique does not correct the cause of pectus excavatum (costal cartilage anomalies), it has gained acceptance. However, this is questionable, according to our in-depth literature study and comparative evaluations of complications after both Nuss and open Ravitch-type repair.