A Hebra

A Watanabe

Aristotle D Protopapas

CB Huddleston

CJ Peden

D Nuss

DH Kim

DP Croitoru

FM Haecker

GS Zallen

HJ Park

J Dzielicki

J Schalamon

JP Jacobs

K Ohno

K Schaarschmidt

KA Miller

KA Molik

PC Wu

RA Boehm

S Engum

S Hosie

S Uemura

Thanos Athanasiou

WM Jo

Journal of Cardiothoracic Surgery

English

PubMed

Springer - Publisher Connector

Peri-operative data on the nuss procedure in children with pectus excavatum: independent survey of the first 20 years' data

Crossref

BioMed CentralJournal of Cardiothoracic Surgery
ssOpen AcceReview
Peri-operative data on the nuss procedure in children with pectus 
excavatum: independent survey of the first 20 years' data
Aristotle D Protopapas* and Thanos Athanasiou
Address: Department of Biosurgery & Surgical Technology, Imperial College London, St. Mary's Hospital, London, W2 1NY, UK
Email: Aristotle D Protopapas* - aristotelis.protopapas02@ic.ac.uk; Thanos Athanasiou - thanos.athanasiou@ic.ac.uk
* Corresponding author    
Abstract
Objective: To review the literature and assess the cumulative data on the Nuss operation in
children on its twenty years' anniversary: The Nuss procedure corrects the pectus excavatum by
minimal access semi-permanent insertion of metal bars in order to reduce the deformity and
refashion the contour of the growing thorax. The advantage over previous techniques is avoidance
of osteochondrotomies and thence allowance for normal growth of the thorax.
Study design: PubMed search was performed. Primary outcomes were mortality, morbidity and
individual complications. Secondary outcomes were procedure time and hospital stay.
Results: We merged the data from 19 reports comprising 1949 children of mean age 10.6 years.
No mortality was observed and the procedure was associated with morbidity of 15.4%. The
commonest complications are bar-related adverse events (5.7%) and pneumothorax (3.5%). The
average procedure time and the average hospital stay were 68 minutes and 5.5 days respectively.
Conclusion: 20 years of initial evidence suggests that the Nuss group of procedures is a safe
minimal access option for correction of pectus excavatum in childhood.
Introduction
The cardiothoracic surgeons are moving towards mini-
mally invasive techniques. Such a technique is the Nuss
repair (alias Minimally Invasive Repair of Pectus Excava-
tum or Miniature Access Pectus Excavatum Repair) for
pectus excavatum (funnel chest) [1], the commonest chest
wall anomaly in humans [2], first described in 1594 by
Johannes Schenk, occurring in approximately 1 in every
400 births, males being afflicted 5 times more often than
females. The indication for correction is primarily cos-
metic, although the potential for cardiorespiratory
improvement can be considered.
The original Nuss technique has being previously
described [1,24]. Its principle is the permanent reduction
of the bone deformity by insertion of one (or more) mal-
leable metal bars in order to refashion the contour of the
growing thorax.
Advantages and disadvantages of the Nuss in relation to
open techniques (such as Ravitch [2] and Willital-Hegem-
ann that include extensive thoracic incisions and multiple
thoracic osteochondrectomies (resections of ribs and car-
tilage) are presented in Table 1.
The principal advantage over these techniques is avoid-
ance of osteochondrotomies and thence allowance for
Published: 4 July 2008
Journal of Cardiothoracic Surgery 2008, 3:40 doi:10.1186/1749-8090-3-40
Received: 20 March 2008
Accepted: 4 July 2008
This article is available from: http://www.cardiothoracicsurgery.org/content/3/1/40
© 2008 Protopapas and Athanasiou; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
Journal of Cardiothoracic Surgery 2008, 3:40 http://www.cardiothoracicsurgery.org/content/3/1/40normal growth of the thorax, as subperichondral resection
of the costal cartilages may halt the growth of the thoracic
cage in toddlers and adolescents.
The metalwork is later removed as a day-case operation
(nor requiring overnight stay in hospital) under general
anaesthesia.
The Nuss operation can be performed with or without use
of thoracoscopy. The selection of age for the Nuss varies
with clinical, personal and socio-economical reasons
(such as change of school and fear of intimidation by new
peers), while removal of bars is scheduled within two to
three years from the insertion. In Britain, some surgeons
prefer to perform Nuss around the age of 10, before the
child changes schools and thence is exposed to new peers.
Some other surgeons will perform Nuss earlier, deciding
on parental preference and individual clinical circum-
stances.
Materials and methods
We searched the literature with a simple strategy : 
PubMed search   
Last Date performed: 31 December 2006
Search keyword ‘Nuss’, language English, Humans, chil-
dren  
Cross-validation by hand search to identify case series and
exclude isolated case reports.   
Primary outcomes: Mortality, morbidity, individual com-
plications
Secondary outcomes: Procedure time and hospital stay.  
Descriptive and summary statistics were performed.
Denominators were related to actual data. Missing data
were not defaulted.
Table 1: Perceived advantages and disadvantages of minimal access strategy for correction of pectus in childhood in comparison to 
pre-existing conventional techniques
Advantages Disadvantages
Short hospital stay Cost of thoracoscopy and equipment
Minimal trauma Second procedure for bar removal
Allowance for skeletal growth Capnothorax in thoracoscopy
Table 2: The series merged, 20 years of Nuss operations in children 1987–2006
Reference
number
Patients
operated
Type of study Number of 
centres
Comment
1 329 Retrospective One Series update on ref. 24
3 21 Comparative One
4 52 Retrospective One
5 335 Retrospective One Encompasses ref. 19
6 53 Retrospective One
10 22 Retrospective One
11 40 Retrospective Not reported
12 172 Retrospective Eight
13 31 Retrospective One
15 20 Retrospective One Modified technique
16 36 Comparative One
23 27 Retrospective One Subgroup of all-age cohort
8* 107 Comparative One Similar data to ref. 9
9* 107 Retrospective Not reported Similar data to ref. 8
14 80 Comparative One
17** 35 Comparative One Same centre as ref. 18
18** 21 Retrospective One Same centre as ref. 17
22 461 Retrospective One
Total 1949Page 2 of 5
(page number not for citation purposes)
Journal of Cardiothoracic Surgery 2008, 3:40 http://www.cardiothoracicsurgery.org/content/3/1/40Results
Selection of reports
18 series of Nuss on children were identified (Table 2),
originating from one or more of seven countries, or one of
five of the United States of America.
Of these, there were at least three reports preceded by oth-
ers with apparently overlapping cohorts, [2] by [20,3] by
[13] and [14,5] by [19] so we utilised data from the larger
and more up to date ones [2,3,5].
Interestingly, two reports from neighbouring countries
[Japan, South Korea, [8,9]) over a similar period had the
same number of subjects (107 each), similar but not iden-
tical demographics (age, gender) and similar outcomes.
Both reports have being included separately in our survey.
Two reports from the same centre seemed to report on
separate cohorts [17,18] and have being also included
separately in our survey.
Demographics (Table 3)
1949 children have had Nuss operations. Mean age was
10.6 years, ratio male: female 77:23.
Morbidity and Mortality
No mortality was observed and the incidence of morbid-
ity was 15.4%. The most commonly reported complica-
tions were:
1. Bar-related events (bar displacement requiring revision)
(111 events, incidence 5.7%) and
2. Pneumothorax (68 events including those treated with-
out chest drain, overall incidence 3.5%).
The incidence of wound infection was 2.2%, the incidence
of other pleuropulmonary complications including effu-
sions and atelectasis/pneumonia was 2%. Other compli-
cations were less common (Table 4).
Other Perioperative Data
The average length of operation in minutes was 68 min-
utes (range 28–200).
Average Hospital stay was 5.5 days (range 2–27 days).
Conclusion
We hope that this brief independent survey will offer the
necessary peri-operative data on this now well-established
cosmetic intervention in children: The Nuss procedure
has been performed all around the world with no
reported mortality for 20 years (1987–2007), indicated
primarily for cosmesis in the paediatric sufferer of pectus
excavatum. Potential cardiorespiratory improvement is
not as yet confirmed, whilst the co-existence of Marfan's
syndrome can be ruled out by pre-operative echocardiog-
raphy.
The variations of the Nuss procedure stem from thoraco-
scopic or open, and then thoracoscopy with single or dou-
ble-lumen ventilation (in toddlers double lumen
ventilation may be cumbersome given their tracheal size).
Table 3: Cumulative perioperative data on 20 years of Nuss operations in children 1987–2006
Reference
 number
Patient
number
Average Age Average
Operating
 Time
Average
Hospital Stay
1 329 11 years Not reported 5 days
3 21 14.4 years 53' Not reported
4 52 Unknown 106' 3.9 days
5 335 8 years Not reported Not reported
6 53 9 years 76' 8.9 days
10 22 15.5 years Not reported 13.4 days
11 40 17.6 years 126' Not reported
12 172 15.1 years 76' Not reported
13 31 14.5 years Not reported 4 days
15 20 14 years 75' 5.5 days
16 36 12.3 years 96' 5.5 days
8 107 7.9 years 67' 8 days
9 107 7.5 years 48' Not reported
14 80 11.5 years 53' 3.7 days
17 35 9.5 years 198' 4.8 days
18 21 8.2 years Not reported 4.9 days
22 461 15.2 years 52' 5.3 days
23 27 5.9 years 52' 4.9 days
Total 1949 10.6 years 68' 5.5 daysPage 3 of 5
(page number not for citation purposes)
Journal of Cardiothoracic Surgery 2008, 3:40 http://www.cardiothoracicsurgery.org/content/3/1/40Bar stabilisers have evolved as a valid addition to the tech-
nique [11].
Pneumothorax and bar-related events (pain, dislocation
or infection) may complicate the procedure and are the
primary post operative points of concern. Pneumothorax
is as expected, commoner with thoracoscopy: the tech-
nique may involve carbon dioxide insufflation (capnot-
horax [25] where single lumen tracheal intubation is
utilised.
Our observations reinforce these of a previous smaller
multi-centre cumulative report on 251 cases 7 years ago
[21] and a recent case review by the inventor of the tech-
nique [24].
The advantages of this procedure include the following:
the short hospital stay and limited invasion surgery which
allows for growth in the skeleton as opposed to the osto-
chondrectomies (Table 1). On the balance is the obvious
cost of the thoracoscopy and specialised equipment as
well as the second outpatient-day case procedure of
removal of the bar(s).
We have now reached the point of adequate experience
with Nuss that the purchasers may decide on strategies
after careful individual cost-effectiveness assessment.
Most workers timed the operation at an age appropriate to
the cosmetic expectations of the patient and family con-
sidering the growth spurt of teenagers, namely prior to the
early teens. It is not unusual to perform Nuss in young
adults as a matter of surgeon's and patient's preference,
where care should be exercised for the bar recipient not to
be exposed to vigorous activity prior to removal of the bar
as displacement is a recognised complication associated
with contact sports, trauma or intense manual labour[26].
Limitations of the study and future research
Not all reported series include the data for the variables
studied, the length of postoperative in-hospital stay being
one important one. This might have an impact on the
results. Post operative hospital stay is a surrogate index of
performance, especially in paediatric populations. It is
evident in the literature that the available data have not
been based in comparative high quality studies and
patient based outcomes such as Health Related Quality of
life and patient satisfaction which are important consider-
ations in therapeutic decision making. Also the long-term
results of the procedure are not being discussed in this
paper.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AP conceived the research idea and drafted the manu-
script. TA corrected the manuscript. Both authors read and
approved the final manuscript.
References
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Review and discussion of the complications of minimally
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2. Huddleston CB: Pectus excavatum.  Semin Thorac Cardiovasc Surg
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3. Boehm RA, Muensterer OJ, Till H: Comparing minimally invasive
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39:391-5.
6. Watanabe A, Watanabe T, Obama T, Ohsawa H, Mawatari T, Ichimiya
Y, et al.: The use of a lateral stabilizer increases the incidence
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Surg 2004, 77(1):296-300.
7. Ohno K, Morotomi Y, Ueda M, Yamada H, Shiokawa C, Nakaoka T,
et al.: Comparison of the Nuss procedure for pectus excava-
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8. Jo WM, Choi YH, Sohn YS, Kim HJ, Hwang JJ, Cho SJ: Surgical treat-
ment for pectus excavatum.  J Korean Med Sci 2003, 18:360-4.
9. Uemura S, Nakagawa Y, Yoshida A, Choda Y: Experience in 100
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10. Haecker FM, Bielek J, von Schweinitz D: Minimally invasive repair
of pectus excavatum (MIRPE) – the Basel experience.  Swiss
Surg 2003, 9(6):289-95.
11. Schaarschmidt K, Kolberg-Schwerdt A, Dimitrov G, Straubeta J: Sub-
muscular bar, multiple pericostal bar fixation, bilateral tho-
racoscopy: A modified Nuss repair in adolescents.  J Pediatr
Surg 2002, 37(9):1276-80.
12. Hosie S, Sitkiewicz T, Petersen C, Gobel P, Schaarschmidt K, Till H,
et al.: Minimally invasive repair of pectus excavatum – the
Nuss procedure. A European multicentre experience.  Eur J
Pediatr Surg 2002, 12(4):235-8.
13. Jacobs JP, Quintessenza JA, Morell VO, Botero LM, van Gelder HM,
Tchervenkov CI: Minimally invasive endoscopic repair of pec-
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14. Miller KA, Woods RK, Sharp RJ, Gittes GK, Wade K, Ashcraft KW,
et al.: Minimally invasive repair of pectus excavatum: a single
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15. Hebra A, Gauderer MW, Tagge EP, Adamson WT, Othersen HB Jr:
A simple technique for preventing bar displacement with the
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Table 4: Complications of 20 years of Nuss operations in children 
1987–2006
Complication Cumulative
Bar-related adverse events 111 (37%)
Pneumothorax 68(23%)
Other Pleuropulmonary, except pneumothorax 39(13%)
Wound infection 43(14%)
Pericardial effusion 28(9%)
Hemothorax 12(4%)
Total 301Page 4 of 5
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16. Wu PC, Knauer EM, McGowan GE, Hight DW: Repair of Pectus
Excavatum Deformities in Children: A New Perspective of
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minimal invasive techniques.  J Pediatr Surg 2001, 36(2):324-8.
18. Engum S, Rescorla F, West K, Rouse T, Scherer LR, Grosfeld J: Is the
grass greener? Early results of the Nuss procedure.  J Pediatr
Surg 2000, 35(2):246-51.
19. Park HJ, Lee SY, Lee CS, Youm W, Lee KR: The Nuss procedure
for pectus excavatum: evolution of techniques and early
results on 322 patients.  Ann Thorac Surg 2004, 77(1):289-95.
20. Croitoru DP, Kelly RE Jr, Goretsky MJ, Lawson ML, Swoveland B,
Nuss D: Experience and modification update for the mini-
mally invasive Nuss technique for pectus excavatum repair
in 303 patients.  J Pediatr Surg 2002, 37(3):437-45.
21. Hebra A, Swoveland B, Egbert M, Tagge EP, Georgeson K, Othersen
HB Jr, et al.: Outcome analysis of minimally invasive repair of
pectus excavatum: review of 251 cases.  J Pediatr Surg 2000,
35(2):252-7.
22. Dzielicki J, Korlacki W, Janicka I, Dzielicka E: Difficulties and limi-
tations in minimally invasive repair of pectus excavatum-6
years experiences with Nuss technique.  Eur J Cardiothorac Surg
2006, 30(5):801-4.
23. Kim DH, Hwang JJ, Lee MK, Lee DY, Paik HC: Analysis of the Nuss
Procedure for Pectus Excavatum in Different Age Groups.
Ann Thorac Surg 2005, 80(3):1073-7.
24. Nuss D: Recent experiences with minimally invasive pectus
excavatum repair "Nuss procedure".  Jpn J Thorac Cardiovasc
Surg 2005, 53:338-44.
25. Peden CJ, Prys-Roberts C: Capnothorax: Implications for the
anaesthetist.  Anaesthesia 1991, 48:664-6.
26. Schalamon J, Pokall S, Windhaber J, Hoellwarth M: Minimally inva-
sive correction of pectus excavatum in adult patients.  J Tho-
rac Cardiovasc Surg 2006, 132(3):524-9.Page 5 of 5
(page number not for citation purposes)


03.07.14 KB. Ok to add published version to spiral, OA paperTo review the literature and assess the cumulative data on the Nuss operation in children on its twenty years' anniversary: The Nuss procedure corrects the pectus excavatum by minimal access semi-permanent insertion of metal bars in order to reduce the deformity and refashion the contour of the growing thorax. The advantage over previous techniques is avoidance of osteochondrotomies and thence allowance for normal growth of the thorax

Protopapas, AD

Athanasiou, T

Spiral - Imperial College Digital Repository

BioMed CentralJournal of Cardiothoracic SurgeryssOpen AcceReviewPeri-operative data on the nuss procedure in children with pectus excavatum: independent survey of the first 20 years' dataAristotle D Protopapas* and Thanos AthanasiouAddress: Department of Biosurgery & Surgical Technology, Imperial College London, St. Mary's Hospital, London, W2 1NY, UKEmail: Aristotle D Protopapas* - aristotelis.protopapas02@ic.ac.uk; Thanos Athanasiou - thanos.athanasiou@ic.ac.uk* Corresponding author    AbstractObjective: To review the literature and assess the cumulative data on the Nuss operation inchildren on its twenty years' anniversary: The Nuss procedure corrects the pectus excavatum byminimal access semi-permanent insertion of metal bars in order to reduce the deformity andrefashion the contour of the growing thorax. The advantage over previous techniques is avoidanceof osteochondrotomies and thence allowance for normal growth of the thorax.Study design: PubMed search was performed. Primary outcomes were mortality, morbidity andindividual complications. Secondary outcomes were procedure time and hospital stay.Results: We merged the data from 19 reports comprising 1949 children of mean age 10.6 years.No mortality was observed and the procedure was associated with morbidity of 15.4%. Thecommonest complications are bar-related adverse events (5.7%) and pneumothorax (3.5%). Theaverage procedure time and the average hospital stay were 68 minutes and 5.5 days respectively.Conclusion: 20 years of initial evidence suggests that the Nuss group of procedures is a safeminimal access option for correction of pectus excavatum in childhood.IntroductionThe cardiothoracic surgeons are moving towards mini-mally invasive techniques. Such a technique is the Nussrepair (alias Minimally Invasive Repair of Pectus Excava-tum or Miniature Access Pectus Excavatum Repair) forpectus excavatum (funnel chest) [1], the commonest chestwall anomaly in humans [2], first described in 1594 byJohannes Schenk, occurring in approximately 1 in every400 births, males being afflicted 5 times more often thanfemales. The indication for correction is primarily cos-metic, although the potential for cardiorespiratoryimprovement can be considered.The original Nuss technique has being previouslydescribed [1,24]. Its principle is the permanent reductionof the bone deformity by insertion of one (or more) mal-leable metal bars in order to refashion the contour of thegrowing thorax.Advantages and disadvantages of the Nuss in relation toopen techniques (such as Ravitch [2] and Willital-Hegem-ann that include extensive thoracic incisions and multiplethoracic osteochondrectomies (resections of ribs and car-tilage) are presented in Table 1.The principal advantage over these techniques is avoid-ance of osteochondrotomies and thence allowance forPublished: 4 July 2008Journal of Cardiothoracic Surgery 2008, 3:40 doi:10.1186/1749-8090-3-40Received: 20 March 2008Accepted: 4 July 2008This article is available from: http://www.cardiothoracicsurgery.org/content/3/1/40© 2008 Protopapas and Athanasiou; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5(page number not for citation purposes)Journal of Cardiothoracic Surgery 2008, 3:40 http://www.cardiothoracicsurgery.org/content/3/1/40normal growth of the thorax, as subperichondral resectionof the costal cartilages may halt the growth of the thoraciccage in toddlers and adolescents.The metalwork is later removed as a day-case operation(nor requiring overnight stay in hospital) under generalanaesthesia.The Nuss operation can be performed with or without useof thoracoscopy. The selection of age for the Nuss varieswith clinical, personal and socio-economical reasons(such as change of school and fear of intimidation by newpeers), while removal of bars is scheduled within two tothree years from the insertion. In Britain, some surgeonsprefer to perform Nuss around the age of 10, before thechild changes schools and thence is exposed to new peers.Some other surgeons will perform Nuss earlier, decidingon parental preference and individual clinical circum-stances.Materials and methodsWe searched the literature with a simple strategy : PubMed search   Last Date performed: 31 December 2006Search keyword ‘Nuss’, language English, Humans, chil-dren  Cross-validation by hand search to identify case series andexclude isolated case reports.   Primary outcomes: Mortality, morbidity, individual com-plicationsSecondary outcomes: Procedure time and hospital stay.  Descriptive and summary statistics were performed.Denominators were related to actual data. Missing datawere not defaulted.Table 1: Perceived advantages and disadvantages of minimal access strategy for correction of pectus in childhood in comparison to pre-existing conventional techniquesAdvantages DisadvantagesShort hospital stay Cost of thoracoscopy and equipmentMinimal trauma Second procedure for bar removalAllowance for skeletal growth Capnothorax in thoracoscopyTable 2: The series merged, 20 years of Nuss operations in children 1987–2006ReferencenumberPatientsoperatedType of study Number of centresComment1 329 Retrospective One Series update on ref. 243 21 Comparative One4 52 Retrospective One5 335 Retrospective One Encompasses ref. 196 53 Retrospective One10 22 Retrospective One11 40 Retrospective Not reported12 172 Retrospective Eight13 31 Retrospective One15 20 Retrospective One Modified technique16 36 Comparative One23 27 Retrospective One Subgroup of all-age cohort8* 107 Comparative One Similar data to ref. 99* 107 Retrospective Not reported Similar data to ref. 814 80 Comparative One17** 35 Comparative One Same centre as ref. 1818** 21 Retrospective One Same centre as ref. 1722 461 Retrospective OneTotal 1949Page 2 of 5(page number not for citation purposes)Journal of Cardiothoracic Surgery 2008, 3:40 http://www.cardiothoracicsurgery.org/content/3/1/40ResultsSelection of reports18 series of Nuss on children were identified (Table 2),originating from one or more of seven countries, or one offive of the United States of America.Of these, there were at least three reports preceded by oth-ers with apparently overlapping cohorts, [2] by [20,3] by[13] and [14,5] by [19] so we utilised data from the largerand more up to date ones [2,3,5].Interestingly, two reports from neighbouring countries[Japan, South Korea, [8,9]) over a similar period had thesame number of subjects (107 each), similar but not iden-tical demographics (age, gender) and similar outcomes.Both reports have being included separately in our survey.Two reports from the same centre seemed to report onseparate cohorts [17,18] and have being also includedseparately in our survey.Demographics (Table 3)1949 children have had Nuss operations. Mean age was10.6 years, ratio male: female 77:23.Morbidity and MortalityNo mortality was observed and the incidence of morbid-ity was 15.4%. The most commonly reported complica-tions were:1. Bar-related events (bar displacement requiring revision)(111 events, incidence 5.7%) and2. Pneumothorax (68 events including those treated with-out chest drain, overall incidence 3.5%).The incidence of wound infection was 2.2%, the incidenceof other pleuropulmonary complications including effu-sions and atelectasis/pneumonia was 2%. Other compli-cations were less common (Table 4).Other Perioperative DataThe average length of operation in minutes was 68 min-utes (range 28–200).Average Hospital stay was 5.5 days (range 2–27 days).ConclusionWe hope that this brief independent survey will offer thenecessary peri-operative data on this now well-establishedcosmetic intervention in children: The Nuss procedurehas been performed all around the world with noreported mortality for 20 years (1987–2007), indicatedprimarily for cosmesis in the paediatric sufferer of pectusexcavatum. Potential cardiorespiratory improvement isnot as yet confirmed, whilst the co-existence of Marfan'ssyndrome can be ruled out by pre-operative echocardiog-raphy.The variations of the Nuss procedure stem from thoraco-scopic or open, and then thoracoscopy with single or dou-ble-lumen ventilation (in toddlers double lumenventilation may be cumbersome given their tracheal size).Table 3: Cumulative perioperative data on 20 years of Nuss operations in children 1987–2006Reference numberPatientnumberAverage Age AverageOperating TimeAverageHospital Stay1 329 11 years Not reported 5 days3 21 14.4 years 53' Not reported4 52 Unknown 106' 3.9 days5 335 8 years Not reported Not reported6 53 9 years 76' 8.9 days10 22 15.5 years Not reported 13.4 days11 40 17.6 years 126' Not reported12 172 15.1 years 76' Not reported13 31 14.5 years Not reported 4 days15 20 14 years 75' 5.5 days16 36 12.3 years 96' 5.5 days8 107 7.9 years 67' 8 days9 107 7.5 years 48' Not reported14 80 11.5 years 53' 3.7 days17 35 9.5 years 198' 4.8 days18 21 8.2 years Not reported 4.9 days22 461 15.2 years 52' 5.3 days23 27 5.9 years 52' 4.9 daysTotal 1949 10.6 years 68' 5.5 daysPage 3 of 5(page number not for citation purposes)Journal of Cardiothoracic Surgery 2008, 3:40 http://www.cardiothoracicsurgery.org/content/3/1/40Bar stabilisers have evolved as a valid addition to the tech-nique [11].Pneumothorax and bar-related events (pain, dislocationor infection) may complicate the procedure and are theprimary post operative points of concern. Pneumothoraxis as expected, commoner with thoracoscopy: the tech-nique may involve carbon dioxide insufflation (capnot-horax [25] where single lumen tracheal intubation isutilised.Our observations reinforce these of a previous smallermulti-centre cumulative report on 251 cases 7 years ago[21] and a recent case review by the inventor of the tech-nique [24].The advantages of this procedure include the following:the short hospital stay and limited invasion surgery whichallows for growth in the skeleton as opposed to the osto-chondrectomies (Table 1). On the balance is the obviouscost of the thoracoscopy and specialised equipment aswell as the second outpatient-day case procedure ofremoval of the bar(s).We have now reached the point of adequate experiencewith Nuss that the purchasers may decide on strategiesafter careful individual cost-effectiveness assessment.Most workers timed the operation at an age appropriate tothe cosmetic expectations of the patient and family con-sidering the growth spurt of teenagers, namely prior to theearly teens. It is not unusual to perform Nuss in youngadults as a matter of surgeon's and patient's preference,where care should be exercised for the bar recipient not tobe exposed to vigorous activity prior to removal of the baras displacement is a recognised complication associatedwith contact sports, trauma or intense manual labour[26].Limitations of the study and future researchNot all reported series include the data for the variablesstudied, the length of postoperative in-hospital stay beingone important one. This might have an impact on theresults. Post operative hospital stay is a surrogate index ofperformance, especially in paediatric populations. It isevident in the literature that the available data have notbeen based in comparative high quality studies andpatient based outcomes such as Health Related Quality oflife and patient satisfaction which are important consider-ations in therapeutic decision making. Also the long-termresults of the procedure are not being discussed in thispaper.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsAP conceived the research idea and drafted the manu-script. TA corrected the manuscript. Both authors read andapproved the final manuscript.References1. Nuss D, Croitoru DP, Kelly RE Jr, Goretsky MJ, Nuss KJ, Gustin TS:Review and discussion of the complications of minimallyinvasive pectus excavatum repair.  Eur J Pediatr Surg 2002,12(4):230-4.2. Huddleston CB: Pectus excavatum.  Semin Thorac Cardiovasc Surg2004, 16:225-32.3. Boehm RA, Muensterer OJ, Till H: Comparing minimally invasivefunnel chest repair versus the conventional technique: anoutcome analysis in children.  Plast Reconstr Surg 2004,114(3):668-73. discussion 674–5.4. Zallen GS, Glick PL: Miniature access pectus excavatum repair:Lessons we have learned.  J Pediatr Surg 2004, 39(5):685-9.5. Park HJ, Lee SY, Lee CS: Complications associated with theNuss procedure: analysis of risk factors and suggested meas-ures for prevention of complications.  J Pediatr Surg 2004,39:391-5.6. Watanabe A, Watanabe T, Obama T, Ohsawa H, Mawatari T, IchimiyaY, et al.: The use of a lateral stabilizer increases the incidenceof wound trouble following the Nuss procedure.  Ann ThoracSurg 2004, 77(1):296-300.7. Ohno K, Morotomi Y, Ueda M, Yamada H, Shiokawa C, Nakaoka T,et al.: Comparison of the Nuss procedure for pectus excava-tum by age and uncommon complications.  Osaka City Med J2003, 49(2):71-6.8. Jo WM, Choi YH, Sohn YS, Kim HJ, Hwang JJ, Cho SJ: Surgical treat-ment for pectus excavatum.  J Korean Med Sci 2003, 18:360-4.9. Uemura S, Nakagawa Y, Yoshida A, Choda Y: Experience in 100cases with the Nuss procedure using a technique for stabili-zation of the pectus bar.  Pediatr Surg Int 2003, 19(3):186-9.10. Haecker FM, Bielek J, von Schweinitz D: Minimally invasive repairof pectus excavatum (MIRPE) – the Basel experience.  SwissSurg 2003, 9(6):289-95.11. Schaarschmidt K, Kolberg-Schwerdt A, Dimitrov G, Straubeta J: Sub-muscular bar, multiple pericostal bar fixation, bilateral tho-racoscopy: A modified Nuss repair in adolescents.  J PediatrSurg 2002, 37(9):1276-80.12. Hosie S, Sitkiewicz T, Petersen C, Gobel P, Schaarschmidt K, Till H,et al.: Minimally invasive repair of pectus excavatum – theNuss procedure. A European multicentre experience.  Eur JPediatr Surg 2002, 12(4):235-8.13. Jacobs JP, Quintessenza JA, Morell VO, Botero LM, van Gelder HM,Tchervenkov CI: Minimally invasive endoscopic repair of pec-tus excavatum.  Eur J Cardiothorac Surg 2002, 21(5):869-73.14. Miller KA, Woods RK, Sharp RJ, Gittes GK, Wade K, Ashcraft KW,et al.: Minimally invasive repair of pectus excavatum: a singleinstitution's experience.  Surgery 2001, 130(4):652-7. discussion657–9.15. Hebra A, Gauderer MW, Tagge EP, Adamson WT, Othersen HB Jr:A simple technique for preventing bar displacement with theNuss repair of pectus excavatum.  J Pediatr Surg 2001,36(8):1266-8.Table 4: Complications of 20 years of Nuss operations in children 1987–2006Complication CumulativeBar-related adverse events 111 (37%)Pneumothorax 68(23%)Other Pleuropulmonary, except pneumothorax 39(13%)Wound infection 43(14%)Pericardial effusion 28(9%)Hemothorax 12(4%)Total 301Page 4 of 5(page number not for citation purposes)Journal of Cardiothoracic Surgery 2008, 3:40 http://www.cardiothoracicsurgery.org/content/3/1/40Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentral16. Wu PC, Knauer EM, McGowan GE, Hight DW: Repair of PectusExcavatum Deformities in Children: A New Perspective ofTreatment Using Minimal Access Surgical Technique.  ArchSurg 2001, 136(4):419-424.17. Molik KA, Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL:Pectus excavatum repair: experience with standard andminimal invasive techniques.  J Pediatr Surg 2001, 36(2):324-8.18. Engum S, Rescorla F, West K, Rouse T, Scherer LR, Grosfeld J: Is thegrass greener? Early results of the Nuss procedure.  J PediatrSurg 2000, 35(2):246-51.19. Park HJ, Lee SY, Lee CS, Youm W, Lee KR: The Nuss procedurefor pectus excavatum: evolution of techniques and earlyresults on 322 patients.  Ann Thorac Surg 2004, 77(1):289-95.20. Croitoru DP, Kelly RE Jr, Goretsky MJ, Lawson ML, Swoveland B,Nuss D: Experience and modification update for the mini-mally invasive Nuss technique for pectus excavatum repairin 303 patients.  J Pediatr Surg 2002, 37(3):437-45.21. Hebra A, Swoveland B, Egbert M, Tagge EP, Georgeson K, OthersenHB Jr, et al.: Outcome analysis of minimally invasive repair ofpectus excavatum: review of 251 cases.  J Pediatr Surg 2000,35(2):252-7.22. Dzielicki J, Korlacki W, Janicka I, Dzielicka E: Difficulties and limi-tations in minimally invasive repair of pectus excavatum-6years experiences with Nuss technique.  Eur J Cardiothorac Surg2006, 30(5):801-4.23. Kim DH, Hwang JJ, Lee MK, Lee DY, Paik HC: Analysis of the NussProcedure for Pectus Excavatum in Different Age Groups.Ann Thorac Surg 2005, 80(3):1073-7.24. Nuss D: Recent experiences with minimally invasive pectusexcavatum repair "Nuss procedure".  Jpn J Thorac CardiovascSurg 2005, 53:338-44.25. Peden CJ, Prys-Roberts C: Capnothorax: Implications for theanaesthetist.  Anaesthesia 1991, 48:664-6.26. Schalamon J, Pokall S, Windhaber J, Hoellwarth M: Minimally inva-sive correction of pectus excavatum in adult patients.  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Peri-operative data on the Nuss procedure in children with pectus excavatum: independent survey of the first 20 years' data.

Cho SJ: Surgical treatment for pectus excavatum.

Choda Y: Experience in 100 cases with the Nuss procedure using a technique for stabilization of the pectus bar. Pediatr Surg Int

Comparing minimally invasive funnel chest repair versus the conventional technique: an outcome analysis in children. Plast Reconstr Surg

CS: Complications associated with the Nuss procedure: analysis of risk factors and suggested measures for prevention of complications. J Pediatr Surg

et al.: Comparison of the Nuss procedure for pectus excavatum by age and uncommon complications. Osaka City Med J

et al.: The use of a lateral stabilizer increases the incidence of wound trouble following the Nuss procedure. Ann Thorac Surg

Glick PL: Miniature access pectus excavatum repair: Lessons we have learned. J Pediatr Surg

Minimally invasive repair of pectus excavatum – the Nuss procedure. A European multicentre experience. Eur J Pediatr Surg

Minimally invasive repair of pectus excavatum (MIRPE) – the Basel experience. Swiss Surg

Minimally invasive repair of pectus excavatum: a single institution's experience. Surgery

Othersen HB Jr: A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum.

Pectus excavatum. Semin Thorac Cardiovasc Surg

Submuscular bar, multiple pericostal bar fixation, bilateral thoracoscopy: A modified Nuss repair in adolescents. J Pediatr Surg

Tchervenkov CI: Minimally invasive endoscopic repair of pectus excavatum.

TS: Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg

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Peri-operative data on the nuss procedure in children with pectus excavatum: independent survey of the first 20 years' data

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