Body measurement changes in adults with pectus excavatum after the Nuss procedure: A study of 272 patients

doi:10.21203/rs.3.rs-3102359/v1

Background

Pectus excavatum is the most common congenital abnormality of the chest wall. Most patients with pectus excavatum have slim bodies. Some studies have been conducted on the physical growth of children and adolescents who underwent the Nuss procedure. This study aimed to evaluate body measurement changes in adult patients with pectus excavatum after the Nuss procedure.

Methods

A total of 272 adult pectus excavatum patients, who underwent the Nuss procedure and pectus bars removal from August 2014 to December 2020, were evaluated retrospectively. Body measurements [body height, body weight (BW), and body mass index (BMI)] of the patients were collected before Nuss repair and after bar removal. Associations between changes in body measurements and clinical and radiological features were evaluated.

Results

BW and BMI were significantly increased after pectus bar removal compared to preoperative parameters (62.3 ± 9.7 kg vs 60.8 ± 8.3 kg, P < 0.01 and 20.4 ± 2.6 vs 20.1 ± 2.4, P = 0.01, respectively). In further analysis, young males (< 30 years, n = 226) or those with more severe deformity (Haller index in CT ≥ 4, n = 104), had a significant improvement in BW and BMI (62.2 ± 8.9 kg vs 60.1 ± 7.1 kg, P < 0.01 and 20.4 ± 2.6 vs 19.9 ± 2.1, P < 0.01; 62.9 ± 9.7 kg vs 60 ± 8.3 kg, P < 0.01 and 20.5 ± 2.6 vs 20 ± 2.4, P < 0.01, respectively) after removal of the bar.

Conclusions

BW and BMI were significantly increased after completing surgical correction of pectus excavatum using the Nuss procedure, in young adult males or patients with more pronounced deformities.

Pectus excavatum

Nuss procedure

Body measurements

Body development

Physical growth

Body weight

Body height

Pectus excavatum (PE), or funnel chest, is the most frequent chest wall deformity, accounting for > 90% of all congenital chest wall anomalies. PE presents with anterior chest wall depression due to dorsal deviation of the sternum and the third to seventh rib or costal cartilage [1]. PE is mainly diagnosed in the neonatal period but may become apparent with age [2]. These patients are generally characterized by thin and tall body shapes, and it is believed that more severe PE may be accompanied by an increased risk of growth restriction [1, 3].

Surgical correction is a standard treatment for PE. The Nuss procedure is one of the most common approaches to PE repair; it involves applying outward pressure to the inward sternum using a custom-contoured Nuss bar without cartilage resection [4]. As technology matures, PE correction for children and young people can also be used for adult PE correction.

Whether the body measurement of patients with PE can improve after surgery is a topic worthy of discussion. Some studies have reported improvement of body weight (BW) and body height gain in children with PE after the Nuss procedure [3, 5]. Therefore, we were intrigued about whether the adult population also exhibits a similar outcome. However, there is little information about changes in body measurements in the adult population with PE who underwent the Nuss procedure [6]. This retrospective study focused on changes in body measurement in young adults who underwent the Nuss procedure for PE.

Patients

Adult patients (≥ 18 years old), who underwent Nuss repair for PE followed by bar removal surgery between August 2014 and December 2020 at our hospital, were assessed retrospectively. Preoperative and post-bar-removal parameters were collected, including BW (kg), body height (cm), body mass index (BMI), sex, and Haller index (HI) [7, 8]. The Institutional Review Board and the Ethics Committee of the Taipei Tzu-Chi Hospital agreed with the publication of this study, Taipei, Taiwan, ROC (IRB No: 09-XD-097). The Institutional Review Board waived the need for patient consent due to the study’s retrospective nature.

The major indications for surgery are based on at least two of the following conditions: (1) progressive dyspnea or chest pain, (2) restrictive ventilatory defect, (3) exercise intolerance, (4) aggravation of the deformity, (5) presence of cardiac compression, (6) HI > 3.25, and (7) mitral valve prolapse [9–11]. The correction duration was approximately 3 years, and we excluded patients with a correction duration of < 2 years or > 6 years.

Operative procedures

Nuss procedure

A modified Nuss procedure with bilateral thoracoscopy was performed with right-to-left mediastinal dissection [12–14]. In brief, the patient was placed in the supine position, and the patient’s arms were abducted at approximately 70° relative to the body’s longitudinal axis, after general anesthesia with a single-lumen endotracheal tube. We dissected the subcutaneous and submuscular tissues and opened the pleural cavity near the highest point of the deformity. An intraoperative thoracoscope was routinely applied to watch the introducer to create a mediastinal dissection from right to left to avoid cardiac injury during the operation. One to three bars (Zimmer Biomet, Jacksonville, FL, USA) with a pre-bent to bridge shape were pulled back by connecting them to a 28-Fr chest tube via the substernal tunnel. The pectus bar was rotated, anchored, and fixed with either heavy non-absorbing sutures or a 1-mm stainless steel wire across the nearby rib at both ends of the bar. After completion of anesthesia, the patients underwent chest radiography and were closely monitored for 12–24 h.

Surgical techniques for bars removal

The pectus bars were generally removed after at least 2 years of repair. This procedure was performed as previously described [13]. After general anesthesia and single-lumen intubation, the patient was placed in the supine position, and their arms were abducted. The skin was incised through previous scars, the end of the bars were exposed, and the fixation materials and bars were removed. Bleeding on the operation field and rough surfaces of the callus were checked, and hemostatic gauze was applied to prevent oozing. Finally, the incisional wound was closed, covered, and compressed using a 6-inch elastic bandage.

Postoperative care and follow-up

Patient-controlled epidural analgesia with opioids (morphine or fentanyl) and nonsteroidal anti-inflammatory agents were used for analgesia. The patients were discharged with adequate pain control using oral analgesics. Regular follow-up appointments were performed at 2 weeks, 1 month, 3 months, and 6 months, and then once or twice annually until bar removal. After bar removal, the pain was controlled by NSAID, and patients were mostly discharged on the third postoperative day. Outpatient clinic follow-up was 2 weeks after bar removal and annually thereafter.

Statistical analysis

Mean ± SD or range were used for descriptive data and continuous variables. For continuous data, Student’s t-test was performed to compare postoperative and preoperative values. The chi-squared or Fisher’s exact test was performed for between-group comparisons of categorical variables. Statistical significance was defined as a P-value of < 0.05. Pearson correlation coefficient was used to measure the strength of a linear association between two variables. SPSS (version 24; IBM, Armonk, NY, USA) was used for statistical analyses.

The mean age of patients receiving the Nuss procedure (pre-Nuss procedure, pre-N) was 24.9 ± 4.6 (range: 18–43) years, and the mean age after removal of the bar (post-bar removal, post-R) was 29.0 ± 4.9 (range: 22–48) years (Table 1). The mean interval of correction duration was 3.6 ± 1.2 years (range: 2.8–6.0 years). The distributions of age and sex at the time of repair are shown in Figure 1. Most patients underwent correction using two bars (217 patients, 79.7%). The bar size ranged from 11 to 14 in. All bars were successfully removed. The mean preoperative chest X-ray HI (CXR-HI) was 4.05 ± 1.17, and 3.21 ± 0.64 in postoperative bar removal CXR-HI. Postoperative CXR-HI was significantly improved compared to preoperative CXR-HI (P < 0.01).

Table 1. Patient characteristics

Characteristics (n = 272)
Age, mean ± SD
pre-N	24.9 ± 4.6 (range: 18–43)
post-R	29.0 ± 4.9 (range: 22–48)
Male (%)	255 (93.7)
Female (%)	17 (6.2)
Body height, cm, mean ± SD
pre-N	174 ± 6.1 (range: 152–190)
post-R	174.3 ± 6.2 (range: 152–190)
Body weight, kg, mean ± SD
pre-N	61.3 ± 8 (range: 40–95)
post-R	62.9 ± 9.5 (range: 39.2–112.6)
BMI, mean ± SD
pre-N	20.1 ± 2.4 (range: 13.9–29.2)
post-R	20.4 ± 2.6 (range: 14.9–35.54)
Interval of correction years, mean ± SD	3.6 ± 1.2 (range: 2.8–6.0)
Chest X-ray Haller index, mean ± SD
pre-N	4.05 ± 1.17 (range: 2.50–11.70)
post-R	3.21 ± 0.64 (range: 2.02–6.60)
Bar numbers
One Bar (%)	55 (20.2)
Two Bars (%)	217 (79.7)

Characteristics of patients before the Nuss procedure (pre-Nuss procedure, pre-N) and after bar removal (post-bar removal, post-R). SD standard deviation, cm centimeter, kg kilogram, BMI body mass index

Changes in postoperative body measurements for sex, age, and HI are shown in Tables 2–4. BW and BMI were significantly increased post-operation compared to those pre-operation (BW 60.8 ± 8.3 kg vs. 62.3 ± 9.7 kg, P < 0.01; BMI 20.1 ± 2.4 kg/m² vs. 20.4 ± 2.6 kg/m², P = 0.01) (Table 2). Further, in males only, BW and BMI were significantly greater post-operation compared to those pre-operation (BW 61.3 ± 8 kg vs. 62.9 ± 9.5 kg, P < 0.01; BMI 20.1 ± 2.3 kg/m² vs. 20.5 ± 2.6 kg/m², P < 0.01). However, no significant changes were seen in the female group (N = 17).

Table 2. Comparisons of body measurements with respect to sex.

	pre-N	post-R	P-value
Total (n = 272)
Body height, cm, mean ± SD	174 ± 6.1	174.3 ± 6.2	0.1
Body weight, kg, mean ± SD	60.8 ± 8.3	62.3 ± 9.7	<0.01*
BMI, mean ± SD	20.1 ± 2.4	20.4 ± 2.6	0.01*
Male (n = 255)
Body height, cm, mean ± SD	174.5 ± 5.7	174.9 ± 5.8	0.09
Body weight, kg, mean ± SD	61.3 ± 8	62.9 ± 9.5	<0.01*
BMI, mean ± SD	20.1 ± 2.3	20.5 ± 2.6	<0.01*
Female (n = 17)
Body height, cm, mean ± SD	166.7 ± 6.9	166.6 ± 7.1	0.873
Body weight, kg, mean ± SD	53.9 ± 9.9	52.9 ± 7.8	0.513
BMI, mean ± SD	19.4 ± 3.5	19.1 ± 2.5	0.539

Comparisons of body measurements with respect to sex before the Nuss procedure (pre-Nuss procedure, pre-N) and after bar removal (post-bar removal, post-R). SD standard deviation, cm centimeter, kg kilogram, BMI body mass index

In the older age group (≥30 years, N = 33), there were no significant postoperative changes in either sex (male N = 29, female N = 4) (Table 3). In the young age group (<30 years, N = 239), postoperative BW and BMI were significantly larger than preoperative values (BW 60.2 ± 7.5 kg vs. 61.7 ± 9.2 kg, P < 0.01; BMI 19.8 ± 2.1 kg/m² vs. 20.3 ± 2.6 kg/m², P < 0.01). A similar trend was seen in young males (N = 226) (BW 60.1 ± 7.1 kg vs. 62.2 ± 8.9 kg, P < 0.01; BMI 19.9 ± 2.1 kg/m² vs. 20.4 ± 2.6 kg/m², P < 0.01) but not in young females (N = 13).

Table 3. Comparisons of body measurements with respect to age.

	pre-N	post-R	P-value
≥30 years (n = 33)
Body height, cm, mean ± SD	173.1 ± 7.4	174.3 ± 7.7	0.063
Body weight, kg, mean ± SD	65.7 ± 11.9	66.5 ± 12	0.479
BMI, mean ± SD	21.8 ± 3.2	21.8 ± 2.7	0.856
<30 years (n = 239)
Body height, cm, mean ± SD	174.1 ± 5.9	174.4 ± 5.9	0.065
Body weight, kg, mean ± SD	60.2 ± 7.5	61.7 ± 9.2	<0.01*
BMI, mean ± SD	19.8 ± 2.1	20.3 ± 2.6	<0.01*
≥30 years
Male (n = 29)
Body height, cm, mean ± SD	174.5 ± 6.6	175.8 ± 6.7	0.075
Body weight, kg, mean ± SD	66.4 ± 11.7	67.9 ± 12.1	0.206
BMI, mean ± SD	21.7 ± 2.9	21.8 ± 2.8	0.752
Female (n = 4)
Body height, cm, mean ± SD	162.8 ± 4.4	163.2 ± 5.5	0.604
Body weight, kg, mean ± SD	60.3 ± 13.6	56.8 ± 4.4	0.579
BMI, mean ± SD	22.8 ± 5.5	21.4 ± 1.7	0.531
<30 years
Male (n = 226)
Body height, cm, mean ± SD	174.5 ± 5.6	174.7 ± 5.6	0.063
Body weight, kg, mean ± SD	60.1 ± 7.1	62.2 ± 8.9	<0.01*
BMI, mean ± SD	19.9 ± 2.1	20.4 ± 2.6	<0.01*
Female (n = 13)
Body height, cm, mean ± SD	167.9 ± 7.2	167.7 ± 7.4	0.46
Body weight, kg, mean ± SD	51.9 ± 8.2	51.8 ± 8.4	0.871
BMI, mean ± SD	18.3 ± 2	18.3 ± 2.3	0.929

Comparisons of body measurements with respect to age before the Nuss procedure (pre-Nuss procedure, pre-N) and after bar removal (post-bar removal, post-R).

BMI, body mass index; SD, standard deviation

In the HI ≥4 group (N = 111), postoperative BW and BMI showed a significant increase (BW 60.3 ± 8.6 vs 62.3 ± 9.9, P < 0.01: BMI 19.8 ± 2.4 vs 20.3 ± 2.6, P = 0.01) (Table 4). In males with (N = 104) HI ≥4, postoperative BW and BMI also significantly increased (BW 61 ± 8.3 kg vs. 62.9 ± 9.7 kg, P < 0.01; BMI 20 ± 2.4 kg/m² vs. 20.5 ± 2.6 kg/m², P < 0.01). There was no significant change in females (N = 7) with HI ≥4. In patients with HI <4 (N = 161), only postoperative BW was significantly increased (61.2 ± 8.1 kg vs. 62.2 ± 9.5 kg, P = 0.022). There was no significant change in males only (N = 151) or females only (N = 10) with HI <4.

Table 4. Comparison of body measurements with respect to the severity of pectus deformity.

HI ≥ 4 (n = 111)	pre-N	post-R	P-value
Body height, cm, mean ± SD	174.2 ± 6	174.7 ± 5.8	0.072
Body weight, kg, mean ± SD	60.3 ± 8.6	62.3 ± 9.9	<0.01*
BMI, mean ± SD	19.8 ± 2.4	20.3 ± 2.6	0.01*
HI < 4 (n =161)
Body height, cm, mean ± SD	173.8 ± 6.2	174.1 ± 6.4	0.131
Body weight, kg, mean ± SD	61.2 ± 8.1	62.2 ± 9.5	0.022*
BMI, mean ± SD	20.2 ± 2.3	20.5 ± 2.7	0.072
HI ≥ 4
Male (n = 104)
Body height, cm, mean ± SD	174.6 ± 5.7	175.1 ± 5.5	0.064
Body weight, kg, mean ± SD	61 ± 8.3	62.9 ± 9.7	<0.01*
BMI, mean ± SD	20 ± 2.4	20.5 ± 2.6	<0.01*
Female (n = 7)
Body height, cm, mean ± SD	168 ± 7.8	168.6 ± 7.4	0.084
Body weight, kg, mean ± SD	50.8 ± 8.3	53 ± 8.5	0.253
BMI, mean ± SD	17.9 ± 1.7	18.7 ± 2.6	0.243
HI < 4
Male (n = 151)
Body height, cm, mean ± SD	174.4 ± 5.8	174.7 ± 5.9	0.09
Body weight, kg, mean ± SD	61.5 ± 7.8	62.9 ± 9.3	0.06
BMI, mean ± SD	20.2 ± 2.2	20.6 ± 2.7	0.09
Female (n = 10)
Body height, cm, mean ± SD	165.3 ± 6.5	165.8 ± 6.9	0.244
Body weight, kg, mean ± SD	56 ± 10.8	52.8 ± 7.7	0.117
BMI, mean ± SD	20.6 ± 4.1	19.3 ± 2.6	0.148

Comparison of body measurements before the Nuss procedure (pre-Nuss procedure, pre-N) and after bar removal (post-bar removal, post-R) with respect to the severity of pectus deformity.

BMI, body mass index; SD, standard deviation; HI, Haller index

Pearson correlation coefficient was used to measure the strength of a linear association between difference in bodyweight (dBW) and difference in Haller index (dHI) (Table 5). Pearson correlation coefficient between dBW and dHI was -0.107 (P=0.077). A P value <0.1 was considered significant here.

Table 5. Correlation between difference in bodyweight (dBW) and difference in Haller index (dHI).

		dHI
dBW	Pearson r	-0.107
	P value	0.077*

dHI: CXR-HI before pectus bars extraction minus CXR-HI before surgery.

dBW: Pre-surgery body weight minus post-surgery body weight.

CXR-HI Chest X-ray Haller index, *P<0.1

PE is associated with connective tissue disorders, implying that it may be related to abnormal cartilage development [15]. Depression of the anterior chest wall is associated with sternal weakness and flexibility abnormality, rib overgrowth, and bony thorax development failure [1]. PE may occur with birth; it has an uneven progression, and deterioration of the deformity usually occurs during the pubertal growth spurt. The deformity is stable in adulthood, implying an obvious linkage with skeletal growth [15]. PE is often associated with several genetic syndromes that cause hyaline cartilage defects, thereby disturbing the structure of costal cartilage [16]. Rickets is not involved in PE deformities because no association has been found between PE and vitamin D metabolism [17]. PE can cause restrictive lung ventilation, heart compression, and scoliosis, leading to exercise intolerance, poor endurance, chest discomfort, shortness of breath, and low self-esteem [1].

Park et al. reported that growth development which includes BW, body height, and BMI are retarded in PE patients between 3 and 20 years of age, compared with those of the healthy population, and the degree of growth retardation is related to the timing of surgery and the severity of PE. Growth development improves with early correction of the deformation [3]. Kim et al. also reported that the release of cardiac compression after the Nuss procedure in children and teenagers with PE, gained adequate blood circulation and resulted in the restoration of BW and body height growth, suggesting that the Nuss procedure may have a positive effect on physical growth [5]. However, most of these reports are about children and adolescents; therefore, we conducted a retrospective study of adults with PE who underwent the Nuss procedure, to determine the effect on body measurement in these populations.

In our study, no significant change in body height was observed, but we found that young adult males under 30 years of age with PE, showed significant increases in BW and BMI after the Nuss procedure and bar removal. However, there was no change in those aged > 30 years. The age cutoff point was set at 30 years because the majority of patients who underwent the Nuss procedure in this study were aged < 30 years. BW growth benefits may be related to cardiopulmonary benefits in adult patients after the procedure [18] with improved emotional well-being and self-esteem [19]. A possible reason for the lack of body growth benefits in patients older than 30 years is that the number of cases were too small for these patients, and there is still much to understand about the effects of the procedure in this group. According to current findings, young adults with PE who undergo the Nuss procedure can have a positive effect on BW growth.

HI also called the pectus severity index, evaluates the severity of the pectus defect at the level of maximal depression, by comparing the ratio of the lateral diameter of the chest to the sternum-to-spine distance [7]. A normal chest HI is ≤ 2.5 and patients with a HI > 3.25 are suggested to be referred for surgery [10]. In this study, we found that only young adult males with a HI ≥ 4 can benefit from BW growth after the Nuss procedure, and tend to show better resolution of symptoms with a satisfactory and improved quality of life. We found that the Pearson correlation coefficient between difference in Haller index (dHI) and difference in bodyweight (dBW) showed a significant negative correlation, suggesting that correction from more severe HI is associated with more BW growth.

The current study’s limitations are its retrospective single-center design and small sample size. Furthermore, only a few cases have been reported in the adult female population. Therefore, more sophisticated studies with a larger sample size are needed to determine the effects of surgical intervention on body measurements and overall health outcomes in adult populations with PE.

This study showed that adult patients with PE who underwent the Nuss procedure, experienced a significant increase in BW and BMI after removal of the pectus bar, and this was particularly significant in young males and those with more severe deformities.

BW- Body weight

CXR-HI- Chest X-ray Haller index

HI- Haller index

PE- Pectus excavatum

BMI- Body mass index

dBW- difference in bodyweight

dHI- difference in Haller index

Ethics approval and consent to participate

The Institutional Review Board and the Ethics Committee of the Taipei Tzu-Chi Hospital agreed with the publication of this study, Taipei, Taiwan, ROC (IRB No: 09-XD-097). The Institutional Review Board waived the need for patient consent due to the study’s retrospective nature.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analyzed during this study are included in this published article; further inquiries can be directed to the corresponding author.

Competing interests

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

Funding

This study was supported by a grant from the Taipei Tzu Chi Hospital and the Buddhist Tzu Chi Medical Foundation. (Grant No.: TCRD-TPE-112-C1-1)

Author contributions

YLC contributed to the study conception and design. NT wrote the manuscript’s main text. IST, YJF, and NT organized the database. IST performed the statistical analyses. All authors have contributed to the manuscript and approved the submitted version.

Acknowledgments

We sincerely thank the Taipei Tzu Chi Hospital and the Buddhist Tzu Chi Medical Foundation for supporting us to complete this study.

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No competing interests reported.

Body measurement changes in adults with pectus excavatum after the Nuss procedure: A study of 272 patients

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Patients

Operative procedures

Nuss procedure

Surgical techniques for bars removal

Postoperative care and follow-up

Statistical analysis

Results

Discussion

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Author contributions

Acknowledgments

References

Additional Declarations

Status:

Journal Publication

Version 1