Preoperative clinical characteristics of PE patients who underwent VATS-NUSS
Table 1 shows the preoperative clinical characteristics of 365 PE patients undergoing VATS for the NUSS procedure. The median age at operation was 15.61 ± 3.73 years (range, 5 to 27 years). A total of 84.65% were male. PE was commonly detected at puberty (n = 328, 89.9%). Underweight (BMI <18.5) was found in 84.4% of the patients, and no patient was recorded as overweight or obese. A total of 1.37% of the patients experienced previous PE repair surgery (n = 5). Of the 365 patients, 288 had symmetric PE (78.90%), and 77 had asymmetric PE (21.10%). Additionally, in Table 1, the numeric distribution of each morphologic type and subtype of pectus is described in detail.
Palpitations were present in 81.64% of the patients (n = 298). The other common symptoms were inferiority complex (n = 262, 71.78%), dyspnea on exertion (n = 218, 59.73%), shortness of breath while exercising (n = 203, 55.62%), development of poor physical health (n = 192, 52.60%), and chest pain while exercising (n = 149, 40.82%); dsementia was uncommon (n = 3, 0.82%) (Table 1).
Table 1. Preoperative clinical characteristics of patients (n = 365)
Characteristics
|
Patients
(n = 365)
|
Age
|
|
Mean ± SD – years
|
15.61 ± 3.73
|
Range – years
|
5 – 27
|
Male sex – no. (%)
|
309 (84.65)
|
BMI – no. (%)
|
|
Underweight (BMI <18.5)
|
308 (84.4)
|
Normal (18.5≤ BMI <23.0)
|
57 (15.6)
|
Overweight and obesity (BMI³ 23)
|
0 (0.0)
|
Time PE was detected – no. (%)
|
|
At birth
|
11 (3.0%)
|
Childhood
|
26 (7.1%)
|
Puberty
|
328 (89.9%)
|
Previous PE repair surgery – no. (%)
|
5 (1.37)
|
Family history of PE – no. (%)
|
46 (12,60)
|
Comorbidity – no. (%)
|
|
Prolonged respiratory tract inflammation
|
2 (0.55)
|
Asthma
|
1 (0.27)
|
Congenital heart disease
|
22 (6,03)
|
Scoliosis
|
1 (0.27)
|
Dementia
|
3 (0.82)
|
Marfan syndrome
|
1 (0.27)
|
PE defect type – no. (%)
|
|
Bilateral symmetry
|
288 (78.90)
|
Asymmetry to the right
|
70 (19.18)
|
Asymmetry to the left
|
7 (1.92)
|
Morphologic Classification a – no. (%)
|
|
Type 1A: prototype
|
252 (69.04)
|
Type 1B: broad-flat
|
70 (19.18)
|
Type 2A: eccentric
|
|
Type 2A1: focal
|
14 (3.84)
|
Type 2A2: broad-flat
|
3 (0.82)
|
Type 2A3: long canal
|
1 (0.27)
|
Type 2B: unbalanced
|
24 (6.58)
|
Type 2C: combined
|
1 (0.27)
|
Clinical symptoms
|
|
Inferiority complex – no. (%)
|
262 (71,78)
|
Chest pain while exercising – no. (%)
|
149 (40.82)
|
Dyspnea on exertion – no. (%)
|
218 (59.73)
|
Shortness of breath while exercising – no. (%)
|
203 (55.62)
|
Palpitations – no. (%)
|
298 (81.64)
|
Development of poor physical health – no. (%)
|
192 (52.6)
|
Dsementia – no. (%)
|
3 (0.82)
|
a Morphologic classification by Hyung Joo Park [18]
Preoperative subclinical characteristics of PE patients who underwent VATS-NUSS
The preoperative subclinical characteristics of 365 PE patients undergoing VATS for the NUSS procedure are summarized in Table 2. ECG abnormalities were documented in 41.10% (n = 150); the most common abnormality on ECG was sinus tachycardia (n = 90, 26.66%); increased right ventricular mass was present in 9.04% of the patients (n = 33), RBBB in 4.93% (n = 18), LBBB in 1.10% (n = 4), ectopic rhythm in 1.37% (n = 5), sinus bradycardia in 0.27% (n = 1), increased left ventricular mass in 0.27% (n = 1), and atrial fibrillation in 0.27% (n = 1). On Doppler echocardiography, 6.58% of patients had tricuspid valve regurgitation (n = 24), while the figure for mitral valve regurgitation was 3.84% (n = 14); PFO was detected among 22 patients (6.03%); and elevated PAP was detected in 33 patients (3.94%). The mean ejection fraction (EF) was 67.39 ± 5.91%. In 365 patients with PE presenting for surgical treatment, the mean FVC was 63.80 ± 11.26, the mean FEV1 was 70.69 ± 11.8%, the mean FEV1/FVC was 111.91 ± 9.45, and the mean FEF25
Table 2. Preoperative Subclinical Characteristics of Patients (n = 365)
Characteristics
|
Patients
(n = 365)
|
Electrocardiogram abnormalities – no. (%)
|
150 (41.10)
|
Sinus tachycardia – no. (%)
|
90 (24.66)
|
Sinus bradycardia – no. (%)
|
1 (0.27)
|
Right bundle branch block (RBBB) – no. (%)
|
18 (4.93)
|
Left bundle branch block (LBBB) – no. (%)
|
4 (1.10)
|
Increased right ventricular mass – no. (%)
|
33 (9,04)
|
Increased left ventricular mass – no. (%)
|
1 (0,27)
|
Ectopic rhythm – no. (%)
|
5 (1,37)
|
Atrial fibrillation – no. (%)
|
1 (0,27)
|
Doppler echocardiography results
|
|
Tricuspid valve regurgitation – no. (%)
|
24 (6.58)
|
Mitral valve regurgitation – no. (%)
|
14 (3.84)
|
PFO – no. (%)
|
22 (6.03)
|
Elevated PAP – no. (%)
|
33 (9.04)
|
EF (n = 365)
|
|
Mean ± SD – %
|
67.39 ± 5.91
|
Range – %
|
56 - 79.51
|
Pulmonary function tests
|
|
FVC – Mean ± SD
|
63.80 ± 11.26
|
FEV1% – Mean ± SD
|
70.69 ± 11.8
|
FEV1/FVC – Mean ± SD
|
111.91 ± 9.45
|
FEF25-75% – Mean ± SD
|
98.62 ± 23.65
|
Classification of pulmonary function test value
|
|
FVC < 80% – no. (%)
|
334 (93.56%)
|
FEV1< 80% – no. (%)
|
277 (77.59%)
|
FEV1/FVC < 70% – no. (%)
|
2 (0.57%)
|
FEF25-75% < 60% – no. (%)
|
12 (3.34%)
|
Chest CT scan
|
|
Twisting the sternum – no. (%)
|
79 (21.64)
|
Scoliosis – no. (%)
|
3 (0.82)
|
Heart compression, the heart pushes to the left – no. (%)
|
58 (15,89)
|
Bronchiectasis – no. (%)
|
2 (0.55)
|
Haller index measuring on X-ray and CT scan
|
|
Haller index on chest CT scan (n = 365)
|
|
Mean ± SD
|
3.81 ± 0.78
|
Range
|
2.58 – 14.5
|
Haller index on chest X-ray (n = 365)
|
|
Mean ± SD
|
3.83 ± 0.98
|
Range
|
2.56 – 14.5
|
SD: standard deviation;RBBB: right bundle branch block; LBBB; left bundle branch block; PFO: patent foramen ovale; PAP:pulmonary artery pressure; CT: computed tomography
Operative characteristics of PE patients who underwent VATS-NUSS
One bar was indicated for most patients (n = 350, 95.89%), and two bars were required in 15 patients (4.11%). The mean operative time was 49.54 minutes. A total of 85.48% of the patients had a left operative wound from the left to the right pleural cavity (n = 312), while 14.52% had a left to the right pleural cavity (n = 53). Steel sutures on the left side combined with Vicryl sutures on the right side were commonly utilized to fix metal corrective bars (n = 320, 87.67%). Epidural anesthesia was used for postoperative
Table 3. Operative Characteristics of Patients (n = 365)
Characteristics
|
Patients
(n = 365)
|
Number of bars – no. (%)
|
|
One bar
|
350 (95.89)
|
Two bars
|
15 (4.11)
|
VATS side – no. (%)
|
|
Left VATS
|
308 (84.38)
|
Right VATS
|
43 (11.78)
|
Bilateral VATS
|
14 (3.84)
|
The steel introducer – no. (%)
|
|
Left-to-right
|
312 (85.48)
|
Right-to-left
|
53 (14.52)
|
Method of metal corrective bar fixation – no. (%)
|
|
Steel sutures (left) + Vicryl sutures (right)
|
320 (87.67)
|
Steel sutures (right) + Vicryl sutures (left)
|
34 (9.32)
|
Bilateral steel sutures
|
10 (2.74)
|
Bilateral Vicryl sutures
|
1 (0.27)
|
Postoperative pain relief by epidural anesthesia – no. (%)
|
278 (76.16)
|
Accidents in surgery – no. (%)
|
1 (0.27)
|
Operative time
|
|
Mean ± SD – Mins
|
49.54
|
Range – Mins
|
20 – 140
|
SD: standard deviation
Postoperative characteristics of PE patients who underwent VATS-NUSS
The length of postoperative hospitalization ranged from 1 to 13 days (Mean: 5.1). Early postoperative complications were recorded up to 30 days during the hospital stay. These events largely consisted of pneumothorax (n = 5, 1.37%), pleural bleeding/pleural fluid (n = 2, 0.55%), pleural hematoma (n = 1, 0.27%), pneumonia (n = 1, 0.27%), surgical wound infection (n = 1, 0.27%), incision fluid accumulation (n = 3, 0.82%), metal bar infection (n = 1, 0.27%), atelectasis (n = 3, 0.82%), and fever (n = 8, 2.19%). In the late postoperative complications, surgical wound infection (n = 2, 0.55%), metal bar deviation (n = 5, 1.37%), metal bar allergy (n = 10, 2.74%), recurrent PE (n = 2, 0.55%), and persistent PE (n = 5, 1.37%) were observed. No deaths occurred (Table 4).
Bar removal after VATS-NUSS
Table 4 also indicates the outcomes related to the bar removal that was carried out in 175 patients (47.95%). The time the bar was in situ ranged from 2 to 49 months (mean: 28.89±7.48 years). In 3 patients (1.71%), bar removal was performed early, less than 1 year, due to metal bar allergy. We recorded a mean operative time at bar removal of 34.09 ± 10.61 minutes and a length of hospitalization following bar removal of 2.4 ± 1.34 days. Of 175 patients who underwent bar removal, the most frequent complication was pneumothorax, which was diagnosed in 19 (10.85%) patients; surgical wound infection in 1 patient and incision fluid accumulation in 1 patient were observed following bar removal.
Table 4. Postoperative Data of Patients
|
Patients
(n = 365)
|
Length of postoperative hospitalization
|
|
Mean ± SD – days
|
5.1
|
Range – days
|
1 – 13
|
Early postoperative complications
|
|
Pneumothorax – no. (%)
|
5 (1.37)
|
Pleural bleeding / pleural fluid – no. (%)
|
2 (0.55)
|
Pleural hematoma – no. (%)
|
1 (0,27)
|
Pneumonia – no. (%)
|
1 (0.27)
|
Surgical wound infection – no. (%)
|
1 (0.27)
|
Incision fluid accumulation – no. (%)
|
3 (0.82)
|
Metal bar infection – no. (%)
|
1 (0.27)
|
Atelectasis – no. (%)
|
3 (0.82)
|
Fever – no. (%)
|
8 (2.19)
|
Late postoperative complications
|
|
Surgical wound infection – no. (%)
|
2 (0.55)
|
Metal bar deviation – no. (%)
|
5 (1.37)
|
Metal bar allergy – no. (%)
|
10 (2,74)
|
Recurrent PE – no. (%)
|
2 (0.55)
|
Persistent PE – no. (%)
|
5 (1.37)
|
|
Patients
(n = 175)
|
Time the bar was in situ – no. (%)
|
|
< 1 – years
|
3 (1.71)
|
1 £ - < 2 – years
|
16 (9.14)
|
2 £ - < 3 – years
|
103 (58.86)
|
3 £ - < 4 – years
|
49 (28.00)
|
³ 4 – years
|
4 (2.29)
|
Mean ± SD – months
|
28.89 ± 7.48
|
Range – months
|
2 – 49
|
Operative time at bar removal
|
|
Mean ± SD – mins
|
34.09 ± 10.61
|
Range – mins
|
20 – 110
|
Length of hospitalization following bar removal
|
|
Mean ± SD – days
|
2.4 ± 1.34
|
Range – days
|
1 – 14
|
Complications at bar removal
|
|
Pneumothorax – no. (%)
|
19 (10.85)
|
Surgical wound infection – no. (%)
|
1 (0.57)
|
Incision fluid accumulation – no. (%)
|
1 (0.57)
|
Mid-term to long-term outcome in PE patients undergoing VATS-NUSS
Towards mid-term results at 6 – 30 months postoperatively, there were 124 out of 365 patients (33.97%). Of 124 patients, most patients had unremoved bars (n = 121, 97.58%), and only 3 patients had removed bars (2.42%). Most patients had body weight gain (n = 97, 78.23%), increased physical activity and improved health (n = 115, 92.74%). In 124 patients, the mean BMI index was 18.77 ± 0.92 kg/m², and the Haller index on chest X-ray was 2.44 ± 0.15. Overall, the patients receiving bar removal had a significantly higher mean BMI index compared to those not yet receiving bar removal (20.30 ± 1.11 vs 18.73 ± 0.89) (p <0.05). The proportion of patients with increased physical activity and improved health following surgery differed significantly between those receiving bar removal (n = 43, 100.00%) and those not yet receiving bar removal (n = 112, 92.56%) (p <0.05) (Table 5).
Postoperative long-term results at over 30 months are also indicated in Table 5. A total of 220 out of 365 patients (60.27%) were included in this phase. Of those, 172 received bar removal (78.18%), and 48 had not yet received bar removal (21.82%). A total of 217 patients (98.64%) had both body weight gain, increased physical activity and improved health. In 220 patients over 30 months postoperatively, the mean BMI index was 19.02 ± 0.99 kg/m², and the Haller index on chest X-ray was 2.45 ± 0.21. Overall, the patients receiving bar removal had a significantly higher mean BMI index compared to those not yet receiving bar removal (19.13 ± 1.01 vs 18.62 ± 0.82) (p <0.05).
Table 5. Mid-term to long-term postoperative outcome in PE patients
Mid-term postoperative outcome (n = 124)
(6–30 months postoperatively)
|
|
All patients
(n = 124)
|
Bar removal
|
p value
|
Yes (n=3)
|
No (n=121)
|
Count (% of total)
|
Count (% of total)
|
Count (% of total)
|
Body weight gain
|
97 (78.23)
|
3 (100.00)
|
94 (77.69)
|
1.000*
|
Increased physical activity and improved health
|
115 (92.74)
|
3 (100.00)
|
112 (92.56)
|
<0.05*
|
|
Mean (SD)
|
Mean (SD)
|
Mean (SD)
|
|
BMI index - kg/m²
|
18.77 ± 0.92
|
20.30 ± 1.11
|
18.73 ± 0.89
|
<0.05**
|
Haller index on chest X-ray
|
2.44 ± 0.15
|
2.5 ± 0.17
|
2.44 ± 0.15
|
0.382**
|
Long-term postoperative outcome (n = 220)
(over 30 months postoperatively)
|
|
All patients
(n = 220)
|
Bar removal
|
p value
|
Yes (n=172)
|
No (n=48)
|
Count (% of total)
|
Count (% of total)
|
Count (% of total)
|
Weight gain
|
217 (98.64)
|
171 (99.42)
|
46 (95.83)
|
0.321*
|
Increased physical activity and improved health
|
217 (98.64)
|
171 (99.42)
|
46 (95.83)
|
0.990*
|
|
Mean (SD)
|
Mean (SD)
|
Mean (SD)
|
|
BMI index - kg/m²
|
19.02 ± 0.99
|
19.13 ± 1.01
|
18.62 ± 0.82
|
<0.001**
|
Haller index on chest X-ray
|
2.45 ± 0.21
|
2.46 ± 0.23
|
2.41 ± 0.14
|
0.067**
|
BMI: body mass index; SD: standard deviation; * Chi-square test, ** Mann–Whitney U test