eComment. The Nuss technique: A track full of hazards

Following a well-conducted prospective study, Bilgi and coworkers report the assessment of complication occurrence at the time of bar removal in patients having undergone a Nuss operation ([1]. We would like to congratulate the authors for this nice contribution to the highly debated field of pectus surgical repair. In fact, this work deserves some additional comments. First, the overall complication rate was 17.5%, but the authors, surprisingly, state that the initial procedure is associated with a 3-5% morbidity rate, according to their mentioned references [1]. The discrepancy between percentages could mean that the step of bar removal is found to be the riskiest procedure in the surgical course of patients undergoing the Nuss technique, which is obviously unrealistic [2]. Otherwise, we take the opportunity to mention that the authors failed to refer to additional cases of patients sustaining lethal or near-fatal haemorrhagic complications at the time of bar removal as a consequence of ventricle laceration [3–5]. All these patients were wearer of a single bar. The cause of these catastrophic outcomes is thought to be a postoperative pericardial effusion leading to a "symphysis", i.e., a complete obliteration of the space between the pericardium and heart, and dense fusion of all adjacent tissues and bar, as shown by Bouchard and coworkers [3]. Another uncommon mechanism of heart lesion is the progressive intracardiac migration of the bar, which was retrospectively noticed by Sakakibara and coworkers on chest computed tomography performed before bar removal [5]. Similar findings were shown in a 18-year-old boy, whose history were reported in The DailyMail in 2014 (http://www.dailymail.co.uk/health/article-2739727/Bullied-teenager-nearly-died-steel-bar-inserted-disguise-sunken-chest-came-1cm-heart.html). Bar removal and cardiac repair required a 14-hour procedure under CPB. Fortunately, the patient made a satisfactory recovery. Apart from that, difficulties occasionally encountered during bar removal due to neo-ossification are other causes for concern. Finally, the safety of the so-called minimally invasive Nuss procedure appears for us strongly questionable [2]. Consequently, in our Institution we have opted to routinely perform pectus excavatum repair by means of a simplified Ravitch-type procedure including the placement of a straight titanium plate secured to the base of sternum. This device is easily removed under local anaesthesia through a 1-cm long lateral incision during an outpatient procedure 6 months after the initial operation, as shown on the video available on the CTSnet website (http://www.ctsnet.org/article/simplified-open-repair-pectus-deformities).

Conflict of interest: none declared.

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