Efficacy of a modified nuss procedure with a pre-shaped t-ended bar and intercostal fixation for adult pectus excavatum_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LUAN Haoran , TENG Jiping , ZHU Zhijun , WU Jinlong , LI Guoqing , LUO Congcong ,  WANG Mingsong

Department of Thoracic Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, P. R. China;

Corresponding?author：

WANG Mingsong, Email: 13764517021@163.com

Keywords：

Adult; minimally invasive surgery; modified Nuss bar; pectus excavatum; intercostal fixation (rib-locking) technique

DOI：

10.7507/1007-4848.202508052

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Objective To evaluate the short-term efficacy and safety of a modified Nuss procedure utilizing a pre-shaped bar with T-shaped ends and an intercostal fixation (rib-locking) technique for the repair of pectus excavatum in adults. Methods A retrospective analysis was conducted on the clinical data of 166 patients with chest wall deformities who underwent surgical treatment at our center between August 2020 and May 2023. Preoperative and postoperative Haller indices were compared. Operative time, length of hospital stay, and perioperative complications were recorded. Follow-up was conducted at 3 months, 1 year, 2 years, and 3 years postoperatively to assess satisfaction with chest wall appearance and quality of life. Results The median operative time was 35 (range: 30-45) min, and the median length of hospital stay was 4 (3-5) days. All patients were discharged after recovery, with no perioperative mortality. The median Haller index decreased from 4.3 (3.6-5.1) preoperatively to 2.9 ( 2.6-3.1) postoperatively. Only 2 patients (1.2%) required thoracic drainage due to pneumothorax or pleural effusion. Bar displacement occurred in 1 patient (0.6%), which was managed by re-operation 2 months postoperatively. At 2 and 3 years postoperatively, >98% of patients remained "very satisfied" with the cosmetic results. All followed-up patients reported their quality of life as "better" or "much better" after the minimally invasive repair of pectus excavatum. Conclusions The modified procedure can achieve satisfactory correction in adult pectus excavatum with a low incidence of complications and bar displacement. It possesses clinical application value, though further validation through multicenter prospective studies is warranted.

1.	Janssen N, Daemen JHT, van Polen EJ, et al. Pectus excavatum: Consensus and controversies in clinical practice. Ann Thorac Surg, 2023, 116(1): 191-199.
2.	Nuss D, Obermeyer RJ, Kelly RE. Nuss bar procedure: Past, present and future. Ann Cardiothorac Surg, 2016, 5(5): 422-433.
3.	Ewert F, Syed J, Kern S, et al. Symptoms in pectus deformities: A scoring system for subjective physical complaints. Thorac Cardiovasc Surg, 2017, 65(1): 43-49.
4.	Kelly RE, Shamberger RC, Mellins RB, et al. Prospective multicenter study of surgical correction of pectus excavatum: Design, perioperative complications, pain, and baseline pulmonary function facilitated by internet-based data collection. J Am Coll Surg, 2007, 205(2): 205-216.
5.	Nuss D, Kelly RE, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg, 1998, 33(4): 545-552.
6.	Kelly RE, Goretsky MJ, Obermeyer R, et al. Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg, 2010, 252(6): 1072-1081.
7.	de Loos ER, Pennings AJ, van Roozendaal LM, et al. Nuss procedure for pectus excavatum: a comparison of complications between young and adult patients. Ann Thorac Surg, 2021, 112(3): 905-911.
8.	Fenikowski D, Tomaszek L. Intravenous morphine infusion versus thoracic epidural infusion of ropivacaine with fentanyl after the Ravitch procedure: A single-center cohort study. Int J Environ Res Public Health, 2022, 19(18): 11617.
9.	Schier F, Bahr M, Klobe E. The vacuum chest wall lifter: an innovative, nonsurgical addition to the management of pectus excavatum. J Pediatr Surg, 2005, 40(3): 496-500.
10.	St-Louis E, Miao J, Emil S, et al. Vacuum bell treatment of pectus excavatum: an early North American experience. J Pediatr Surg, 2019, 54(1): 194-199.
11.	Obermeyer RJ, Cohen NS, Kelly RE, et al. Nonoperative management of pectus excavatum with vacuum bell therapy: a single center study. J Pediatr Surg, 2018, 53(6): 1221-1225.
12.	Huerta CT, Alligood DM, Davis JK, et al. Outcomes after pectus excavatum repair: a nationwide comparison of Nuss versus Ravitch operations. J Surg Res, 2024, 303: 381-389.
13.	Akhtar M, Razick DI, Saeed A, et al. Complications and outcomes of the Nuss procedure in adult patients: a systematic review. Cureus, 2023, 15(2): e35142.
14.	Lo PC, Tzeng IS, Hsieh MS, et al. The Nuss procedure for pectus excavatum: an effective and safe approach using bilateral thoracoscopy and a selective approach to use multiple bars in 296 adolescent and adult patients. PLoS One, 2020, 15(5): e0233547.
15.	Pawlak K, G?siorowski ?, Gabryel P, et al. Early and late results of the Nuss procedure in surgical treatment of pectus excavatum in different age groups. Ann Thorac Surg, 2016, 102(5): 1711-1716.
16.	Kim DH, Hwang JJ, Lee MK, et al. Analysis of the Nuss procedure for pectus excavatum in different age groups. Ann Thorac Surg, 2005, 80(3): 1073-1077.
17.	Aly MR, Farina JM, Botros MM, et al. Minimally invasive repair of pectus excavatum in adults: a review article of presentation, workup, and surgical treatment. J Thorac Dis, 2023, 15(9): 5150-5173.
18.	Nuss D. Minimally invasive surgical repair of pectus excavatum. Semin Pediatr Surg, 2008, 17(3): 209-217.
19.	Jaroszewski DE, Ewais MAM, Chao CJ, et al. Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (≥30 years). Ann Thorac Surg, 2016, 102(3): 993-1003.
20.	Skrzypczak PJ, Rozmiarek M, Dobiecki T, et al. A large single-center propensity score-matched cohort study on outcomes and complications based on the number of corrective bars used in the Nuss procedure. Sci Rep, 2024, 14(1): 28285.
21.	Park HJ, Rim G, Yoon SK, et al. Surgical adjuncts in minimally invasive repair of pectus excavatum and carinatum deformities: techniques for internal visualization, sternal elevation, and bar fixation. J Thorac Dis, 2025, 17(9): 7306-7317.
22.	Li G, Jiang Z, Xiao H, et al. A novel modified Nuss procedure for pectus excavatum: a new steel bar. Ann Thorac Surg, 2015, 99(5): 1788-1792.
23.	Velazco CS, Arsanjani R, Jaroszewski DE. Nuss procedure in the adult population for correction of pectus excavatum. Semin Pediatr Surg, 2018, 27(3): 161-169.
24.	Parrado RH, Thornburg D, Kang P, et al. Elastomeric pain pumps as an adjunct for postoperative pain control after minimally invasive repair of pectus excavatum. J Laparoendosc Adv Surg Tech A, 2021, 31(3): 331-335.
25.	Linton SC, Tian Y, Zeineddin S, et al. Intercostal nerve cryoablation reduces opioid use and length of stay without increasing adverse events: a retrospective cohort study of 5442 patients undergoing surgical correction of pectus excavatum. Ann Surg, 2024, 279(4): 699-704.
26.	Graves CE, Moyer J, Zobel MJ, et al. Intraoperative intercostal nerve cryoablation during the Nuss procedure reduces length of stay and opioid requirement: a randomized clinical trial. J Pediatr Surg, 2019, 54(11): 2250-2256.
27.	DiFiore JW, Robertson JO, Chhabada S, et al. Next day discharge after the Nuss procedure using intercostal nerve cryoablation, intercostal nerve blocks, and a perioperative ERAS pain protocol. J Pediatr Surg, 2022, 57(2): 213-218.
28.	Hoksch B, Kocher G, Vollmar P, et al. Nuss procedure for pectus excavatum in adults: long-term results in a prospective observational study. Eur J Cardiothorac Surg, 2016, 50(5): 934-939.
29.	Jaroszewski DE, Fonkalsrud EW. Repair of pectus chest deformities in 320 adult patients: 21-year experience. Ann Thorac Surg, 2007, 84(2): 429-433.
30.	Ahmed HS, Pulkurthi SR, Dias AF, et al. Bar dislocation after pectus excavatum repair: a systematic review of risk factors, stabilization techniques, and management strategies. J Chest Surg, 2025, 58(3): 85-98.
31.	Melhado C, Highet A, Mukherjee N, et al. Effect of medial stabilizer chest position on pectus bar dislocation. Pediatr Surg Int, 2024, 40(1): 232.
32.	Ravanbakhsh S, Farina JM, Botros P, et al. Sex differences in objective measures of adult patients presenting for pectus excavatum repair. Ann Thorac Surg, 2022, 114(4): 1159-1167.

1. Janssen N, Daemen JHT, van Polen EJ, et al. Pectus excavatum: Consensus and controversies in clinical practice. Ann Thorac Surg, 2023, 116(1): 191-199.
2. Nuss D, Obermeyer RJ, Kelly RE. Nuss bar procedure: Past, present and future. Ann Cardiothorac Surg, 2016, 5(5): 422-433.
3. Ewert F, Syed J, Kern S, et al. Symptoms in pectus deformities: A scoring system for subjective physical complaints. Thorac Cardiovasc Surg, 2017, 65(1): 43-49.
4. Kelly RE, Shamberger RC, Mellins RB, et al. Prospective multicenter study of surgical correction of pectus excavatum: Design, perioperative complications, pain, and baseline pulmonary function facilitated by internet-based data collection. J Am Coll Surg, 2007, 205(2): 205-216.
5. Nuss D, Kelly RE, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg, 1998, 33(4): 545-552.
6. Kelly RE, Goretsky MJ, Obermeyer R, et al. Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg, 2010, 252(6): 1072-1081.
7. de Loos ER, Pennings AJ, van Roozendaal LM, et al. Nuss procedure for pectus excavatum: a comparison of complications between young and adult patients. Ann Thorac Surg, 2021, 112(3): 905-911.
8. Fenikowski D, Tomaszek L. Intravenous morphine infusion versus thoracic epidural infusion of ropivacaine with fentanyl after the Ravitch procedure: A single-center cohort study. Int J Environ Res Public Health, 2022, 19(18): 11617.
9. Schier F, Bahr M, Klobe E. The vacuum chest wall lifter: an innovative, nonsurgical addition to the management of pectus excavatum. J Pediatr Surg, 2005, 40(3): 496-500.
10. St-Louis E, Miao J, Emil S, et al. Vacuum bell treatment of pectus excavatum: an early North American experience. J Pediatr Surg, 2019, 54(1): 194-199.
11. Obermeyer RJ, Cohen NS, Kelly RE, et al. Nonoperative management of pectus excavatum with vacuum bell therapy: a single center study. J Pediatr Surg, 2018, 53(6): 1221-1225.
12. Huerta CT, Alligood DM, Davis JK, et al. Outcomes after pectus excavatum repair: a nationwide comparison of Nuss versus Ravitch operations. J Surg Res, 2024, 303: 381-389.
13. Akhtar M, Razick DI, Saeed A, et al. Complications and outcomes of the Nuss procedure in adult patients: a systematic review. Cureus, 2023, 15(2): e35142.
14. Lo PC, Tzeng IS, Hsieh MS, et al. The Nuss procedure for pectus excavatum: an effective and safe approach using bilateral thoracoscopy and a selective approach to use multiple bars in 296 adolescent and adult patients. PLoS One, 2020, 15(5): e0233547.
15. Pawlak K, G?siorowski ?, Gabryel P, et al. Early and late results of the Nuss procedure in surgical treatment of pectus excavatum in different age groups. Ann Thorac Surg, 2016, 102(5): 1711-1716.
16. Kim DH, Hwang JJ, Lee MK, et al. Analysis of the Nuss procedure for pectus excavatum in different age groups. Ann Thorac Surg, 2005, 80(3): 1073-1077.
17. Aly MR, Farina JM, Botros MM, et al. Minimally invasive repair of pectus excavatum in adults: a review article of presentation, workup, and surgical treatment. J Thorac Dis, 2023, 15(9): 5150-5173.
18. Nuss D. Minimally invasive surgical repair of pectus excavatum. Semin Pediatr Surg, 2008, 17(3): 209-217.
19. Jaroszewski DE, Ewais MAM, Chao CJ, et al. Success of minimally invasive pectus excavatum procedures (modified Nuss) in adult patients (≥30 years). Ann Thorac Surg, 2016, 102(3): 993-1003.
20. Skrzypczak PJ, Rozmiarek M, Dobiecki T, et al. A large single-center propensity score-matched cohort study on outcomes and complications based on the number of corrective bars used in the Nuss procedure. Sci Rep, 2024, 14(1): 28285.
21. Park HJ, Rim G, Yoon SK, et al. Surgical adjuncts in minimally invasive repair of pectus excavatum and carinatum deformities: techniques for internal visualization, sternal elevation, and bar fixation. J Thorac Dis, 2025, 17(9): 7306-7317.
22. Li G, Jiang Z, Xiao H, et al. A novel modified Nuss procedure for pectus excavatum: a new steel bar. Ann Thorac Surg, 2015, 99(5): 1788-1792.
23. Velazco CS, Arsanjani R, Jaroszewski DE. Nuss procedure in the adult population for correction of pectus excavatum. Semin Pediatr Surg, 2018, 27(3): 161-169.
24. Parrado RH, Thornburg D, Kang P, et al. Elastomeric pain pumps as an adjunct for postoperative pain control after minimally invasive repair of pectus excavatum. J Laparoendosc Adv Surg Tech A, 2021, 31(3): 331-335.
25. Linton SC, Tian Y, Zeineddin S, et al. Intercostal nerve cryoablation reduces opioid use and length of stay without increasing adverse events: a retrospective cohort study of 5442 patients undergoing surgical correction of pectus excavatum. Ann Surg, 2024, 279(4): 699-704.
26. Graves CE, Moyer J, Zobel MJ, et al. Intraoperative intercostal nerve cryoablation during the Nuss procedure reduces length of stay and opioid requirement: a randomized clinical trial. J Pediatr Surg, 2019, 54(11): 2250-2256.
27. DiFiore JW, Robertson JO, Chhabada S, et al. Next day discharge after the Nuss procedure using intercostal nerve cryoablation, intercostal nerve blocks, and a perioperative ERAS pain protocol. J Pediatr Surg, 2022, 57(2): 213-218.
28. Hoksch B, Kocher G, Vollmar P, et al. Nuss procedure for pectus excavatum in adults: long-term results in a prospective observational study. Eur J Cardiothorac Surg, 2016, 50(5): 934-939.
29. Jaroszewski DE, Fonkalsrud EW. Repair of pectus chest deformities in 320 adult patients: 21-year experience. Ann Thorac Surg, 2007, 84(2): 429-433.
30. Ahmed HS, Pulkurthi SR, Dias AF, et al. Bar dislocation after pectus excavatum repair: a systematic review of risk factors, stabilization techniques, and management strategies. J Chest Surg, 2025, 58(3): 85-98.
31. Melhado C, Highet A, Mukherjee N, et al. Effect of medial stabilizer chest position on pectus bar dislocation. Pediatr Surg Int, 2024, 40(1): 232.
32. Ravanbakhsh S, Farina JM, Botros P, et al. Sex differences in objective measures of adult patients presenting for pectus excavatum repair. Ann Thorac Surg, 2022, 114(4): 1159-1167.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

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