EUPSA webinar " Controversies in Pectus Excavatum repair Short bar vs intermediate/long bar"
With Dr. Frank Martin Hecker & Dr. Hans Pilegaard · hosted by Dr. em gootee
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Donald Nuss published the original minimally invasive pectus repair technique in 1998 after 10 years of experience starting in the late 1980s.
In Nuss's original 1998 publication, the illustrated bar was intermediate or long length with bridge fixation technique demonstrated.
In Basel's first 35 pectus repair patients (published after 2 years), major complications included bar displacement, hematothorax, pneumothorax, and re-operation.
Bar displacement in the horizontal plane (shifting) and downward slipping were observed complications in early Basel experience.
Hourglass effect can occur with two lateral stabilizers or a long bar alone in patients aged 14–15 during pubertal growth spurt.
Intermediate bar length is selected by placing the bar tip between the frontal and mid-axillary lines for stability and to allow lateral stabilizer placement.
Fifteen years ago, secondary bar dislocation rates ranged from 10% (Nuss group) to 27% in published multi-center studies.
Bridge technique (crossbar or parallel bar fixation) increases stability and decreases secondary displacement risk, introduced by Doctor Park from Korea.
Skin incision between frontal and mid-axillary lines with intermediate bar produces nearly invisible scar formation, especially in female patients.
Scope positioned in upper chest (above lower position) provides better visualization and avoids diaphragm injury risk.
Patient positioning with arms above head allows scope movement side-to-side and patient tilted fully to right allows viewing anterior chest wall.
Asymmetric bar design (longer on non-stabilizer side) prevents bar end from dropping into chest when ribs are horizontal.
Bar entry and exit should be medial to the highest point of the deformity for optimal correction.
Overcorrection during bar bending is necessary because the bar will deepen after placement in the chest.
In asymmetric deformities, stabilizer should be placed on the side with better plateau (right side if deformity goes left, left side if goes right).
Medial stabilizer placement (not lateral) provides superior rotational stability because the turning point is eliminated.
Patients younger than 18 years mostly need one bar; patients older than 30 years need 2–3 bars in 80% of cases.
In very deep excavations, first bar is placed higher than deepest point (often at nipple level) to elevate sternum and facilitate placement of lower bar at deepest point.
Harmonic scalpel can be used to create mediastinal tunnel by cutting and dissecting, easier than introducer in tight spaces.
Large or extra-large introducers should be used (not small) for adequate rigidity; extra-large requires steel wire elevation to prevent intercostal muscle stripping.
Steel wire through introducer eyelet with pumping movements gradually elevates sternum and allows introducer passage.
High bar placement uses small incision around nipple to position stabilizer in midline beneath pectoral muscle.
Steel wire placed around bar before turning allows elevation of bar end to facilitate stabilizer placement.
Crossbar technique (introduced by Pilegaard in 2015) is useful for very short narrow chests and when rib position blocks direct access to deepest point.
Two parallel bars can use same exit on one side; placing both stabilizers on same side with upper flap above lower flap creates bridge effect.
Patients over 30 years can be successfully repaired with Nuss procedure using multiple bars despite increased chest wall rigidity.
Oldest patient Pilegaard operated was 64-year-old former GP in Shanghai who had severe symptoms; after two-bar repair, walking distance increased from 100–150 meters to several kilometers due to relieved cardiac compression.
Ravitch procedure creates rigid chest wall through cartilage ossification, making chest wall inflexible like a wall.
Pilegaard published paper on adults over 30 years showing no increased complications compared to younger patients.
Patient compliance is very important for postoperative course; patients should not be too young for surgery.
Vacuum bell treatment started 2.5 years after Nuss procedure in Basel program; patient referrals increased significantly after both options became available.
Patients with mild pectus at age 6–7 years are considered for conservative vacuum bell treatment with follow-up every 2–3 years.
Pectus excavatum always worsens during puberty; 10–15% of vacuum bell patients are not successful and require surgery.
Male patients aged 14–15 often refuse to continue vacuum bell treatment and request surgery instead.
About 80–85% of patients starting vacuum bell treatment are successful; 10–15% (especially males) are unsuccessful and majority request surgery.
CO2 insufflation is used during procedure; double-lumen intubation was abandoned due to lengthy preparation time.
Intermediate bar allows growth without hourglass effect because it is placed in front of chest wall rather than extending to lateral chest wall.
Pilegaard's current bar design is intermediate length (asymmetric: longer on opposite side from stabilizer).
New stabilizer system allows placement in front with longer bar; new asymmetric stabilizer has longer flap on one side to prevent upper flap from going between ribs.
Asymmetric bar design allows growth without hourglass deformity because shorter side retracts as patient widens.
Medial stabilizer placement produces less pain and allows 85% of patients to be discharged on day two after surgery.
Pilegaard has used over 2500–3000 steel bars in more than 2000 Aarhus cases without nickel allergy problems.
Infection rate is less than 1% after changing from single-dose to 3-day intravenous antibiotic prophylaxis.
In Basel experience over 23 years, no bar removal or revision was required due to allergy.
Basel sends patients with positive personal or family allergy history for specific testing; 4–5 patients total required titanium bars.
MRI scanning is safe with pectus bars in place; no reservations for MRI use.
Airport security detection of pectus bars is inconsistent: daughter of Basel airport security chief tested 25–30 checkpoints and only 40% of machines detected the bar.
Many patients with pectus bars pass through airport security without triggering alarms.
Two stabilizers should not be used in growing patients because they cause an hourglass effect, according to Donald Nuss.
Nickel allergy is a contact allergy affecting skin; implants inside the body do not cause problems according to dermatologist consultation.