The Nuss Procedure: Surgical Correction of Pectus Excavatum in Adults

By Nicholas Baker, MD, and Tadeusz D. Witek, MD

To ensure access to surgical correction of pectus excavatum and continuity of care to adult patients at UPMC, Nicholas Baker, MD, and Tadeusz Witek, MD, of the UPMC Department of Cardiothoracic Surgery Division of Thoracic Surgery were trained in the Nuss procedure approximately two years ago by Donald Nuss, MD, MBChB, and his colleagues at Eastern Virginia Medical School. Dr. Baker and Dr. Witek now perform the Nuss procedure at UPMC to correct pectus excavatum in adults.

In patients with pectus excavatum (PE), the sternum is sunken or pushed inward. Although PE may be evident at birth, it often worsens during puberty or early adolescence. As a result, individuals with PE may develop cardiopulmonary symptoms as they grow, for example presenting with exercise intolerance in late adolescence or as an adult. PE is typically corrected during childhood or midadolescence; however, some patients with PE pursue surgical correction as an adult due to cardiopulmonary symptoms or psychological symptoms, such as significant anxiety about their physical appearance. Of note, in a single-center study of more than 100 patients with PE who underwent surgical correction, 89% reported psychological difficulties caused by the PE chest deformity.

In our thoracic surgical practice, we evaluate adult patients for surgical correction of PE, typically after referral from a cardiologist or pulmonologist treating them for restrictive pulmonary disease, cardiac compression, or valvular abnormalities. Nonoperative treatments are very uncommon in adults, and the Nuss procedure is a preferred surgical procedure to correct PE. During the Nuss procedure, a curved metal bar is inserted through small incisions using a camera for visualization and maneuvered to apply pressure to the sternum, resulting in an often immediate alleviation of symptoms. The Nuss procedure is typically performed by a cardiothoracic surgeon rather than by a general surgeon and is almost always an elective procedure. Surgery should be considered when a patient’s Haller index score is more than 3.25. Patients must be able to tolerate lung isolation as the lungs are collapsed to obtain adequate visualization during the procedure. We consider the Nuss procedure for individuals 16 years of age or older.

While performing the Nuss procedure, small (5 cm maximum), bilateral incisions are made, and a tunnel is created underneath the ribs using video-assisted thoracoscopic surgery (VATS). The sternum is retracted under VATS visualization using a special retractor. A curved bar is placed through the tunnel. The bar is initially placed inside of the U-curve facing anteriorly and is then flipped such that the U-curve faces posteriorly and the bar presses upward on the sternum. A bracket is sutured to the chest wall muscle, and the bar is affixed to the chest wall. Often, two bars are necessary to hold the sternum in the correct anatomic position in adults.

Patients are followed in the clinic 2 weeks, 1 month, 3 months, and 6 months post-procedure, and then yearly, with chest x-rays, symptom assessment, physical exams, and reminders to avoid high-contact activities. After three years with regular follow-up, the bars are straightened and removed using bilateral 3 cm–4 cm incisions. A thoracotomy is not required for either placement or removal of the bars.

Our expertise with VATS greatly enhanced our adoption of the procedure. Minimally invasive guidance while creating the tunnel, retracting the sternum, and placing the bar is considered the gold standard for the procedure. Cameras and VATS make the Nuss procedure safer, and VATS assistance lowers the complication rate of the procedure.

We frequently apply cryo-analgesia, targeted ablation of the intercostal nerves using extreme cold that lasts up to three months, to alleviate postoperative pain as the bone matures into its new shape. The average hospital stay after the Nuss procedure is three days, although some patients stay longer for pain control. In one study, 50% of patients reported no pain three months after the Nuss procedure, and the remainder of the cohort had significantly decreased pain intensity with time. In 19 patients with 10-year follow-up, two-thirds reported no pain and one-third reported minimal pain that did not require pain relief when performing certain movements. Strikingly, 95% would recommend surgical correction of PE to other afflicted adults.

Complications after the Nuss procedure have been minimal. Some patients have had reactions to stainless steel bars, but in the United States only titanium will be used moving forward. Over the three-year course of treatment, there is a small risk (less than 10%) that a Nuss bar will slip or flip so that it is curved incorrectly. Patients must refrain from contact sports or activities when the bar is in place due to the risk of displacing the bar. Calcifications may complicate bar removal.

Large, single-institution series assessing outcomes in 129 adolescent and adult patients who underwent the procedure over a 12-year period and 93 adult patients treated over an eight-year period documented satisfaction with the outcomes of the Nuss procedure, with more than 90% of the patients reporting satisfaction with the cosmetic results of the operation and approximately 90% reporting better quality of life 6 months, 1 year, and 3 years after the procedure and 6 years after bar removal.

Our focus on chest wall surgery and mechanics and the need to provide excellent care to adults who require PE correction provided a strong impetus to acquire the skills necessary to do the Nuss procedure. The UPMC Department of Cardiothoracic Surgery Division of Thoracic Surgery aims to lead the field in all aspects of thoracic surgery so that we can consistently provide life-changing care to our patients.