1. Ju Mei, Guoqing Li, Zhaolei Jiang, Fangbao Ding
Efficacy and Safety of Novel Modified Nuss Procedure for Pectus Excavatum with A New Steel Bar
Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
Ju Mei, Guoqing Li, Zhaolei Jiang, Fangbao Ding

2. No disclosure 2.
We have no disclosure.

3. Backgroud
Nuss procedure is considered the most popular minimally invasive technique for the correction of pectus excavatum
However, the installation and removal of steel bar sometimes is difficult and traumatic in Nuss procedure
To simplify the procedure and decrease the difficulty and trauma, we designed a new steel bar and applied it in minimally invasive surgical correction for pectus excavatum
The aim of this study is to examine the efficacy and safety of this novel modified Nuss procedure for pectus excavatum with the new steel bar.

4. Bar Configuration
One end of the steel bar is fused with bar stabilizer, and the other end is designed to connect with the introducer or stabilizer
The steel bars are divided into large and small sizes according to different lengths, thicknesses, and widths. The small size is used for children, and the large size is used for adolescents or adults
The steel bars have 15 different specifications, which are distinguished by the different lengths, which variy from 12 to 26 cm
A stainless steel bar was curved according to the normal structure of the human anteriorchest wall
One end of the steel bar was fused with bar stabilizer, and the other end was designed to connect with the introducer or stabilizer
The steel bars were divided into large and small sizes according to different lengths, thicknesses, and widths
The small size was used for children, and the large size was used for adolescents or adults
The steel bars had 15 different specifications, which were distinguis-hed by the different lengths, which varied from 12 to 26 cm
Each specification had a difference of 1 cm

5. Bar Accessories
Bar accessories include the introducer, stabilizer, and gasket
The introducer and stabilizer are of different sizes to match the bars of different sizes
Bar accessories include the introducer, stabilizer, and gasket
The introducer and stabilizer are of different sizes to match the bars of different sizes
The gaskets include: thickening gasket & lengthening gasket
Thickening gasket: adjust the height of the lowest point of the sternum
Lengthening gasket: improve the length of contact surface for stabiliz-er and ribs

6. Technique
The distance between the bilateral anterior axillary lines of the intercostal level corresponding to the lowest point of the sternum is measured intraoperatively
The length of the bar is 2 to 3 cm longer than the distance
A 5mm diameter thoracoscope is used to guide the procedure
Bilateral vertical skin incisions about 1.5 to 2.5 cm are made near the middle axillary line

7. Technique
After the bar is tied to the end of the introducer, the introducer is inserted into the right thoracic cavity
The bar is pushed in and pulled out through the tunnel after the introducer without turning it over, and the deformity is corrected
After the introducer is removed, a stabilizer is placed on the left side of the bar to support and fix the bar

9. Preoperative & Postoperative CT
Preoperative & postoperative Computed Tomography

10. Bar removal
After the surgery, the bar is removed between 1.5 and 4 years depending on growth
In children or adolescents, the bar was removed about 2 years after the operation. However, the bar should be kept for a longer time (3–4 years) in patients with recurrent pectus excavatum or in adult patients.

11. Clinical Experience----Patients
From July 2010 to July 2011, 147 patients with pectus excavatum
underwent this novel modified Nuss procedure
118 male and 29 female
Age: 3-35 years (mean, 10.35±6.72 years; median, 9 years)
Haller index: 3.38 – (mean, 4.83±1.41; median, 4.52)
Symmetrical pectus excavatum cases
Asymmetrical pectus excavatum cases
Recurrent pectus excavatum cases

12. Clinical Experience----Early results
The novel modified Nuss procedure was successfully performed in all patients
1 bar was placed in 144 cases (98.0%)
2 bars were placed in 3 cases (2.0%)
3 patients (2.0%) had a unilateral thickening gasket placed
4 patients (2.7%) had lengthening gasket placed
3 unilateral; 1 bilateral

13. Clinical Experience----Early results
Operation time
25.25±2.37 mins for primary pectus excavatum
63.76±29.15 mins for recurrent pectus excavatum
Postoperative hospital stays: 3 to 8 days (mean, 4.85±0.22 days)
All patients had a satisfactory orthopedic result at discharge
There was no perioperative death or cardiac perforation

14. Clinical Experience----Follow-up results
Follow-up time: 32 – 44 months (mean, 35.8±5.2 months)
Steel bars were in the original position in 132 patients (89.8%) before the bar was removed
Of the other 15 patients, 3 patients (2.0%) with significant bar shift required reoperation, the bar shifted slightly in 12 patients
134 patients underwent bar removal during the follow-up
orthopedic and functional results were excellent in 121 cases (90.3%)
Haller index: 2.67±0.18; median, 2.59
No patient had recurrence
The other 13 patients are waiting for the bar removal.

15. Conclusion
This novel modified Nuss procedure is a safe, effective, and convenient treatment for pectus excavatum
Main advantages of this novel modified Nuss procedure:
All the steel bars are premade into different sizes
Both bar installation and removal are convenient and less traumatic
Less postoperative pain and no limitation of the growth
Long-term follow-up are warranted
1. The steel bars are produced before the operation and divided into different sizes. We can choose the suitable bar for each patient.
2. The steel bar is installed or removed by pushing and pulling without flipping, which reduces the difficulty of the operation and decreases intraoperative trauma.
3.The bar is mainly supported by the ribs in our procedure, which can effectively decrease the postoperative pain. Also, the bar is fixed on the anterior chest wall, so it doesn’t limit the normal growth.

16. Thanks