Lorenz Bar Repair of Pectus Excavatum in the Adult Population: Should it be Done? (2025)

Upper sternal depression following Lorenz bar repair of pectus excavatum

Pediatric Surgery International, 2008

An upper sternal depression following Lorenz bar repair of pectus excavatum (PE) represents a partial recurrence and poses a difficult problem for the surgeon. There is no published experience detailing the management options or best course of therapy for this complication. This study presents our institutional experience in treating eight patients with this specific subtype of recurrence and we discuss intraoperative considerations which aid in the identification and better management of this deformity. A retrospective review (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006) of patients undergoing primary repair of PE with a Lorenz bar procedure identified eight patients who experienced upper sternal depression with the bar still in place following initial repair of PE. All patients were revised with the insertion of a second bar to elevate the upper sternal depression. Data collected for each patient included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes. The mean age at the time of Lorenz bar repair and surgical revision was 20.8 ± 9.5 and 21.5 ± 10.1 years, respectively. A majority of patients (87.5%) were male. The mean time to reoperation was 23.8 ± 11.8 months. Following this second procedure, no patient has experienced bar displacement, recurrence of the upper sternal depression, or has required a third procedure. Our limited experience supports the use of a second Lorenz bar in the treatment of upper sternal depression after bar correction of a PE deformity. Appropriate recognition and treatment of this entity will advance patient outcomes and satisfaction after surgery for PE deformities.

Pectus excavatum repair after sternotomy: the Chest Wall International Group experience with substernal Nuss bars

European Journal of Cardio-Thoracic Surgery

OBJECTIVES: Patients with pectus excavatum (PE) after prior sternotomy for cardiac surgery present unique challenges for repair of PE. Open repairs have been recommended because of concerns about sternal adhesions and cardiac injury. We report a multi-institutional experience with repair utilizing substernal Nuss bars in this patient population. METHODS: Surgeons from the Chest Wall International Group were queried for experience and retrospective data on PE repair using substernal Nuss bars in patients with a history of median sternotomy for cardiac surgery (November 2000 to August 2015). A descriptive analysis was performed. RESULTS: Data for 75 patients were available from 14 centres. The median age at PE repair was 9.5 years (interquartile range 10.9), and the median Haller index was 3.9 (interquartile range 1.43); 56% of the patients were men. The median time to PE repair was 6.4 years (interquartile range 7.886) after prior cardiac surgery. Twelve patients (16%) required resternotomy before support bar placement: 7 preemptively and 5 emergently. Sternal elevation before bar placement was used in 34 patients (45%) and thoracoscopy in 67 patients (89%). Standby with cardiopulmonary bypass was available at 9 centres (64%). Inadvertent cardiac injury occurred in 5 cases (7%) without mortality. CONCLUSIONS: Over a broad range of institutions, substernal Nuss bars were used in PE repair for patients with a history of sternotomy for cardiac surgery. Several technique modifications were reported and may have facilitated repair. Cardiac injury occurred in 7% of cases, and appropriate resources should be available in the event of complications. Prophylactic resternotomy was reported at a minority of centres.

A 10-year review of a minimally invasive technique for the correction of pectus excavatum

Journal of Pediatric Surgery, 1998

The aim of this study was to assess the results of a 10-year experience with a minimally invasive operation that requires neither cartilage incision nor resection for correction of pectus excavatum. From 1987 to 1996, 148 patients were evaluated for chest wall deformity. Fifty of 127 patients suffering from pectus excavatum were selected for surgical correction. Eight older patients underwent the Ravitch procedure, and 42 patients under age 15 were treated by the minimally invasive technique. A convex steel bar is inserted under the sternum through small bilateral thoracic incisions. The steel bar is inserted with the convexity facing posteriorly, and when it is in position, the bar is turned over, thereby correcting the deformity. After 2 years, when permanent remolding has occurred, the bar is removed in an outpatient procedure. Of 42 patients who had the minimally invasive procedure, 30 have undergone bar removal. Initial excellent results were maintained in 22, good results in four, fair in two, and poor in two, with mean follow-up since surgery of 4.6 years (range, 1 to 9.2 years). Mean follow-up since bar removal is 2.8 years (range, 6 months to 7 years). Average blood loss was 15 mL. Average length of hospital stay was 4.3 days. Patients returned to full activity after 1 month. Complications were pneumothorax in four patients, requiring thoracostomy in one patient; superficial wound infection in one patient; and displacement of the steel bar requiring revision in two patients. The fair and poor results occurred early in the series because (1) the bar was too soft (three patients), (2) the sternum was too soft in one of the patients with Marfan's syndrome, and (3) in one patient with complex thoracic anomalies, the bar was removed too soon. This minimally invasive technique, which requires neither cartilage incision nor resection, is effective. Since increasing the strength of the steel bar and inserting two bars where necessary, we have had excellent long-term results. The upper limits of age for this procedure require further evaluation.

Use of sternal plate for pectus excavatum repair in adults leads to minimal postoperative pain

Journal of surgical case reports, 2018

Pectus excavatum is a chest wall deformity that results in caved-in or sunken appearance of lower half of anterior chest. Surgical treatment is favored when functional or cosmetic concerns arise. We present a case and series of six patients (mean haller index: 4.28) who had repair with minimal pleural disruption and sternal plate. After a broad bilateral inframammary skin incision, the anterior aspect of sternum is identified and incised. Next, the surgeon hyperextends and fixates the bone in its desired position by applying manual dorsal pressure through a small intercostal incision. Superior and inferior fasciocutaneous flaps are raised and then advanced to reconstruct the soft tissue defect. All patients had durable repair of the chest wall abnormalities and they had minimal pain during the postoperative period. No analgesia medication was necessary 1 month post-operatively. This may provide significantly less pain compared to the Nuss or Ravitch procedures to fix Pectus excavatum.

Repair of pectus deformities with sternal support

Journal of Pediatric Surgery, 1994

During the past 25 years, 252 children underwent repair of pectus deformities. There were 195 male and 57 female patients, of whom 227 had pectus excavatum and 25 had pectus carinatum. Of the 252 patients, 113 underwent repair at between 2 and 5 years of age. Exercise limitation was reported by 51 %, and 32 % had frequent respiratory infections or asthma. Repair was performed through a transverse incision with subperiosteal resection of the lower four or five costal cartilages, from sternum to costochondral junction bilaterally. A transverse wedge osteotomy was made through the anterior table of the sternum, with fracture but no displacement of the posterior table. For children younger than 5 years (n = 108), the periosteal sheath of the fifth rib from each side was sewn together behind the sternal tip. For older patients (n = 136), a thin steel strut was used for sternal support for 6 months. There were no deaths within the first year. Complications included seroma (16), atelectasis (12), pneumothorax (three), and recurrent chest depression (three). More than 98 % of patients had improvements in exercise tolerance, endurance, respiratory symptoms, and cosmetic appearance; these improvements were considered excellent results. Operation at an early age with routine use of substernal support with minimal preoperative and postoperative testing has provided exceUent results at a low cost.

Sternal elevation techniques during the minimally invasive repair of pectus excavatum

Interactive CardioVascular and Thoracic Surgery, 2019

Summary The aim of the review was to evaluate the routine use of sternal elevation techniques (SETs) during minimally invasive repair of pectus excavatum (MIRPE, the Nuss procedure). We performed a review of the literature between January 1998 and September 2018 with focus on different methods of SET during MIRPE. Reported effects and side effects were evaluated and compared with our own experience concerning the routine use of the vacuum bell for sternal elevation during MIRPE during the last 13 years. SET is more often used in adult patients than in adolescents. SET improves visualization and safety of MIRPE. Advancement of the pectus introducer, retrosternal dissection and placement of the pectus bar are easier. The risk of cardial and/or pericardial lesion is reduced significantly. Different types of retractors, a crane combined with a wire and/or customized hooks are reported to be used as SET. Furthermore, routine use of a subxiphoid incision is reported. However, more technic...

A simple technique for preventing bar displacement with the nuss repair of pectus excavatum

Journal of Pediatric Surgery, 2001

Background/Purpose: The most common complication of the minimally invasive technique for repair of pectus excavatum (MIRPE) is bar displacement, which has been reported to occur in 9.5% of all cases, particularly in teenaged patients. The use of a lateral stabilizing bar has improved stability but has not eliminated the occurrence of this problem. The authors report a new technique added to the standard MIRPE that creates an additional third point of fixation of the pectus bar to prevent displacement.

Stabilization of Flail Chest and Fractured Sternum by Minimally Invasive Repair of Pectus Excavatum

The Thoracic and Cardiovascular Surgeon Reports, 2015

We report a 55-year-old male patient with a massive flail chest that required chest stabilization by minimally invasive repair of pectus excavatum (MIRPE) employing a Nuss bar. Surgical stabilization of severe flail chest and fractured sternum with Nuss bar by MIRPE is a safe and useful treatment modality in properly selected patients.

Post bar removal results of pectus deformity patients who underwent minimally invasive correction

Wideochirurgia I Inne Techniki Maloinwazyjne, 2022

Introduction: The most common chest wall deformities are pectus excavatum and pectus carinatum. Surgical repair of these deformities via minimally invasive technique using pectus bars is commonly preferred by numerous thoracic surgeons. Despite this common choice for treatment, the duration of the bar stay, the bar removal process, the possible complications and ways to prevent them have been debated over the years and still there is no single decision. Aim: To determine the decision making, surgical outcomes and negative factors in the bar removal process. Material and methods: There were 1032 patients underwent bar removal between 2006-2020 and their data was recorded prospectively. We analyzed patients' demographics, family history, Haller index, bar count, body mass index, stabilizer and wire usage, length of hospital stay, time until bar removal, incision side and complications retrospectively. Results: There was no significant correlation between BMI and surgery time (p = 0.748). There was no statistically significant correlation between the age groups and the number of pectus bars removed. The other factors showed no significant difference. The surgery time was found to be significantly longer in those with callus tissue (p = 0.002). Conclusions: These findings suggest that pectus bars can be left in place for a shorter time than the standard 3-year interval without any additional recurrence risk and without compromising quality of life. As a result, patients with persistent pain after pectus repair should be well evaluated for the possibility of life-threatening complications during bar removal.

Repair of pectus excavatum and carinatum in adults

The American Journal of Surgery, 1999

BACKGROUND: There is sparse published information regarding the repair of pectus chest deformities in adults. This report summarizes our clinical experience with the surgical repair of pectus excavatum and carinatum deformities in 25 adults. METHODS: During the past 11 years, 25 patients 20 years of age or older (mean 31) with symptomatic pectus excavatum (23) or carinatum (2) deformities underwent surgical repair using a temporary internal sternal support bar. RESULTS: Each of the patients with decreased stamina and endurance or dyspnea with exercise experienced marked clinical improvement within 4 months postoperation. Exercise-induced asthma was improved in 6 of 7 patients; chest pain was reduced in each of 9 patients. Postoperative complications included pneumothorax (1), keloid (2), and discomfort from sternal bar (2). The sternal bar was removed 7 to 10 months postoperation in 19 patients; there has been no return of preoperative symptoms or recurrent depression in any patient with a mean follow-up of 4.8 years. CONCLUSIONS: For adults who have symptoms and activity limitations related to uncorrected pectus chest deformities, surgical repair can be performed with low morbidity, low cost, minimal limitation in activity, and a high frequency of symptomatic improvement. The operation in adults is more difficult than in children, although the results are similar.

Radiologic factors related to double-bar insertion in minimal invasive repair of pectus excavatum

World Journal of Pediatrics, 2014

Background: Pectus excavatum is the most common congenital chest wall deformity, with a high incidence in live births. This study aimed to evaluate the measured factors on CT images related to the number of pectus bars for surgical correction. Methods: A total of 497 patients who had undergone minimally invasive repair between April 2007 and July 2011 were classified into single-bar (n=358) and doublebar (n=139) insertion groups. We measured eight distinct distances and one angle on CT scans to refl ect quantitative assessment. Univariate analysis and multivariate logistic regression analysis were performed to detect statistically significant association between radiologic measurements and the pectus bars required. Results: After adjusting for age and gender, the transverse distance (T), the transverse distance of the depression area (A), the inclined distance of the depression area (B), the AP distance of the depression area (C), the depression angle (G), and the eccentric distance of deformity (E) were signifi cantly correlated with double-bar insertion. The regression model showed that age (P<0.0001), gender (P<0.0001), depression angle (G) (P<0.0001), direction of the depression (DD) (P<0.0001) and depression depth (D) (P<0.0001) were significantly associated with double-bar insertion. Conclusion: CT scan provides useful factors which can be of assistance in predicting the number of pectus bars for the surgical correction of pectus excavatum.

Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients

The Journal of Thoracic and Cardiovascular Surgery, 2014

and, finally, by means of a totally endoscopic technique. It is important to note that when performing a totally endoscopic procedure, a quick and safe conversion to minithoracotomy under direct view can be made if circumstances demand, which would still offer significantly reduced chest trauma. Totally endoscopic surgery in other fields, such as atrial septal defect repair and coronary artery bypass grafting, has shown improved quality of life but with longer clamping and CPB times during the learning curve. 3,4 Considering that the TEAVR cases described here were our first procedures, we believe that clamping and CPB times were acceptable and suggest that the learning curve associated with TEAVR could be shorter than that reported with totally endoscopic coronary artery bypass grafting. The potential of this approach could be further enhanced by the development of endoscopic sizers as well as dedicated instruments for decalcification. Second-generation sutureless bioprostheses could also simplify implantation, although this did not require more than 45 minutes in either patient. Devices to facilitate a technically demanding aortotomy closure are also critically important. In fact, closing the aorta consumed more than 30% of the clamping time in both cases, despite the fact that we selected patients with adequate working space around the ascending aorta. Last but not least, surgical robots may offer additional benefits to the totally endoscopic approach. Previously, only a proof-of-concept in cadavers 5 through a standard minithoracotomy access has been published.

Long-term results after the modified Ravitch procedure performed in children and adolescents – a one-time procedure without the need to use additional support of the sternum. A retrospective study

Polish Journal of Cardio-Thoracic Surgery, 2020

Introduction: Pectus excavatum is a depression of the sternum. Pectus carinatum, in contrast, is the convexity of the sternum. The mixed form is an intermediate condition. Surgical intervention is the treatment of choice. The techniques most commonly used include the Ravitch and the Nuss procedures. Aim: To assess the immediate and long-term results of the original modification of the surgical treatment for anterior chest wall deformation. Material and methods: The modification is based on the Ravitch procedure. The difference is that the ends of the resected cartilages are shaped like a blade in order to be inserted into the previously prepared wedge-shaped hollows located on both edges of the sternum. The result is long lasting without the need to use additional brackets. Results: The follow-up examinations performed in 72 patients, including 57 boys and 15 girls, were the basis to produce longterm results. As for the type of deformity, out of 57 patients operated on due to pectus excavatum, 43 expressed satisfaction with the very good result. Similar satisfaction was reported in 7 out of 11 patients operated on due to pectus carinatum. There were 4 cases with the mixed form who had very good long-term results. Wound dehiscence was observed in 13 subjects, with one documented recurrence. Conclusions: The alternative treatment we propose is a one-time procedure without the need to use additional support of the sternum. Good long-term results make the procedure suitable to be used more frequently in all types of deformities.

Nuss procedure in adult pectus excavatum: a simple artifice to reduce sternal tension

Interactive CardioVascular and Thoracic Surgery, 2013

Nowadays the Nuss operation represents the standard surgical choice for pectus excavatum repair in children and teenagers. Some concerns have been raised regarding its applicability in adults, as compared with younger patients, in view of the higher rate of complications after surgery. We describe an easy trick that has been performed on a 36-year-old man with a moderate pectus excavatum after an unsatisfactory Nuss procedure. It consisted of a T-shaped partial anterior sternotomy, performed after positioning Q3

Pectus Carinatum : A Novel Method of Sternal Fixation

Lebanese Medical Journal, 2016

Clinical experience of repair of pectus excavatum and carinatum deformities

Cardiovascular Journal Of Africa, 2013

Background: We present the results of surgical correction of pectus excavatum (PE) and pectus carinatum (PC) deformities in adults, and also report a new method of sternal support used in surgery for PE deformities. Methods: We present the results of 77 patients between the ages of 10 and 29 years (mean 17) with PE (n = 46) or PC (n = 31) deformities undergoing corrective surgery from 2004 to 2011, using the Ravitch repair method. Symptoms of the patients included chest pain (15%) and tachycardia (8%). Three patients underwent repair of recurrent surgical conditions. Results: All of the patients with dyspnoea with exercise experienced marked improvement at five months post operation. Complications included pneumothorax in 5.1% (n = 4), haemothorax in 2.6% (n = 2), chest discomfort in 57% (n = 44), pleural effusion in 2.6% (n = 2), and sternal hypertrophic scar in 27% (n = 21) of patients. Mean hospitalisation was eight days. Pain was mild and intravenous analgesics were used for a mean of four days. There were no deaths. Results after surgical correction were very good or excellent in 62 patients (80%) at a mean follow up of three years. Three patients had recurrent PE and were repaired with the Nuss procedure. In three patients who underwent the Ravitch procedure, a stainless steel bar was used for sternal support instead of Kirschner wire. Conclusions: Pectus deformities may be repaired with no mortality, low morbidity, very good cosmetic results and improvement in cardiological and respiratory symptoms.

Pectus Excavatum Surgery: Sternochondroplasty Versus Nuss Procedure

Annals of Thoracic Surgery, 2009

The repair of pectus excavatum (PE) by minimally invasive Nuss surgery is well established, but its complication rate is high and its indication is indiscriminate. Sternochondroplasty (SCP) provides good results with a low complication rate but requires a small transverse incision.To compare SCP and Nuss, we analyzed 40 patients with PE who underwent surgery (SCP, n = 20; Nuss, n = 20). Thirty subjects (75.0%) were male and 10 (25.0%) were female. In the SCP group, 9 (45.0%) had symmetric PE, and 11 (55.0%) had asymmetric PE. In the Nuss group, 17 (85%) had symmetric PE, and 3 (15%) had asymmetric PE (p = 0.020).The mean duration of SCP was 229.5 minutes, and the mean duration of Nuss was 54.3 minutes. The average length of hospital stay was 4 days with SCP and 6.3 days with Nuss (p = 0.172). The SCP results were favorable in 18 subjects (90%) and fair in 2 subjects (10%). In the Nuss group, we observed 17 patients (85.0%) with favorable results and 3 (15.0%) with poor results. Patients with asymmetric PE exhibited severe pectus carinatum. No complications were found in 17 patients (85%) in the SCP group. In the Nuss group, 9 patients (45.0%) had 13 complications (65.0%; p = 0.004).Sternochondroplasty surgery yielded better results than the Nuss procedure and more patients with asymmetric PE, less pain, and fewer complications. Nuss surgery had shorter operating times than SCP, younger patients, more symmetric PE, and 3 patients who experienced severe postoperative asymmetric pectus carinatum. In summary, for asymmetric PE the best indication is SCP.

Simplified open repair for anterior chest wall deformities. Analysis of results in 205 patients

Orthopaedics & Traumatology: Surgery & Research, 2012

Introduction: Pectus deformities are the most frequently seen congenital thoracic wall anomalies. The cause of these conditions is thought to be abnormal elongation of the rib cartilages. We here report our clinical experience and the results of a sternochondroplasty procedure based on the subperichondrial resection of the elongated cartilages. Hypothesis: This technique is a valuable surgical strategy to treat the wide variety of pectus deformities. Patients and methods: During the period from October 2001 through September 2009, 205 adult patients (171 men and 34 women) underwent pectus excavatum , carinatum (19) or arcuatum (5) repair. The patients' pre and postoperative data were collected using a computerized database, and the results were assessed with a minimum 2-year follow-up. Results: The postoperative morbidity rate was minimal and the mortality was nil. The surgeon graded cosmetic results as excellent (72.5%), good (25%) or fair (2.5%), while patients reported better results. Patients with pectus excavatum were found to have much more patent foramen ovale (PFO) than the normal adult population, which occluded after the procedure in 61% of patients, and significant improvement was found in exercise cardiopulmonary function and exercise tolerance at the 1-year follow-up. Discussion: Our sternochondroplasty technique based on the subperichondrial resection of the elongated cartilages allows satisfactory repair of both pectus excavatum and sternal prominence. It is a safe procedure that might improve the effectiveness of surgical therapy in patients with pectus deformities. Level of evidence: Level IV. Retrospective study.

Sternal Cleft and Pectus Excavatum: A Combined Approach for the Correction of a Complex Anterior Chest Wall Malformation in a Teenager

The Annals of thoracic surgery, 2015

Congenital sternal cleft is a rare chest wall malformation. Because of the flexibility of the chest in infants, surgical repair should be performed by primary closure in the neonatal period. In adolescents and adults, different techniques have been suggested to overcome the lack of sternal bone tissue. We describe a very rare case of an 18-year-old woman with a complete bifid sternum associated with pectus excavatum for whom a satisfactory cosmetic and functional result was obtained by adequate surgical planning, which entailed a combination of two standardized surgical techniques.

From pullout-techniques to modular elastic stable chest repair: the evolution of an open technique in the correction of pectus excavatum

Journal of Thoracic Disease

Background: Traditionally open procedures have been replaced by minimally invasive techniques in the correction of pectus excavatum. Efforts to improve the extent of mobilization of the chest wall and its stabilization have led to constant modifications. There is currently no consensus about the best procedure for correction of pectus excavatum. Methods: Based on the contributions of a single institution for the last 60 years, we present the various strategies used for the correction of pectus excavatum and the evolution of operational procedures. These approaches are compared with those performed internationally at similar periods. Results: Resections with external extension achieved moderate results and were modified in 1962 to the "Shred" method. The establishment of the "Strut" method in 1963 and, in 1977, its extension with the erection of the lower rib arches significantly improved patient outcomes. The "minimization" of the procedure in 2006 was accompanied by an increase in wound healing disorders and recurrent deformities. Since 2010, elastic stable chest repair (ESCR) has provided lossless mobilization and sternal elevation for healing costosternal pseudarthrosis and allowed correction of complex recurrences with excellent cosmeticfunctional results. Strong asymmetric or broad-base deformities can now be stabilized using a modular hybrid technique of transsternal bar and locked plates. Conclusions: ESCR marks the end of the 60-year development of an open procedure and, after lossfree mobilization of the chest wall by elastic-stable biomechanical management, optimizes the possibility of anatomical reconstruction of the chest wall during initial and re-interventions, achieving a permanent, physiologically stable remodeling of the chest wall.