In our study, we found that delayed pectus bar removal following Nuss repair did not compromise overall patient outcomes. Notably, we observed no cases of massive bleeding during or after bar removal, which contrasts with findings from previous studies [18]. Additionally, our results suggest that longer correction periods may not be necessary.
Comparison with similar researchIn recent decades, the Nuss procedure has achieved broad acceptance as a surgical intervention for patients diagnosed with PE. The Nuss procedure has been consistently reported to exhibit a significantly shorter operation duration than the Ravitch procedure [19]. Regardless of the patient’s age, the Nuss procedure yields satisfactory cosmetic results. Although a higher recurrence rate of the deformity has been observed in younger individuals, the differences did not reach statistical significance (P >0.05) [6]. Previous studies have discussed the technique and its complications [20, 21]. and reported the optimal duration of correction as 2–3 years. However, in some cases, the bar may need to be removed earlier or later than the standard timeframe owing to individual circumstances. The removal of the bar more than 10 years after the initial procedure has been observed in certain instances, although such cases are relatively uncommon. The decision to remove the bar is usually based on factors such as the stability of the chest wall, the presence of any complications or discomfort associated with the bar, and the patient’s age. Our study contributes to the existing knowledge by specifically examining patients with a correction duration exceeding 3 years, providing valuable insights into the impact of delayed bar removal.
The removal of the Nuss bar is commonly performed as an outpatient procedure without complications. While the occurrence of massive bleeding during bar removal is rare, it presents a critical and life-threatening danger. Reports have documented instances of significant bleeding following bar removal, resulting from bleeding in the bar track, myocardial injury, lung laceration, and aortic laceration [22, 23]. While the incidence of complications related to bleeding during pectus bar removal is relatively low, it remains a significant concern [6, 22, 23]. The risk factors associated with major bleeding include migration of the bar, reoperation, erosion of the sternum, intrathoracic infection, or pericarditis. Considering patient safety and in the event of unforeseen major complications, it may be necessary to perform the pectus bar removal as an in-patient procedure, following a previously described protocol [16], especially in patients with risk factors for bleeding. In our study, no major bleeding was observed, and the overall complication rate was 4.8% (26/542). Among the rare instances of pneumothorax during Nuss bar removal, one patient in our cohort received intra-operative pleural drainage.
Explanations of findingsTable 2 illustrates the analysis conducted after PSM, demonstrating the association of other surgical factors. We excluded patients due to lost follow-up, early removal of the bar related to intractable pain, wound infection, and allergy to the bar after the Nuss procedure. The results showed significant differences in the age of bar removal (P < 0.001), duration of correction (P < 0.001), callus formation (P = 0.029), operation time (P = 0.026), and blood loss (P = 0.017) between the two groups. Nonetheless, no substantial disparities were observed in relation to gender, BMI, HI, bar number, duration of hospital stay, complications, or radiographic improvement. Notably, a significant variation in operation time post-PSM suggests a possible association with callus formation. Our study reported no significant radiographic improvement or major complications post-procedure. Additionally, observed P-values for HI (CXR) before repair (P = 0.408), HI (CXR) after removal (P = 0.398), and improvement after repair (%) (P= 0.132) did not reach statistical significance. These findings suggest that delaying bar removal does not yield additional image-based improvements, indicated by similar HI values pre- and post-removal. In our previous study, we investigated bar rotation by measuring the slope angle of bars in patients undergoing a procedure, finding that cases with a slope angle > 30° showed reduced clinical improvement [17]. However, due to a limited sample size and specific exclusion criteria, we could not comprehensively analyze outcomes post-bar removal, hindering significant observations in this subgroup. Importantly, the incidence of complications did not exhibit any statistically significant differences between the groups, both pre- (P = 0.325) and post-PSM (P = 0.648).
Strengths and limitationsWhile this study offers valuable insights, it is crucial to recognize its limitations. The relatively small number of cases and its retrospective nature may have introduced inherent biases and limitations in data collection. To overcome these limitations, we suggest conducting larger multicenter studies and performing meta-analyses across multiple centers. The reliance on medical records and the potential for incomplete follow-up data may have impacted the accuracy and completeness of the results.
Implications and actions requiredFuture research directions can be postulated based on the study findings. Prospective studies involving larger multicenter cohorts would provide a more robust analysis of the risks and benefits of delayed bar removal in the Nuss procedure. Long-term follow-up studies focusing on patient-reported outcomes, quality of life, and cosmetic results would further contribute to our understanding of the optimal duration of bar retention. Investigating the impact of individual patient factors on the outcomes of delayed bar removal could also provide valuable insights for personalized treatment approaches.
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