Use of a pectus bar for surgical stabilization of cardiopulmonary resuscitation induced flail chest.

A flail chest can occur when cardiopulmonary resuscitation causes extensive rib fractures. Despite successful cardiopulmonary resuscitation, if the flail chest is not treated, the patient may not survive regardless of the correction of the primary condition that caused the cardiac arrest. Therefore, if flail chest persists despite the appropriate conservative management to correct the flail chest, active surgical management is essential. We present a successful surgical treatment with a pectus bar for a patient with flail chest, caused by extensive segmental rib fractures sustained during cardiopulmonary resuscitation for a massive pulmonary thromboembolism.

Routine use of chest radiographs in the post-operative management of pectus bar removal: necessity or futility.

BACKGROUND: While there is literature on techniques for pectus bar removal, there are limited reports on post-operative management. This can include obtaining a postoperative chest radiograph (CXR) despite the minimal risk of associated intra-thoracic complications. This is a review of our experience with bar removal and lack of routine post-operative CXR. METHODS: A single institution retrospective chart review was performed from 2000 to 2015. Patients who underwent a pectus bar removal procedure were included. We assessed operative timing of bar placement and removal, procedure length, intra-operative and post-operative complications and post-operative CXR findings, specifically the rate of pneumothoraces. RESULTS: 450 patients were identified in this study. Median duration of bar placement prior to removal was 35 months (interquartile range 30 and 36 months). Sixtey-four patients obtained a post-operative CXR. Of these, only one (58%) film revealed a pneumothorax; this was not drained. A CXR was not obtained in 386 (86%) patients with no immediate or delayed complications from this practice. Median follow-up time for all patients was 11 months (interquartile range 7.5-17 months). DISCUSSION: The risk for a clinically relevant pneumothorax is minimal following bar removal. This suggests that not obtaining routine imaging following bar removal may be a safe practice.

Electrocardiographic characteristics of patients with funnel chest before and after surgical correction using pectus bar: A new association with precordial J wave pattern.

OBJECTIVE: Abnormal ECG findings suggestive of cardiac disease are frequent in patients with funnel chest, although structural heart disease is rare. Electrocardiographic characteristics and changes following new surgical treatments in young adults are not described so far. The aim of the study was to analyze electrocardiographic characteristics of patients with funnel chest before and after minimally invasive funnel chest correction by the Nuss procedure. METHODS: Twenty-six patients with surgical correction of funnel chest using pectus bar were included. Twelve-lead ECGs before and later than one year after surgery were analyzed. RESULTS: In postoperative ECGs, amplitude of P wave in lead II and negative terminal amplitude of P wave in lead V1 decreased from 0.13 to 0.10mV (p=0.03), and from 0.10 to 0.04mV (p<0.001), respectively. Mean QRS duration decreased from 108ms to 98ms (p=0.003) after correction. A pathological left and right Sokolow-Lyon index was observed in 35% and 23% of patients before, versus 8% (p=0.04) and 0% (p=0.01) after correction, respectively. In contrast, the rate of patients with J wave pattern in precordial leads V4-V6 increased from 8% before to 42% after surgery (p=0.004). CONCLUSIONS: ECG abnormalities in patients with funnel chest are frequent, and can normalize after surgical correction by the Nuss procedure. De novo J wave pattern in precordial leads V4-V6 is a frequent finding after surgical funnel chest correction using pectus bar.

The role of chest radiography following pectus bar removal.

PURPOSE: Surgical correction of pectus excavatum (PE) via a minimally invasive approach involves placement of a steel bar, which is subsequently removed. The purpose of our study was to evaluate the incidence of pneumothorax and the role for chest radiography (CXR) in patients undergoing pectus bar removal. METHODS: A retrospective review of 84 patients who underwent pectus bar removal from 2006 to 2014 was performed. Results of postoperative CXR, repeat imaging, need for chest thoracostomy tube placement, and complications were analyzed. RESULTS: Mean Haller index prior to correction was 4.3 ± 0.9. The mean time between PE repair and bar removal was 2.3 ± 0.6 years. Sixty-one patients (72.6 %) had a postoperative CXR. Thirty-one (50.8 %) had no acute findings, 20 (32.8 %) had findings of atelectasis or subcutaneous emphysema, and 10 (16.4 %) had a pneumothorax. One patient (1.6 %) had a second postoperative CXR for a small pneumothorax and rib fractures. There were two complications (2.4 %). No chest tubes were placed for pneumothorax, and 95 % of patients were discharged the day of surgery. CONCLUSION: Postoperative CXR following pectus bar removal is unnecessary given the low incidence of postoperative pneumothorax requiring intervention. Patients can be safely discharged the day of surgery without the need for routine postoperative chest imaging.

Patient satisfaction after Nuss procedure with one or two bars in young adults: A propensity score-matched cohort study.

BACKGROUND: The Nuss procedure is the primary treatment for pectus excavatum (PE), but patient expectations are not always met. In our unit, our standard approach in the last few years has been the routine application of two bars instead of one. We aimed to retrospectively assess the impact of this approach on patient satisfaction, quality of life (QoL) and safety. METHODS: A retrospective study included 182 patients over 16 years old who underwent the Nuss procedure for PE between January 2007 and September 2021. Patients were categorized into one-bar or two-bar correction groups. Propensity score matching (PSM) was used, resulting in 30 patients in each group. Primary endpoints were QoL and cosmetic satisfaction, while secondary endpoints included complications and recurrence. RESULTS: After PSM, both groups showed similar general characteristics. Patients treated with two bars reported fewer psychological complaints post-surgery (93.3% vs. 73.3%, p = 0.031). There were no significant differences in QoL improvement (96.7% in both groups, p = 0.197), perioperative complications (p = 0.771) or recurrence (one patient in the one-bar group, p = 1.000). CONCLUSIONS: Our study reveals that patients undergoing the Nuss Procedure for PE with two bars exhibit comparable clinical outcomes and QoL to those with one bar. However, patients with two bars may have higher levels of psychological well-being and satisfaction, indicating potential benefits associated with this approach. These findings suggest potential advantages of the two-bar approach, but further research with larger sample sizes is warranted to confirm these observations.

Long-term patient perception of pain control experience after participating in a trial between patient-controlled analgesia and epidural after pectus excavatum repair with bar placement.

BACKGROUND: Pain control is the dominant management issue after bar placement for pectus excavatum. We previously conducted a prospective, randomized trial comparing patient-controlled analgesia (PCA) to thoracic epidural (EPI) documenting similar objective outcomes. Our impression is that the subjective cognitive experience differs between the groups, which impacts trial results interpretation. Therefore, we conducted a survey to ascertain patient recollection and impression of their experience. METHODS: By telephone questionnaire, yes/no questions included early course recall, anxiety, if they would choose the same arm, do the operation again, or recommend it to friends. Qualitative questions included description, location, and time of peak pain. The graded question addressed severity of pain (1-5). RESULTS: We contacted 27 EPI and 38 PCA patients with a median follow-up of 3.2 y. The majority (~/= 85%) of both groups remembered the first 2 d. Mean pain severity was 3.0 in both groups (3 = bad, but tolerable). Description, location, and time of peak pain responses did not differ. Anxiety was reported by 30% of EPI group and 18% of PCA group (P = 0.37). Approximately 15% of both groups still think about the pain. No differences were seen in nausea, emesis, constipation, itching, or sleepiness. Most patients would choose the same group (87% PCA, 81% EPI, P = 0.73), have the operation again (87% PCA, 74% EPI, P = 0.21), and recommend the operation to friends (100% PCA, 96% EPI, P = 0.42). CONCLUSIONS: Long-term recall after repair of pectus excavatum with bar placement does not substantially differ between those managed with an epidural or PCA.

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

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.

Nuss Technique for Pectus Excavatum in Adult Patients: Cosmetic Satisfaction and Improvement of Quality of Life in a Single-Center Experience.

Objectives: Since its introduction, the Nuss minimally invasive procedure for pectus excavatum (PE) repair (MIRPE) has become the method of choice. The current study describes our experience of PE correction in adults, with particular focus on postoperative outcomes, pain, quality of life, and patients' satisfaction. Methods: We enrolled for this observational study n = 93 adult patients from 2011 to 2018. The Haller index was used to quantify PE severity. Pulmonary function tests and cardiac examinations were performed preoperatively; we developed a standardized surgical technique and postoperative treatment, including follow-up at 3, 12, and 24 months after surgery and 6 months after bar removal. We also evaluated the quality of life and the satisfaction with the cosmetic result after the procedure with standardized questionnaires. Results: No operative or perioperative deaths occurred nor life-treating complications. Thirteen complications occurred in 12 patients, with a total complication rate of 14% (n = 13/93). Pain intensity decreased in the follow-up [pain score visual analog scale at 3 months: median 1 (0-8); 12 months: median 1 (0-5); and 24 months: median 1 (0-4)]. Better or much better quality of life after the Nuss procedure was observed: n = 79 (84.1%) at 3 months, n = 80 (86%) at 12 months, and n = 85 (91.4%) at 24 months. After 2 years of observation, more than 90% of patients described improvement in their quality of life and satisfaction with the cosmetic results. Only a very small group of patients suffered from pain in the follow-up. Conclusion: Our results demonstrate that the MIRPE procedure is safe and can be performed with excellent results in adults both for improvement of quality of life and for satisfaction with cosmetic results.

A new minimally invasive technique for correction of pectus carinatum.

BACKGROUND: The Abramson technique for the correction of pectus carinatum (PC) is commonly performed worldwide. However, the postoperative complications of this technique related to bar fixation, including wire breakage and bar displacement, are relatively high. In this study, a new minimally invasive technique for correction of PC is described, in which the pectus bar is secured by bilateral selected ribs, and for which no special fixation to the rib is needed. METHODS: The procedure was performed by placing the pectus bar subcutaneously over the sternum with both ends of the bar passing through the intercostal space of the selected rib at the anterior axillary line. The protruding sternum was depressed by the bar positioned in this 2 intra- and 2 extra-thorax manners. Between October 2011 and September 2019, 42 patients with PC underwent this procedure. RESULTS: Satisfactory cosmetic results were obtained in all the patients. The mean operation time was 87.14 min, and the mean postoperative stay was 4.05 days. Wound infection occurred in 3 patients, 2 were cured by antibiotics, and 1 received bar removal 4 months after the initial operation due to the exposure of the implant resulting from uncontrolled infection. Mild pneumothorax was found in 3 patients and cured by conservative treatment. One patient suffered from hydropneumothorax, which was treated with chest drainage. The bars were removed at a mean duration of 24.4 months since primary repair in 20 patients without recurrence. CONCLUSIONS: This new technique for minimally invasive correction of PC deformity is a safe and feasible procedure yielding good results and minimal complications.

Pectus bar removal - why, when, where and how.

OBJECTIVE: Despite its less invasive nature, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. On the other hand, Pectus bar removal (PBR) is often considered a simple procedure and often scheduled in an outpatient setting. However, several studies report near-fatal complications not only during bar placement, but also during bar removal. The aim of our study was to clarify why a pectus bar should be removed, timing for removal, where PBR should be performed, and overall setup for safe removal. METHODS: A comprehensive review was performed in accordance with PRISMA guidelines, searching for articles published since 1998 in English. "Pectus bar removal AND (near-fatal) complications" were the applied terms. Inclusion criteria were articles reporting on the focus of PBR after MIRPE. Eligible study designs included (retrospective) case study series, case report and reviews. Full-text articles in which the technique in general was described were omitted. RESULTS: Recently published results of an online survey raised awareness about type and number of possible complications during PBR. Furthermore, our comprehensive literature review identified only a few, but serious complications during PBR. CONCLUSIONS: PBR has a high safety profile but in rare cases may be associated with major complications such as life-threatening hemorrhage from various thoracic sources. This risk is higher in patients with a history of complex MIPRE. In an effort to decrease these complications we recommend bilateral opening of surgical incisions, unbending the bar and meticulous mobilization of the bar. To manage these complications if they occur, we recommend removal in a hospital setting with adequate resources and personal including cardiac surgeons. If the postoperative course is uneventful discharge on the same day is reasonable.

Life-threatening complications and mortality of minimally invasive pectus surgery.

The prevalence and type of life-threatening complications related to the minimally invasive repair of pectus excavatum (MIRPE) and bar removal are unknown and underreported. The purpose of this communication is to make surgeons aware of the risk of these life threatening complications as well as the modifications which have been developed to prevent them. METHODS: Data related to life-threatening complications of Pectus Excavatum (PE) patients was obtained from four sources: 1. A survey of Chest Wall International Group (CWIG) surgeons who specialize in repairing congenital chest wall malformations, 2. Papers and case reports presented at CWIG meetings, 3. Review of medico-legal cases from the USA and 4. A systematic review of the literature related to major complications post MIRPE. RESULTS: From 1998 to 2016, we identified 27 published cases and 32 unreported life-threatening complications including: cardiac perforation, hemothorax, major vessel injury, lung injury, liver injury, gastrointestinal problems, and diaphragm injury. There were seven cases of major complications with bar removal (reported and non-reported) with two lethal outcomes. Mortality data with bar placement surgery: Four published death cases and seven unpublished death cases. The overall incidence of minor & major complications post MIRPE has been reported in the literature to be 2-20%. The true incidence of life-threatening complications and mortality is not known as we do not know the overall number of procedures performed worldwide. However, based on data extrapolated from survey information, the pectus bar manufacturer in the USA, literature reports, and data presented at CWIG meetings as to the number of cases performed we estimated that approximately fifty thousand cases have been performed and that the incidence of life-threatening complications is less than 0.1% with many occurring during the learning curve. Analysis of the cases identified in our survey revealed that previous chest surgery, pectus severity and inexperience were noted to be significant risk factors for mortality. CONCLUSIONS: Published reports support the safety and efficacy of MIRPE; however major adverse outcomes are underreported. Although major complications with MIRPE and pectus bar removal surgery are very rare, awareness of the risk and mortality of life-threatening complications is essential to ensure optimal safety. Factors such as operative technique, patient age, pectus severity and asymmetry, previous chest surgery, and the surgeon's experience play a role in the overall incidence of such events. These preventable events can be avoided with proper training, mentoring, and the use of sternal elevation techniques. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level IV.

Technical consideration of the MOVARPE technique in intricate pectus excavatum deformity.

BACKGROUND: For the correction of pectus excavatum (PE) deformities in adolescents, adults, and generally in asymmetric cases, a semi-open approach called the MOVARPE (minor open videoendoscopically assisted repair of pectus excavatum) technique is used, consisting of standard pectus bar implantation hybridized with auxiliary sternum osteotomy and multiple chondrotomies. In this study, we report our experiences, discuss pros and cons, and provide technical refinements. METHODS: Between September 2005 and March 2015, 61 patients were selected to undergo the MOVARPE instead of the standard MIRPE (minimally invasive repair of pectus excavatum) procedure because of age or specific morphologic characteristics of PE. Patient age ranged from 14 to 45 years (mean 23.4 years). RESULTS: Auxiliary incisions for skeletal relaxation enabled symmetric remodeling and, in most cases, circumvented the need for a second pectus bar. The bars were left in position for a mean of 19.3 months (range: 12 to 35 months). There were no major complications. Minor complications such as pleural effusion, temporary pneumothorax, and mild recurrence of the deformity after bar removal were seen at rates similar to those for standard techniques. In the current study reporting outcomes of the previously described MOVARPE procedure, the authors saw no evidence of a possible disadvantage in the overall concept or execution of the procedure for the suggested indication. CONCLUSION: From this experience, we can state that, as an alternative to the MIRPE technique, MOVARPE is a method that offers high efficacy, particularly for rigid and complex pectus excavatum deformities at or beyond puberty.

Comparative studies of different types of osteosynthesis on the human corpse preparation in bilateral antero-lateral flail chest.

INTRODUCTION: Bilateral flail chest injuries are challenging in treatment and comparatively often require an operative stabilization of the anterior chest wall to re-establish normal physiological conditions of the chest wall in shape and statics. Various procedures have been described which are technically sophisticated for the surgeon. Consequently there is an increasing interest in potentials of operative care and their effectiveness on the anterolateral chest wall. MATERIALS AND METHODS: 12 Human cadavers were prepared and the natural Sternum Position (NP) was marked. A digital probe was fixed to the sternum at the height of the 4th intercostal space in order to measure and compare the stability of the thorax. Readings were taken of the sternal displacement at 1-5cm sagittal distance from NP in starting conditions and from every combination of materials. Serial osteotomies were performed on 2 locations on ribs 2-8 to induce bilateral flail chest. Afterwards the stabilization was achieved with different implants: RESULTS: The osteotomies lead to a subsidence of the sternum occurred to almost 75 mm from NP which corresponds to a maximal unstable situation. The unstable chest wall showed substantially more stabilization through the use of locking plates. Our materialcombinations showed a stability of up to 60% of normal. The more ribs were treated osteosynthetically, the higher the stability of the chest wall. DISCUSSION AND CONCLUSIONS: Locking plate fixation offers anatomically realignment of the ribs whereas metal strut support only lifts up the chest wall, but could not provide realignment of the dislocated ribs.

Nuss procedure for pectus excavatum in adults: long-term results in a prospective observational study.

OBJECTIVES: Since the end of the 1990s, the management of pectus excavatum has undergone major changes. The Nuss procedure (pectus bar) has been the method of choice for patients with pectus excavatum at Bern University Hospital for over a decade. The current study will describe our experiences, with a particular focus on long-term results in adults. METHODS: The prospective observational study began in autumn 2002. The Haller index was used to quantify pectus excavatum severity. Pulmonary function tests and cardiac examinations were performed preoperatively, and a standardized management for surgical techniques and for the pre- and postoperative treatments including long-term follow-up at 3, 12 and 36 months after surgery was developed. Quality of life and satisfaction with the cosmetic result after the Nuss procedure were evaluated. RESULTS: Better or much better quality of life after the Nuss procedure was observed: n = 108 (88.4%) at 3 months, n = 97 (89.0%) at 12 months and n = 87 (92.5%) at 36 months. Pain intensity decreased in the follow-up [pain score visual analogue scale (VAS) at 3 months: median 1 (0-7), 12 months: median 1 (0-4), 36 months: median 0.8 (0-5)]. After long-term observation, over 90% of patients described their quality of life after the operation as being better or much better. Satisfaction with the cosmetic results of the operation was also very high, with >90% of patients being satisfied. Only a very small group of patients suffered from pain in the long-term follow-up. Complications were rare (14.7%) and could be treated in most cases without reoperation. CONCLUSION: Our results demonstrate that the Nuss procedure is safe and can be performed with excellent results in adults, both in the short term and in the long term. The improved quality of life and patients' satisfaction with cosmetic results remained high in the long-term follow-up, 10 years after the surgical procedure.

Pectus bar removal: surgical technique and strategy to avoid complications.

BACKGROUND: Pectus bar removal is the final stage of the procedure for minimally invasive repair of pectus excavatum. Based on our experience with one of the largest scale data, we would like to address the important issues in pectus bar removal, such as appropriate duration of bar maintenance, techniques for bar removal, and strategies to avoid complications. METHODS: Between September 1999 and August 2015, we operated on 2,553 patients with pectus excavatum and carinatum using pectus bars for a minimally invasive approach. Among them, 1,821 patients (71.3%) underwent pectus bar removal as a final stage of pectus deformity repair, and their data were analyzed retrospectively to identify the outcomes and adverse effects of the pectus bar removal procedure. The mean age of the patients was 9.13 years (range, 16 months to 44 years) and the male to female ratio was 3.55. The study is approved by the Institutional Review Board (IRB), the ethical committee of Seoul St. Mary's Hospital. The IRB has exempted the informed consent from every patient in this study due to this is a retrospective chart review without revealing any patients' personal data. RESULTS: Our technique involved straightening of the bar in a supine position. The overall mean duration of pectus bar maintenance was 2.57 years (range, 4 months to 14 years). The mean duration was 2.02 years (range, 4 months to 7 years) for children under 12 years, 2.99 years (range, 7 months to 9 years) for teenagers aged 12-20 years, and 3.53 years (range, 3 months to 14 years) for adults over 20 years. Forty-eight patients (2.6%) underwent bar removal more than 5 years after bar insertion and 58 patients (3.2%) underwent bar removal earlier than initially planned. The most common adverse reaction after bar removal was wound seroma including infection (43 patients, 2.36%). Recurrence after bar removal occurred in nine patients (0.49%), and seven of these required redo repair (0.38%). CONCLUSIONS: Pectus bar removal is a safe and straightforward procedure with a low rate of complication.

Minimally invasive repair of pectus excavatum.

Pectus excavatum, an acquired or congenital depression of the anterior chest wall, is the most commonly occurring chest wall deformity. Patients with pectus excavatum experience psychosocial and physiologic consequences such as impaired social development and pulmonary and/or cardiac dysfunction as a result of the deformity. Traditionally, repair of the defect was performed with a major open operation, the most common being based on modifications of the Ravitch procedure. In the late 1990's, the operative approach was challenged with a new minimally invasive technique described by Dr. Donald Nuss. This approach utilizes thoracoscopic visualization with small incisions and placement of a temporary metal bar positioned behind the sternum for support it while the costal cartilages remodel. Since introduction, the minimally invasive repair of pectus excavatum (MIRPE) has become accepted in many centers as the procedure of choice for repair of pectus excavatum. In experienced hands, the procedure has excellent outcomes, shorter procedural length, and outstanding cosmetic results. However, proper patient selection and attention to technical details are essential to achieve optimal outcomes and prevent significant complications. In the following, we describe our perspective on pectus excavatum deformities, operative planning, and technical details of the MIRPE procedure.

The bridge technique for pectus bar fixation: a method to make the bar un-rotatable.

PURPOSE: Pectus bar rotation is a major challenge in pectus repair. However, to date, no satisfactory technique to completely eliminate bar displacement has been introduced. Here, we propose a bar fixation technique using a bridge that makes the bar unmovable. The purpose of this study was to determine the efficacy of this bridge technique. METHODS: A total of 80 patients underwent pectus bar repair of pectus excavatum with the bridge technique from July 2013 to July 2014. The technique involved connecting 2 parallel bars using plate-screws at the ends of the bars. To determine bar position change, the angles between the sternum and pectus bars were measured on postoperative day 5 (POD5) and 4 months (POM4) and compared. RESULTS: The mean patient age was 17.5 years (range, 6-38 years). The mean difference between POD5 and POM4 were 0.23° (P=.602) and 0.35° (P=.338) for the upper and lower bars, respectively. Bar position was virtually unchanged during the follow-up, and there was no bar dislocation or reoperation. CONCLUSIONS: A "bridge technique" designed to connect 2 parallel bars using plates and screws was demonstrated as a method to avoid pectus bar displacement. This approach was easy to implement without using sutures or invasive devices.

The search for stability: bar displacement in three series of pectus excavatum patients treated with the Nuss technique

OBJECTIVES: To compare bar displacement and complication rates in three retrospective series of patients operated on by the same surgical team. METHOD: A retrospective medical chart analysis of the three patient series was performed. In the first series, the original, unmodified Nuss technique was performed. In the second, we used the ''third point fixation'' technique,and in the last series, the correction was performed with modifications to the stabilizer and stabilizer position. RESULTS: There were no deaths in any of the series. Minor complications occurred in six (4.9 percent) patients: pneumothorax with spontaneous resolution (2), suture site infection (2), and bar displacement without the reoperation need (2). Major complications were observed in eight (6.5 percent) patients: pleural effusion requiring drainage (1), foreign body reaction to the bar (1), pneumonia and shock septic (1), cardiac perforation (1), skin erosion/seroma (1), and displacement that necessitated a second operation to remove the bar within the 30 days of implantation (3). All major complications occurred in the first and second series. CONCLUSION: The elimination of fixation wires, the use of shorter bars and redesigned stabilizers placed in a more medial position results in a better outcome for pectus excavatum patients treated with the Nuss technique. With bar displacement and instability no longer significant postoperative risks, the Nuss technique should be considered among the available options for the surgical correction of pectus excavatum in pediatric patients.