What are the risks and benefits of minimally invasive repair of pectus excavatum (MIRPE)?

Updated: Oct 30, 2018
  • Author: Andre Hebra, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Answer

The acceptance and popularity of MIRPE developed quickly since its introduction in 1997. The principal advantages of this new technique are based on the fact that incising the anterior chest wall, raising the pectoralis muscle flaps, resecting the rib cartilages, and performing a sternal osteotomy are not needed. This leads to a much shorter operating time, minimal blood loss, and early return to full activity because the stability and strength of the chest wall is not compromised. The apparent simplicity of the technique, combined with the early good results reported, contributed to the enthusiastic widespread use of this operation by many pediatric surgeons.

Unfortunately, a relatively high rate of complications was reported when many different surgeons performed the operation, probably reflecting the learning curve associated with the introduction of this new technique. Since the first MIRPE was performed, the bar has been modified 4 times and is now strong enough to withstand the pressure of even the most severe deformity. The poor results likely occurred early in the reported series because the bar was too soft, was removed too soon, or was not stabilized adequately. Experience has shown that stabilization of the bar is absolutely essential for success, and the use of a lateral stabilizing bar and the third point of fixation (when appropriate) minimizes the occurrence of bar displacement.

An interesting observation has been that complications, mainly bar displacement, have appeared to be more common in teenaged patients. Initially, the MIRPE was limited to the younger prepubertal patients (aged 3-12 y), which probably accounted for the rare occurrence of bar displacement in the first report by Nuss. [10] Older patients were offered the procedure because of the success of the procedure in young patients. Only later was the importance of proper stabilization of the bar identified and the lateral stabilizing bar was introduced (in 1998), followed by the addition of the third point of fixation technique (in 2000) to provide additional support and stability for the bar. The results seemed to have improved so much that the operation is now considered in adult patients with pectus excavatum.

Fortunately, most factors that may lead to complications and poor results were related to early inexperience, and these factors have been corrected. Moreover, the introduction of thoracoscopy when performing MIRPE has significantly enhanced the surgeon's ability to pass the bar precisely behind the sternum, avoiding the risk of cardiac or vascular injury. Reassuringly, one reported case of cardiac perforation occurred prior to the routine use of thoracoscopy.


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