Thoracoscopic Nuss procedure for young adults with pectus excavatum: excellent midterm results and patient satisfaction.

BACKGROUND: Chest wall remodeling by substernal placement of a Nuss bar is the treatment of choice for children with pectus excavatum; however, it has not yet gained widespread acceptance in adults. We demonstrate that thoracoscopic Nuss bar insertion in young adults is safe and leads to excellent results. METHODS: Adult patients who underwent thoracoscopic Nuss bar insertion at one institution between 2006 and 2012 were identified. Data on demographics, postoperative outcomes, quality of life, and cosmetic satisfaction was collected. A validated single-step quality of life survey was administered to patients. Student's t test and the Wilcoxon rank sum test were used for statistical analysis. RESULTS: Seventy-three patients (65 male, 8 female) with a median age of 20 years (range, 16 to 51) were included. The median follow-up was 44.6 months (range, 36.9 to 73.26). Most patients (59 of 73, 81%) had one bar placed. The median length of hospital stay was 5 days (range, 3 to 9) and the median duration of epidural anesthesia was 3 days (range, 0 to 7). There were 4 reoperations (5.5%) in the immediate postoperative period: 2 for bar displacement and 2 for poor cosmesis. All reoperations were performed thoracoscopically. Other postoperative complications included pneumothorax (3 of 73, 4.1%) and ileus (1 of 73, 1.3%). Fifty-one patients participated in a quality-of-life survey (73% response rate). The mean self-esteem score improved from 4.6 of 10 preoperatively to 6.5 of 10 postoperatively (p=0.002). The social impact of the pectus deformity became less significant (mean preoperative score 3.6, mean postoperative score 2.8, p=0.02). The severity of initial postoperative pain was much improved on follow-up. The vast majority of patients (41 of 51, 80%) were satisfied with the cosmetic result, and 96% (49 of 51) would opt to have the surgery again. CONCLUSIONS: For young adults who wish to correct their pectus deformity, a thoracoscopic Nuss procedure is safe and results in a high rate of patient satisfaction, significant improvement in self-image, and excellent midterm cosmetic results.

Thoracoscopic sympathetic clipping for hyperhidrosis: long-term results and reversibility.

OBJECTIVE: The study objectives were to assess 1) postoperative satisfaction and the occurrence of compensatory sweating after endoscopic thoracic sympathetic clipping in a consecutive series of patients and 2) the reversibility of adverse effects by removing the surgical clips. METHODS: Between June 1998 and March 2006, 727 patients undergoing bilateral endoscopic thoracic sympathetic clipping for hyperhidrosis or facial blushing were prospectively followed for postoperative satisfaction and subjective compensatory sweating. The effect of removing the surgical clips was assessed in 34 patients who underwent a subsequent reversal procedure after endoscopic thoracic sympathetic clipping. Satisfaction and compensatory sweating were assessed using a visual analogue scale ranging from 0 to 10, with 10 indicating the highest degree. RESULTS: Follow-up was complete in 666 patients (92%). The median age was 26.9 years, and 383 (53%) were men. The level of sympathetic clipping was T2 in 399 patients (55%), T2+3 in 55 patients (8%), and T3+4 in 273 patients (38%). Median follow-up was 10.4 months (range 0-83 months). Excellent satisfaction (8-10 on visual analogue scale) was seen at last follow-up in 288 (74%) of the T2 group, 33 (62%) of the T2+3 group, and 184 (85%) of the T3+4 group. Postoperative satisfaction was significantly higher in the T3+4 group when compared with the T2 or T2+3 groups (P < .01). Severe compensatory sweating (8-10 on the visual analogue scale) was reported in 42 (13%) of the T2 group, 11 (28%) of the T2+3 group, and 17 (8%) of the T3+4 group. Postoperative compensatory sweating was significantly lower in the T3+4 group when compared with the T2 or T2+3 groups (P < .05). Thirty-four patients have subsequently undergone removal of the surgical clips after endoscopic thoracic sympathetic clipping. Follow-up was complete in 31 patients. The reasons for removal included severe compensatory sweating in 32 patients, anhydrosis of the upper limb in 4 patients, lack of improvement or recurrence of hyperhidrosis in 5 patients, and other adverse symptoms in 5 patients. The reversal procedure was done after a median time of 11.0 months (range 1-57 months) after endoscopic thoracic sympathetic clipping. The initial level of clipping was T2 in 21 patients, T2+3 in 7 patients, and T3+4 in 6 patients. There was a trend toward fewer subsequent reversal procedures in the T3+4 group when compared with the T2 or T2+3 groups (P = .06). Fifteen patients (48%) reported a substantial decrease in their compensatory sweating (5-10 on the visual analogue scale) after reversal. Thirteen patients (42%) reported that their initial hyperhidrosis or facial blushing has remained well controlled (8-10 on the visual analogue scale) after reversal. There was no significant relationship between the original level of clipping and the interval between endoscopic thoracic sympathetic clipping and the subsequent reversal and reversibility of symptoms. CONCLUSION: When compared with endoscopic thoracic sympathetic clipping at the T2 or T2+3 levels, endoscopic thoracic sympathetic clipping at the T3+4 level was associated with a higher satisfaction rate, a lower rate of severe compensatory sweating, and a trend toward fewer subsequent reversal procedures. Subjective reversibility of adverse effects after endoscopic thoracic sympathetic clipping was seen in approximately half of the patients who underwent endoscopic removal of surgical clips. Although yet to be supported by electrophysiologic studies, reversal of sympathetic clipping seems to provide acceptable results and should be considered in selected patients.