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Absorbable Stabilisation of the Bar inMinimally Invasive Repair of Pectus Excavatum M. Torre1, V. Jasonni1, C. Asquasciati1, S. Costanzo1, M. V. Romanini2, P. Varela3 1 Pediatric Surgery, G. Gaslini Institute, Genova, Italy2 Plastic Surgery, IST, University of Genova, Genova, Italy3 Pediatric Surgery, Calvo Mackenna Hospital, Santiago, Chile Results: The surgical technique for the stabilisa- tion of the bar was identical in both groups, but Introduction: The minimally invasive repair of in group 1 the stabiliser was fastened to the bar pectus excavatum has become the preferred with a steel wire, while in group 2 polyglycolic technique in most centres. One of the most im- sutures were used. No differences in local dis- portant technical points for the final result is sta- comfort or postoperative pain were observed be- bilisation of the bar, usually obtained by one or tween the groups. The LactoSorb® stabiliser was two metal stabilisers. Recently, long-term ab- palpable for at least 6–9 months, and progres- sorbable stabilisers have become available (Lac- sively disappeared at 9–12 months. In group 1 toSorb®, Biomet, Jacksonville, FL, USA). Made of we observed 6 local complications. In particular, poly-L-lactic and polyglycolic acid, they have two patients presented with infection, one of been introduced with the aim of reducing local them associated with a skin lesion and opening discomfort and making removal of the bar easier.
over the metallic stabiliser (revision of the wound Their efficacy for the stabilisation of the bar has was performed). Another patient developed a not been proved yet. In this paper we compare thoracic wall haematoma after suffering a trauma the surgical outcome in two groups of patients, over the metallic stabiliser, 13 months after oper- one treated with metallic and the other with ab- ation. Three patients developed a seroma. In group 2 we observed 3 subcutaneous swellings Material and Methods: A total of 280 patients at the site of the LactoSorb® stabiliser at 6, 8 and underwent pectus excavatum repair using a Nuss 9 months after the operation. We did not observe technique in two centres. In 194 patients (group either skin lesions or infections. In the group with 1), operated on since 2001, the metallic stabiliser metallic stabiliser, 3 patients (1.5 %) had bar dislo- was used. In 86 patients (group 2), operated on cation, while we did not observe bar instability in since February 2007, the LactoSorb® stabiliser the group with LactoSorb® stabiliser.
was preferred. We compared both groups in Conclusions: LactoSorb® stabiliser is safe and ef- terms of surgical details, local symptoms or com- fective for stabilising the bar in pectus surgery.
plications, and bar instability rate.
We suggest its routine use as it appears to be less traumatic and could make bar removal easier.
Recently, absorbable stabilisers have become available (LactoSorb® stabiliser, Biomet, Jackson- Bar displacement is one of the most serious com- ville, FL, USA). They are made of poly-L-lactic and plications of minimally invasive repair of pectus polyglycolic acid, and are completely absorbed by excavatum (MIRPE) [7, 8]. Many techniques have 12 months. This material has been used for many been proposed to increase the stability of the bar years in other kinds of surgery (craniofacial, or- [2, 3,10]. Most surgeons fix the bar with the help thopaedic surgery), and has been proven to be of one or two metallic stabilisers [4, 6]. At the safe in children [1]. The absorbable stabiliser was time of bar removal, the metallic stabiliser has introduced in pectus surgery with the aim of re- to be dissected and detached from the bar; in ducing local complications and discomfort, and cases with a bilateral stabiliser two incisions making bar removal easier. In cases requiring bi- lateral stabilisation the double incision is avoided.
Torre M et al. Absorbable Stabilisation of … This document was prepared for the exclusive use of Michele Torre. Unauthorized distribution is strictly prohibited.
The efficacy of the LactoSorb® stabiliser for the stabilisation ofthe bar has not been proved yet. The aim of our paper was tocompare two groups of patients, one treated with metallic andthe other with absorbable stabilisers.
This is a retrospective study on patient series from two centreswhich have used MIRPE and the Nuss technique [6] since 2001and 2005, respectively. The technical details for stabilisationare the same for both centres: one stabiliser on the left, 4stitches between the bar and the adjacent ribs on the right.
The LactoSorb® stabiliser has been used in both centres since2007. Once introduced, in one centre it was used in all patients;in the other centre, the LactoSorb® stabiliser has been used in allpatients under 15 years of age, while the metallic stabiliser was were passed through the holes of the stabiliser fixing it to the still preferred for patients over 15 years of age (considered at pectoral muscles. This manoeuvre was easier in patients in greater risk of destabilisation). The LactoSorb® stabiliser has the group 2, because the surgeon was able to see the needle through same shape and size as the metallic one, it has the same holes No differences were observed between the groups with regard to All patients operated with MIRPE in both centres were consid- postoperative pain or hospitalisation. In both groups, pain was ered. Patients were divided into two groups. Group 1 (metallic managed during the first three days by a peridural infusion of stabilisation) included all patients in whom stabilisation was fentanyl and levobupivacaine, associated with intravenous bo- achieved with a left-sided metallic stabiliser (172 cases) and a luses of paracetamol and/or ketorolac. After the fourth day, only minority of patients (22 cases) at the beginning of our experi- oral paracetamol and codeine were given. Pain was evaluated ence who underwent stabilisation on both sides. The total num- with a pain numeric score from 1 to 10, and analgesia doses were ber of patients included in group 1 was 194.
adjusted accordingly. None of the patients in both groups re- Group 2 (LactoSorb® stabilisation) included all patients operated ported significant (requiring medication) local discomfort.
on since February 2007 in one centre and since March 2007 in The LactoSorb® stabiliser was palpable under the skin for 6–9 the other, in whom stabilisation was achieved by an absorbable months. After approximately 3 months it started to change its LactoSorb® stabiliser on the left side. None of the patients in this shape and became slightly mobile. At 6–9 months the stabiliser group received bilateral stabilisers. The total number of patients was progressively less palpable and between 9 and 12 months it included in group 2 was 86. Two bars (and two stabilisers) were inserted only in very selected cases (4 patients in each group), Local complications were reported in 6 cases of group 1 (3 %).
when one bar alone was unable to correct the thoracic defect.
Wound infection was observed in 2 cases. In one of them (a very The following were evaluated for both groups: technical details, slim 13-year-old boy) the skin over the metallic stabiliser started discomfort associated with the presence of the stabiliser, local to damage and opened at 2 months after the operation. Three complications, instability rate. In all patients of group 2 the bar weeks after wound revision, the skin opened again; a Goretex is still in site, so we could not compare bar removal between the sheet was then placed over the metallic stabiliser and the skin was closed; no other troubles were observed. Another patient Student t-test was used for statistical analysis to compare the developed a haematoma of the thoracic wall at the site of the parameters of the two groups (age of the patients, pain score, stabiliser after a local trauma, at 13 months from the operation.
Three patients developed a seroma (two of them with bilateralmetallic stabilisers).
In group 2 we did not observe any infections. Three patients (3.5 %) developed a subcutaneous collection at the site of the sta- biliser at 6, 8 and 9 months from the operation, respectively. We MIRPE according to Nuss [5] was performed in a total of 280 pa- tried to puncture it: in two of them we obtained few ml of fluid tients in the two centres. In group 1 (194 patients with metallic (culture examination was negative), in the third case no free stabilisation) the follow-up ranged from 6 to 87 months, with a liquid was collected. In all of these cases the absorption was In group 2 (86 patients with LactoSorb® stabilisation) the mean The bar was instable in 3 cases (1.5 %) of group 1, while none of follow-up was 12 months, with a standard deviation (SD) of 4.7, and a range from 5 to 20 months. The mean age of group 2 pa-tients was 15.5 (3.4 SD), and ranged between 6 and 22 years. Nostatistical differences were found between the groups regarding The technical details of the stabilisation were similar for both The lateral stabiliser has been demonstrated to be a very effec- groups. The metallic stabiliser was fastened to the bar with a tive tool which contributes to the stability of the bar after pectus steel wire, while the LactoSorb® stabiliser was secured with a repair [4, 5]. However, metallic stabilisers can become a source polyglycolic suture. In both groups other absorbable stitches of trouble, and some authors prefer not to use them. An in- Torre M et al. Absorbable Stabilisation of … This document was prepared for the exclusive use of Michele Torre. Unauthorized distribution is strictly prohibited.
creased incidence of wound complications (dermatitis, seroma, In conclusion, this is the first report in which the results of ab- infections) associated with the use of local stabilisers has been sorbable stabilisation are shown. The LactoSorb® stabiliser is safe and as effective as the metallic stabiliser in fixing the bar.
The introduction of a new absorbable stabiliser (LactoSorb®) had We suggest the routine use of the LactoSorb® stabiliser, as it ap- the aim of reducing these complications and making bar remov- pears to be less traumatic and requires less dissection at the time al easier. This material has previously been used for a long time in humans without adverse effects; however one possible con-cern could regard the efficacy of a device which loses its strength and disappears within a few months. Although our results arepreliminary and a longer follow-up is required, the most impor- tant finding of the present study is the efficacy of LactoSorb® sta- 1 Barry L, Eppley. Use of resorbable plates in pediatric facial fractures.
biliser in fixing the bar. According to our data, it appears even su- J Oral Maxillofac Surg 2005; 63: 385–391 2 Hebra A, Swoveland B, Egbert M, Tagge EP, Georgeson K, Othersen Jr HB, perior to metallic stabilisers, but in our opinion this difference Nuss D. Outcome analysis of minimally invasive repair of pectus exca- was not significant, because the patients’ numbers and surgeons’ vatum: review of 251 cases. J Pediatr Surg 2000; 35: 252–257; discus- experience were different between the two groups. The efficacy of LactoSorb® in stabilising the bar over a longer period, despite 3 Hebra A, Gauderer MW, Tagge EP, Adamson WT, Othersen Jr HB. A sim- its progressive absorption after few months, could be explained ple technique for preventing bar displacement with the Nuss repair ofpectus excavatum. J Pediatr Surg 2001; 36: 1266–1268 by the formation of adhesions and calcifications around the bar.
4 Hosie S, Sitkiewicz T, Petersen C, Göbel P, Schaarschmidt K, Till H, Noat- Local complications were rare in both groups. One specific com- nick M, Winiker H, Hagl C, Schmedding A, Waag KL. Minimally invasive plication of the absorbable stabiliser was the subcutaneous col- repair of pectus excavatum – the Nuss procedure. A European multi- lection we observed in three cases during the process of absorp- centre experience. Eur J Pediatr Surg 2002; 12: 235–238 5 Nuss D, Croitoru DP, Kelly Jr RE, Goretsky MJ, Nuss KJ, Gustin TS. Review tion of the LactoSorb®. Actually this was clinically not particu- and discussion of the complications of minimally invasive pectus ex- larly relevant and culture examinations excluded infection. We cavatum repair. Eur J Pediatr Surg 2002; 12: 230–234 think that this fluid or semi-fluid collection may be due to the 6 Nuss D, Kelly RE, Croitoru DP, Katz ME. A 10 year review of a minimally dissolution and substitution of the LactoSorb® material during invasive technique for the correction of pectus excavatum. J Pediatr the absorption process, and therefore we consider it more as part 7 Park HJ, Chung WJ, Lee IS, Kim KT. Mechanism of bar displacement and of this process than as a true complication. In contrast, the me- corresponding bar fixation techniques in minimally invasive repair of tallic stabiliser probably contributed to the local complications pectus excavatum. J Pediatr Surg 2008; 43: 74–78 observed in group 1, in particular infections, opening of the skin 8 Petersen C, Leonhardt J, Duderstadt M, Karck M, Ure BM. Minimally in- vasive repair of pectus excavatum – shifting the paradigm? Eur Another specific advantage of the absorbable stabiliser was an 9 Saxena AK. Pectus bar removal after minimal invasive repair of pectus easier and faster dissection of the tip of the bar at the time of its excavatum: advantages of bar stabilizer anvil tool. Ann Thorac Surg removal. Actually, the dissection of the metallic stabiliser, often covered by scar tissue or bone, and detachment of the stabiliser 10 Uemura S, Nakagawa Y, Yoshida A, Choda Y. Experience in 100 cases from the bar, can be sometimes quite difficult and time consum- with the Nuss procedure using a technique for stabilization of the pec-tus bar. Pediatr Surg Int 2003; 19: 186–189 ing procedures, so that a new instrument has been introduced to 11 Watanabe A, Watanabe T, Obama T, Oshawa H, Mawatari T, Ichimiya Y, make these manoeuvres easier [9]. It is logical to expect an easi- Abe T. The use of a lateral stabilizer increases the incidence of wound er and less traumatic removal of the absorbable stabiliser, but trouble following the Nuss procedure. Ann Thorac Surg 2004; 77: Torre M et al. Absorbable Stabilisation of … This document was prepared for the exclusive use of Michele Torre. Unauthorized distribution is strictly prohibited.

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