Placement of pectus bar for pectus excavatum (also known as MIRPE or the Nuss procedure)

# Guidance
This document replaces previous guidance on minimally invasive placement of pectus bar (interventional procedure guidance 3).
Current evidence on the safety and efficacy of placement of pectus bar for pectus excavatum (also known as MIRPE  or the Nuss procedure) is adequate to support its use provided that normal arrangements are in place for clinical governance, consent and audit.
Placement of pectus bar for pectus excavatum should be carried out only by surgeons with cardiac and thoracic training and experience, who are capable of managing cardiac or liver injury, and where there are facilities for this.
This procedure should be carried out only by surgeons with specific training in inserting the device, and they should perform their initial procedures with an experienced mentor.# The procedure

# Indications and current treatments
Pectus excavatum is the most common congenital deformity of the sternum and anterior chest wall. The cosmetic disfigurement of pectus excavatum may sometimes be accompanied by impaired cardiac or respiratory function.
Surgery may be carried out in mid-to-late childhood, and includes open surgical repair involving subperichondrial resection of abnormal costal cartilages, transverse osteotomy and internal fixation of the sternum (the Ravitch procedure).

# Outline of the procedure
Placement of pectus bar for pectus excavatum is carried out with the patient under general anaesthesia. The procedure is performed through several small incisions on either side of the chest, and is usually carried out under visualisation by thoracoscopy.
After subcutaneous tunnelling, a curved steel (pectus) bar is inserted behind the ribs and sternum with its concavity facing anteriorly. The bar is then rotated through 180 using a 'flipper' device, so that its convexity faces anteriorly, pushing out the sternum and correcting the deformity. Sometimes two bars are used.
Various fixation techniques are used to keep the bars in place, including lateral stabilisers attached to the bars and ribs using wires and/or sutures.
Sections 2.3 and 2.4 describe efficacy and safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the overview.

# Efficacy
Data from a UK register for 260 patients recorded cosmetic appearance scores preoperatively (on a scale from 1  to 10 ) and postoperatively (from 1  to 10 ). Of 109 patients with preoperative scores and 119 patients with postoperative scores, the mean scores were 3.1 and 8.4, respectively (mean follow-up 369 days). A case series of 947 patients reported that of 521 patients who had the bar removed and had a follow-up of 2 years, 83% had an 'excellent' cosmetic result, 12% had a 'good' result, 2% had a 'fair' result (method of assessment not stated) and 2% had recurrence of pectus excavatum (absolute figures not stated) (follow-up 115 years).
In a survey of 45 patients, the mean patient satisfaction score for postoperative appearance was 4.1 (0.8) (on a scale from 1  to 5 ) at 54-month follow-up. The patients rated their self-esteem preoperatively as 6.3 (1.2). This score improved to 7.9 (0.8) after the procedure (on a scale from 1  to 10 ) (mean follow-up 54 months). When asked if they would have the operation again, the mean patient score was 9.1 (on a scale from 0  to 10 ).
In a survey of 43 patients who had either the Nuss procedure or the Ravitch procedure, there were no reported differences in health-related quality of life (assessed using the Child Health Questionnaire) or in physical and psychosocial quality of life (assessed using the Pectus Excavatum Evaluation Questionnaire) between the groups (mean follow-up 16 months).
The Specialist Advisers listed the key efficacy outcomes as cosmetic appearance and patient satisfaction.

# Safety
In 2 case series of 167 and 172 patients, each reported 1 case of intraoperative liver perforation. In 2 case series of 167 and 322 patients, each reported 1 case of intraoperative cardiac perforation. A case report described cardiac injury during surgery in all 4 patients resulting in 1 death.
The case series of 167 patients reported 15 cases of intraoperative rupture of the intercostal muscles (in older patients), 10 cases of haemothorax or haematopneumothorax and 7 cases of minor pericardial tears (follow-up not stated).
Data from the UK register reported perioperative adverse events in 9% (24/260) of patients and postoperative adverse events in 19% (49/260) of patients (follow-up 42477 days).
In 3 case series, bar displacements required surgical revision in 7% (50/668), 3% (11/322) and 2% (3/167) of patients, respectively (follow-up not stated).
In 4 case series and the UK register, pneumothorax occurred in 55% (369/668), 7% (24/322), 3% (5/172), 9% (15/167) and 2% (6/260) of patients, respectively.
The studies of 668, 322 and 172 patients reported pneumonia in 7, 3 and 3 patients; and pleural effusion in 5, 8 and 3 patients, respectively (follow-up not stated). The studies of 322 and 172 patients and the UK register data for 260 patients reported pericardial effusion in 8, 1 and 1 patients, respectively (timing of events not stated). In the study of 668 patients pericarditis was reported in 6 patients (timing of event not stated). The UK register reported 1 case of perioperative lower lobe collapse and 1 case of persistent air leak.
The retrospective case series of 863 patients reported metal allergies in 2% (19/863) of patients.
The Specialist Advisers listed adverse events as injury to the lungs, heart, mammary artery and liver; pericarditis; pericardial effusion; bar migration; pleural effusion; pneumothorax; haemothorax; infection; osteochondrodystrophy; pain; metal allergy; and anaesthetic complications.# Further information

# Information for patients
NICE has produced information on this procedure for patients and carers ('Understanding NICE guidance'). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedure guidance process.
It updates and replaces NICE interventional procedure guidance 3.
We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available.
Changes since publication
January 2012: minor maintenance.
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Clinical Excellence 2009.  All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
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