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Eur J Cardiothorac Surg 2006;29:1-5
© 2006 Elsevier Science NL

Nuss procedure improves the quality of life in young male adults with pectus excavatum deformity

George Krasopoulos, Michael Dusmet, George Ladas, Peter Goldstraw *

Royal Brompton Hospital, Department of Thoracic Surgery, Sydney Street, London SW3 6NP, UK

Received 9 March 2005; received in revised form 5 September 2005; accepted 7 September 2005.

* Corresponding author. Tel.: +44 20 73518558/9; fax: +44 20 73518560. (Email: P.Goldstraw{at}rbh.nthames.nhs.uk).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Objective: The Nuss procedure is a minimally invasive pectus repair. This study represents an attempt towards exploring the changes in quality of life and overall satisfaction in young male adults who underwent a Nuss procedure. Methods: We have included 20 male patients with a median age of 18 years (range: 14–37 years). We have used two specific questionnaires: the two-step Nuss evaluation Questionnaire modified for Adults (NQ-mA) and a new Single Step Questionnaire (SSQ). The data was analysed using Wilcoxon signed rank test to determine statistical significance of differences, with a <0.05 level of significance. Spearman's correlation coefficient was used to assess the correlation between the answers. Results: The primary indication for surgery was cosmetic. Both questionnaires were adequate to measure disease-specific quality-of-life changes after surgery and were able to confirm the positive impact of surgery on both the physical and the physiological well-being of young adults. Statistical analysis of the scoring of the individual questions and the total score of individual patients revealed a statistically significant improvement (p < 0.05) following surgery. The SSQ had a highly significant correlation to the NQ-mA questionnaire (correlation coefficient = 0.682, p = 0.001). Overall, the SSQ revealed a statistically significant improvement (p = 0.001) in self-esteem and a high level of satisfaction following the Nuss procedure. Only two patients fell into a low satisfaction group. Conclusion: The Nuss procedure has already been shown to have a positive impact on both the physical and psychosocial well-being of children who are suffering from pectus excavatum deformity. We have shown a similar positive impact in young male adults, in the short term.

Key Words: Pectus deformity • Nuss procedure • Quality of life • Outcome


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Pectus excavatum is the most common congenital deformity of the sternum and anterior chest wall. It occurs in 1 of 1000 live births, with a 3–4:1 male predominance [1]. Although most patients have no cardiovascular or respiratory problems, the cosmetic disfigurement can cause a serious loss of self-esteem and affect social behaviour. As a consequence a proportion of patients with this condition pursue surgical correction for what is essentially a cosmetic problem.

Until recently the Ravitch procedure (with all its modifications) represented the only reliable technique for correction, giving good long-term cosmetic results [2]. The development of the Nuss procedure [3] and techniques using customised silicon implants [4] represent less invasive options. However, the long-term results of these new techniques are only now emerging. The Nuss procedure is a video-assisted, minimally invasive technique that offers a less traumatic procedure with preservation of the costal cartilages. The cosmetic result, even in adults, appears to be satisfactory. The procedure has been shown to be safe [5,6]. Wide access to information via the Internet has led to many adult sufferers seeking surgeons who undertake this appealing new method.

This study assesses the effect of the Nuss procedure on the quality of life and overall satisfaction in young adults. For this purpose, we have used two specially constructed questionnaires; one that we have devised, as well as the questionnaire that has been developed and validated by Dr Nuss's team.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 5. Conclusions
 References
 
We have included all 20 young male adults who underwent a Nuss procedure at the Royal Brompton Hospital over a 24-month period. We had no female patients or children treated in our institution for pectus excavatum during this period of time. Although the primary indication for surgery was cosmetic in every case, two of the patients also had signs of cardiac compression by the deformed sternum with an ejection murmur over the pulmonary valve. Further, two patients complained of shortness of breath on exertion with occasional sternal pain.

Sternum–vertebral ratio indices do not form part of our pre-operative assessment. We remain unaware at present of any correlation between pre-/post-operative (dis-)satisfaction and such indices. We therefore did not feel it would be relevant to include them in the pre- or post-operative assessment or into the analysis of the results of the patients included in this paper.

All patients were asked to complete the appropriate questionnaires regarding their pre-operative and post-operative condition. We administered the two-step Nuss Questionnaire modified for Adults (NQ-mA), and the new Single Step Questionnaire (SSQ) that we developed.

The Nuss Questionnaire, first published and validated by Dr Nuss and his team [7] was applied to a paediatric population (patients and their parents) and was used to assess the effect that this procedure had on physical and psychosocial functioning. We had to modify this questionnaire for use in adults to develop the NQ-mA (Table 1 ). In addition, we reversed the scoring of the first three questions from the original Nuss Questionnaire because we believed that this would enable us to better assess the effect of the operation on the patient's condition. This change also allowed us to summate the scores for each individual question to create a total score for each patient.


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  		Table 1. Nuss Questionnaire modified for Adults and the median values per question obtained
 
In parallel we also developed a new Single Step Questionnaire in an attempt to provide a simpler assessment that was more relevant to the young adults under investigation (Table 2 ). The SSQ was designed in such a way that the degree of satisfaction from the operation was assessed not only by a single specific question (question 14 in the NQ-mA), but also by the overall obtainable score. Any aggregated score above 41, where the maximum score was 84, was considered to be a satisfactory outcome. During the design and development of the SSQ we consulted the psychology department from our institution.


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  		Table 2. Single Step Questionnaire and the median values per question obtained
 
The SSQ was assessed in a test–retest reliability study (five patients), with approximately 2 weeks between the first and the second administration, with statistically significant correlation (Fig. 1 ). The Spearman's correlation coefficient for the total scores was 0.975 (p = 0.005) and for the median of each of the questions was 0.915 (p < 0.0001). This test–retest reliability study had proven the ability of the SSQ to provide reproducible results and allowed us to proceed into the formal administration of the questionnaire to all who underwent Nuss procedure in our institution.


Figure 1
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  		Fig. 1. Test–retest reliability study for five patients. The medians for the individual SSQ questions demonstrate a Spearman's correlation coefficient of 0.915 (p < 0.0001).

 
All patients were interviewed about their pre-operative condition using the NQ-mA questionnaire; 10 of them before their operation date and 10 after their operation date. There was no difference in their responses to the NQ-mA questions (correlation coefficient of 0.088, p = 0.001), therefore, their answers were further analysed as a single group; the pre-operative NQ-mA. All patients were also interviewed at 5 months post-surgery (NQ-mA and SSQ). The questionnaire was administered by a non-medically qualified research assistant, who was blinded to the development of the questionnaires and to the end points of the study.

We analysed the results from the SSQ and compared the results with those obtained by the NQ-mA test, which we considered as an adequately validated reference questionnaire. We used Wilcoxon signed rank test to determine statistical significance of differences, with a <0.05 level considered as significant. Spearman's correlation coefficient was used to assess the correlation between the answers received on the test–retest study, the correlation between the total scores obtained from the post-operative NQ-mA and the SSQ, and finally, the correlation between the net gain in total scores from the NQ-mA and the SSQ. Spearman's correlation coefficient value of 1 indicates complete agreement.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 5. Conclusions
 References
 
All 20 patients were male, with a median age of 18 years (range: 14–37 years) at the time of operation. They all underwent a conventional video-assisted Nuss procedure (Fig. 2 ). A single metal bar was used in 19 patients and 1 received two bars.


Figure 2
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  		Fig. 2. Pre-Nuss correction (A) and post-Nuss correction (B) of pectus excavatum deformity.

 
The median in-hospital stay was 6 days (range: 3–10 days). The post-operative complications that were recorded included: troublesome pain requiring maximum analgesia in nine patients; a small apical pneumothorax in seven patients; return to theatre for evacuation of post-chest drain removal haemothorax in one patient; a pleural effusion in one patient; superficial wound infection around a stabiliser in 1 and a protruding stabilising wire which had to be removed in 1 further patient. All pneumothoraces resolved spontaneously within 24 h. The haemothorax was cause by bleeding from an adhesion between the apex of the lung and the thoracic cavity that had been avulsed during the removal of the chest drain. It was successfully drained using VATS and did not compromise the rehabilitation of the patient. The pleural effusion and the superficial wound infection did not require re-intervention and they were both treated conservatively.

Analysis of the median scores obtained for each question and the total score of the individual patients in the NQ-mA revealed a statistically significant (p = 0.001) improvement following the operation (Figs. 3 and 4 ). NQ-mA domains for social function and self-esteem (questions 1–13) demonstrated a highly significant improvement following surgery (p = 0.001–0.008). NQ-mA domains for physical condition (questions 14–16) showed a statistically significant improvement only for the degree of dyspnoea (question 15, p = 0.005).


Figure 3
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  		Fig. 3. Changes in medians for the individual NQ-mA questions demonstrate a statistical significant (p = 0.001) improvement following the Nuss correction.

 

Figure 4
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  		Fig. 4. Total scores obtained per patient for NQ-mA demonstrate a statistical significant (p = 0.001) improvement following the Nuss correction.

 
The total scores obtained with the SSQ showed significant correlation with the total scores obtained from the post-operative NQ-mA, with a Spearman's correlation coefficient of 0.682 (p = 0.001).

The total scores obtained from the SSQ were also significantly correlated to the net gain in the total scores (post-operative value – pre-operative value) obtained from the NQ-mA, with a Spearman's correlation coefficient of 0.527 (p = 0.017).

Overall, the SSQ revealed a high level of satisfaction (Fig. 5 ) following the Nuss procedure (median for question 14 = 5, mean total score = 65, limits: 49–75). Only two patients were assigned in the low satisfaction zone, with a total score between 41 and 52.8 (poor satisfaction cut-off point = average of the 30% lower scores = 52.8).


Figure 5
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  		Fig. 5. Total scores per patient for the SSQ. Only two patients were assigned in the low satisfaction zone (total score lower than 52.8 but higher than 41).

 
When the patients were questioned about changes in their self-esteem through SSQ-questions 8 and 9 there was a statistically significant improvement with surgery (p = 0.001). We subtracted the median score for SSQ-question 9 from that for SSQ-question 8 to assess the net gain in self-esteem. This revealed an increase of 4 points (range: 1–9) in this evaluation.

We attempted to assess the impact of surgical wounds on the overall cosmetic result using our SSQ. It was evident (question 6) that most of our patients (13/20) were very satisfied with their scars, scoring maximum points. Three patients had scored 2, revealing a degree of concern regarding their scars. None of the patients was really disturbed (score = 1) by the appearance of the surgical scars.

The awareness that patients might suffer having a metallic bar and stabilisers restricting chest wall movement was also assesses through SSQ-question 13 and it was clear that all patients were conscious of the presence of these foreign bodies but did not consider them to be a major inconvenience (median 4). Only one patient expressed troublesome awareness of the bar (score = 2), and no patient found the bars excessively intrusive.

Almost all patients, 17/20 (85%), considered that they had made the right decision to have the operation. However, one patient (5%) felt that he would not make the same decision if given another chance and two (10%) were unsure.

The SSQ highlighted that pain was a major issue during the hospital stay. The median score for SSQ-question 10 was 2, indicating that even with maximal analgesia pain was a significant problem after this operation. Pain was well controlled after some weeks, and none of our patients were on analgesics 4–5 months after surgery.

Both questionnaires confirmed the positive impact that surgery had on physical and physiological well-being in these young adults. The SSQ was validated, assessing the level of satisfaction in a single step, simple and reliable manner.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
5. Conclusions
 References
 
We have shown that despite the short-term morbidity of this operation the Nuss procedure has a beneficial impact on the quality of life of these young male adults.

Although there are multiple individual, social and environmental factors that interact in creating one's own assessment of body image, we know that patients who are dissatisfied with their body image can experience an improvement in quality of life after receiving medical attention [8,9].

The initial report by Lawson et al. [7] highlighted the positive impact that Nuss correction of pectus excavatum could have on the physical and physiological well-being of a paediatric population. Roberts et al. [10] have also shown that this operation can also have an important impact on the patients’ perception of quality of life. Our study has shown similar benefits to self-esteem and in social behaviour for young adults who underwent Nuss correction. Statistical significance was reached despite the small number of patients, underlining the substantial and uniform improvement seen in these domains.

Unlike Lawson et al. [7], we were unable to confirm any significant changes in function other than subjective improvement in dyspnoea scores. This may indicate that correction in an adult population has no impact on exercise capacity or that improvement results from a willingness to undertake regular exercise and to train after cosmetic improvement.

There were no female patients in our study group. This was not because we had actively excluded them but because we had no adult female patients seeking to undergo pectus correction during the period of the study. As a consequence we cannot extrapolate our results to reflect the female population with pectus deformity who may undergo Nuss correction.

We have shown the SSQ to be a simple and valid method of overall assessment of benefit in adult male patients. It only requires to be applied once, as opposed to the NQ-mA, and it also takes into account changes in behaviour and self-esteem, issues such as the impact of surgical scars on the cosmetic result, short- and long-term pain and the awareness of having a metallic bar and stabilisers restricting chest wall movement. As this is an elective, primarily cosmetic procedure, we considered these issues to be important when requesting informed consent. Patients considered the cosmetic result to be highly acceptable but pain was considered troublesome during the early post-operative period. Although this was not a factor that dissuaded them from having the operation, it is an issue which we will seek to improve with our pain specialist team. We had not used epidural analgesia routinely, mainly because of the likelihood of neurological complications that were considered unacceptable in the setting of a purely cosmetic operation. This question will be reconsidered in the light of the findings of this paper.

We, like others [10], remain unsure about the long-term effect that surgery has on the patients’ own body image. The effects that we have demonstrated may be lost with time and longer follow-up is required. Any studies of the long-term results of the Nuss procedure in adults should extend some years after the removal of the bars. Until such data exists some clinicians may remain reluctant to offer the Nuss procedure to adults in need.

It remains our intention to undertake longer-term studies of this subject with a mean follow-up extended to 5 or more years, looking not only on the outcome but also on the satisfaction and overall improvement in the quality of life of the young adults with Nuss correction of pectus excavatum deformity. We report this early experience as we hope that other groups starting to use this new technique in the adult setting may find our results encouraging.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
References
 
The SSQ represents a single step, easy to use tool that appears well suited to measure quality of life and overall satisfaction in young male adults following pectus correction. The Nuss procedure has been shown to have a positive effect on both the physical and psychosocial well-being of children who are suffering from pectus excavatum deformity. We have shown it to have a similar positive impact in young male adults in the short term. Further studies are needed to verify the long-term effect after removal of the pectus bar.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 

  1. Molik KA, Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL. Pectus excavatum repair: experience with standard and minimal invasive techniques. J Pediatr Surg 2001;36:324-328.[CrossRef][Medline]
  2. Robicsek F, Fokin A. Surgical correction of pectus excavatum and carinatum. J Cardiovasc Surg (Torino) 1999;40(5):725-731.[Medline]
  3. Nuss D, Croitoru DP, Kelly Jr. RE, Goretsky MJ, Nuss KJ, Gustin TS. Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg 2002;12(4):230-234.[CrossRef][Medline]
  4. Horch RE, Springer O. Minimally-invasive endoscopic correction of funnel chest deformity via an umbilical incision. Aesthetic Plast Surg 2002;26(4):295-298.[Medline]
  5. Croitoru DP, Kelly Jr. RE, Goretsky MJ, Lawson ML, Swoveland B, Nuss D. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37:437-445.[CrossRef][Medline]
  6. Hosie S, Sitkiewicz T, Petersen C, Gobel P, Schaarschmidt K, Till H, Noatnick M, Winiker H, Hagl C, Schmedding A, Waag KL. Minimally invasive repair of pectus excavatum—the Nuss procedure. A European multicentre experience. Eur J Pediatr Surg 2002;12(4):235-238.[CrossRef][Medline]
  7. Lawson ML, Cash TF, Akers R, Vasser E, Burke B, Tabangin M, Welch C, Croitoru DP, Goretsky MJ, Nuss D, Kelly Jr. RE. A pilot study of the impact of surgical repair on disease-specific quality of life among patients with pectus excavatum. J Pediatr Surg 2003;38:916-918.[Medline]
  8. Cash TF, Fleming EC. The impact of body image experiences. Development of the body image quality of life inventory. Int J Eating Disord 2002;31:445-460.
  9. Lacey HJ, Birtchnell SA. Body image and its disturbances. J Psychosom Res 1986;30:623-631.[Medline]
  10. Roberts J, Hayashi A, Anderson JO, Martin JM, Maxwell LL. Quality of life of patients who have undergone the Nuss procedure for pectus excavatum: preliminary findings. J Paediatr Surg 2003;38:779-783.[Medline]



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