Surgical management of pectus excavatum in China: results of a survey amongst members of the Chinese Association of Thoracic Surgeons

Ruiqing Shi, Liang Xie, Gang Chen, Qi Zeng, Xuming Mo, Jiming Tang, Haiyu Zhou, Dongkun Zhang, Xiong Ye, Zihao Zhou, Dan Tian, Cheng Deng, Xiaosong Ben, Guibin Qiao


Background: At present, there are no randomized trial or higher levels of evidence than case studies to guide thoracic surgeons in the field of thoracic deformities, typically for pectus excavatum. This study investigates the current clinical practices amongst the Chinese Association of Thoracic Surgeon (CATS) members in order to seek potential consensus and divergence.
Methods: A web-based questionnaire was designed by a subgroup of CATS Pectus Excavatum Management Working Group and was sent to all of the CATS members. The questionnaire was composed of 27 questions concerning debatable sections, including preoperative evaluations, indications, timings of surgery, anesthesia and analgesia methods, rehabilitations.
Results: A total of 385 questionnaires were mailed to available CATS members. Moreover, 208 questionnaires were retrieved, of them 170 were finally available for analysis. Results of high consensus were extracted. Besides well-known factors such as complaints of symptoms, a moderate to severe deformity by physical exam, a Haller CT index >3.2, pulmonary function deviance, and cardiology evaluation abnormality, cosmetic requests and severe social-psychological problems from deformity come to be the most common reasons (17.34% and 56.89%) for PE patients’ demands for surgery, and also occupy high percentages (49.41% and 89.41%) in indications of surgery. Concerning CT scan, 3D reconstruction of the chest is performed additionally by two thirds (64.12%) of the investigated cohort. Two surgeons out of three (66.47%) responders consider the optimal age for surgery is 6–12 years old. After the Nuss procedure, the majority of responders (79.41%) agree on the removal of the bar 2–3 years after surgery. To deal with complicated or severe deformities, 84.71% of surgeons utilize the double bar or multiple bar techniques. The majority of responders (92.35%) prefer general anesthesia combined with intubation in PE surgery, as well as in the procedure of the Nuss bar removal (72.35%).
Conclusions: The survey reveals a remarkable consistency of practice patterns in several aspects. Adequate preoperative evaluations are needed. Cosmetic request and psychological discomfort from deformity are crucial indications for surgery. We had better perform PE surgery before patients’ puberty and bar removal 3 years after surgery. Several surgical skills are fully debated to enhance orthopedic effect and diminish complications. General anesthesia combined with intubation is considered as a standard maneuver. Surgeons now pay more and more attention to perioperative rehabilitations. The given results can be used as evidence in guiding clinical practice in circumstances where no evidence of higher levels exists, although divergences exist. Future studies, especially randomized trials, are needed to establish clinical practice guidelines for thoracic surgeons in PE surgery.