Pectus bar removal - why, when, where and how.

Objective: Despite its less invasive nature, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. On the other hand, Pectus bar removal (PBR) is often considered a simple procedure and often scheduled in an outpatient setting. However, several studies report near-fatal complications not only during bar placement, but also during bar removal. The aim of our study was to clarify why a pectus bar should be removed, timing for removal, where PBR should be performed, and overall setup for safe removal.

Methods: A comprehensive review was performed in accordance with PRISMA guidelines, searching for articles published since 1998 in English. "Pectus bar removal AND (near-fatal) complications" were the applied terms. Inclusion criteria were articles reporting on the focus of PBR after MIRPE. Eligible study designs included (retrospective) case study series, case report and reviews. Full-text articles in which the technique in general was described were omitted.

Results: Recently published results of an online survey raised awareness about type and number of possible complications during PBR. Furthermore, our comprehensive literature review identified only a few, but serious complications during PBR.

Conclusions: PBR has a high safety profile but in rare cases may be associated with major complications such as life-threatening hemorrhage from various thoracic sources. This risk is higher in patients with a history of complex MIPRE. In an effort to decrease these complications we recommend bilateral opening of surgical incisions, unbending the bar and meticulous mobilization of the bar. To manage these complications if they occur, we recommend removal in a hospital setting with adequate resources and personal including cardiac surgeons. If the postoperative course is uneventful discharge on the same day is reasonable.