Minimally invasive repair of pectus excavatum: Analysis of the NSQIP database and the use of thoracoscopy

Background: The minimally invasive repair of pectus excavatum (MIRPE) has been widely accepted and has become a viable alternative to the open Ravitch technique. MIRPE has evolved over time with some advocating that a safe repair can be accomplished without direct visualization utilizing thoracoscopy. The MIRPE with and without a thoracoscopic approach has not been previously analyzed from a nationwide database to determine differences in safety and short-term outcomes. Methods: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) 2012–2015 database was used in identifying patients that had MIRPE using Current Procedural Terminology (CPT) codes and ICD-9CM/ICD-10CM postoperative diagnosis codes. Outcomes of interest were readmissions, reoperations, complications, cardiothoracic injury, operative time, and duration of hospital stay after surgery for MIRPE with and without thoracoscopy. Descriptive statistics, simple and multivariable logistic regressions, Fisher's exact, and Wilcoxon rank sum test were used to determine any differences in 30-day postoperative outcomes. Results: There were 1569 MIRPE cases included. 15.9% (N = 249) of MIRPE were done without thoracoscopy. There were no significant differences with the use of thoracoscopy compared to without thoracoscopy in the rate of readmissions (2.5 vs 4.8%; p = 0.06), reoperations (1.4 vs 2.0%; p = 0.57), postoperative complications (2.6% vs 3.2%; p = 0.52), and cardiothoracic injuries (0.2% vs 0.0%; p = 1.00). Unadjusted odds ratios (ORs) for readmission and reoperation comparing MIRPE with thoracoscopy to MIRPE without thoracoscopy were 0.51 (p < 0.05) and 0.71 (p = 0.50), respectively. Adjusted ORs were 0.49 (p = 0.04) and 0.71 (p = 0.50), respectively. There were no reported deaths, but two cardiothoracic injuries were recorded in the group with thoracoscopy. MIRPE with thoracoscopy was associated with longer operative time (mean 13.0 min; p = 0.00) and longer hospital stay (mean 0.37 days; p < 0.01) compared to MIRPE without thoracoscopy. No data were available for the severity of the pectus defect. Conclusion: MIRPE has a low adverse event rate with no difference in reoperations, postoperative complications, and cardiothoracic injuries with or without the use of thoracoscopy. There may be a higher rate of readmissions in the nonthoracoscopic group. While the technique used remains the surgeon's decision, the use of thoracoscopy may be unnecessary and is at an added cost. Type of study: Treatment study (retrospective comparative study). Level of evidence: Level III.