Implementation of a safety protocol for removal of bars in the pectus excavatum

Extraction of bars during Minimally Invasive Repair for Pectus Excavatum (MIRPE) is susceptible to complications ranging from mild to severe. Objective: to compare the outcomes following the implementation of a Bar Extraction Safety Protocol (BESP) to determine its effectiveness in reducing complications.

Retrospective comparative cohort study. Inclusion criteria: Patients who underwent bar removal from November 2013 to March 2024, in whom BESP was implemented, compared with a historical cohort operated on previously. Protocol includes: a) Preoperative measures: during implantation, use of smooth bars, a minimum of two bars with lateral stabilizers, sternal elevation; pre-removal: chest X-rays. b) Intraoperative measures: bilateral incisions, bar straightening, and "safety string" maneuver. c) Postoperative measures: 24-hour admission to the pediatric intensive care unit (PICU) and post-removal chest X-ray. Complications were classified using the Clavien-Dindo (C-D) system, focusing on clinically relevant ones (C-D ≥ II). Statistical analysis was performed using the chi-squared test (Stata v16).

Sixty-seven patients were included; 62 were male. Mean age at surgery: 17 years (range 14-24). Thirty patients (43 bars) operated on pre-BESP, 37 (81 bars) post-BESP. Pre-BESP bars were serrated; post-BESP bars were smooth. Bar dwell time was 27 months (IQR 23-33) pre-BESP and 24 months (IQR 23-25) post-BESP. Hospital stay was 1 day in both groups (maximum: 16 vs. 4 days). Clinically relevant complications occurred in 20% of pre-BESP patients and 0% post-BESP (p=0.048).

Implementation of BESP significantly reduced complications after bar removal, improving safety during bar removal in the MIRPE.