Buffalo chest after minimally invasive repair of pectus excavatum for pectus excavatum: results of the Chest Wall International Group (CWIG) survey.

Background: The term "Buffalo chest" (BC) refers to a communication between the pleural cavities, a rare but potentially severe condition reported after minimally invasive repair of pectus excavatum (MIRPE) for pectus excavatum (PE). Literature highlights cases of life-threatening bilateral spontaneous pneumothorax (SP) in patients undergoing this procedure. Subpleural blebs are a frequent condition in adolescent populations and preventing related consequences should be advisable. This study aims to assess, through a survey, whether experts in pectus surgery consider Nuss repair a risk factor of BC and to explore recommendations to address this complication. Methods: An electronic survey including 29 questions on pre-, intra-, and post-operative management of PE patients, as well as knowledge and management of BC, was designed. The survey was distributed to surgeons affiliated with the Chest Wall International Group (CWIG) between March and September 2024. Results: Among the 62 responders, mostly experienced surgeons, fewer than half were aware of BC. Only 33% routinely adopted computed tomography (CT) scans to search for blebs prior to Nuss repair. Among the respondents, 42% had managed patients with spontaneous unilateral pneumothorax, and 18% had encountered cases of bilateral SP. Severe symptoms included dyspnea in 24% of bilateral pneumothorax cases, with two occurrences of cardiac arrest. While 45% of surgeons recognized BC as an underestimated condition, only 27% advocated for practical preventive measures. Conclusions: BC remains an underrecognized condition among pectus surgeons despite its potentially severe implications. Given the notable incidence of SP after Nuss repair, lung bleb evaluation should be integral to pre-operative assessment and the thoracoscopic treatment of blebs if present. A multicenter study is warranted to better understand the incidence, clinical consequences and the best treatment option to prevent and treat pneumothorax, particularly bilateral cases, after MIRPE.