Pectus Excavatum and CarinatumWhat are pectus deformities?Approximately one in every 600 persons have an abnormal overgrowth of the lower costal cartilages between the ribs and sternum which pushes the sternum inward (excavatum) (85%) or outward (carinatum) (15%). Persons with excavatum also often have a narrow chest.
The scar seen on the right is what is used with an open approach to the defect. What problems do pectus deformities cause?In addition to the unattractive appearance, pectus excavatum usually displaces the heart into the left chest and limits full lung expansion. Importantly, pectus deformities, in the vast majority of cases, cause no physical or medical problem. However, an occasional child may experience considerable decrease in stamina and endurance during exercise, with shortness of breath. Occasionally, a child may experience pain or discomfort in the lower chest. Will the pectus deformity improve with time?Pectus deformities usually become more severe during adolescent growth years and remain the same after age 18 years throughout life. Body building exercises will not alter the ribs and cartilage of the chest wall. Pectus deformity repairConventional Approach:The surgical technique for repair has improved greatly during the past 25 years. The abnormal three to five cartilages on each side of the lower chest are removed while carefully preserving the covering periosteum. The sternum is elevated to the desired position and is supported by a thin metal bar that is attached to a rib on each side. The periosteum will form new cartilage and become solid in the normal position over a several weeks. The hospital stay averages 3 days. Blood transfusions are very rarely necessary. Most patients return to school or work within 2 weeks. Heavy physical activity is limited for 2 to 3 months. The sternal bar is removed on an out-patient basis in 6 months. Thereafter, the patient may participate in vigorous physical activities, including body contact sports. This conventional approach has excellent cosmetic results and a very good long-term follow up shows a sustained repair in most children. Nuss Procedure:Recently, a newer approach to pectus excavatus has been used. This entails the placement of a bar under the sternum, without the need for removing abnormal cartilages. This results is virtually no blood loss, a shorter operating time and a very cosmetic scar. The procedure is shown below, but may not be ideal for some patients. Those with a pectus carinatum and some older children are not candidates for this procedure.   This figure shows the bar outside of the patient at the beginning of the case. Note the size of the bar, and how the it conforms to an ideal shape of the chest. This figure shows the bar passing under the sternum. Once past, the bar is rotated which pushes the sternum into a correct position. Typically, the bar remains in this position for approximately 2 to 3 years. Although generally well tolerated, this procedure does require the child to be on significant pain medication in the postoperative period. Occasionally, the bar may become displaced (rotates down), and this will require a minor surgical procedure to replace the bar in a correct position. How frequent are complications?Complications are uncommon, and rarely of serious nature. Fluid in the wound, mild hyperthrophy of the scar, air in the chest (pneumothorax) occurs in less than 10%. Recurrence of the pectus deformity is seen in about 1% of patients. What tests should be performed before considering surgery?A routine chest X-ray is all that is necessary for most patients and will permit calculation of the pectus severity index. An EKG or ECHO study is helpful only if your pediatricians notes a heart murmur or if there is known heart disease. Additional studies, e.g. CT scan, pulmonary function tests are expensive and do not influence the decision for surgery. What are the long term results following repair?More than 96% have considered the result very good to excellent. Both patients and parents are among the most gratified of any patients that require any type of operation. The best results are obtained when physicians who do the procedure on a frequent basis perform the operation. What is the best age for operation?The operation is technically easiest to perform and the recovery is faster in preadolescent children; however, almost half of the patients undergoing operation are teenagers. During the past few years several adults over the age of 21 years have undergone repair. How should we decide whether to have an operation?Discuss the options thoroughly with your family, physicians who are very familiar with the condition, and with patients who have undergone the operation in the past. Most patients who have undergone the repair of a pectus deformity are very pleased to speak to others about their experience. Postoperative CareThis surgery entails the placement of a surgical steel bar under the sternum. Because of this surgery the following restrictions apply:
Reference and source of surgical figures:
Suggested readings authored by the University of Michigan, Section of Pediatric Surgery
This information is provided by the University of Michigan Department of Surgery, Section of Pediatric Surgery and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. For additional health information, please contact your health care provider or our offices. |
