pectus_excavatum(1)Pectus excavatum is an indentation of the chest. Other names include funnel chest, concave chest, or simply pectus. Pectus is the most common deformity of the chest wall and is seen in up to 0.8% of the population (including mild cases).  It is more common in boys than in girls, by about a 5:1 ratio. Mild pectus excavatum is treated with exercise while moderate and severe deformities are candidates for surgical repair. A common misconception is that pectus abnormalities are merely a cosmetic issue. As a result, people frequently go untreated. In severe cases, the condition may compromise heart function, especially during exercise or exertion.  Mild lung impairment may also bee seen.  Many patients experience shortness of breath and early fatigue upon attempting exercise.

A pectus excavatum evaluation includes surgical consultation, an MRI or reduced-dose CT scan of the chest, echocardiogram, pulmonary function tests, and extensive discussions with the patient and their families about the diagnosis and treatment options.  Exercise testing may also be helpful in some cases.

Severity of pectus excavatum is often graded using a pectus index, also called the Haller index. The Haller index is most frequently calculated using CT measurements of the internal transverse diameter of the thorax measured between the inside of the rib cage, divided by the shortest anteroposterior depth as measured from the internal aspect of the sternum to the anterior cortex of the closest vertebral body. This is done during expiration, as an typical “breath hold” CT or MRI may falsely reduce the index.  Most patients need an MRI or CT scan only if they are considered surgical candidates. An index >3.2 warrants repair if the patient is symptomatic.

Criteria for Surgical Repair of Pectus Excavatum

Two or more of the following criteria groups indicate that surgery may be your best option for treatment:

  1. Pectus index (Haller index) greater than 3.2
  2. Symptomatic, severe deformity with symptoms (symptoms include exercise intolerance, chest pain, lack of endurance, shortness of breath, asthma-like symptoms or asthma diagnosis, frequent upper respiratory infections, or scoliosis)
  3. Cardiac compression or displacement with mitral valve prolapse, murmur, or conduction abnormalities
  4. Restrictive or obstructive lung disease on Pulmonary Function Tests
  5. Pulmonary compression
  6. Failed previous repair

Some insurance plans have adopted an alternative criteria of functional impairment (one or more of the following):

  1. Total lung capacity (TLC) less than 80% of predicted
  2. Right ventricular compression
  3. Objective evidence of exercise intolerance (oxygen uptake/carbon dioxide production) by non-invasive studies (exercise echocardiogram or treadmill test)

Alternative Criteria

A multicenter trial published in a major journal of medicine suggests that all patients with significant pectus should be considered for repair. The article noted a very significant psychological impact of the deformity that resolved after repair. The abstact of this article is available by clicking on the following link: Surgical Repair of Pectus Excavatum Markedly Improves Body Image and Perceived Ability for Physical Activity: Multicenter Study.

Surgical Options for Pectus Excavatum

Two procedures are commonly used to correct chest wall anomalies:

Nuss Procedure – a minimally invasive surgery that involves reshaping the chest wall by passing a strong metal bar across the chest and under the sternum.

Ravitch Procedure – a surgical treatment that involves making an incision across the chest and removing abnormal rib cartilages

Length of Stay, Activity Restrictions:

Median length of hospital stay is 3 to 5 days depending on center, with a range of 3 to 14 days. Parents often ask about recovery time. Return to normal activity is highly variable. Most patients are on pain medicine for 2 to 6 weeks after surgery. Children cannot be on narcotic pain medicine at school, so this tends to be the limiting factor in recovery. The activity restrictions are: no contact sports for 3 months, no heavy lifting or wearing backpacks for 2 months,  running and swimming are okay at 6 weeks. Patient may get the incisions wet after 5 days. Patient may walk for exercise as soon as they are home.

Pain Control:

Pain control service at Phoenix Children’s Hospital will help manage and keep the patient comfortable post-operatively. This specialized service is composed of board certified pediatric anesthesiologists with special interests in pain control.

Infusion catheters (OnQ or Moog catheters) are placed at surgery in some patients to supplement post-operative pain control. Each type infuses a local anesthesia (ie lidocaine or bupivacaine) along the chest wall and helps decrease the patient’s narcotic needs.

Current management of pectus excavatum: a review and update of therapy and treatment recommendations. Jaroszewski D, Notrica D, McMahon L, Steidley DE, Deschamps C. Journal of the American Board of Family Medicine. 2010 Mar-Apr;23(2):230-9

Choosing the Best Surgeon for the Nuss Procedure

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