What is pectus excavatum?
Pectus excavatum, sometimes referred to as "funnel chest," is the most common congenital chest wall deformity. It is felt to be secondary to abnormal growth of the costal cartilages between the breastbone (sternum) and ribs. The abnormal growth of the cartilages causes the breastbone to appear sunken or, on some occasions, rotate to one side or the other. It usually involves the middle lower portion of the sternum and may worsen as the child grows.
What causes pectus excavatum?
Although the exact cause of pectus excavatum is unknown, 46 percent of patients have a family history of pectus excavatum. In addition pectus excavatum tends to affect males more often than females. This suggests that there are some genetic factors involved with pectus excavatum including male gender. Overall the incidence of pectus excavatum is reported to be 1 in 1000.
What problems does pectus excavatum cause?
In moderate and severe pectus excavatum, the heart can be compressed and displaced into the left chest. This may limit the amount of blood the heart can pump per beat. This may become evident when the patient exercises and his heart has to beat faster to compensate for this compression. In addition the defect may reduce the amount of air entering the lungs. This again can become evident during exercise when the patient feels that he cannot keep up with his peers secondary to shortness of breath. Other problems include pain as well as the psychosocial effects of having a deformed chest.
What are the symptoms of pectus excavatum?
- Exercise intolerance and shortness of breath: The overwhelming majority of children with pectus excavatum have some sort of exercise intolerance. They get short of breath or have lack of endurance when they exercise with their peers. A common scenario is that the parents notice their child cannot keep up with other children on sports teams, due to shortness of breath and decreased endurance with physical activity.
- Chest pain: This is usually intermittent and may or may not be associated with exercise. The exact etiology of the pain is unknown although two thirds of surgical patients with pectus excavatum have a history of chest pain.
- Psychosocial effects: Most children as they enter their teenage years are very self-conscious and concerned with their body image. Teenagers with pectus excavatum tend to be insecure about their chest wall deformity. This may cause them to alter their behavior in that they avoid physical education or activities that involve their shirt being off, such as swimming.
What are the treatment options for pectus excavatum?
For symptomatic pectus excavatum, surgical repair can be accomplished in one of two ways.
The classic approach, modified Ravitch, involves an incision made down the center of the defect. The deformed cartilages attached to the breastbone are then removed and a portion of the breastbone is cut allowing the breastbone to be moved forward into a more normal position. The breastbone is then secured with surrounding muscle and sutured. Some prefer to use a short metal bar or "strut" to help support the sternum.
The Nuss procedure has gained in popularity over the past 10 years. This is referred to as the minimally invasive pectus repair. This involves a small incision on each side of the chest. A small video camera is placed inside the chest cavity to guide the repair. A metal bar is then curved to match the contour of the patient's chest. One end is then placed through the small incision on the side of the chest, passed into the chest under the deformity and out the other side of the chest. The bar is then secured into place there by lifting the pectus excavatum defect out and into normal position. In severe deformities, frequently in older children and young adults, it often takes two of these bars placed at the same time. These bars stay in place two to three years.
How long will my child be in the hospital?
The average stay for a child who undergoes the Nuss procedure is approximately five days. Initially pain will be controlled with an epidural catheter. This is a catheter that goes into the back in order to give a constant infusion of pain medicine. After two to three days the catheter will be removed and the patient will be started on oral pain medications. By the time they are discharged from hospital they will be eating, walking, and comfortable with oral pain medication.
What complications are associated with the operation?
- Pneumothorax; Pneumothorax is an accumulation of air or gas in the pleural space. The majority of times this just requires observation and a follow-up chest x-ray. On occasion a chest tube may be required.
- Bleeding; This is an extremely rare complication of this procedure. Should it occur, a larger incision to open the chest would be required.
- Pleural effusion; Pleural effusion is when there is fluid around the lung. Most of the time this can be watched with chest x-rays. However, on rare occasion a chest tube or drain is required.
- Infection; Infection is rare with the operation. Antibiotics are given at the time of surgery and following surgery in hopes of preventing this complication.
- Bar displacement; As the child grows there is some risk that the bar could move. On rare occasions this would require reoperation to reposition the bar. With the most recent modification of the Nuss procedure, the incidence of bar displacement is less than 2 out of 100 patients.
- Pectus excavatum recurrence: The largest series in the literature reports a recurrence rate of approximately 5 percent. It is felt that this could be due to having the procedure done too early prior to their pubertal growth spurt and/or not leaving the bar in place long enough.
What tests are required for a pectus excavatum evaluation?
A thorough medical history and physical exam is required on every patient. A chest x-ray and chest CT scan is performed to assess the severity of the pectus as well as to evaluate the compression of the heart and lungs. An echocardiogram to evaluate heart function is often performed if surgery has been considered. In addition, if there is a history of exercise intolerance or shortness of breath, pulmonary function tests are often obtained.
This surgery requires insurance prior approval and can be denied if symptoms are not severe enough.
Who do I contact for further information or an appointment?
James E Davis, MD
Division of Pediatric Cardiothoracic Surgery & Transplantation
Tina Davenport, ARNP
For Appointment, please call Susan Crimmins, RN