What is pectus excavatum?
This term refers to a chest wall deformity resulting in a sunken breastbone (sternum). It is sometimes called “funnel chest” and usually involves the lower half of the sternum. Although it is most common in the middle of the chest, it may move to one side, usually the right.
Are there special considerations for adults with pectus excavatum?
Although the majority of patients with pectus excavatum undergo repair during childhood, there are no contraindications for repair in the adult. As will be described below, both the open Ravitch and Nuss type of repair can be successfully performed in the adult with excellent results.
What causes pectus excavatum?
The cause is unknown, although most people with the condition have had it since birth or early infancy. It may occur as a result of uncoordinated growth between the ribs and the chest. If the ribs grow faster than the expansion of the heart and lungs (which push the sternum outward), then the sternum will be pushed inward. Once this has occurred, the deformity either persists or gets worse.
What effect does pectus excavatum have on the heart and lungs?
For normal day-to-day activities, there is no impact on heart or lung function. Most children and adults will have a lung capacity slightly below average but still within what is considered the normal range. However, the ability of the heart to pump effectively during strenuous exercise may not be normal. Several medical studies have indicated that the sternum may press on the heart enough that the heart cannot fill with blood and pump it out as rapidly as with a normal chest. These same studies demonstrate that the pumping ability of the heart is improved following surgical repair of pectus excavatum.
However, there generally is no change in lung capacity following repair.
What are the symptoms of pectus excavatum?
The symptoms of pectus excavatum generally fall into three categories:
- Pain. It is not clear what causes the pain. It may have something to do with the way the pectoral muscles cross the chest to attach to the ribs and breastbone. The pain usually is not severe or long lasting when it occurs.
- Decreased exercise tolerance. This is probably related to the effect of the breastbone deformity on the heart as previously mentioned.
- Appearance. Many of those with pectus excavatum are very unhappy with the way their chests look. Whenever the chest is exposed (such as when swimming), it is common for other children to notice this and comment on it or make fun of the appearance. This may cause enough uneasiness that a child alters his or her behavior. The child may no longer want to go swimming, won’t shower with others during gym class, change clothes away from other children and avoid other activities that may call attention to the deformity. Some children are significantly affected by this and may withdraw socially to some degree. Such psychosocial problems can also persist into adolescence and adulthood.
Should children (or adults) with pectus excavatum have it repaired?
Repair of pectus excavatum is not recommended unless the patient has symptoms. These symptoms can fall into any of the three categories just listed. Some may consider the third category as “cosmetic” but, in reality, this deformity can have a profound effect on a child’s self-image.
Most patients do not need or desire an operation after they have had a chance to talk over the implications of this condition.
What is the operation like and what are the complications?
The operation involves removal of the ends of the ribs as they attach to the sternum in the depressed area. The lining membrane around the rib is left in place. The sternum is then broken horizontally at the point where it turns downward and is straightened out. It is held in this position using stitches, the adjacent ribs and usually a metal bar or strut that goes under the sternum to keep it in an outward position. This all takes place under the skin. This operation generally is referred to as the Ravitch procedure, named for the surgeon who developed it.
Like any operation, there is some postoperative pain, which is treated with either intravenous painkillers or an epidural catheter. An epidural catheter is frequently used for women undergoing childbirth for relief of labor pains. Usually, the patient is given oral pain medicines by the third day following the operation.
There have been very few complications of this operation. There have been no instances in which the patient required a blood transfusion, although a sample of blood is taken as a precaution. Infection is rare, as well. Occasionally, a patient develops a fluid collection under the skin requiring removal with the use of a syringe.
What other types of operations or treatments are available?
Although there are some advocates for a variety of braces, there is no evidence that these slow the progression of the chest deformity, nor do any of these improve it. There is no harm in trying this approach, but it may be uncomfortable.
The Nuss procedure has become more popular over the last 10 years. This operation has been described generally as “minimally invasive.” An incision is made on each side of the chest wall. A bar is bent into the desired shape of the chest wall. A large surgical clamp is passed through one side of the chest, under the sternum and out the other side. The bar is pulled through using the clamp with the curve of the bar in the opposite direction. It then is flipped over and, in the process, bends the sternum outward, stretching the ribs as it does so. The bar is left in place for several months or years. A comparison of the Nuss minimally invasive procedure and the Ravitch procedure, published in the Journal of Pediatric Surgery, shows no advantage for the Nuss procedure.
Another procedure that has been used for pectus excavatum involves detaching the sternum from the ribs and flipping it over. This has not been as successful as the other procedures that have been described.
What can the patient do after going home from the operation?
The usual hospitalization is 3 or 4 days after the operation. Activities are restricted. There can be no lifting or athletic activities for several weeks while the ribs are growing back. In general, the recovery process takes about 6 months. Children can return to school in two weeks, but cannot participate in gym class for two months and adults generally can return to normal activity but should avoid strenuous exercise. The metal bar or strut placed at the time of repair is removed within six months after the operation. This removal is a minor procedure that does not require overnight stay in the hospital. Once recovery is complete, normal activities including sports can be resumed without restriction.
What is the best operation for pectus excavatum?
Although there is a theoretical appeal to a minimally invasive operation, the Nuss procedure really may not fall into that category. Patients generally stay in the hospital longer than with the Ravitch procedure and require narcotic pain medication longer, although those differences are small. The advantage of the Nuss procedure is that children can resume normal activities sooner because the chest wall is still intact. The ribs must grow back for complete chest wall stability to occur with the Ravitch procedure, and that may take six months to occur. The likelihood of recurrence of the chest deformity after the Nuss procedure has been slightly greater than with the Ravitch procedure. There have been ongoing modifications of the Nuss procedure to improve the results and eliminate complications, some of which have been life threatening. The Nuss procedure, while initially developed for children, can also be performed in adults.
What are the long-term results of operation for pectus excavatum?
A number of studies have been performed after the repair of pectus excavatum. The recurrence rate with the Ravitch procedure is very low (1-2%). As far as symptoms are concerned, the results can be evaluated on the basis of the specific symptoms before the operation:
- Pain. Of all patients who undergo the operation because of pain, about 40-50% are improved.
- Exertional symptoms. When patients feel that they don’t have the same endurance as other children, about 60% are improved after repair.
- When this is the major complaint, 95% of patients are happy after the operation. As with any operation, a surgical scar will be present.
Benjamin Kozower, MD, MPH, is director of the Adult Pectus Excavatum Clinic.