Pectus Excavatum

A 16-year-old male with pectus excavatumPectus excavatum is a malformation of the chest wall in which several ribs and the sternum grow abnormally, resulting in a caved-in, or sunken appearance. It is a relatively common congenital deformity and occurs more often in males than in females. Approximately 40% of pectus excavatum patients have one or more family members with the defect.

Often present at birth, the condition may also develop during puberty and can range from mild to severe. Although its causes are not completely understood, the condition is believed to arise from excessive growth of the cartilage connecting the ribs to the breastbone, which pulls the sternum inward.

Pectus excavatum can compromise lung and heart capacity, especially when it is severe, causing the patient to experience fatigue, shortness of breath, chest pain, and a fast heartbeat. In some patients, the proximity of the sternum and the pulmonary artery may cause a heart murmur. For ordinary everyday activities, a person with pectus excavatum may have no symptoms, but with rigorous exercise, symptoms often appear. Lung capacity may be curtailed because lungs are confined and cannot properly expand. During exercise, the patient compensates by engaging the diaphragm in breathing in order to enable the lungs to expand more and obtain adequate oxygen and carbon dioxide exchange for the demands of the body. The additional energy utilized for breathing in this manner contributes to fatigue. Patients with severe pectus excavatum often notice that they are incapable of similar levels of activity as their peers. This can be especially difficult for adolescents, who often withdraw from participating in sports or other high stress physical activities.

A CT scan of a 14 year old male with severe pectus excavatumIn addition to its more serious symptoms, pectus excavatum may have negative psychosocial effects in children and teenagers, who experience self-consciousness and difficult peer interactions stemming from their appearance. Often these patients avoid activities that expose the chest.

Multiple tools are used to diagnose the condition and gauge its extent, including:

  • Visual examination of the chest
  • Ausculation — analysis of sounds of the heart and chest to detect the condition's effect on heart and lung function
  • Electrocardiogram (ECG)
  • Echocardiogram (a noninvasive test that takes a picture of the heart taken with sound waves)
  • Pulmonary function testing (patient breathes into a mouthpiece connected to an instrument that measures the amount of air breathed over a period of time)
  • Chest X-ray
  • CT-scan
  • Haller Index: A measure of the extent of pectus excavatum by means of the CT scan. It is calculated by obtaining the ratio of the horizontal distance of the inside of the ribcage and the shortest distance between the vertebrae and sternum. A Haller Index of greater than 3.25 is generally considered severe (a normal Haller Index is 2.5).

Pectus Excavatum: Podcast by Lyall A. Gorenstein, MD » 

Surgical Treatment

The ideal age for surgical treatment of pectus excavatum is between 12 and 18 years. The goal of surgery to correct a pectus excavatum defect is to improve the patient's breathing, posture and cardiac function, in addition to giving the chest a normal appearance. This is typically accomplished by repositioning the breastbone. Surgical repair has excellent success rates, with cardiovascular and lung function return to near normal in the majority of patients. Our surgeons are able to treat most pectus excavatum patients — both adolescents and adults — using minimally invasive techniques.

Recovery after pectus excavatum repair varies depending on the patient's age and the amount of chest depression. Most patients leave the hospital within 3 to 5 days and can return to school or work within two to three weeks. Patients must avoid vigorous exercise for the first month after surgery, and contact sports for three months after surgery.

Nuss Procedure

X-ray of a 15 year old male after undergoing the Nuss procedure.The minimally invasive Nuss procedure is performed with general anesthesia. Performed using video-assisted thoracoscopic surgery or VATS, the Nuss procedure creates a horizontal passage underneath the sternum through two small incisions in the side of the patient's chest. A separate, small incision enables the surgeon to view the inside of the chest with the thoracoscopic camera. A convex bar known as the Lorenz pectus bar is specially shaped to fit the patient's anatomy, inserted through the passage, and then turned to push the sternum outward. The bar must remain in place for a minimum of three years while the chest contour re-forms to its new shape. The bar is removed as an outpatient procedure.

Many adults have undergone minimally invasive pectus repair with the Nuss procedure, which was originally developed for the repair of pectus excavatum in children. The results appear to be as good as with the modified Ravitch procedure (description follows below), which has been the traditional approach to repairing pectus excavatum in adults. 

Modified Ravitch Repair

The procedure is performed with the patient under general anesthesia.

Utilizing a horizontal incision, the modified Ravitch technique involves removing small pieces of deformed chest cartilage and repositioning the protruding ribs and sternum. To support the repaired chest architecture, titanium bars are secured to the ribs and sternum.

Previously, the supports used to keep the sternum in place needed to be removed after several years. The bars currently used are secured to the chest wall in such a fashion that they can remain permanently in place, thereby avoiding the need for a second operation.