What is the treatment approach for pectus excavatum?

Treatment Approach for Pectus Excavatum

The minimally invasive repair of pectus excavatum (MIRPE), also known as the Nuss procedure, is the preferred surgical treatment for pectus excavatum due to its excellent outcomes, shorter procedural length, and superior cosmetic results compared to traditional open techniques. 1

Clinical Assessment

Physical Examination

• Evaluate the severity of sternal depression
• Assess for associated conditions:
  • Scoliosis (occurs in approximately 33% of individuals with certain syndromes) 2
  • Kyphosis 2
  • Marfan syndrome features 2
  • Body habitus (thin patients are ideal candidates for MIRPE) 2

Diagnostic Evaluation

• Chest CT scan to:
  • Quantify the severity of the deformity
  • Evaluate cardiac and pulmonary compression
  • Assess body habitus and chest wall anatomy 2
• Echocardiography to evaluate for:
  • Mitral valve prolapse (common association) 2
  • Other cardiac abnormalities 2
• Pulmonary function tests to assess respiratory impact

Treatment Algorithm

Non-surgical Management

• Indicated for:
  • Mild deformities without physiological or psychological impact
  • Patients with contraindications to surgery
  • Very young patients (can be observed until optimal surgical timing)

Surgical Indications

1. Physiological indications:

   • Cardiac compression with functional impairment
   • Pulmonary restriction
   • Exercise intolerance
   • Chest pain

2. Psychological indications:

   • Body image concerns
   • Psychosocial impact

Surgical Options

1. Minimally Invasive Repair (Nuss Procedure)

• First-line surgical approach for most patients 1

• Technique:

  • Thoracoscopic visualization
  • Small lateral incisions
  • Placement of a curved metal bar behind the sternum
  • Bar remains in place for 2-3 years while chest wall remodels
  • Bar removal as outpatient procedure

• Best candidates:

  • Children and adolescents (optimal age 12-16 years)
  • Symmetric deformities
  • Good chest wall flexibility

• Modifications for complex cases:

  • Asymmetric bars for eccentric deformities
  • Double bar technique for adults or severe deformities 3
  • Multipoint wire fixations to prevent bar displacement 3

2. Open Repair (Modified Ravitch Procedure)

• Consider for:

  • Severe rigid deformities
  • Failed Nuss procedure
  • Significant asymmetry
  • Older adults with less chest wall flexibility

• Technique:

  • Subperichondrial resection of abnormal costal cartilages
  • Sternal osteotomy
  • Internal fixation

3. Custom 3D Prosthetic Implants

• Consider for:
  • Primarily aesthetic concerns
  • Patients seeking less invasive options
  • Contraindications to other surgical approaches 4

Potential Complications

Nuss Procedure Complications

• Pneumothorax (7.5% of cases) 3
• Bar displacement (3.4% of cases) 3
• Pain (can be significant)
• Infection
• Hemothorax

Open Procedure Complications

• Larger scars
• Longer recovery time
• Chest wall rigidity
• Recurrence

Special Considerations

Timing of Surgery

• Optimal timing: early adolescence (12-16 years) when chest is still malleable
• Adults: can still undergo repair but may require modified techniques

Associated Conditions

• Marfan syndrome: requires comprehensive cardiovascular evaluation 2
• Scoliosis: evaluate for Chiari malformation which may be linked to scoliosis development 2
• Cardio-facio-cutaneous syndrome: may have additional musculoskeletal issues requiring multidisciplinary care 2

Postoperative Care

• Pain management protocol
• Activity restrictions for 6-8 weeks
• Bar remains in place for 2-3 years
• Regular follow-up to monitor for complications

The treatment of pectus excavatum has evolved significantly with the introduction of minimally invasive techniques. Patient selection and thorough preoperative planning are essential for achieving optimal outcomes and minimizing complications.