Who should patients with severe pectus carinatum be referred to for surgical evaluation?

Referral for Pectus Carinatum: Thoracic Surgeon is the Appropriate Specialist

Patients with severe pectus carinatum should be referred to a board-certified thoracic surgeon with expertise in chest wall deformities for surgical evaluation and management.

Background on Pectus Carinatum

Pectus carinatum (PC) is a protrusion of the sternum due to overgrowth of the costal cartilages. While less common than pectus excavatum, it appears to be more frequent than previously believed. The condition can have both physical and psychological impacts:

• Physical symptoms often include:

  • Exertional dyspnea and exercise limitation (93% of patients) 1
  • Frequent respiratory infections (58% of patients) 1
  • Chest discomfort (42% of patients) 1
  • Asthma (27% of patients) 1

• Psychological impact:

  • Body image concerns
  • Social anxiety and withdrawal
  • Reduced quality of life

Diagnostic Evaluation

Before referral, initial evaluation should include:

• Chest radiography as an initial screening tool 2
• CT scan for precise characterization of anatomy and degree of deformity 2
• Assessment of pectus severity score (width of chest divided by distance between sternum and spine)
  • Normal chest: 2.56
  • Pectus carinatum patients: average 1.73 1

Referral Pathway

When to Refer to a Thoracic Surgeon

Referral to a thoracic surgeon is indicated when:

1. The deformity is severe and symptomatic
2. There is progression of the deformity
3. The patient experiences significant physical symptoms (dyspnea, exercise limitation)
4. The deformity causes significant psychological impact affecting quality of life 2

Why a Thoracic Surgeon?

1. Specialized Training: Thoracic surgeons have specific training in chest wall deformities and their correction 3

2. Volume-Outcome Relationship: Higher-volume centers and specialists in thoracic surgery demonstrate improved perioperative outcomes and better long-term survival 3

3. Surgical Expertise: The American College of Chest Physicians guidelines specifically state that "surgeons with training and expertise in CHD should perform operations" for chest wall and related conditions 3

4. Multidisciplinary Approach: Thoracic surgeons typically work within multidisciplinary teams that can address all aspects of care 3

Treatment Options Available Through Thoracic Surgery Referral

A thoracic surgeon can offer:

1. Surgical correction options:

   • Modified Ravitch procedure: Subperiosteal resection of deformed cartilages, transverse osteotomy of anterior sternum with cartilage wedge insertion 1, 4
   • Minimally invasive approaches for select cases 5

2. Non-surgical management:

   • Bracing for mild to moderate cases, particularly in younger patients with flexible chest walls 2, 5
   • Physical therapy for associated musculoskeletal issues 2

Outcomes After Surgical Correction

Surgical correction by experienced thoracic surgeons has demonstrated:

• Excellent cosmetic results in 92% of patients 4
• Alleviation of respiratory symptoms and chest discomfort in virtually all patients 1
• Diminished exercise limitation 1
• Low complication rates (primarily minor issues like hypertrophic scarring) 1
• Short hospital stays (average 2.6 days) 1
• Very good to excellent long-term results in 98% of patients 1

Important Considerations

• Many physicians are unaware of the beneficial effects and low comorbidity related to surgical correction and therefore erroneously advise patients against the operation 4

• Patients with associated connective tissue disorders require comprehensive management and may need cardiovascular evaluation 2

• For patients with Marfan syndrome or other connective tissue disorders, cardiovascular management takes precedence over pectus repair 2

Conclusion

While many healthcare providers may underestimate the impact of pectus carinatum on patients' quality of life and physical functioning, the evidence clearly supports referral to a thoracic surgeon for evaluation and management. The thoracic surgeon can offer both surgical and non-surgical options with excellent outcomes and low morbidity.