What are the treatment options for Pectus excavatum?

Treatment Options for Pectus Excavatum

The optimal treatment for pectus excavatum depends on the severity of the deformity, associated symptoms, and patient age, with surgical correction recommended when there is cardiopulmonary compromise, significant psychological impact, or severe cosmetic concerns. 1

Clinical Assessment

• Evaluate for associated conditions:

  • Marfan syndrome features (aortic root dilation, ectopia lentis, wrist/thumb sign) 1
  • Mitral valve prolapse, which is commonly associated with pectus excavatum 2
  • Scoliosis, kyphoscoliosis, or other skeletal abnormalities 2

• Assess severity and impact:

  • Cardiopulmonary symptoms (dyspnea, exercise intolerance)
  • Psychological impact (body image concerns, social withdrawal)
  • Haller index measurement (CT ratio of transverse chest diameter to anteroposterior diameter)

Diagnostic Imaging

• Chest radiography: Initial screening tool to identify structural abnormalities of the sternum, ribs, and thoracic spine 2

• CT scan: Gold standard for evaluation of chest wall deformities 1

  • Allows precise characterization of anatomy and degree of deformity
  • Useful for surgical planning with 3D reconstructions
  • Calculate Haller index (severe typically >3.25)

• MRI: Superior for soft tissue evaluation 2, 1

  • Particularly valuable for post-treatment evaluation
  • Better demonstration of soft-tissue relationships

Treatment Options

1. Non-Surgical Management

• Appropriate for mild deformities without physiological compromise
• Options include:
  • Physical therapy for associated musculoskeletal issues
  • Vacuum bell therapy (external suction device)
  • Psychological support and counseling

2. Surgical Approaches

• Minimally Invasive Repair of Pectus Excavatum (MIRPE/Nuss Procedure) 3, 4

  • Current procedure of choice for most patients
  • Involves thoracoscopic placement of a curved metal bar behind the sternum
  • Bar remains in place for 2-4 years while chest wall remodels
  • Advantages: Shorter procedure time, smaller incisions, excellent cosmetic results
  • Complications: Pneumothorax (7.5%), bar displacement (3.4%) 4

• Modified Ravitch Procedure

  • Open surgical approach involving resection of abnormal costal cartilages
  • Preferred for severe asymmetric deformities or older patients with rigid chest walls
  • More invasive but may be more appropriate for complex cases

• Camouflage Techniques 5

  • Implantation of custom-shaped materials (e.g., porous polyethylene)
  • Less invasive option for mild to moderate deformities
  • Focus on cosmetic improvement rather than structural correction

Surgical Indications

Surgery should be considered when:

1. Cardiopulmonary compromise is present
2. Significant psychological impact affecting quality of life
3. Haller index >3.25 (indicating severe deformity)
4. Progressive worsening of the deformity

Special Considerations

• Timing: Optimal age for MIRPE is typically during pre-adolescent growth spurt (8-14 years) when the chest wall is still flexible

• Adults: Can still undergo repair but may require modified techniques:

  • Double bar or compound bar technique 4
  • Higher complication rates and more postoperative pain

• Marfan Syndrome Patients: Delay pectus repair if aortic root dilation is approaching surgical thresholds (≥4.5 cm), as aortic surgery takes precedence 1

• Asymmetric Deformities: May require specially shaped bars (asymmetric or "seagull" bars) for optimal correction 4

Postoperative Care

• Pain management: Thoracic epidural catheter for 3-5 days 6
• Activity restrictions for 4-6 weeks
• Bar removal after 2-4 years
• Regular follow-up to monitor for complications and assess results

Outcomes

• Success rates of 93-95% with excellent, very good, or good results reported 6
• Poor results (2-5%) typically due to thoracic asymmetry or sternal rotation
• Average hospital stay: 5-7 days 6

The choice between surgical and non-surgical management should be based on a thorough evaluation of the severity of the deformity, associated symptoms, and the patient's goals for treatment.