What are the management options for pectus excavatum?

Management of Pectus Excavatum

For symptomatic pectus excavatum, surgical repair using the minimally invasive Nuss procedure or modified Ravitch technique is recommended, with choice depending on patient age, severity, and preference, while asymptomatic mild cases can be observed. 1, 2

Initial Evaluation and Indications for Treatment

Clinical Assessment

• Evaluate for cardiopulmonary symptoms including decreased exercise tolerance (present in 67% of surgical candidates), frequent respiratory infections (32%), chest pain (8%), and asthma (7%) 3
• Assess severity using the pectus severity index (chest width divided by distance from posterior sternum to anterior spine), with normal being 2.56 and surgical candidates averaging 4.65 3
• Perform cardiac evaluation to document cardiac deviation into the left hemithorax (present in essentially all surgical candidates) and screen for mitral valve prolapse, particularly in patients with connective tissue disorders 4, 3
• Screen for associated genetic syndromes including Marfan, Noonan, Loeys-Dietz, and Ehlers-Danlos syndromes, as pectus excavatum may be a phenotypic feature requiring comprehensive cardiac workup 5, 4

Preoperative Testing

• Obtain spirometry to document baseline restrictive respiratory pattern and establish potential for improvement 6, 3
• Perform echocardiography to assess cardiac function and rule out structural abnormalities like mitral valve prolapse or pulmonary stenosis 4, 6
• Measure vital capacity, which typically increases by 11% within 9 months post-repair 3

Surgical Management Options

Minimally Invasive Repair of Pectus Excavatum (MIRPE/Nuss Procedure)

The Nuss procedure is the preferred minimally invasive approach utilizing thoracoscopic visualization with small incisions and temporary metal bar placement behind the sternum for support during costal cartilage remodeling 1

Key characteristics:

• Excellent cosmetic outcomes with shorter procedural length in experienced hands 1
• Longer hospital stay (mean 3.9 days) compared to other techniques 2
• Higher analgesic requirements with 100% requiring epidural or patient-controlled analgesia 2
• Higher complication rate (35.7%) compared to open techniques 2
• Higher costs (mean $43,749) 2
• Successful outcomes in adults with resolution of symptoms and improved quality of life 7

Modified Ravitch Procedure

The Ravitch procedure remains the most commonly chosen option (selected by 60.9% of patients when given choice) 2

Technique involves:

• Subperiosteal resection of abnormal cartilages 3
• Transverse wedge osteotomy of the anterior sternum 3
• Internal support with steel strut for 6 months 3

Outcomes:

• Moderate hospital stay (mean 2.2 days) 2
• Moderate analgesic needs (50% requiring epidural/PCA) 2
• Lower complication rate (14.3%) 2
• Moderate costs (mean $27,414) 2
• Excellent long-term results with >97% achieving very good or excellent outcomes at mean 12.6-year follow-up 3

Leonard Procedure

The Leonard procedure offers the lowest resource utilization among surgical options 2

Advantages:

• Shortest hospital stay (mean 1.5 days) 2
• Lowest analgesic requirements (only 5% needing epidural/PCA) 2
• Lowest costs (mean $18,094) 2
• Lowest complication rate (9.1%) 2
• Selected by 23.9% of patients when given choice 2

Novel Techniques

Double Pectus Up bar technique represents emerging innovation for severe deformities, utilizing two bars at the major sternal defect with complete invisibility of the implant, though requiring further validation 6

Age-Specific Considerations

Pediatric Patients

• Repair can be performed safely before age 11 years with 177 children successfully treated in one large series 3
• Earlier repair may prevent progressive symptoms as deformity can worsen with growth 7

Adult Patients

• Adults with severe symptoms are appropriate surgical candidates with 38 adults successfully repaired in one series 3
• Symptoms may not manifest until adulthood and can worsen over time, making age alone not a contraindication 7
• Successful Nuss repair is achievable in adults with resolution of symptoms and improved quality of life 7

Expected Outcomes and Complications

Symptomatic Improvement

• All patients with preoperative respiratory symptoms, exercise limitation, and chest pain experience improvement following repair 3
• Vital capacity increases by mean 11% within 9 months postoperatively 3

Complications

Overall complication rate is 16.3% across all techniques, with specific complications including 2, 3:

• Hypertrophic scar formation (most common)
• Atelectasis and pleural effusion
• Recurrent sternal depression (5 cases in 375 patients)
• Pericarditis
• No mortality reported in large series 3

Special Clinical Contexts

Associated Conditions

• In osteogenesis imperfecta, restrictive respiratory pattern may be more severe with lateral thoracic involvement 4
• In kyphoscoliosis with pectus excavatum, cardiac migration to left hemithorax may limit surgical working angles 4
• Complete cardiac evaluation is mandatory when genetic syndromes are suspected 4

Imaging for Surgical Planning

• MRI can facilitate surgical chest wall reconstruction planning and is particularly useful for pectus excavatum diagnosis and management 5
• CT with IV contrast can provide detailed anatomic assessment when surgical planning requires precise measurements 5