What are the treatment options for a pediatric or young adult patient with Pectus Excavatum?

Treatment Options for Pectus Excavatum in Pediatric and Young Adult Patients

For pediatric patients under 10 years, initiate targeted exercises and rehabilitation; for ages 10-15 years, add vacuum bell therapy to the exercise regimen; and for patients 16 years and older, offer surgical correction with the Nuss procedure (MIRPE) as the gold standard. 1

Age-Stratified Treatment Algorithm

Children Under 10 Years

• Begin with conservative management consisting of targeted exercises and structured rehabilitation programs 1
• No surgical intervention is indicated in this age group unless severe cardiopulmonary compromise exists
• Monitor for progression of deformity and development of symptoms

Adolescents 10-15 Years

• Continue exercise-based rehabilitation and add vacuum bell therapy based on patient compliance and motivation 1
• Vacuum bell therapy can be offered as a non-invasive adjunct to physical therapy
• This age group represents a transition period where conservative measures are maximized before considering surgery

Patients 16 Years and Older

• Surgical correction becomes the primary treatment option, with the Nuss procedure (MIRPE) representing the gold standard 1, 2
• Surgery is indicated when the deformity causes:
  • Cardiopulmonary symptoms (exercise intolerance, dyspnea)
  • Significant psychological distress
  • Progressive worsening of the deformity 1, 2

Surgical Considerations

The Nuss Procedure (MIRPE)

• Involves retrosternal insertion of a patient-shaped bar under thoracoscopic control, which remains in place for 3 years 1
• This minimally invasive approach has become standard for both pediatric and adolescent patients 3, 1
• Major complications occur in only 1-2% of cases, particularly when videothoracoscopy is utilized 2
• Post-surgical outcomes show improvements in lung function, exercise capacity, and significant reductions in depression and anxiety 2

Adult Patients (Special Considerations)

• Adults can successfully undergo MIRPE, though the procedure is more complex due to increased chest wall calcification and rigidity 3
• Requires advanced preoperative evaluation and technique modifications 3
• Higher risk of complications compared to pediatric patients, but still achieves highly successful results with symptom resolution 3

Critical Pre-Treatment Evaluation

Mandatory Cardiac Assessment

• Complete cardiac evaluation is mandatory when genetic syndromes are suspected, particularly connective tissue disorders 4, 5
• Pectus excavatum can be associated with mitral valve prolapse, especially in connective tissue syndromes 4
• Specific syndromes requiring thorough cardiac workup include:
  • Marfan syndrome: Requires comprehensive aortic assessment; pectus excavatum scores 1 point in systemic features 5
  • Noonan syndrome: May present with pectus excavatum alongside cardiac alterations such as pulmonary stenosis 4, 5
  • Osteogenesis imperfecta: May have more severe restrictive respiratory patterns requiring careful preoperative assessment 5

Imaging Studies

• MRI facilitates surgical chest wall reconstruction planning and is particularly useful for diagnosis and management 4
• CT with IV contrast provides detailed anatomic assessment when surgical planning requires precise measurements 4

Special Clinical Scenarios

Patients with Congenital Heart Disease

• If pectus excavatum coexists with congenital heart disease requiring extracardiac conduit repair, perform pectus repair first, followed by cardiac surgery 6 weeks or later 6
• This sequence eliminates possible extrinsic compression of the conduit by the depressed sternum 6
• Avoid simultaneous cardiac and pectus excavatum repair due to potential major complications 6
• For patients who have already undergone cardiac surgery via median sternotomy, pectus repair can be safely performed afterward, avoiding pleural or pericardial entry 6

Patients with Kyphoscoliosis

• Cardiac migration to the left hemithorax may occur, limiting working angles during surgical procedures 4, 5
• Requires careful surgical planning and potentially modified approaches

Key Pitfalls to Avoid

• Never perform simultaneous cardiac and pectus repair due to risk of chest wall instability and life-threatening complications 6
• Ensure thoracoscopic guidance during Nuss procedure to minimize major complications 2
• In adults, do not underestimate the increased technical complexity and need for specialized preoperative evaluation 3
• Always screen for genetic syndromes before proceeding with any intervention, as these patients require comprehensive cardiac evaluation 4, 5