Pectus Excavatum Repair: Advanced Techniques for Surgeons

Pectus excavatum, often referred to as "sunken chest" or "funnel chest," is the most common congenital deformity of the anterior chest wall, characterized by a concave sternum. This deformity can have significant implications for patients, ranging from cosmetic concerns to serious physiological effects, including respiratory and cardiovascular complications. The surgical repair of pectus excavatum, therefore, is a critical procedure that demands precision, expertise, and a thorough understanding of the condition.

Indications for Pectus Excavatum Repair

The decision to proceed with pectus excavatum repair is often multifactorial, depending on the severity of the deformity, the presence of symptoms, and patient preference. The main indications include:

1. Severe Chest Wall Deformity: When the sternum's depression significantly affects the patient's appearance, leading to psychological distress or social anxiety, surgical correction is often recommended.
2. Respiratory Dysfunction: Severe pectus excavatum can impair lung function by restricting thoracic volume, leading to decreased exercise tolerance, dyspnea, and frequent respiratory infections.
3. Cardiovascular Implications: The deformity can compress the heart, particularly the right ventricle, leading to decreased cardiac output and symptoms such as fatigue, palpitations, or syncope.
4. Physical Limitations: Some patients experience significant physical limitations, including reduced stamina and difficulty performing strenuous activities due to the mechanical constraints imposed by the chest wall deformity.
5. Psychosocial Concerns: The psychological impact of the deformity, especially in adolescents, can be profound, contributing to low self-esteem, depression, and social withdrawal.

Preoperative Evaluation

Before considering surgery, a comprehensive preoperative evaluation is essential to determine the severity of the condition and to plan the surgical approach. The evaluation typically includes:

1. Clinical Assessment: A detailed history and physical examination are crucial. The Haller index (ratio of the transverse diameter of the chest to the anteroposterior distance) is often used to quantify the severity of pectus excavatum. A Haller index greater than 3.25 is generally considered an indication for surgery.
2. Imaging Studies: CT scans or MRI are used to assess the extent of the deformity, evaluate the impact on the heart and lungs, and plan the surgical approach. These imaging modalities provide a three-dimensional view of the chest wall anatomy.
3. Pulmonary Function Tests (PFTs): PFTs are used to evaluate any restrictive lung disease caused by the deformity. Patients with significant respiratory compromise may benefit most from surgical correction.
4. Cardiac Evaluation: An echocardiogram or cardiac MRI may be necessary to assess the heart's function and to identify any compression effects on the cardiac chambers, particularly the right ventricle.
5. Psychological Assessment: Particularly in adolescents, a psychological evaluation may be recommended to assess the impact of the deformity on mental health and to ensure the patient is prepared for the physical and emotional challenges of surgery.

Contraindications

While pectus excavatum repair is generally safe and effective, certain contraindications should be considered:

1. Poor General Health: Patients with significant comorbidities, such as severe cardiopulmonary disease, may not tolerate surgery well.
2. Inadequate Chest Wall Compliance: In older adults, the chest wall may be less compliant, making the correction more challenging and potentially less effective.
3. Uncontrolled Respiratory Infections: Active respiratory infections must be treated before surgery to reduce the risk of postoperative complications.
4. Inadequate Patient or Family Support: Given the recovery process's complexity, patients without sufficient support may struggle with postoperative care and adherence to follow-up.

Surgical Techniques and Steps

Two primary surgical techniques are employed in pectus excavatum repair: the Nuss procedure and the Ravitch procedure. The choice of technique depends on the patient's age, severity of the deformity, and surgeon's expertise.

1. Nuss Procedure:

The Nuss procedure is a minimally invasive technique that has gained popularity due to its less invasive nature and excellent cosmetic results.

• Preoperative Preparation: The patient is placed under general anesthesia. A single dose of prophylactic antibiotics is administered to reduce the risk of infection.
• Incision and Bar Insertion: Two small incisions are made on either side of the chest. A curved steel bar, shaped to match the desired chest contour, is inserted beneath the sternum using a thoracoscope for guidance. The bar is then rotated to push the sternum outward.
• Bar Fixation: The bar is secured to the ribs with stabilizers to prevent rotation or displacement. The incisions are closed, and a chest drain may be placed if necessary.
• Postoperative Care: The bar remains in place for about 2-3 years to allow the chest to remodel into the corrected shape. Postoperative pain management is crucial, often requiring epidural analgesia or patient-controlled analgesia (PCA).

2. Ravitch Procedure:

The Ravitch procedure is an open surgical technique that involves removing abnormal cartilage and repositioning the sternum.

• Preoperative Preparation: Similar to the Nuss procedure, the patient is placed under general anesthesia with prophylactic antibiotics.
• Incision and Cartilage Resection: A midline incision is made over the sternum. The abnormal costal cartilages are resected, and the sternum is elevated and secured with a bar or struts.
• Sternal Fixation: The sternum is fixed in the corrected position using metal bars or plates. The pectoralis major muscle flaps may be used to cover the bar or struts to reduce the risk of infection and improve cosmesis.
• Postoperative Care: Pain management is a priority, and the patient may require hospitalization for several days. The chest drain is typically removed after 24-48 hours, and the patient is encouraged to start mobilizing as soon as possible.

Postoperative Care

Postoperative care is critical for ensuring a successful outcome and minimizing complications. Key aspects include:

1. Pain Management: Effective pain control is essential, particularly in the early postoperative period. Epidural analgesia, PCA, and oral analgesics are commonly used.
2. Respiratory Support: Early ambulation and respiratory exercises, such as incentive spirometry, are encouraged to prevent atelectasis and other pulmonary complications.
3. Wound Care: The surgical site must be kept clean and dry. Patients are advised on proper wound care techniques, including the use of sterile dressings and monitoring for signs of infection.
4. Activity Restrictions: Patients are typically advised to avoid heavy lifting, contact sports, and other activities that may place stress on the chest wall for several months postoperatively.
5. Follow-up: Regular follow-up visits are crucial to monitor the healing process, check the position of the bar or struts, and address any complications that may arise.

Possible Complications

While pectus excavatum repair is generally safe, it carries the risk of complications, which can vary depending on the surgical technique and patient factors:

1. Bar Displacement: In the Nuss procedure, the bar may rotate or displace, requiring reoperation.
2. Infection: Surgical site infections, including deep sternal wound infections, are rare but serious complications that may require prolonged antibiotic therapy or surgical debridement.
3. Pneumothorax: The insertion of the bar or struts may lead to pneumothorax, necessitating chest tube placement.
4. Cardiac Injury: Although rare, cardiac perforation or arrhythmias can occur due to the proximity of the bar to the heart.
5. Chondritis or Osteomyelitis: In the Ravitch procedure, infection of the cartilage or bone may occur, potentially leading to the need for surgical removal of the affected tissue.
6. Recurrence of Deformity: Although uncommon, recurrence of the chest wall deformity can occur, particularly if the bar or struts are removed prematurely.

Different Techniques

Aside from the Nuss and Ravitch procedures, several variations and adjunctive techniques are available:

1. Magnetic Mini-Mover Procedure (3MP): This minimally invasive technique uses magnetic force to gradually correct the deformity over time. A magnet is implanted under the skin and connected to an external brace.
2. Hybrid Techniques: Some surgeons combine elements of both the Nuss and Ravitch procedures to achieve optimal correction in complex cases.
3. Customized Bars: Advances in 3D printing have enabled the development of customized bars tailored to the patient's anatomy, potentially improving outcomes.

Prognosis and Outcome

The prognosis for patients undergoing pectus excavatum repair is generally excellent, particularly with early intervention. Most patients experience significant improvement in cosmetic appearance, respiratory function, and overall quality of life. The long-term outcomes are favorable, with low recurrence rates and high patient satisfaction.

Alternative Options

For patients who are not candidates for surgery or prefer non-surgical management, alternative options include:

1. Vacuum Bell Therapy: This non-invasive method uses a suction device to gradually elevate the sternum. It is typically used in mild to moderate cases and may require long-term treatment.
2. Physical Therapy: While not curative, physical therapy can improve posture, strengthen the chest wall muscles, and alleviate some symptoms associated with pectus excavatum.
3. External Bracing: Similar to orthodontic braces, external chest braces can be used to apply pressure and gradually correct the deformity. However, this method is less effective in severe cases.

Average Cost

The cost of pectus excavatum repair can vary widely depending on the technique used, the surgeon's experience, and the healthcare setting. In the United States, the cost typically ranges from $40,000 to $80,000, including preoperative evaluation, surgery, and postoperative care. Insurance coverage may vary, and patients are advised to check with their providers regarding potential out-of-pocket expenses.

Recent Advances

Recent advances in pectus excavatum repair have focused on improving cosmetic outcomes, reducing complications, and enhancing patient comfort:

1. 3D Imaging and Printing: The use of 3D imaging and printing has revolutionized preoperative planning, allowing for the creation of patient-specific surgical plans and customized implants.
2. Minimally Invasive Techniques: Innovations in minimally invasive techniques, including the use of smaller incisions and less invasive instruments, have reduced recovery times and improved cosmetic results.
3. Enhanced Recovery Protocols: The development of enhanced recovery after surgery (ERAS) protocols has led to shorter hospital stays, improved pain management, and faster return to normal activities.

Conclusion

Pectus excavatum repair is a complex but highly effective procedure that can significantly improve patients' lives. Whether opting for the minimally invasive Nuss procedure or the traditional Ravitch approach, surgeons must carefully evaluate each patient, considering their unique anatomy, symptoms, and goals. With ongoing advancements in surgical techniques and technology, the future of pectus excavatum repair looks promising, offering hope and healing to those affected by this common congenital deformity.