Pectus excavatum describes an abnormal configuration of the chest, where the sternum (breast bone) pushes into the heart and lungs, giving the chest a "caved-in" or sunken appearance. It is a developmental anomaly (occurs during development of the skeleton, during childhood) and is usually not present at birth. It has also been called "funnel chest."
Pectus excavatum is relatively rare, affecting roughly 1 in 1,000 children. Boys are more frequently affected than girls. There may be a family history of the disorder, with other affected relatives.
Although there is no proven cause for this disorder, it is felt that the cartilages, which connect the ribs to the sternum, grow "too long" during childhood and adolescence and, as a result, are too large for the child's chest cage, and that these abnormal cartilages subsequently "push" the sternal bone inward.
Most children with pectus excavatum have this condition as an isolated defect. Rare children have other associated conditions, such as Marfan's syndrome, Poland's syndrome, or various connective tissue disorders. Other children can develop pectus excavatum as a consequence of complicated surgery during early childhood, such as repair of a congenital diaphragmatic hernia.
Some children with pectus excavatum are completely asymptomatic. Others develop symptoms which are most likely due to compression of the heart and/or lungs, such as shortness of breath with exertion, chest pain, palpitations (rapid heart rate), recurrent respiratory infections, or asthma. Other children may develop significant psychological distress, with self-image problems and embarrassment.
Unfortunately, many commercially available medical textbooks touch only superficially on pectus excavatum. They typically summarize outdated, poorly-planned and designed studies which failed to show significant improvements in pulmonary function tests and thus often conclude that pectus excavatum repair is a "cosmetic procedure" without true physiologic benefit. As we now know, that conclusion is probably flawed.
The primary physiological problem with pectus excavatum may not be compression of the lungs but, rather, may be compression of the right ventricle of the heart, which results in decreased cardiac output and impaired blood flow to the lungs during vigorous exercise. Correction of pectus excavatum has been clearly shown to improve this.
We believe that articles of note include:
In summary, recent studies of children and young adults with pectus excavatum, before and after surgical repair, have documented significant improvements in heart function, exercise tolerance, and quality of life. All studies are from reputable authors and are peer-reviewed. The Ravitch technique of pectus excavatum repair, as popularized recently by Haller (Johns Hopkins) and Fonkalsrud (UCLA) has an extensive history and well-documented success. The Nuss technique, as detailed by Dr. Nuss and performed extensively throughout the United States and Europe, has also been shown to result in similar improvements.
Unfortunately, there is no proven non-operative technique for the correction of pectus excavatum.
The minimally-invasive, or "Nuss" technique, for the repair of pectus excavatum, was originally reported in 1997 and has been performed by surgeons in our department since 1999. This involves temporary placement of one or more metal bars in the chest to push the sternal bone forward. These bars are guided between the ribs, into the chest, with use of a thoracoscope (small diameter telescope), inserted into the chest during the surgical procedure through small incisions. Bars are typically removed after 2 to 2.5 years.
The Ravitch technique of pectus excavatum repair was originally described in the 1950's, was popularized more recently by Haller (Johns Hopkins) and Fonkalsrud (UCLA), and has an extensive history and well-documented success. This technique may be preferred in some patients, such as some older children and young adults, and in some patients with very asymmetric deformities.
Both techniques are performed in the operating room, under general anesthesia, and typically require postoperative recovery stays in the hospital for four to seven days.
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