Pediatric Surgery



Pectus excavatum

Pectus excavatum is the most common congenital chest wall deformity, also known as "funnel chest" or "sunken chest." It involves a depression of the anterior chest wall and the sternum. It is often present at birth and is usually noted within the first year of life.

Before surgeryPectus excavatum tends to run in the family and occurs more frequently in boys than girls. The cause is still unknown. There is an association of pectus excavatum with other musculoskeletal abnormalities such as Marfan's syndrome or scoliosis.

The extent of deformity and symptoms from pectus excavatum range from mild to severe. A pectus is usually well tolerated in infancy or childhood. An operation to correct the deformity may be indicated if there are severe symptoms related to lung or heart function--particularly if diagnostic tests document these limitations. Cosmetic and psycho-social considerations may also lead to a decision to operate on a child with pectus. The decision to perform a corrective procedure for pectum excavatum must be made carefully, allowing time for consideration of the risks and benefits by both parents and children.

The operation

The operative management of pectum excavatum has evolved over time. Since the 1940s, pectus excavatum has been treated by removal of the cartilage connecting some of the ribs to the sternum along with cutting through part of the sternum to allow it to be pulled forward. Over the last decade a less invasive approach to pectus excavatum has been developed.

The "Nuss" procedure or pectum bar operation, was developed as an alternative to the traditional method for management of pectum excavatum. This operation involves the placement of a customized, long, curved metal bar under the sternum. Two small incisions are made on each side of the chest to allow insertion of the bar. Another small incision is made to insert a thoracoscope, which allows us to watch the bar as it goes under the sternum. The bar is secured to the ribs on the side of the chest and pushes the sternum forward. Neither the rib cartilages nor sternum are cut. The bar usually remains in place for two years and is then removed with a second, smaller operation. The principle of the pectus bar operation is that the rib cartilage remodel while the bar is in place--similar to the remodeling of the mouth with orthodonture.

Bar placed under sternum
Bar is elevated
 
The bar is placed under the sternum
The bar is twisted to elevate the sternum.
 
Final result
Final result

X-ray
X-ray view of the pectus bar in place

A twelve-year follow-up study on the Nuss Procedure shows no recurrence of the deformity after the bar is removed.

The pectus bar procedure is certainly not painless and children stay in the hospital for four to seven days after the operation. We place an epidural catheter, similar to that used for women in labor, for pain control after the operation. This is very effective in reducing discomfort.

Preoperative evaluation

At the initial appointment we will perform a complete history and physical examination and discuss the procedure and postoperative course in detail. We will help you to decide along with your child whether this operation is reasonable for your situation. We may order additional tests to evaluate your child's heart or lung function and a CT scan of the chest to determine the level and severity of the pectus. Parents and children often like to think about the operation for some time after their first appointment and discussion of the issues involved.

Several weeks after
Appearance of the chest several weeks after the pectus bar operation

Once the decision to proceed with pectus repair has been made, you will be taken to meet the surgery scheduler. She will be your contact person. We must obtain approval from your insurance carrier prior to scheduling the operation. Sometimes some discussion with the insurance carrier is necessary in order to establish the medical indication for the procedure. Once insurance approval has been obtained, the scheduler will inform you of the operation date as well as the date of your PAT'S (Pre-Admission Testing) appointment. It will be necessary to return to the clinic prior to the operation for fitting of the pectus bar. This bar is individually molded to each child's anatomy.

Hospital stay

Nurses will make every effort to keep your child comfortable and pain-free. The pain control team will be contacted to manage your child's post-surgical pain and will decide when to remove the epidural catheter. The pediatric surgery team will make rounds as a group daily. We are available at any time to answer any questions you may have concerning the progress of your child.

It is not uncommon to admit children to the Pediatric Intensive Care Unit after the operation for close observation of respiratory function. They may also need assistance with movement. When your child's condition is stabilized and the pain is under control, he/she will then be transferred to a pediatric ward.

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