2007

Minimally Invasive Repair of Pectus Excavatum in Pediatric Patients

Points to Remember

• Pectus excavatum is a progressive chest deformity that becomes most marked in puberty. It causes a sunken appearance of the anterior chest and presents in about 1 in 1,000 births.
• Severe pectus excavatum impairs cardiovascular and pulmonary function by laterally displacing the heart and reducing respiratory function. Surgery is indicated in these cases.
• A minimally invasive surgical approach that inserts a bracing bar to remodel the anterior chest yields excellent results.
• Early evaluation is recommended so surgery can be timed to occur during the growth spurt, between the ages of 11 and 14 years, before bones and cartilage mature.

The Challenge

Pectus excavatum is a progressive chest deformity causing depression of the sternum and anterior chest. The condition, which may be familial, presents in about 1 in 1,000 births and becomes most marked during puberty. In patients with severe pectus excavatum, cardiovascular function may be impaired through lateral displacement of the heart, producing right ventricular filling problems. Also, decreased flexibility of the chest wall and compression of the lungs affect respiratory function. These patients' cardiovascular and respiratory deficits generally benefit from surgical correction of the chest deformity. However, in the past, the surgery was difficult for patients — especially children — to tolerate. It involved breaking the sternum and removing cartilage and could take up to 6 hours, with a high risk of blood loss and a prolonged hospital stay.

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A New Approach

A minimally invasive surgical approach has emerged over the past decade to repair pectus excavatum, primarily in teenagers and children, but in selected adult patients as well. In a 45-minute procedure, a customized stainless steel bar is inserted into the chest cavity to brace and remodel the anterior chest wall. The technique involves 2 small (2-3 cm) incisions on each side of the chest. A bowed bar is threaded through the chest cavity, between the sternum and the heart, under guidance with a thoracoscope. Once inserted, the bowed side is rotated 90º upward, so it pushes against the anterior chest to facilitate bone remodeling. To ensure adequate pain control and patient mobility after the procedure, a hospital stay of about 4 days is usually required.

Patients can resume most activities in 2 weeks, competitive sports in 12 weeks, and high-impact sports such as football after about 6 months. The stainless steel bar is left in place for approximately 3 to 5 years, until the chest wall is mature. The bar is then removed in a simple outpatient procedure. Surgeons at Mayo Clinic have extensive experience with this technique, having performed more than 200 procedures since 1996, with no serious complications.

Indications and Diagnosis

Lack of endurance during exercise is the most common symptom caused by pectus excavatum. Radiographic imaging confirms the deformity. A Haller index of greater than 3.5 denotes a clinically severe deformity. Pulmonary function tests often demonstrate values less than 80% of normal. Expected values, in young, healthy, fit children or teens should be 110% of normal. Functional impairment, Haller index, or psychological impairment qualifies the surgery as reimbursable by most insurance companies.

Children in whom there is no evidence of impairment are not candidates for surgery. Mild conditions may be of cosmetic importance, but they may improve with physical therapy.

Key Diagnostic Elements in Pediatric Pectus Excavatum