140: Primary Repair of Pectus Excavatum

Introduction

Pectus excavatum is the most common congenital anterior chest wall defect, characterized by a posterior depression of the sternum and inferior costal cartilages. The deformity can be present at birth or develop during childhood. The sternal depression may worsen as the child grows, often peaking during pubertal growth. Incidence is reported at 1 per 1000 children. It is more common in males; the male to female ratio is 4:1. The etiology of the defect is unknown, although there is a suggestion of an intrinsic abnormality of costochondral cartilage due to the occurrence of pectus excavatum in patients with connective tissue disorders. Scoliosis is present in up to 20% of patients with pectus excavatum. In addition, a family history of pectus excavatum is present in up to 40% of patients, suggesting a genetic predisposition. Approximately one third of all children with pectus excavatum have a severe deformity that warrants evaluation for surgical repair.¹

Meyer first attempted surgical repair in 1911 and Sauerbruch in 1913.¹ In 1939, Ochsner and DeBakey reviewed the techniques of repair and reported outcomes with high morbidity and mortality.¹ Ravitch² described a technique in 1949 involving division of xiphoid from sternum, excision of deformed costal cartilages, division of intercostal bundles from sternum, transverse sternal osteotomy at junction of manubrium; angling of sternum anteriorly and suturing in position. Welch modified this technique in 1958, emphasizing the preservation of perichondrial sheaths of costal cartilages and preservation of intercostal bundles. This modified Ravitch technique is the basis of current open repair performed 50 years later.^3,4

In 1998, Nuss reported his 10-year experience with a minimally invasive technique for pectus excavatum repair. This procedure involves placement of an internal stainless steel bar to reshape the chest wall without excision of costal cartilages or sternal osteotomy.¹ The Nuss minimally invasive pectus excavatum repair has become an appealing surgical option to the traditional open repair, with excellent outcomes and a low morbidity.

General Principles

Pectus excavatum includes a spectrum of severity from mild to severe. Mild to moderate deformities can benefit from an exercise and posture program, and yearly follow-up. Those patients with severe deformities should undergo a complete evaluation to define the degree of deformity and physiologic impairments which will aid in determining candidacy for surgical intervention. Approximately two-thirds of patients are treated nonoperatively.^1,4,5

Although pectus deformities may be present at birth and noticeable in early childhood, it is usually not until older childhood or teenage years that children and their parents seek evaluation and treatment. During puberty, the pectus deformity often deepens and becomes more symptomatic. Patients may describe symptoms of dyspnea on exertion, shortness of breath, exercise intolerance, air hunger, decreased endurance, and pain at the sternal border. Teenagers also present with issues with body image, which can have debilitating and life-altering psychosocial effects.^...