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INTRODUCTION

Pectus excavatum (PE) is the most commonly occurring chest wall deformity. It is thought to result from unbalanced growth of the costochondral regions of the anterior chest wall, leading to symmetric and asymmetric abnormalities.1 Meyer and Sauerbruch first reported on the surgical repair of PE in 1911 and 1919, respectively.2,3 In 1949 Ravitch4 set the fundamentals of PE surgical correction, and in 1998 Nuss5 introduced a minimally invasive alternative to the modified Ravitch procedure. The techniques for primary repair of chest wall deformities, including PE, are described in Chapter 141. However, recurrence does occur with these techniques and in experienced hands, it can range from 2% to 10%.

GENERAL PRINCIPLES

The technique for open repair of pectus excavatum, first described by Ravitch and later modified by Haller,6 consists of removal of deformed costal cartilages, repositioning of the sternum with a transverse osteotomy, elevation of the inferior sternal fragment, and placement of a temporary metal bar beneath the sternum to prevent depression of the sternum. The bar remains in place for up to 6 to 9 months until the costal cartilages have regenerated and the chest wall has become firm and rigid.

The Ravitch technique has been largely replaced by the minimally invasive approach described by Nuss,5 which makes use of the flexibility of the costal cartilages. The Nuss approach involves placing a custom round steel bar just behind the sternum and traversing to the pleural spaces to create outward pressure on the sternum at the point of concavity without costal cartilage resection or sternum osteotomy. Since it was described, the Nuss procedure has undergone several modifications. Compared with the Ravitch procedure, the Nuss procedure has some clear advantages including smaller incisions, shorter operative time, and less operative blood loss due to the less invasive nature of the procedure.7 In pediatric patients, the complication rate is similar regardless of the surgical approach but results differ in adults; adult patients undergoing the Nuss procedure have a higher incidence of complications such as bar displacement and reoperations.8

The rates of recurrence from several experienced centers are depicted in Table 142-1. Recurrence of pectus excavatum after surgical repair in most series is reportedly rare, but these data may not be entirely accurate. After the introduction of the Nuss approach, the rates of recurrence ranged from 8.5% during the early experience9 to 0.6% more recently10 with an average follow-up of 6 years. Although the majority of reports demonstrate a low recurrence rate for primary repair, we believe that the recurrence rate is most likely much higher. Because primary repair is often performed in young patients, who tend to move more frequently with education and early careers, there may be underrepresentation of recurrence. In addition, after having the knowledge of what the corrective procedure entails, some patients may not seek medical ...

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