What is pectus excavatum?
Pectus excavatum is an abnormal development of the rib cage in which the sternum (breastbone) grows inward, resulting in a noticeable and sometimes severe indentation of the chest wall. Also known as “sunken chest” or “funnel chest,” pectus excavatum can be corrected with the minimally invasive surgical technique called the Nuss procedure or with traditional open surgery, known as the Ravitch procedure. Pectus excavatum occurs in both children and adults but is most commonly noticed in the early teen years. Adults have often been aware of their pectus for many years before seeking treatment.
Symptoms and Causes
What are the symptoms of pectus excavatum?
Due to the pectus, patients may have less space in the chest, which can limit heart and lung function. The symptoms can be both physical and psychological. Physical symptoms can include:
- Shortness of breath with exercise.
- Decreased stamina compared to peers.
- Chest pain.
- Irregular heartbeat.
Psychological symptoms can include:
- Significant embarrassment from the appearance of the chest.
- Self-esteem issues.
- Clinical depression.
Who should seek treatment?
Pectus excavatum is a fairly common congenital (there at birth) deformity. It occurs more often in men than women. Patients should seek treatment if they are having physical symptoms and/or psychological symptoms from their pectus.
Diagnosis and Tests
How is pectus excavatum diagnosed?
The diagnosis of pectus excavatum is made with a simple physical examination. Quite often, the defect does not become noticeable until the early teen years. A more detailed workup, including chest imaging by MRI or CT scan and cardiopulmonary (heart and lungs) exercise testing, accurately measures how serious the pectus is and its effect on cardiopulmonary (heart and lung) function. Echocardiogram and pulmonary function tests (PFT’s) may also be used to evaluate pectus excavatum.
Management and Treatment
How is pectus excavatum treated?
Pectus excavatum can be treated surgically. The primary goal of surgery for pectus excavatum is to correct the chest deformity to improve a patient’s breathing and cardiac function. Repositioning the sternum to a more normal, outward position lessens pressure on the heart and lungs, allowing them to function more normally. The appearance of the chest is also dramatically improved, addressing any psychological symptoms that may also be present.
Pectus excavatum can be corrected with the minimally invasive surgical technique called the Nuss procedure or with traditional surgery, known as the Ravitch procedure. Your surgeon will discuss which procedure is the most appropriate based on several variables.
- The Nuss procedure: After a tiny camera is inserted into the chest to guide the procedure, two small incisions are made on either side of the chest, and a curved steel bar is inserted under the sternum. Individually curved for each patient, the steel bar is used to correct the depression and is secured to the chest wall on each side. The bar is left in place for 3 years and later removed as an outpatient procedure.
- The Ravitch procedure: Also known as the “traditional” or “open” surgical repair of pectus excavatum, the Ravitch procedure involves an incision on the front of the chest with removal of the cartilaginous part of the ribs which have overgrown and caused the sternum to be pushed backwards. This allows the sternum to be pulled forward, away from the heart and lungs and into the normal plane of the chest wall. A small plate and tiny screws are often used to stabilize the sternum in its new position. Alternatively, a small metal bar can be placed behind the sternum to hold it in place for 6 to 12 months. The bar is later removed with a short, outpatient procedure. This bar is smaller than the bar used in the Nuss procedure.
Post-operative recovery and cryoblation
- A new approach to minimizing severe pain after the Nuss procedure is significantly shortening hospital stays and reducing the need for opioid analgesics. The new technique – cryoablation – is being used to “freeze” the intercostal nerves that provide pain sensation to the chest wall. Coupled with injection of local anesthetics (numbing medicine) of those same nerves, and a pre- and postsurgical regimen of oral painkillers, cryoablation has transformed pectus patients’ pain experience.
- Traditionally, pain management in patients undergoing the Nuss procedure required a one-week postoperative hospital stay with epidural anesthesia, followed by several weeks of opioid medication after discharge. The latter is a concern, considering that opioid therapy may increase the risk of addiction.
- With cryoablation, most patients are now able to go home the day after surgery. Some patients do not need any intravenous or oral opioids in the hospital. Those who do require oral opioids typically discontinue their use in one to two days. Before cryoablation-assisted Nuss procedures, the month or more needed for recovery meant that school-age patients had to undergo surgery during summer to avoid missing classes. Now, the reduced length of hospital stay and recovery time give patients greater flexibility in scheduling their PE procedure, which can often be done during winter or spring breaks.
What are the benefits of pectus excavatum surgical repair?
The goal of pectus excavatum repair is to relieve pressure on the heart and lungs that may impair function. This typically leads to improvements in breathing, exercise intolerance and chest pain. It is not uncommon for patients with pectus excavatum to feel as if their breathing and stamina are normal before surgery and then realize they feel much improved following correction.
In patients whose main issue is the abnormal appearance of the chest, there have been dramatic, positive changes in their self-esteem and self-confidence. Complete resolution of clinical depression, including the ability to discontinue medications that had been required for depression, has been seen in patients.
Both the Ravitch and Nuss procedures have excellent results, and patients are almost always satisfied with the way they feel and look following recovery. The recurrence (happens again) rate for both procedures is less than 1%.
What are the risks of surgical repair of pectus excavatum?
The surgical repair of pectus excavatum, like other major surgeries, presents risks. While both the Nuss procedure and the modified Ravitch technique are safe and effective procedures, complications, although rare, can occur.
Possible complications from surgical repair of pectus excavatum include:
- Pneumothorax (air around the lung).
- Pleural effusion (fluid around the lung).
- Bar displacement.
- Pectus excavatum recurrence (comes back) after the bar is removed.
- Injury to surrounding structures.
Outlook / Prognosis
If I don't have surgery, will pectus excavatum harm my heart and lungs or limit my life expectancy?
There is no evidence that pectus excavatum limits life expectancy or causes progressive damage to the heart and lungs over time. It is not uncommon for individuals to develop more symptoms over time. This is likely due to the normal aging process and increasing difficulties compensating for the functional impairments associated with pectus excavatum. This, however, does not mean damage is occurring.
If I have pectus excavatum and need heart surgery, can both procedures be done at the same time?
Yes. Doctors have done combined heart surgery cases with pectus excavatum repair with excellent outcomes. This requires a coordinate approach between the surgeons performing both procedures.
Cleveland Clinic Information
- Learn more about Cleveland Clinic's Pectus Excavatum program.
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