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.