Pectus Excavatum Repair
What is pectus excavatum?
Pectus excavatum is the most common congenital disorder (present at birth) of the anterior chest wall. It is the result of abnormal growth of the cartilages between the ribs and the breastbone (sternum). The abnormal growth causes the sternal bone to move inward and sometimes causes the sternum to rotate to one side or the other. It usually involves the middle lower portion of the sternum and may worsen with age.
What causes pectus excavatum?
Although the exact cause of pectus excavatum is unknown, almost half of patients with this condition have a family history of pectus excavatum. It occurs more in males than females (3:1). Overall, pectus excavatum has been reported to occur in 1 out of every 1,000 people.
What problems can pectus excavatum cause?
Not all patients experience symptoms associated with pectus excavatum. However, if the problem is severe, it can cause problems with heart and lung function. It can place pressure on the heart and push it to the left, limiting the amount of blood that the heart can pump with each beat. The defect can also reduce the amount of air entering the lungs.
What are the symptoms of pectus excavatum?
- Exercise intolerance Most people with pectus excavatum have difficulty exercising and shortness of breath for the reasons mentioned above. During exercise, patients may be unable to keep up with their peers because of shortness of breath.
- Chest pain Patients also experience chest and back pain. This pain may be intermittent and may or may not be associated with exercise. Although the exact cause of the pain is unknown, almost two thirds of patients who present for surgical pectus excavatum repair have a history of chest pain.
- Psychosocial effects Most teenagers are very self-conscious and are concerned with their body image. Teenagers with pectus excavatum may avoid physical education and activities that involve taking their shirt off, such as swimming. This can lead to social isolation.
What are the treatment options for pectus excavatum?
Treatment for pectus excavatum can involve either exercises and physical therapy or surgery. Surgical repair has been shown to improve respiratory problems or heart murmurs if permanent damage has not already occurred.
Who is a good candidate for surgery?
Patients who suffer from the symptoms listed above, and who have a moderate to severe deformity, may be a good fit for surgery. Testing is done before surgery to determine the severity of the pectus deformity in order to help your surgeon plan the procedure. These tests typically include a CT scan of the chest, an ultrasound of your heart (echocardiogram), and breathing tests (pulmonary function studies). After these results have been reviewed, a surgical consultation will be scheduled to decide if surgery may be helpful for you.
What is the surgical procedure called?
The thoracic surgeons at Swedish Medical Center use the video assisted thoracic surgery (VATS) Nuss procedure. The Nuss procedure is state-of-the-art surgical care for pectus excavatum patients and it is the best options for most patients. This is a minimally invasive technique (using very small incisions) that uses a small camera, placed in the right chest (and sometimes in the left chest too), to help direct the placement of one or two bars under the sternum to gradually remold the breast bone to a flatter shape. The operating time is shorter with this technique and very little blood is lost. Patients see a dramatic difference as soon as they wake from surgery. These bars stay in place for two to three years.
How long are patients in the hospital?
As with any surgical procedure, the recovery after pectus excavatum repair varies. Most patients are in the hospital for about four to five days after surgery. When patients feel well and their pain is controlled on medications taken by mouth, they can be discharged home. Follow up appointments in the thoracic surgery clinic are scheduled one to two weeks after discharge with a chest X-ray.
Is the surgery painful?
Right before surgery, the anesthesiologist may place a small catheter in the patient’s back (epidural), to help with pain control after the operation. Other medications are also used to help manage pain so patients can be comfortable and functional. It is important for patients to comfortably take deep breaths, cough and walk after the operation. Some patients may wake up after surgery with a small drainage tube in the chest to drain fluid or air for a few days. This will be removed during the hospital stay.
What are some possible complications of surgery?
- Pneumothorax This is the accumulation of air in the pleural space, between the outside of the lung and the inside of the chest wall. Most of the time this only requires a follow up chest X-ray. However, a chest drain may be required as mentioned above in 2 percent of patients.
- Pleural effusion This is the accumulation of fluid in the same pleural space, between the lung and the chest wall. This may require a follow-up chest X-ray or a chest drain may be required.
- Bleeding This is a rare complication, but if there is bleeding during the operation, a larger incision may be required.
- Infection Infection is also rare with the operation. Antibiotics are used in the first 24 hours after surgery to prevent infection. If the incisions or the bar become infected (in 2 percent of patients), more antibiotics may be needed. Rarely, patients develop an allergic reaction to the metal (1 percent of patients) and the bar may need to be replaced or removed.
- Bar displacement The bars can move out of position (10 percent chance) and may need to be adjusted in the operating room. With recent modifications in the Nuss procedure, the incidence of bar displacement is less than 2 out of 100 patients. To prevent the bar from moving too much, patients are asked to limit their physical activitites in the first 3 months after surgery.
- Pectus excavatum recurrence According to the research, there is about a 5 percent chance that the sternum will curve in again after surgery. This may happen when surgeries are performed prior to growth spurts (puberty) or not leaving the bar in long enough.
- Risk of death There have been very few reports in the medical literature of injuries to the heart during bar placement over the last 25 years.
What does surgical recovery look like?
- Patients are asked to exercise their lungs by using an incentive spirometer and Acapella device every day for six weeks after surgery. These exercises help loosen the ligaments around the sternum and help to remold the chest. They improve the way the chest looks over time. It is also helpful for patients to take a deep breath and hold it for short periods of time.
- Short (ten minute) walks are recommended two to three times a day. Patients are often very tired after surgery. Strength and stamina are slow to return. Patients should gradually increase the amount of time or distance walked over time.
- No lifting more than five pounds for six weeks. Patients should also avoid the following: Pulling themselves up with one arm, lifting their arms above their head, lying or sleeping on their side. Lifting a heavy backpack is also avoided for three months.
- After six weeks patients can slowly become more active until three months, at which point activities such as biking, swimming, soccer or running are encouraged. Contact sports such as football and hockey are avoided while the bar is in place.
How do patients care for the surgical incisions?
- Patients may shower daily and wash the incision areas gently with warm water and soap.
- No soaking in the bathtub or swimming for two weeks.
- The steri-strips taped over the incision may fall off on their own or may be safely removed after ten days.
- Any remaining staples or sutures will be removed at the office visit after surgery.
- Slight bruising, itchiness and numbness at the incision are a normal part of healing.
When can patients return to work or school?
Most patients are able to return to work or school within two to three weeks after surgery. This is a decision made between you, your doctor and your school or employer.
When should patients call the office?
If a patient has a problem or question, they are encouraged to call the office and ask to speak to the clinic nurse, during business hours. After hours they will speak to the physician on call.
Call if having persistent problems with:
- Chest pain or rapid heart rate (more than 100 beats per minute)
- Difficulty breathing comfortably, or shortness of breath
- Fever greater than 101.5 degrees
- Increasing pain or not enough pain control
- Redness around or drainage from the incision
- No bowel movement for two days in a row
- Nausea lasting more than 24 hours
- Sudden changes in the way you feel or if there is concern that the bar(s) has moved
Otherwise, patients should call if they suddenly feel unwell and they feel that the bar may be the reason. Questions or health concerns not related to the bar should be discussed with the primary-care doctor, who may or may not ask for our help.
What long-term care is needed?
Typically the bar(s) is removed around three years after the operation. The bar is removed in the operating room, and patients can expect to leave the same day with pain medication to use at home as needed. The Nuss procedure has shown to have sustained results after the bar(s) have been removed. Studies show that less than 5 percent of patients have the deformity come back after the bar(s) has been removed.
Patients may be asked to fill out a questionnaire about the surgery at specific times before or after the operation. These surveys and patient input will help us improve our selection and care of patient seeking pectus excavatum surgery at Swedish Medical Center. This data may also be used in research presented at national and international thoracic surgery meetings.
Read this blog by Dr. Weinsheimer for more about pectus excavatum repair and fixing chest wall deformities.