Pectus Excavatum

An informational brochure for

Patients and Families with
" caved-in" chest
Pediatl'ics Surgery
96 J onathan Lucas Street
Suite418CSB
PO Box 250613
Charleston SC 29425
Learn about the
treatment of this
congenital chest
wall malfonnation.
This brochure
contains the
answers to
frequently asked
questions about
Pectus Excavatum
A ndre. H eb ra. M . D .
Chief, D ivision o f
P e d w / r i c S w g e r y
P r o f e s s o r o f S l I I g e r y
a n d P e a i a / r i c s
Ph(843) 792-3851
1-800-424-6872
Pager (843) 792-2123
E-Mail: hebra@l1lllsc.edu
FREQUENTLY ASKED QUESTIONS ABOUT CORRECTIVE
SURGERY FOR PECTUS EXCAVATUM USING THE MINI-
MALLY INVASIVE TECHNIQUE (ALSO KNOWN AS THE
NUSS OPERATION):
1) How does the minimally-invasive approach
differ from the old surgical repair?
The M inimally Invasive Operation for repair of Pectus Excava-
tum, also known as the NUSS OPERATION, is a completely dif-
ferent surgery from what it used to b e. The open Ravitch opera-
tion required making an incision in the anterior chest - the front of
the chest - and then removing segments of all the rib s affected b y
the pectus. The outer layer of the cartilage rib s (perichondrium) is
preserved in order to allow the rib s to grow b ack. The sternum
must b e fractured in at least one area to allow for it to b e b ent in
the appropriate position. Complications of the open operation in-
clude b leeding, infection, injury to the lungs and pleura, and possi-
b le need for placement of chest drains. The end result is rated as
very good b ut it does leave a long scar on the chest. With the new
technique (known as the Nuss operation or the minimally invasive
repair), it is not necessary to create any large incisions or to re-
move/fracture any rib s or cartilage, or sternum. The surgeon is
ab le to approach the chest with small lateral chest wall incisions
and, using a special camera (thoracoscope), the surgeon can visual-
ize the inside of the chest so that a stainless steel b ar can b e placed
in order to correct the deformity. A gain, this is accomplished with-
out cutting anything, without b reaking b ones, without removing
any cartilage. The duration of the entire operation is much shorter.
With the open repair, the operation may take 4to 5hI'S. With the
Nuss technique, the operation is typically completed in just ab out
an hour.
2) What type of patient should be considered for
this operation? What are the indications for sur-
gery? What is the chest index? Is it a cosmetic
operation?
Patients must b e carefully evaluated prior to surgery. The things
that we look for are -#1 - how severe is the deformity (one must
determine the chest index). #2, what kind of physiologic impair-
ment it is causing to the patient. #3, what is the psychosocial im-
pact of the deformity.
The chest index is a measurement taken on the CT scan of the
chest in which a ratio is ob tained b etween the lateral and ante-
rior-posterior diameter of the chest wall. A normal chest index is
2. 5. Patients with an index greater than 3. 2 have a fairly pro-
nounced and severe pectus excavatum and will typically need
operative correction. Even if asymptomatic, those patients usu-
ally b enefit form the corrective surgery.
M any patients with mild to moderate pectus excavatum will not
report any significant shortness of b reath. H owever, upon further
questioning, one may find that the child can't keep up with their
peers in the same physical activities that they used to. They get
tired more easily. Or, as summer comes around, they don't want
to take their shirt off for sports, swimming, or around other chil-
dren. Typically affected children always leave their shirt on if
they're in the pool. Clearly such patients would b enefit from the
surgery.
A parallel comparison can b e made with children b orn with Cleft
Lip & Palate - that repair could b e considered a cosmetic repair.
H owever, no one would allow a child to goon in life with a cleft
lip deformity. Pectus deformity is no different. The only differ-
ence is that you can hide it under a shirt. But it's still a deform-
ity of the sternum and the chest that deserves to b e corrected if it
is causing significant concerns to the patient &family.
3) Is there an ideal age group for the new op-
eration?
The ideal age for the minimally invasive operation is b etween 8-
12years. The main reason for that is that the child should b e old
enough to understand what's ahead, to understand reasons for
surgery, to understand what's involved in recovery from surgery.
M oreover, b etween 8-12 years, the rib s and cartilage are still soft
enough so that the surgeon can repair the deformity using the
pectus-b ar easily. The recovery from surgery at that age is much
easier than it is for teenagers. H owever, age b y itself is not con-
sidered a contraindication for surgery. A s a matter of fact, many
adult patients have undergone the Nuss operation with excellent
results.
Tr e a tme n t o f P e c tus Exc a va tum
4) How does the Minimally Invasive operation
work?
The M inimally Invasive operation (Nuss technique) is done
through 2 small lateral chest wall incisions -- one on each side of
the chest, lateral to the nipple area. A small 5mm camera is also
inserted into the chest. This will allow the surgeon to have direct
visualization of the placement of the b ar and all the important
structures inside your chest (such as the heart, b lood vessels, and
lungs). The surgeon will know exactly where to place the b ar.
Through these small lateral chest wall incisions, a special curved
stainless steel b ar (also known as the LORENZ pectus b ar) is
passed b ehind the sternum.
The b ar comes in different length according to age and patient
size. Then the b ar is selected at the time of surgery and is b ent b y
the surgeon after certain measurements of the chest are taken. The
b ar will have a smooth concave shape to it in order to allow for its
placement b ehind the sternum. The b ar is passed through the
small lateral chest wall incision, under the sternum, in front of the
heart, all the way to the other side of the chest. The b ar is than
flipped, such that the sternum is raised and the entire chest wall is
remodeled. The entire maneuver is done under thoracoscopic visu-
alization.
Essentially, what the operation is like placing an internal "b race".
The b race (pectus b ar) will displace the rib s and the sternum for-
ward, keeping it in that position until complete remodeling of the
chest wall has occurred. This process typically takes two years.
Fort that reason, the b ar is left in place for at least two years.
The b ar is kept in secure position b y sutures that attach it to the
chest wall muscle fascia. In addition, alateral stab ilizer (a type of
T-connector) is attached to the sides of the b ar for extra points of
fixation. Finally, a third point of fixation (an extra stitch that is
placed around a rib and around the b ar itself) can b e used to hold it
in place right next to the sternum.
The operation is done under general anesthesia. In addition, a
thoracic epidural should b e considered.
The thoracic epidural requires placement of a little catheter in
the epidural space (mid-b ack) b y the anesthesiologist. This tech-
nique is similar to the one employed for delivering b ab ies. The
epidural catheter can remain in place for several days after sur-
gery, allowing doctors from the pain team to deliver certain types
of pain medications to facilitate the management of pain & dis-
comfort after surgery. The medications will have a numb ing ef-
fect, so that the child is essentially numb and with minimal pain
from ab out the nipple level down. The catheter can b e left in
place for ab out 3days after surgery.
It is important to rememb er that anytime apatient receives a
thoracic epidural, it will b e necessary to place a Foley catheter --
a catheter to drain the b ladder. The reason for that is b ecause
those patients who have an epidural will have troub le voiding.
With the Foley, the patient can void normally into a b ag. Once
the epidural is removed, the Foley catheter is removed as well.
Patients typically will b e discharged home with oral-pain medi-
cine. Typically, a narcotic pain medication like Tylenol with co-
deine or Percocet will b e necessary for 1to 2weeks. A dditionally,
an anti-inflammatory medication (like M otrin, A live or A dvil) is
also utilized.
7) How long will the bar stay in place? When
and how is it removed?
The b ar stays in place for ab out 2years and most studies have
shown that this will give the chest enough time to remodel itself
and assume a new "normal" shape.
The operation for b ar removal is relatively simple. It is usually
done as an outpatient procedure. It does require general anesthe-
sia. The surgeon will reopen one or two of the small lateral inci-
sions and essentially pull the b ar out. The incision is closed and
the whole procedure takes just a few minutes. Patients usually
go home shortly after surgery, on the same day.
i / --
J l
i /
" .
_ , _ ., - - / ' PP.C ' t.us Bar
I
CT Scan appearance of the chest in a patient with Pectus
Excavatum
8) Are there common problems or complications
associated with this procedure?
The most common prob lems and complications related to surgery
have changed since the operation was first reported in 1996. In the
initial series of several hundred patients it was found that the
most common complications were b ar displacement, pneumotho-
rax, and infection. H owever, as the technique has improved, the
complication rate has dramatically decreased. For instance, b ar
displacement -which was reported in almost 10%of the patents - IS
now reported in ab out 1%. Other prob lems such as Infection and
pneumothorax are very rare. The use of thoracoscopy has also
helped in making this a safer operation.
Occasionally we may see patients that have an initial excellent
cosmetic result b ut the chest may change and the rib s may do
funny things. Some patients may experience different growth rate
of the rib s on the left and right side of the chest (this is particularly
a concern in patients with severe asymmetry of the chest prior to
any corrective surgery). It has b een reported b efore that rib s and
cartilage can grow in an unusual way that you didn't expect. This
may result in an asymmetric appearance of the chest even after a
successful operation using the minimally invasive technique. Un-
fortunately the surgeon cannot control the rate of b one and carti-
lage growth in a developing child.
10) How long does the patient stay in the hospi-
tal after surgery?
Immediately after surgery, the patient is taken to the recovery
room and than to a general care floor in the hospital. Usually there
is no need for critical care monitoring or leuadmission. The room
is fairly typical for most hospitals; nurses come in and check on the
patient frequently. Other services that will b e involved in the pa-
tient's care include the pain management, child life and physical &
occupational therapy. A ll providers will concentrate specifically on
the needs of the pectus repair patients.
The average length of stay varies b etween 5-7 days. A s a rule, the
younger child will stay less and the older child and young adults
will stay longer. A gain, if the rib s are soft and the repair is very
easy, odds are that the patent will stay in the hospital just a few
days.
Patients and families are advised to pick a vacation time to have
the surgery done - usually around summertime - b ecause most
children will have to stay out of school for ab out 2weeks after sur-
gery to b e ob served closely at home. Physical activities will b e lim-
ited and patients will not b e ab le to lift up their b ook b ags for al-
most one month after surgery.
Patients are instructed not to lift more than ab out 10 pounds after
surgery, which, as most parents know, is lighter than the average
b ook b ag these days. A lso, patients can't return to either PE or
sports until cleared b y their surgeon. Typically patients are seen
b ack in the surgeon's office 2weeks after discharge from the hospi-
tal and, at that time, it is determined, b ased on the individual pa-
tient's progress, when they can gob ack to physical activities. Gen-
erally speaking, most patients will return to sports and normal
physical activities 4- 6weeks after surgery. H owever, contact
sports (which include soccer and footb all) should b e avoided for at
least 6months.
D espite such initial restrictions, after approximately 4- 6weeks,
the patient should b e fully recovered and should b ecome very, very
active. It is important to b uild up muscle. It is important to regain
strength. Thus patients should b e participating in sports, running,
swimming, b iking, and especially weight-lifting. It is desirab le that
children recovering from pectus surgery should b uild their pector-
alis (chest), deltoid (shoulder), and ab dominal muscles. Working-
out with weights is very important after cleared b y the surgeon.
12) How do the kids who have had the Nuss re-
pair feel about it?
This operation has truly revolutionized the way pectus excavatum
has b een managed. The operation is well accepted b y patients and
parents as well as the community in general and the pediatricians.
It is less invasive, less traumatic, and it gives patients an excellent
functional and cosmetic result. The majority of patients are well
informed ab out their surgical options and they will seek surgical
treatment using the minimally invasive technique. The overall
satisfaction rate with the procedure has b een rated as excellent or
very good b y more than 90% of patients.
The Nuss procedure usually seems to b e quite a life-changing op-
eration. M ost parents and the children just cannot b elieve the dif-
ference it has made in their lives - something that they prob ab ly
would not admit to prior to surgery has caused them to have a
whole new outlook on their futures as well as their perception of
themselves and their own wellb eing.
A dditional information ab out corrective surgery for Pectus Exca-
vatum can b e found at the following web site:
emedicine.com (search words: Pectus Excavatum)
An informational brochure for Patients
and Families with "caved-in" chest
Pediatrics Surgery
96J onathan Lucas Street
Suite418CSB
PO Box 250613
Charleston SC 29425
Ph(843) 792-3851
1-800-424-6872
Pager (843) 792-2123
E-M ail: hebra@mllsc.edll
A fter M inimally Invasive Repair