|
Pectus excavatum is a depression of the sternum and
anterior chest. The deformity is sometimes referred to as sunken or
funnel chest and may appear as though someone has punched in the
chest. The severity of the depression ranges from mild to severe.
Mild cases may respond to an exercise and posture program, whereas
more severe cases require surgical correction.
Pectus excavatum tends to run in families and is
often present at birth. The deformity usually progresses as the
child grows, often showing dramatic deterioration during the
pubertal growth spurt.
In the past, a variety of radical procedures were
advocated. However, in 1987 a new technique for correction of pectus
excavatum was developed by Dr. Donald Nuss, a pediatric surgeon at
Children's Hospital of the The King's Daughters and Eastern Virginia
Medical School in Norfolk, Virginia. This "minimally invasive"
procedure has been refined and modified for more than fifteen years
in over 450 patients. The Nuss Procedure for the correction
of pectus excavatum results in minimal blood loss and much shorter
recovery time. In addition, Dr. Nuss and Children's Hospital have
developed a center for pectus excavatum care which includes not only
non-operative treatment for milder cases but operative and
post-operative clinical pathways and standards of care. A
comprehensive pectus program has been developed that includes a
Nurse Coordinator, Pediatric Anesthesia, Child Life Therapy and
Physical Therapy along with patient and family education materials,
to complement this revolutionary new surgical procedure.
 |
 |
|
|
|
Surgical correction of pectus excavatum is done for
medical reasons. Children with moderate to severe defects often
experience shortness of breath, exercise intolerance and chest pain.
These are the results of compression and displacement of the heart
and secondary lung compression.
After a complete health history, a thorough physical
exam, chest measurements, and photographs, children whose condition
is considered severe enough to warrant surgery are sent for further
evaluation of their cardiac status, pulmonary function, and a CT
scan. These studies help determine whether the patient fulfills the
criteria for surgery, since not every child requires surgical
correction.
The operation is easier and the recovery time faster
in children who are preadolescent, because their bones and cartilage
are more flexible. However, there has been an increase in the number
of teenagers undergoing the procedure and results are equally good
in older patients up to the mid-twenties.
The operation for correction starts with general
anesthesia and the placement of an epidural catheter for the
management of pain after the operation. Two lateral incisions are
made on either side of the chest for insertion of a curved steel bar
under the sternum. A separate, small lateral incision is made to
allow for a thorascope (small camera) for direct visualization as
the bar is passed under the sternum. The bar is individually curved
for each patient. The bar is used to pop out the depression. It is
then fixed to the ribs on either side and the incisions are closed
and dressed. A small steel, grooved plate may be used at the end of
the bar to help stabilize and fix the bar to the rib. The bar is not
visible from the outside and stays in place for a minimum of two
years. When it is time, the bar is removed as an outpatient
procedure.
 |
 |
|
|
|
Complications of this minimally invasive surgery are
uncommon. Air in the chest (pneumothorax) is the most frequent
complication but usually requires no treatment other than
observation and aggressive deep breathing therapy to help promote
faster resolution. Bar displacement may occasionally require
repositioning, and as with all surgeries, the potential for
infection is closely monitored and presently the infection rate is
less than 1%.
The immediate recovery time in the hospital is 4-5
days. Attention is paid to postoperative pain management,
encouragement to breathe deeply, assistance with movement (so as not
to dislodge the bar), and patient/parent education. After discharge,
the patient is expected to slowly resume normal, but restricted,
activity. Most children are able to return to school in two to three
weeks, with exercise restrictions for six weeks (i.e. no physical
education, no heavy lifting, etc.). Once fully recovered they may
return to regular activity.
The pectus support bar is removed between two to
four years after insertion on an outpatient basis. The procedure is
done under general anesthesia and in over 160 patients who have had
their bars removed there were no complications. Patients were able
to leave the hospital within one to two hours after bar removal.
Patients who reside more than one hour from the hospital are exected
to spend their first night in town.
Long-term follow-up (over 15
years) shows the Nuss Procedure provides excellent results with less
than 5% recurrence of the deformity after the bar is removed.
For more information on Pectus Excavatum and the
Nuss Procedure, click on:
-
Sunken chest, raised hopes: New surgery fixes deformity with less
trauma than ever
-
Abstract of a paper presented in May 1997 at a meeting of the
American Pediatric Surgery Association, by Donald Nuss, MB,
ChB, Robert E. Kelly Jr., MD, Daniel P. Croitoru, MD, Michael E.
Katz, MD, and Barbara Swoveland, RNC, MSN, Departments of Surgery
and Radiology, Children's Hospital of The King's Daughters and
Eastern Virginia Medical School, Norfolk, Virginia.
- Nuss, D, Kelly Jr RE, Croitoru DP, Katz ME. A 10 Year Review
of a Minimally Invasive Technique for the Correction of Pectus
Excavatum. J Pediatr Surg 1998 April: 33(4): 545-552
- Nuss, D, Kelly Jr RE, Croitoru DP, Swoveland B. Repair of
Pectus Excavatum. Pediatric Endosurgery & Innovative Techniques.
1998 Winter; 2(4): 205-221
- Croitoru DP, Kelly RE Jr, Goretsky MJ, Lawson ML, Swoveland B,
Nuss D. Experience and Modification Update for the Minimally
Invasive Nuss Technique for Pectus Excavatum Repair in 303
Patients. J. Pediatr Surg 2002 March.
|
The
operation.