What is Pectus Excavatum?
Pectus excavatum is a depression in the front center of the chest. It can be observed in early childhood or may develop later during pubertal growth. It can be described as an excessive inward curving of the costal cartilages that connect the ribs to the sternum bone in the front of the chest. The result is a depressed sternum bone that can compress and/or displaced the heart within the chest cavity.
During activity, those with pectus excavatum may experience shortness of breath (difficulty catching their breath), exercise intolerance (tiring easily or stopping during), and/or chest discomfort. Some individuals are not aware of any symptoms but all patients with pectus excavatum should be considered for referral and further evaluation as even those without symptoms can often recognize newly experienced improvement during activity following repair of this condition.
Treatment Overview
The most widely used in successful treatment for pectus excavatum is a minimally invasive surgery developed by Dr. Donald Nuss in the late 1980s and presented to the pediatric surgery community after the publication of his initial 10-year review of his experience with this procedure in 1998. The innovative new “Nuss technique” rapidly became the gold standard treatment for this condition and involves inserting (through very small incisions) a custom-contoured lightweight stainless-steel bar under the central ribs and sternum’s in a way that provides immediate correction by pushing out the sternum thus reshaping the chest depression.
Currently, most patients cared for by the Pediatric Surgeons of West Michigan are discharged from the hospital the day after surgery although infrequently a patient may stay another day. This is in sharp contrast to national averages at other children’s hospitals where hospital stays have traditionally ranged from 3 to 5 days.
Those who undergo the Nuss technique surgery are out of school or work for generally a week and may return with some limitations or restrictions in their activity initially. By six weeks after the surgery, patients can return to full unrestricted activity including participation in all sports. Their progress is checked a couple of weeks after surgery and then at yearly intervals until three years after the initial procedure at which time the bar is removed during a brief outpatient surgery.
Enhanced Recovery
Dr. Marc Schlatter of Pediatric Surgeons of West Michigan in Grand Rapids first learned the minimally invasive “Nuss technique” by observing Dr. Nuss perform this new procedure in several patients in Norfolk, Virginia in the late 1990’s.
Over the past two decades, Dr. Schlatter has been dedicated to making ongoing improvements and modifications in various aspects of his patient’s care in order to enhance their recovery. This focus has led to the successful reduction of the hospital length of stay for his patients to just 1 day, a marked improvement from the national averages of 3 to 5 days at other institutions.
Several factors have contributed to this success including the use of intercostal nerve blocks to help to diminish postoperative pain and the development of a protocol for scheduling pain medications after surgery in a way that serves as a successful “bridge” to the discontinuation of all narcotics within the first week of recovery. Dr. Schlatter’s has an effective communication style that offers his patients clear expectations for their recovery. Perhaps the most important factor to this success has been his focus on addressing patient’s anxiety pre-operatively and diminishing anticipatory stress. He seeks to make the consultation and evaluation process, a helpful educational experience for his patients and families who learn not only about the impact of the central chest depression on the cardiopulmonary system but also are provided compelling information regarding the role that unrecognized or unaddressed anxiety can have on the speed and quality of one’s recovery. Mindfulness techniques have been shown to be a helpful resource in this regard.
These factors have all played a role in improving patient experiences, shortening the length of stay, and enhancing recovery. A summary of Dr. Schlatter’s experience and remarkable results in caring for patients with pectus excavatum was published in the Journal of Pediatric Surgery in April 2019 establishing him as a recognized national and international leader.
Frequently Asked Questions
- Is there an optimal age to perform the minimally invasive repair for pectus excavatum?
Although pectus excavatum can often be seen in early childhood, it’s exceedingly rare for it to cause symptoms until after pubertal growth. The average age of repair is between 14 to 16 years of age. In some symptomatic patients who might be developmentally and structurally “mature”, the surgery has been successful as young as 11 and 12 years of age. Pediatric Surgeons of West Michigan also provide a successful surgical repair of pectus excavatum in adults in their 20’s and 30’s. - Is pectus excavatum repair ever an emergency?
The repair of this condition is never an emergency. Those with severe central depression and/or those developing worsening symptoms of chest discomfort, exercise intolerance, and some shortness of breath are judicious reasons for seeking evaluation. - What is involved in the evaluation of pectus excavatum?
A complete health history is reviewed. The evaluation includes a thorough review of the patient’s observations and symptoms if present possibly related to their pectus excavatum.The evaluation may include additional testing such as a CT scan which can evaluate the severity of the sternal bone depression in the impact it may have on compression and/or displacement of the heart. Depending on the specifics of the patient’s circumstance, additional testing may include a cardiac ultrasound or pulmonary function tests.
- What activity restrictions are there following surgical repair of their pectus excavatum?
Patients are encouraged to be up and moving about immediately after their surgery. This mobility actually helps in facilitating recovery. Patients are off school or work for at least a week. Gradually increasing their activity after 3 to 4 weeks is encouraged although the patient should still avoid vigorous activity in contact sports during this time. After six weeks following surgery, patients can return to full unrestricted activities and sports.
