Want to pick a fight?
Try suggesting to someone at Shriners Hospitals for Children — Northern California that chest wall surgery is “just cosmetic.”
There is a deep psychological impact on a young individual with “funnel chest,” and it appears at a particularly vulnerable time of life, according to Gary Raff, M.D., a cardiothoracic surgeon who is part of the Chest Wall Program team at the Northern California Shriners Hospital.
“These patients are sometimes devastated just by how their chest wall looks and they have all sorts of problems with peer-to-peer interactions,” Dr. Raff said. “You can imagine — because we were all adolescents at one point — you are awkward with your body to begin with, and now you have a chest that sinks in a lot. Are you going to go to the beach and take your shirt off and talk to people?”
As important, there are medical justifications for correcting pectus excavatum too, Dr. Raff insists.
In the past, some have tried to make a claim that there is no health rationale for “funnel chest” correction, asserting that it is not clear that most persons with the condition have impaired health or compromised ability to exercise.
But Dr. Raff said that this misconception comes from looking only at basic pulmonary function tests. Those tests show a wide swath of normal variation between individuals, which makes it difficult to judge where normal ends and compromised begins, and tests done in a child fail to account for how a rib cage stiffens with age.
People with pectus excavatum (PE) who have adequate lung capacity in youth can, and do, run into problems with breathing when they get into their 50s and 60s and their chest is not so pliant for inhaling and exhaling, said Dr. Raff.
Moreover, in an older person, with less flexibility, the procedure becomes more painful and difficult.
Perhaps most important, a depressed sternum can compress the heart and impinge on its filling and the stroke volume it can produce. In particular, it can compromise the right ventricle, as the right ventricle is located in the more anterior position.
“It doesn’t cause heart damage, but it compresses the heart enough in some patients that it can reduce their peak cardiac output and oxygen delivery, and that affects their exercise,” Dr. Raff said.
In a study from France, published as a letter in the Journal of the American College of Cardiology in 2015, physicians tested 17 individuals with pectus excavatum (mean Haller index 5.8) on an exercise bike, and compared them with 17 individuals without a chest defect. In the group with pectus excavatum, the average stroke volume was 81 mL. In the comparison group, the average stroke volume was 112 mL. That difference resulted in a significantly lower average cardiac output of 14 L/min compared with 19.5 L/min in the control group (J Am Coll Cardiol. 2015;66:976–977).
In 2016, investigators from Denmark published a review article looking at the topic of pectus excavatum correction and heart function in the Annals of Cardiothoracic Surgery. Their report, which zeroed in on 21 studies considered to be high quality, concluded that: “Patients frequently report of improved stamina and reduced symptoms during exercise following the correction of their PE. This may be owed to the relief of compressed cardiac chambers with increased anterior-posterior-thoracic dimensions, which again could facilitate an improved filling of the heart.” (Ann Cardiothoracic Surg. 2016;5:485-92.)
Dr. Raff says his experience mirrors the Danish report. His patients often tell him that they could keep up with their peers on the playground in their early grades. But, about the time they hit age 12, they began falling behind, sometimes far behind.
After their surgery, and the healing, “Almost every patient will say, ”You know doc, I feel like I could do so much more than I could do before,” he said.
Many physicians once took a dim view of the surgery too. But that is because of an outdated procedure, and a learning curve. Given the problems with that now outdated procedure, many of those in the referring community wrote the procedure off and have never revisited pectus repair, according to Dr. Raff.
The former, gold standard procedure for pectus excavatum was known as the Ravitch procedure, for its innovator, Mark Ravitch, M.D., of Johns Hopkins University, who introduced the surgery that he had been developing to colleagues in 1947.
The Ravitch procedure is significantly more invasive, though it is still sometimes performed, particularly for pectus carinatum. It involves an incision across the chest, to remove costal cartilage between the ribs and the sternum. Once that cartilage is removed, the sternum is broken to put it in a better position. The assumption is that new cartilage will form and reattach the ribs and sternum and hold the sternum in the new, better position.
In subsequent years, the insertion of a steel bar to raise the sternum was added, originally with the bar inserted through the sternum (until 1961).
Those Ravitch procedures were very invasive surgeries that left a big scar. The main problem with those surgeries was that they were being done in young children and they created a lot of damage, Dr. Raff said.
“It was being done in very young patients and it got a really bad rap because it caused a lot of chest wall damage, and it interfered with chest wall growth as the child grew,” he explained. “So it was being used in kids who were too young and, [as a consequence of the troubling results], chest wall surgery for those defects nearly went out of vogue except for in a few centers.”
But much has changed in the last 30 years. In 1986, Dr. Donald Nuss, then of The Children’s Hospital of the King’s Daughters, Norfolk, Virginia, drew attention to the flexibility of rib cartilage and questioned its removal. He began development of the Nuss procedure, the one used much more frequently today.
The Nuss procedure is done with two small incisions, one on each side of the chest, in line with the deepest part of the depression, and then a tunnel created under the sternum. A convex steel bar is slipped through the tunnel, with the convexity facing posteriorly. Once in position, the steel bar is flipped around, so the convexity pushes the sternum out. The ends of the bar are sutured into the chest wall, sometimes with stabilizers, and eventually scar tissue forms around them, holding the bar in place.
The bar is generally left in place for two years, while permanent remodeling occurs. Sometimes two bars are used.
The optimal age for the procedure is 12-13 years of age, Dr. Raff says.
Reports of the complications rate with the Nuss procedure have been all over the place, reflecting, the growing familiarity with performing the surgery and improvements in the procedure. One report of 251 patients, published in 2000, suggested that the most common complication was movement of the bar after placement requiring reoperation, and it occurred in 9% of patients. More recent reports have had rates of bar displacement as low as 3%.
That same report said that patient satisfaction was good or excellent in 96% of cases (J Pediatr Surg. 2000;35:252-57).
The pain can be quite intense in the first week – and sometimes longer – following the procedure. But, at Shriners Hospitals for Children — Northern California, Dr. Raff performs Nuss surgeries with cryoablation of the nerves around the bar, greatly reducing the need for administration of narcotics.
In the past, Dr. Raff said, patients went home with a prescription of around-the-clock opiate analgesia, usually for three weeks or even longer. It was not a good situation and could create a narcotic dependency in some patients. With the cryoablation, patients rarely need any opioids beyond 24-48 hours.
“It has really been a game changer for the procedure,” says Shinjiro Hirose, M.D., the director of pediatric surgery at Shriners Hospitals for Children — Northern California.
After surgery, patients are movement restricted for about three months. Then it generally takes them a few months to regain the conditioning lost during the three convalescent months.
During the two years the bar is in place, “I’ve had patients who have done basically every sport you can imagine,” Dr. Raff said. “I had a patient who was ejected from a car on three separate occasions. Kept surviving. Once the bar is scarred in, it is not going