Pectus excavatum is a congenital chest wall deformity that is caused by an overgrowth of the cartilage that connects the ribs to the breastbone. This overgrowth causes a depression of the sternum and the chest has a “sunken in” or “funnel chest” appearance. The condition affects more boys than girls. It is often present at birth but becomes more noticeable during times of rapid growth, such as puberty.
Pectus excavatum can range from mild to severe. Those with a mild condition often do not have symptoms. Those with moderate-to-severe condition may have symptoms such as shortness of breath, fatigue, exercise intolerance/limitations and chest pain. With a severe case of pectus excavatum, there can be compression on the heart and lungs. Pectus excavatum may also be associated with scoliosis in some children. Children with pectus excavatum may experience some negative effects on their self-esteem due to the appearance of the chest.
There is no known cause for pectus excavatum. It can sometimes run in families — which suggests genetics may play a role. Pectus excavatum can also be associated with connective tissue disorders such as Marfan syndrome.
Pectus excavatum is diagnosed by a thorough health history and physical examination. A CT scan of the chest is essential as it provides the Haller index. The Haller index is the ratio between the transverse chest diameter (measurement from one side of the ribcage to the other) and the anteroposterior diameter (measurement from the breastbone to the spinal cord) of the chest.
A normal chest ratio is approximately 2.5 and an index over 3.2 is often defined as severe and eligible for the Nuss procedure. The chest CT will also show any displacement or compression of the heart.
Some other tests such as pulmonary function tests or an echocardiogram may be used to determine the extent of heart and lung compression.
The treatment of pectus excavatum is dependent upon the severity of the defect and the child’s symptoms. In most cases, surgery is not indicated. At CHOP, we offer two different treatments for pectus excavatum. We may recommend observation for mild to moderate cases and surgery for more severe/complex cases.
The Nuss procedure is a minimally invasive technique for surgical repair. At CHOP, the Nuss procedure is the most common surgical procedure for pectus excavatum.
For those who are not candidates for the Nuss procedure, the Ravitch procedure can be used for correction.
Although surgery may be recommended for your child, the decision must be made by the child and family to move forward with the procedure.
The night before the procedure your child will be asked to use special cleansing cloths containing 2 percent chlorhexadine gluconate (CHG) to help prevent a surgical site infection. You will be given the cloths and instructions on how to use them at your pre-operative evaluation.
Please let someone from our team know if your child has an allergy/sensitivity to CHG so that an alternative cleanser can be used. You will also be provided with pre-operative fasting instructions at your pre-operative evaluation.
The Nuss procedure is a minimally invasive procedure for surgical correction of pectus excavatum. The procedure involves a concave stainless steel bar that is slipped under the sternum with the assistance of a scope (small camera) using two small incisions on each side of the chest. The bar is then flipped, and the sternum moves to the proper position.
To support the bar and keep it in place, a metal plate called a stabilizer is inserted on both sides of the chest. The stabilizer fits around the bar and into the ribcage where it is secured in place. The bar does have a nickel component; therefore, if your child has a nickel allergy, a titanium bar will be used.
Following the Nuss procedure, your child will remain hospitalized for 4-5 days. The bar and stabilizers are kept in place for 2-3 years.
The bar removal procedure is done as a same day surgery; your child will go home after the procedure. The incisions on the side of the chest will be re-opened and the bar will be removed. The surgeon will use dissolvable sutures to close the incisions.
The Ravitch procedure involves an incision across the chest and the removal of the cartilage that causes the defect. A small bar is then inserted under the sternum to hold it in the desired position. A small drain may be placed at the site of the operation to prevent a fluid collection. The cartilage will regenerate over the next 4-6 weeks, causing the sternum to be in a fixed position.
Following the Ravitch procedure, your child will remain hospitalized for 3-5 days. The bar is removed approximately six months after the procedure.
The length of hospitalization is mainly determined by pain management. At CHOP, multiple ways to control pain are used. Your child may have an epidural catheter in place to provide pain control and/or a PCA machine.
A “pain ball,” a device that is placed under the incisions to provide medication directly to the incisions site, may be used. IV pain medications will be used to control your child’s pain initially.
When your child begins to eat, a combination of oral pain medications and muscle relaxants will be used. Your child will be started on stool softeners and/or laxatives because narcotic medications can cause severe constipation.
The first night after the operation your child will be on bed rest. He/she will be given an incentive spirometer, which encourages deep breaths, to use every hour while awake.
The day after surgery, your child will begin to get out of bed to a chair. It is imperative that your child get out of bed early in the recovery period.
In addition, the health care providers will help your child walk within the hospital room and in the hallways. Again, this is an important part of the recovery process. Your child may also work with a physical therapist.
A chest X-ray will be performed prior to your child being discharged from the hospital. In the hospital, your child will have activity restrictions that will continue after discharge. The restrictions are in place to protect the bar placement. Your child’s surgeon or nurse practitioner will discuss these restrictions with you.
In order to be discharged from the hospital, your child must meet the following criteria:
After being discharged from the hospital, your child will follow-up in the general surgery clinic in 2-4 weeks.
The following restrictions are in place for the first 4 weeks after surgery:
There may be ongoing activity restrictions such as avoidance of football, wrestling and pole vaulting during the entire time the bar is in place.
The bar should not set off metal detectors in the airport. We can provide documentation of the bar if necessary.
No, antibiotics are not required prior to dental procedures while the bar is in place.
Take note of your child’s reaction to wearing earrings or belts. Getting a rash from a belt buckle or swollen ears from stainless steel earrings can be indicative of a nickel allergy.
Let your surgeon know if you have observed the signs of a nickel allergy. Patch testing (special allergy testing) will be arranged to determine whether or not your child has a true nickel allergy. If the testing confirms a nickel allergy, a titanium bar will be used for the procedure.
While it is not mandatory to wear a Medical Alert bracelet, it is strongly recommended. Information can be provided to you at a post-operative visit on obtaining a Medical Alert bracelet. The inscription on the bracelet should read “steel bar in chest, CPR more force, cardioversion ant/post placement.”
Yes, your child can still receive CPR while the bar is in place. Chest compressions should be done with more force due to the bar placement. An AED can also be used with the bar in place; however, the paddle placement will be different. One paddle should be placed on the front of the chest and the other should be on the back.
Depending on your insurance, you may need a prior authorization prior to your clinic visits. When you schedule your appointment, you will be notified if you need a prior authorization/referral. Your primary care physician can help you obtain a referral/prior authorization for your clinic visit. If surgery is recommended for your child, a member of our team will assist you in obtaining any authorizations needed.
Please contact the Division of Pediatric General, Thoracic, and Fetal Surgery to make an appointment to have your child evaluated at 215-590-2730.
Created by: Mary Kate Klarich, MSN, CRNP; Gina Kroeplin, MSN, CRNP & Natalie Walker, MSN, CRNP
Reviewed by: N. Scott Adzick, MD, MMM, FACS, FAAP
Updated: April 2012