Pectus Excavatum
An informational
brochure
Patients
and Families
with
"caved-in"
chest
for
Learn about the
treatment of this
congenital chest
wall malfonnation.
This brochure
contains the
answers to
frequently asked
questions about
Pectus Excavatum
Andre. Hebra. M.D.
Chief, Division of
Pedw/ric Swgery
Professor of SlIIgery
and Peaia/rics
Pediatl'ics Surgery
96 Jonathan Lucas Street
Suite418CSB
PO Box 250613
Charleston· SC 29425
Ph (843) 792-3851
1-800-424-6872
Pager (843) 792-2123
E-Mail: [email protected]
FREQUENTLY ASKED QUESTIONS ABOUT CORRECTIVE
SURGERY FOR PECTUS EXCAVATUM USING THE MINIMALLY INVASIVE TECHNIQUE (ALSO KNOWN AS THE
NUSS OPERATION):
1) How does the minimally-invasive
differ from the old surgical repair?
approach
The Minimally Invasive Operation for repair of Pectus Excavatum, also known as the NUSS OPERATION, is a completely different surgery from what it used to be. The open Ravitch operation required making an incision in the anterior chest - the front of
the chest - and then removing segments of all the ribs affected by
the pectus. The outer layer of the cartilage ribs (perichondrium) is
preserved in order to allow the ribs to grow back. The sternum
must be fractured in at least one area to allow for it to be bent in
the appropriate position. Complications of the open operation include bleeding, infection, injury to the lungs and pleura, and possible need for placement of chest drains. The end result is rated as
very good but 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 remove/fracture any ribs or cartilage, or sternum. The surgeon is
able to approach the chest with small lateral chest wall incisions
and, using a special camera (thoracoscope), the surgeon can visualize the inside of the chest so that a stainless steel bar can be placed
in order to correct the deformity. Again, this is accomplished without cutting anything, without breaking bones, without removing
any cartilage. The duration of the entire operation is much shorter.
With the open repair, the operation may take 4 to 5 hI'S. With the
Nuss technique, the operation is typically completed in just about
an hour.
2) What type of patient should be considered for
this operation? What are the indications for surgery? What is the chest index? Is it a cosmetic
operation?
Patients must be 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 impairment it is causing to the patient. #3, what is the psychosocial impact of the deformity.
The chest index is a measurement taken on the CT scan of the
chest in which a ratio is obtained between the lateral and anterior-posterior diameter of the chest wall. A normal chest index is
2.5. Patients with an index greater than 3.2 have a fairly pronounced and severe pectus excavatum and will typically need
operative correction. Even if asymptomatic, those patients usually benefit form the corrective surgery.
Many patients with mild to moderate pectus excavatum will not
report any significant shortness of breath. However, 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 children. Typically affected children always leave their shirt on if
they're in the pool. Clearly such patients would benefit from the
surgery.
A parallel comparison can be made with children born with Cleft
Lip & Palate - that repair could be considered a cosmetic repair.
However, no one would allow a child to go on in life with a cleft
lip deformity. Pectus deformity is no different. The only difference is that you can hide it under a shirt. But it's still a deformity of the sternum and the chest that deserves to be corrected if it
is causing significant concerns to the patient & family.
3) Is there an ideal age group for the new operation?
The ideal age for the minimally invasive operation is between 812 years. The main reason for that is that the child should be old
enough to understand what's ahead, to understand reasons for
surgery, to understand what's involved in recovery from surgery.
Moreover, between 8-12 years, the ribs and cartilage are still soft
enough so that the surgeon can repair the deformity using the
pectus-bar easily. The recovery from surgery at that age is much
easier than it is for teenagers. However, age by itself is not considered a contraindication for surgery. As a matter of fact, many
adult patients have undergone the Nuss operation with excellent
results.
Treatment of Pectus Excavatum
4) How does the Minimally Invasive operation
work?
The Minimally 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 5 mm camera is also
inserted into the chest. This will allow the surgeon to have direct
visualization of the placement of the bar and all the important
structures inside your chest (such as the heart, blood vessels, and
lungs). The surgeon will know exactly where to place the bar.
Through these small lateral chest wall incisions, a special curved
stainless steel bar (also known as the LORENZ pectus bar) is
passed behind the sternum.
The bar comes in different length according to age and patient
size. Then the bar is selected at the time of surgery and is bent by
the surgeon after certain measurements of the chest are taken. The
bar will have a smooth concave shape to it in order to allow for its
placement behind the sternum. The bar 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 bar is than
flipped, such that the sternum is raised and the entire chest wall is
remodeled. The entire maneuver is done under thoracoscopic visualization.
Essentially, what the operation is like placing an internal "brace".
The brace (pectus bar) will displace the ribs and the sternum forward, keeping it in that position until complete remodeling of the
chest wall has occurred. This process typically takes two years.
Fort that reason, the bar is left in place for at least two years.
The bar is kept in secure position by sutures that attach it to the
chest wall muscle fascia. In addition, a lateral stabilizer (a type of
T-connector) is attached to the sides of the bar for extra points of
fixation. Finally, a third point of fixation (an extra stitch that is
placed around a rib and around the bar itself) can be used to hold it
in place right next to the sternum.
The operation is done under general anesthesia.
thoracic epidural should be considered.
In addition, a
The thoracic epidural requires placement of a little catheter in
the epidural space (mid-back) by the anesthesiologist. This technique is similar to the one employed for delivering babies. The
epidural catheter can remain in place for several days after surgery, allowing doctors from the pain team to deliver certain types
of pain medications to facilitate the management of pain & discomfort after surgery. The medications will have a numbing effect, so that the child is essentially numb and with minimal pain
from about the nipple level down. The catheter can be left in
place for about 3 days after surgery.
It is important to remember that anytime a patient receives a
thoracic epidural, it will be necessary to place a Foley catheter -a catheter to drain the bladder. The reason for that is because
those patients who have an epidural will have trouble voiding.
With the Foley, the patient can void normally into a bag. Once
the epidural is removed, the Foley catheter is removed as well.
Patients typically will be discharged home with oral-pain medicine. Typically, a narcotic pain medication like Tylenol with codeine or Percocet will be necessary for 1 to 2 weeks. Additionally,
an anti-inflammatory medication (like Motrin, Alive or Advil) is
also utilized.
7) How long will the bar stay in place? When
and how is it removed?
The bar stays in place for about 2 years 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 bar removal is relatively simple. It is usually
done as an outpatient procedure. It does require general anesthesia. The surgeon will reopen one or two of the small lateral incisions and essentially pull the bar 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.
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PP.C't.us Bar
CT Scan appearance
Excavatum
of the chest in a patient with Pectus
8) Are there common problems or complications
associated with this procedure?
The most common problems 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 bar displacement, pneumothorax, and infection. However, as the technique has improved, the
complication rate has dramatically decreased. For instance, bar
displacement -which was reported in almost 10% of the patents - IS
now reported in about 1%. Other problems 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 but the chest may change and the ribs may do
funny things. Some patients may experience different growth rate
of the ribs 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 been reported before that ribs 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. Unfortunately the surgeon cannot control the rate of bone and cartilage growth in a developing child.
10) How long does the patient stay in the hospital 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 leu admission. The room
is fairly typical for most hospitals; nurses come in and check on the
patient frequently. Other services that will be involved in the patient's care include the pain management, child life and physical &
occupational therapy. All providers will concentrate specifically on
the needs of the pectus repair patients.
The average length of stay varies between 5-7 days. As a rule, the
younger child will stay less and the older child and young adults
will stay longer. Again, if the ribs 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 - because most
children will have to stay out of school for about 2 weeks after surgery to be observed closely at home. Physical activities will be limited and patients will not be able to lift up their book bags for almost one month after surgery.
Patients are instructed not to lift more than about 10 pounds after
surgery, which, as most parents know, is lighter than the average
book bag these days. Also, patients can't return to either PE or
sports until cleared by their surgeon. Typically patients are seen
back in the surgeon's office 2 weeks after discharge from the hospital and, at that time, it is determined, based on the individual patient's progress, when they can go back to physical activities. Generally speaking, most patients will return to sports and normal
physical activities 4 - 6 weeks after surgery. However, contact
sports (which include soccer and football) should be avoided for at
least 6 months.
Despite such initial restrictions, after approximately 4 - 6 weeks,
the patient should be fully recovered and should become very, very
active. It is important to build up muscle. It is important to regain
strength. Thus patients should be participating in sports, running,
swimming, biking, and especially weight-lifting. It is desirable that
children recovering from pectus surgery should build their pectoralis (chest), deltoid (shoulder), and abdominal muscles. Workingout with weights is very important after cleared by the surgeon.
12) How do the kids who have had the Nuss repair feel about it?
This operation has truly revolutionized the way pectus excavatum
has been managed. The operation is well accepted by 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 about their surgical options and they will seek surgical
treatment using the minimally invasive technique. The overall
satisfaction rate with the procedure has been rated as excellent or
very good by more than 90% of patients.
The Nuss procedure usually seems to be quite a life-changing operation. Most parents and the children just cannot believe the difference it has made in their lives - something that they probably
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 wellbeing.
Additional information about corrective surgery for Pectus Excavatum can be found at the following website:
emedicine.com
(search words: Pectus Excavatum)
An informational
brochure
for Patients
and Families
with "caved-in"
chest
Pediatrics Surgery
96 Jonathan Lucas Street
Suite418CSB
PO Box 250613
Charleston· SC 29425
Ph (843) 792 -3851
1-800-424-6872
Pager (843) 792-2123
E-Mail: [email protected]
After Minimally Invasive Repair