Pediatric Surgery: Chest Wall Deformity

Pectus Excavatum (Funnel Chest)

Basics

  • Posterior Depression of the Sternum & Lower Costal Cartilage
  • Most Common Anterior Chest Wall Malformation (90%)
  • More Common in Males
  • Often Noted in First Years of Life
    • “Growing Out Of” is Rare & May Worsen

Presentation

  • Generally Well Tolerated
  • May Cause Pain or Exercise Intolerance
  • A Large Portion Have Emotional Distress
    • Body Image Concerns May Cause Depression
  • May Impair Cardiopulmonary Function – Debated

Treatment

  • Indications for Surgical Repair:
    • At Least Two of:
      • Symptomatic (Emotional Distress) or Progressive
      • Restrictive Disease on PFT’s
      • Pectus Severity Index (PSI) > 3.25
        • CT – Ratio of Lateral Diameter of Chest to the Distance Between Sternum & Spine
      • Cardiac Abnormalities (MVP, Compression, Displacement, Bundle Branch Block)
      • Failed Prior Repair
  • Age to Repair: 10-15 Years (Pubertal Growth Spurt – Costal Cartilage Still Compliant But Lower Risk of Recurrence)
  • Improves: MVP, Not Lung Volumes

Surgical Procedures

  • Nuss Procedure (Minimally Invasive)
    • Generally the Preferred Procedure
    • Procedure: Pass A Stainless-Steel Bar Through the Anterior Mediastinum to Stabilize
      • Typically Removed After a Few Years
    • If Metal Allergy:
      • Preoperatively: Use Titanium (Less Malleable & More Expensive)
      • Postoperatively: Steroids
    • If Malpositioned or Moves: Reposition & Stabilize Bar
  • Ravitch Procedure (Open)
    • Procedure:
      • Resect Abnormal Subperichondrial Cartilage
      • Sternal Osteotomy to Reposition
      • Internal Fixation with Retrosternal Strut
    • If Sternum Angled/Superior Cartilage Protruding

Pectus Excavatum 1

Nuss Procedure 2

Nuss Procedure 3

Pectus Carinatum (Pigeon Chest)

Basics

  • Sternum Protrudes Forward
  • More Common in Males
  • Most Often Present After Age 11
    • Often Worsens During Pubertal Growth Spurt

Types

  • Chondrogladiolar Prominence
    • Most Common
    • Middle & Lower Portions Protrude Forward
  • Chondromanubrial Prominence
    • Upper Portion Protrudes Forward
    • Body is Deviated Posteriorly
    • Lower Portion Protrudes Forward
      • Characteristic Z-Shape on Lateral View

Presentation

  • Generally Asymptomatic
  • May Cause Pain or Exercise Intolerance
  • A Large Portion Have Emotional Distress
    • Body Image Concerns May Cause Depression

Treatment

  • Primary Tx: Bracing
    • Indications:
      • Emotional Distress
      • Respiratory Symptoms
    • 65-80% Success Rates
    • Generally Required for 4-8 Months
    • High Noncompliance with Therapy
  • If Severe or Unable to Tolerate Bracing: Open Ravitch Procedure
    • *See Pectus Excavatum

Pectus Carinatum 4

Pectus Carinatum Brace 5

References

  1. Ahellwig. Wikimedia Commons. (License: CC BY-SA-3.0)
  2. Koizumi T, Mitsukawa N, Saiga A, Satoh K. Clinical application of Nuss procedure for chest wall deformity in Poland syndrome. Kardiochir Torakochirurgia Pol. 2014 Dec;11(4):421-3. (License: CC BY-NC-ND-3.0)
  3. Zhong W, Ye J, Liu J, Zhang C, Zhao M. Numerical Simulation and Clinical Verification of the Minimally Invasive Repair of Pectus Excavatum. Open Biomed Eng J. 2014 Dec 31;8:147-52. (License: CC BY-NC-3.0)
  4. Jprealini. Wikimedia Commons. (License: CC BY-SA-4.0)
  5. Jung J, Chung SH, Cho JK, Park SJ, Choi H, Lee S. Brace compression for treatment of pectus carinatum. Korean J Thorac Cardiovasc Surg. 2012 Dec;45(6):396-400. (License: CC BY-NC-3.0)