Pectus excavatum (‘funnel chest’ or ‘sunken chest’), is characterized by a depressed sternum.  It is a congenital deformity.  The condition tends to progress with age and worsens during puberty.

     Pectus excavatum is well tolerated in infancy. However, older children may present with chest pain, palpitations, syncope from transient arrhythmia and mitral valve prolapse.

Why Repair A Funnel Chest?

In the past, it was thought that pectus excavatum was repaired merely for cosmetic reasons. However, evidences have shown that there are real impairments of the cardiac and pulmonary functions with reduced life expectancy in cases with significant deformities. Compression and displacement of the heart may cause chest pain with exercise, palpitations and arrhythmia (in 16% of cases), mitral valve prolapse (17%). The lung complications include mild to severe restricted breathing, obstructive airway and increased incidence of pneumonia and asthma. The spirometry is usually 10% to 20% below the expected average for the population and the mean total lung capacity is only 79% of predicted. Lastly, the distorted self image had led to depression and even suicide.

     After repair, these patients have shown normal ventilation scan and consistent decrease in heart rate at a given workload. Their cardiac index improved by 38% (stroke volume) and they can reach exercise target heart rate without becoming symptomatic. The average cardiovascular function increased by greater than one half SD (standard deviation) following the surgical repair of pectus excavatum. There was also marked improvement in the psychosocial well being.  

     Nowadays, an operation is considered if a patient presented with a history of progressive worsening of pectus excavatum, symptoms of exercise intolerance, chest pain, and shortness of breath and clinical evaluations showed cardiac and pulmonary compromise.

Repair

1. Ravitch Operation – Open resection of costal cartilages

 2.   Nuss Procedure (MIRPE - Minimally Invasive Repair of Pectus Excavatum)

     Previously, the condition was treated with the Open Technique (Ravitch procedure, 1949) which was a difficult, complex open and invasive surgery. This procedure involved making a large, transverse sub-mammary chest incision, raising the pectoralis muscle flaps. resecting the costal cartilages and breaking the sternum. The Open Technique operations can take up to six hours with significant blood loss. The patients have to stay in hospital for a considerable length of time and the post-operative pain is significant. One of the major drawback is the fact that the patient is left with a large, unsightly scar in place of the deformity.

     The new Nuss procedure is a minimally invasive surgical approach that inserts a stainless steel bar into the chest cavity through two small incisions of less than 2.5cm to mould and remodel the anterior chest wall. There is no cutting of bones or resection of costal cartilages. It works like the dental braces for mal-aligned teeth. The operation was developed by Professor Donald Nuss in 1986 and reported in 1998. It has since replaced the open technique with excellent results. The bar is left in place for two to three years (longer in adult). The main concern for the operation is a small risk of displacement or infection.

     One bar is usually sufficient except for those patients with long deformity where two bars are needed. The best time for someone to undergo the operation would be between the ages of eight and ten before puberty. It can be done in patients as young as two if the deformity is very severe. The bones in older patients are less malleable. Since this procedure available now is minimally invasive and much easier, more people are prepared to undergo the operation. The recovery is much faster that patients can be start competitive sports again in three months time. The patients should avoid bending or twisting the chest in the first four weeks.

Possible side effects are rare except pain & discomfort in first few weeks.  Others include: metal sensitivity or allergic reactions, surgical trauma to nerve, heart, lungs, bones and tissues, skin irritation, infection, pneumothorax, inadequate remodeling and recurrence after removal