Pectus excavatum

Overview

Pectus excavatum is the most common chest wall deformity in children. Its cause is unclear. The condition is often apparent in the years preceding adolescence and typically becomes more severe over time. It occurs more frequently in boys than in girls.

For most children, this deformity doesn't pose a serious health risk. If necessary, a surgical repair is done to improve heart and lung function as well as chest appearance. One to three years after surgical repair, the patient needs a follow-up procedure to remove the implanted corrective device. Removing these devices can be done without an overnight stay.

Procedure

Pectus excavatum is generally repaired in one of two ways. The traditional approach, called the modified Ravitch procedure, involves a long incision across the chest to remove the deformed cartilage. The sternum is then moved forward and secured in the right position with metal struts. This operation takes about three hours.

Another approach, known as the Nuss procedure, involves making a small incision on each side of the chest. A stainless steel "pectus bar" is inserted through one of these incisions and placed under the sternum, raising the sternum. The bar is then secured to the chest wall using metal stabilizers on each side. This operation takes about two hours.

To lessen postoperative pain, a technique called cryoanalgesia is performed during the surgery. This involves freezing the nerves that supply sensation to the front part of the chest. The area remains numb while the pain resolves, usually in about a month. Sensation to the chest returns in two to three months. With this technique, most patients can go home one day after the operation.

In both operations, all stitches are placed under the skin. These stitches dissolve over time, so they don't have to be removed later on. Your child's incisions will be covered with small bandages.

With the Ravitch repair, the metal struts are removed a year after insertion. A presurgical visit is required. Removal takes about an hour and is performed as an outpatient procedure, so you and your child can return home the same day.

After the Nuss procedure, we remove the pectus bar – or bars, if more than one was used – two to three years after insertion. This outpatient procedure takes about an hour.

Recovery

Pectus excavatum repair is a painful procedure. The length of your child's hospital stay will depend on the pain level experienced after the operation. Most children stay in the hospital for about five days after the operation if a traditional method of pain management is used. In the traditional method, an epidural catheter (placed in the back) is used to give continuous pain medication for several days, when pain is greatest. While the epidural is in place, your child will also have a urinary catheter in place. In addition, your child may be given oxygen with a small tube under the nose. If cryoanalgesia is used for pain control, most patients can go home one day after the operation and a urinary catheter isn't needed.

You can help speed your child's recovery by encouraging deep breathing, walking and sitting in a chair as soon as possible after the operation.

Home Care

After bringing your child home, please keep the following in mind:

• Pain – When your child leaves the hospital, you will be given a prescription for pain medication.
• Activity – Your child may resume regular activities as tolerated.
• Bathing – Your child may shower after two days. Baths are allowed after a week.
• Dressings – Gauze and clear plastic dressings placed over the incisions may be removed a few days after surgery. Over the incision, there will be small strips of white adhesive tape. It's normal to see a small amount of blood on the strips. The skin surrounding the incision may be red and bruised. Eventually, the tape will loosen and fall off.
• Swelling – There may be slight swelling at the incision site. After the incision heals, you'll feel a firm ridge, called a "healing ridge," under the incision. This is where the tissues were sewn together. It may be present for several months.

If all goes well, your child will have a scheduled follow-up visit with us between two and four weeks after leaving the hospital.

If you have any concerns once your child is home, please call the Pediatric Surgery Clinic at (415) 476-2538 (San Francisco clinic) or (510) 428-3022 (Oakland clinic). You should also call if your child develops any of the following:

• A temperature of 101.5 F or higher
• A red incision
• Worsening pain and tenderness at the incision
• Fluid coming from the incision