Pectus excavatum (PE) is the most common congenital chest wall deformity, characterized by a sunken appearance of the breastbone and ribs. This structural variation can cause symptoms like shortness of breath, exercise intolerance, and chest discomfort, in addition to cosmetic concerns. While surgical correction is a serious procedure, modern techniques have been refined to achieve high rates of success and improved patient outcomes. The decision to undergo surgery aims to relieve physical symptoms by creating space for the heart and lungs.
Defining the Primary Surgical Approaches
Modern PE repair involves two distinct procedural methods. The minimally invasive approach, often called the modified technique, is preferred for younger patients with flexible chest structures. This method uses small side incisions to insert one or more curved metal bars beneath the breastbone. The bar is then flipped to push the sternum outward, correcting the indentation. The bar remains in place for several years to allow the chest wall to remodel.
The second method is the open repair, a traditional procedure requiring a longer incision down the center of the chest. This technique involves removing the abnormally formed cartilage connecting the ribs to the breastbone. After the cartilage is excised, the breastbone is repositioned, sometimes using temporary internal support for stabilization. Open repair is considered more extensive because it involves direct cartilage removal and sternal manipulation. The choice depends on the patient’s age, chest stiffness, and the specific shape of the deformity.
Acute Risks During the Procedure
Immediate risks relate to general surgery and the specific anatomical manipulation required. As with any major operation, complications involving anesthesia, such as adverse reactions or respiratory issues, are possible. A unique danger during PE repair involves the proximity of the breastbone to the heart and major blood vessels.
A serious, rare complication during minimally invasive bar insertion is cardiac injury, occurring if the instrument or bar punctures the heart or surrounding sac. Surgeons mitigate this risk using a camera inside the chest (thoracoscopy) to guide the bar’s passage and specialized techniques to elevate the sternum. Despite precautions, the potential for a life-threatening cardiac event is the most feared complication. However, the overall incidence of intraoperative complications for the minimally invasive approach is low.
Another frequent acute issue is pneumothorax, or a collapsed lung, which may occur if the lung lining is inadvertently punctured. This complication is often managed by placing a temporary chest tube to remove air and allow the lung to re-expand. Significant bleeding is also a concern, particularly with the open repair where greater tissue is dissected. The possibility of requiring a blood transfusion is higher with the open technique compared to the minimally invasive bar placement.
Post-Operative Recovery and Potential Complications
The recovery phase involves specific challenges and complications. The most significant post-operative issue is pain, which can be considerable, especially after minimally invasive bar placement due to the forceful reshaping of the chest wall. Effective pain management often involves regional nerve blocks, such as intercostal nerve cryoablation, and intravenous medication. This ensures the patient can breathe deeply and cough effectively.
Infection is a risk following any operation, potentially involving skin incisions or the metal bar. Antibiotics are routinely administered to minimize this risk, but a deep infection involving the bar may necessitate its premature removal. A mechanical issue unique to bar procedures is bar displacement or migration, where the bar shifts out of its intended position. This displacement can cause pain or a recurrence of the deformity.
Bar displacement is reported in four to five percent of adult cases and usually requires a second procedure for repositioning. Recurrence of the deformity is another concern, meaning the chest wall begins to sink again after the bar is removed or the open repair has healed. This risk is low if the bar remains in place for the recommended period, typically three or more years, allowing the chest wall to solidify. These complications emphasize the need for careful follow-up and patient adherence to post-operative restrictions.
Patient Selection and Safety Assessments
Safety is improved by rigorous pre-operative screening. Before surgery, a comprehensive evaluation confirms that the structural impact warrants the inherent surgical risk. This evaluation includes pulmonary function tests (PFTs) to measure lung capacity and identify restrictive breathing patterns caused by the compressed chest.
A cardiac assessment is performed, often including an echocardiogram to check for heart compression or associated conditions. The severity of the deformity is measured using the Haller Index (HI), which is the ratio of the chest’s transverse diameter to the distance between the sternum and the spine, measured on a CT scan. A HI value of 3.25 or greater is often used as a standard threshold for recommending surgery. This methodical approach ensures the operation is primarily reserved for individuals with functional impairment or severe anatomical defects.