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Pectus Excavatum FAQ

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The Nuss Operation, also known as minimally invasive repair of pectus excavatum (MIRPE), is primarily considered for patients with significant pectus excavatum deformity. This condition, often referred to as "sunken chest" or "funnel chest," occurs when the breastbone (sternum) is abnormally depressed, causing the chest to appear concave. 

Lee Physician Group's very own pectus excavatum expert, Dr. Andre Hebra, answers the questions he receives from concerned parents in Southwest Florida.

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Lee Health's Pectus Excavatum Expert

Dr. Hebra emerged as a trailblazer in the early stages of laparoscopic surgical methods with a distinct focus on minimal access surgery and robotic techniques. 

He has made significant contributions to healthcare innovation with over 100 peer-reviewed scientific articles and book chapters to his credit. Recognized for his original research and outstanding teaching, he consistently earns placement in the esteemed "Best Doctors in America" listings. 

Notably, Dr. Hebra spearheaded outcomes research addressing the management of congenital chest anomalies, leading to enhanced care protocols for pediatric patients with pectus excavatum and carinatum.

Patient Considerations for the Nuss Procedure

Learn more about ages, indications and other factors that providers consider when recommending the Nuss Procedure.

Candidates for the Nuss procedure typically include adolescents or young adults:

  • With moderate to severe pectus excavatum deformities, where the depression of the chest wall is significant enough to warrant surgical correction
  • Experiencing physical symptoms such as shortness of breath, chest pain, or exercise intolerance due to the deformity.
  • Experiencing psychological distress or body image issues related to their chest deformity may also be candidates for surgery.

Patients must be carefully evaluated before surgery. The things that we look for are:

  • How severe is the deformity (one must determine the chest Haller index). 
  • What kind of physiologic (cardio-pulmonary) impairment it is causing to the patient. 
  • What is the psychosocial impact of the deformity.

The ideal age for the minimally invasive operation is between 10-12 years. At this age, the child should be old enough to understand what’s ahead, the reasons for surgery and what is involved in recovery from surgery. Moreover, between 10-12 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. The risk of complications is less. It is important to note that age by itself is not considered a contraindication for surgery. Many adult patients have undergone the Nuss operation with excellent results.

The chest index is the measurement taken on a CT or MRI 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 from the corrective surgery. Most patients with a Haller index greater than 4 have exercise intolerance.

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 public spaces or by the pool.

As it relates to the psychological problems caused by the pectus, 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 viewed by many as the same type of challenge. The only difference is that you can hide the caved-in sternum under a shirt. But it remains a congenital deformity of the sternum/chest that deserves to be corrected if it is causing significant psychosocial concerns to the patient & family.

Understanding the Nuss Operation for Pectus Excavatum

The Minimally Invasive Operation for the 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 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 the possible need for replacement of chest drains. The 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 can 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 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 hrs. With the Nuss technique, the operation is typically completed in just about an hour.

Pectus Excavatum Nuss Procedure Questions

The bar is kept in a 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 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.

The operation is done under general anesthesia. In addition, several other modalities that complement general anesthesia can be used, including thoracic epidural, para-spinal nerve block, and Cryoablation. If appropriate, Cryoablation is the preferred treatment modality for the management of pain during and after surgery. Cryoablation provides transient blockage of the intercostal nerves creating a broad area of numbness in the entire front of the chest. The numbness typically persists for several weeks after surgery and provides excellent pain and discomfort control. Other methods, such as thoracic epidural, require the placement of a small 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 on the thoracic region. The catheter of the epidural can be left in place for about 3 days after surgery. As previously mentioned, other more innovative techniques such as local nerve block and having been used with excellent success rates.

Patients typically will be discharged home with oral pain medications. Typically, a narcotic pain medication like Tylenol with codeine or Percocet will be necessary for a short period (no more than 1 to 2 weeks). Additionally, an anti-inflammatory medication (like Motrin, Alive, or Advil) is also utilized in combination with Tylenol. Again, pain specialists will help guide the post-operative pain management protocol for each patient.

The most common problems and complications related to surgery have evolved since the operation was first reported in 1998. In the initial series of several hundred patients, it was found that the most common complications were related to 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 2%. Other problems such as Infection and pneumothorax are very rare. The use of thoracoscopy has also helped in making this a much safer operation. Other very rare complications include the risk of injury to major vessels and the heart – now reported to be less than one in a million cases.

Occasionally we may see patients that have an initial excellent cosmetic result after surgery but the chest may change and the ribs may develop asymmetrical shapes. Some patients may experience different growth rates of the ribs on the left and right sides of the chest (this is particularly a concern in patients with severe asymmetry of the chest before any corrective surgery). It has been reported in the past that ribs and cartilage can grow in an unusual way that was not expected. 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. Such events are rare.

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 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 the chest (such as the heart, blood vessels, and lungs). The surgeon will also elevate the sternum during the procedure for precise placement of the bar behind the point of maximal depression of the sternum. The curved stainless steel curved bar is placed via the two small lateral chest wall incisions.

The bar is available in different lengths according to age and patient size. Then the bar is selected at the time of surgery and is bent (curved) by the surgeon after certain measurements of the chest are taken. The bar will have a smooth concave shape to it 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 with active sternal elevation. The bar is then flipped, such that the sternum is raised and the entire chest wall is immediately remodeled. The entire maneuver is done under thoracoscopic visualization. 

Essentially, the operation allows for the placement of an internal “brace”. The brace (pectus bar) will displace the ribs and the sternum forward, keeping them in that “new” 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 to three years.

Pectus Excavatum After Procedure FAQs

Immediately after surgery, the patient is taken to the recovery room and then to a general care floor in the hospital. Usually, there is no need for critical care monitoring or ICU 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 team (anesthesia), child life, and physical & occupational therapy. All providers will concentrate specifically on the specific needs of the pectus repair patients.

The average length of stay varies based on response to postoperative pain management. It can range from 2 to 6 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 and overall recovery will be faster.

Patients and families are advised to pick a specific time to have the elective surgery done – usually around summertime - because most children will have to stay out of school for about 2 weeks after hospital discharge to recover safely at home. Physical activities will be limited and patients will not be able to lift their heavy book bags for about eight weeks 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 2-3 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. Post-operative physical therapy is rarely necessary.

Despite such initial restrictions, after approximately 6-8 weeks, the patient should be fully recovered and should become very, very active. It is important to build up muscle mass and overall strength. Thus patients should be participating in non-contact sports, running, swimming, biking, and especially weight-lifting. Children recovering from pectus surgery should build their pectoralis (chest), deltoid (shoulder), and abdominal muscles. Working out with weights & machines is very important after being cleared by the surgeon.

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 primary care providers. It is less invasive, less traumatic and it gives patients an excellent functional and cosmetic outcome. 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 in published studies as excellent or very good by more than 90% of patients.

The Nuss procedure is seen by most patients & families to be quite a life-changing operation. Most parents and their children cannot believe the difference the procedure has made in their lives - something that they probably would not admit to before surgery. It has been frequently reported that it has caused them to have a whole new outlook on their future as well as their perception of themselves. Their overall physical endurance and wellbeing are positively impacted.

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