Chest wall deformities

Pectus excavatum

Pectus excavatum (PE) is an abnormal development of the rib cage where the sternum is depressed, resulting in a sunken chest wall deformity. Sometimes referred to as “funnel chest”, pectus excavatum is a deformity often present at birth (congenital) that can be mild or severe.

Symptoms
Most patients do not manifest symptoms, however if present the common symptoms are:

  • Fatigue
  • Shortness of breath
  • Chest pain
  • Tachycardia

Diagnosis
Before any treatment is commenced complete diagnosis of the condition with regards to the heart, lungs and vertebral column must be conducted.
Tests that are included in the diagnostic work-up are:

  • Chest x-ray
  • Pulmonary function test
  • Electrocardiogram
  • Echocardiogram (a picture of the heart)
  • Physical (exercise) test
  • Laboratory studies (blood work)
  • Chromosome studies (if syndrome is suspected)
  • Computed tomography (CT) scan of the chest
  • Allergy tests
  • Conventional photo documentation
  • Videostereoraster examination

Conservative Treatment
Since most patients with mild pectus excavatum do not have symptoms and treatment may not be needed. Physical therapy is recommended and special exercises are recommended especially in younger children that could positively influence the development of the pectus deformity. Early recognition and referral may play a crucial role in the outcomes. In younger patients, once physical therapy is commenced, regular follow-ups are performed to monitor the progression of the pectus excavatum.

Vacuum Bell
A suction cup is used to create a vacuum at the chest wall up to 15% below atmospheric by the patient using a hand pump. Three different sizes exist allowing selection according to the age of the patient.

Surgery
The goal of pectus excavatum repair surgery is to correct the chest deformity. A variety of surgical procedures are available to repair pectus excavatum.

Plier Technique
This is an open technique with 10-12cm incision and is preferred in severe asymmetric or combined forms of pectus deformities.

Nuss Procedure
Uses a video-assisted thoracic surgery (VATS) technique to correct pectus excavatum. Through two small incisions on either side of the chest, a curved steel bar is inserted under the sternum, and the steel bar is used to ‘pop out’ the depression and is then fixed to the ribs on either side. The bar is not visible from the outside and stays in place for a minimum of three years.

Risks of Operative Treatment
The surgical repair of pectus excavatum, is an extensive surgical procedure and presents risks. While both the Nuss procedure and the PLIER technique are safe and effective procedures, complications could occur.
Possible complications from operative repair include:

  • Bleeding
  • Pneumothorax (accumulation of air in the pleural space)
  • Pleural effusion (fluid in the pleural space)
  • Infection
  • Bar displacement

Pectus Carinatum – Pigeon Chest

Pectus carinatum (PC) is an abnormal development of the rib cage where the sternum is elevated, resulting in a elevated chest wall deformity. Sometimes referred to as “pigeon chest”, pectus carinatum is a deformity that can be mild or severe. Pectus carinatum patients do not have heart or breathing problems related to the condition. Many children present with pectus carinatum, however most present with mild forms that do not require any treatment. However, the child is carefully followed-up as they progress through puberty when the deformity could progress during the growth spurt requiring treatment.

Compression Bracing
Pectus carinatum which manifest in mild or moderate forms during childhood or puberty could be corrected using compression bracing. This is the preferred first line of treatment in teenagers and adolescents in whom the chest wall is still “elastic” and correction of the deformity can be performed by excreting controlled pressure through costumed made braces. If the chest wall is “stiff”, compression bracing is not an option and in young adults, correction of these deformities is then done through surgery.

Surgery
Pectus carinatum which manifest in moderate or severe forms during puberty or young adulthood that cannot be corrected by compression bracing require surgical correction. Complex forms, in which assymetric pectus carinatum is present or it co-exists with pectus excavatum, are best corrected using the PLIER technique.

Plier Technique
This is an open technique with 10-12cm incision and is preferred in severe asymmetric or combined forms of pectus deformities. The results of this technique are excellent as the desired correction can be achieved in complex forms of pectus carinatum. Since this is an extra-pleural technique, it is associated with less pain and early recovery. Metal struts are used to stabilize the corrected chest wall which are removed after 15 months.