eMedicine Specialties > Pediatrics: General Medicine > Pulmonology

Pectus Excavatum: Follow-up

Author: Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Sep 21, 2009

Follow-up

Further Inpatient Care

  • During the patient's hospital stay following corrective surgery for pectus excavatum, the author strongly recommends consultation with the anesthesia pain team. With intravenous narcotics and epidural analgesia, the pain that follows surgery can be controlled fairly well.
  • Typically, the thoracic epidural is removed 3-4 days after surgery, and most patients are discharged after 5-7 days. At the time of discharge, pain should be controlled with oral narcotics. NSAIDs, such as ibuprofen or ketorolac tromethamine (Toradol), are frequently added to the postoperative drug regimen. When using NSAIDs, consider adding histamine 2 (H2) blockers to prevent ulcer-related complications.

Further Outpatient Care

  • The typical follow-up postoperative repair of pectus excavatum involves outpatient visits with the pediatric surgeon 2-3 weeks after surgery and at regular intervals after that for the next 2 years. Monitoring patients at least every 3-6 months is recommended to ensure that they are not developing an anterior protrusion of the chest due to too much pressure from the pectus bar. Pectus carinatum as a sequela of MIRPE has been reported.

Transfer

  • Refer patients with pectus excavatum to a pediatric surgeon experienced in the field of congenital chest wall deformities.

Deterrence/Prevention

  • Physical fitness and development of strong anterior chest musculature may improve the appearance of pectus excavatum. However, clinical experience has demonstrated that only mild cases of pectus may benefit from this technique. The deformity worsens in most patients with moderate or severe pectus excavatum, particularly during the physiologic rapid growth of puberty.

Complications

Prognosis

  • The prognosis of pectus excavatum, with treatment, is excellent. Patients with mild pectus excavatum who do not undergo operative correction also have an excellent prognosis. Patients with moderate-to-severe pectus excavatum may experience problems related to cardiopulmonary impairment, decreased exercise tolerance, decreased stamina, and adjustment disorders related to the impact of this deformity on body image and coping mechanisms.
  • Mortality is not associated with the condition.

Patient Education

  • Because of the recent advances in the operative repair of pectus excavatum, education of medical professionals and the public is important. Again, patients with pectus excavatum should be referred to a surgeon experienced in the field of congenital chest wall malformations. Early assessment and follow-up is essential to maximize good outcomes.
  • After operative repair of the pectus excavatum, instruct patients on correct posture to eliminate musculoskeletal pain and to prevent worsening of the spinal deformity. Emphasize that repair of the pectus in itself does not result in correction of any associated spinal deformity or problems related to poor posture.

Miscellaneous

Special Concerns

  • Scoliosis and pectus excavatum
    • An association between anterior chest wall deformities and scoliosis is described in the literature but is poorly defined. Apparently, only 4-5% of patients with severe anterior chest wall deformities have scoliosis of sufficient magnitude to warrant evaluation and observation by a spinal deformity physician.
    • The relationship between anterior chest wall deformity and scoliosis is most clear in patients with Marfan syndrome. Patients with Marfan syndrome who have scoliosis are at high risk for progression of the deformity to unacceptable levels and have not historically responded well to brace therapy. Because of the association between pectus deformities and scoliosis, carefully examine patients with anterior chest wall deformities for signs of scoliosis and perform radiography if indicated. Patients younger than 5 years who present with spinal deformity are at risk for adverse cardiopulmonary sequelae related to the scoliosis. The management of scoliosis in patients with anterior chest wall deformities follows the treatment principles outlined for patients with idiopathic scoliosis.
  • Pouter pigeon breast: This condition represents a rare congenital deformity of the chest characterized by a protrusion of the manubriosternal junction and adjacent costal cartilages, as well as premature sternal ossification. One third of patients with Pouter pigeon breast have concomitant depression of the lower sternum (pectus excavatum). Several cardiovascular abnormalities have been associated with premature sternal ossification, the most common being ventricular septal defect. Surgical correction includes the wide wedge transverse sternotomy at the angle of Louis and subperichondrial resection of the adjacent costal cartilages. Long-term outcomes are encouraging.
  • Poland syndrome: This syndrome is characterized by pectus excavatum, hypoplasia or absence of the breast or nipple, hypoplasia of subcutaneous tissue, absence of the costosternal portion of the pectoralis major muscle, absence of the pectoralis minor muscle, syndactyly or bony abnormalities of the forearm, and absence of costal cartilages or ribs (typically ribs 2-4 or 3-5). Clinical manifestations of Poland syndrome widely vary, and all features rarely affect a single individual.
  • Adult patients with pectus excavatum: During the era of open surgery to repair pectus excavatum, adult patients rarely underwent corrective surgery. However, with the introduction of MIRPE, surgeons have noticed a significant change in the trend for corrective surgery in patients older than 18 years. Although MIRPE can be successfully performed in adult patients, the risk of bar displacement and other complications is increased in that group of patients. In addition, the degree of postoperative pain is more significant and more prolonged.
 


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References
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References

  1. Kelly R, Shamberger R, Hebra A, et al. Prospective Multicenter Study of Surgical Correction of Pectus Excavatum: Design, Perioperative Complications, Pain, and Baseline Pulmonary Function Facilitated by Internet-Based Data Collection. J Am Col Sur. 2007;205:205-16. [Medline].

  2. Cahill JL, Lees GM, Robertson HT. A summary of preoperative and postoperative cardiorespiratory performance in patients undergoing pectus excavatum and carinatum repair. J Pediatr Surg. Aug 1984;19(4):430-3. [Medline].

  3. Weg JG, Krumholz RA, Harkleroad LE. Pulmonary dysfunction in pectus excavatum. Am Rev Respir Dis. Nov 1967;96(5):936-45. [Medline].

  4. Quigley PM, Haller JA, Jelus KL, et al. Cardiorespiratory function before and after corrective surgery in pectus excavatum. J Pediatr. May 1996;128(5 Pt 1):638-43. [Medline].

  5. Peterson RJ, Young WG, Godwin JD, et al. Noninvasive assessment of exercise cardiac function before and after pectus excavatum repair. J Thorac Cardiovasc Surg. Aug 1985;90(2):251-60. [Medline].

  6. Ravitch MM. The operative treatment of pectus excavatum. Ann Surg. 1949;122:429-444.

  7. Nuss D, Kelly RE Jr, Croitoru DP. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg. Apr 1998;33(4):545-52. [Medline].

  8. Hebra A. Minimally invasive repair of pectus excavatum. Semin Thorac Cardiovasc Surg. Spring 2009;21(1):76-84. [Medline].

  9. Nuss D. Recent experiences with minimally invasive pectus excavatum repair "Nuss procedure". Jpn J Thorac Cardiovasc Surg. Jul 2005;53(7):338-44. [Medline].

  10. Hebra A. Minimally invasive pectus surgery. Chest Surg Clin N Am. May 2000;10(2):329-39, vii. [Medline].

  11. Adamson WT, Hebra A, Thomas PB, et al. Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma. J Pediatr Surg. Mar 2003;38(3):354-7; discussion 354-7. [Medline].

  12. Daunt SW, Cohen JH, Miller SF. Age-related normal ranges for the Haller index in children. Pediatr Radiol. Apr 2004;34(4):326-30. [Medline].

  13. Fefferman NR, Pinkney LP. Imaging evaluation of chest wall disorders in children. Radiol Clin North Am. Mar 2005;43(2):355-70. [Medline].

  14. Fonkalsrud EW, Bustorff-Silva J. Repair of pectus excavatum and carinatum in adults. Am J Surg. Feb 1999;177(2):121-4. [Medline].

  15. Frick SL. Scoliosis in children with anterior chest wall deformities. Chest Surg Clin N Am. May 2000;10(2):427-36. [Medline].

  16. Goretsky MJ, Kelly RE, Croitoru D, Nuss D. Chest wall anomalies: pectus excavatum and pectus carinatum. Adolesc Med Clin. Oct 2004;15(3):455-71. [Medline].

  17. Grimes SJ, Acheson LS, Matthews AL, Wiesner GL. Clinical consult: Marfan syndrome. Prim Care. Sep 2004;31(3):739-42, xii. [Medline].

  18. Haje SA. Common questions and answers to pectus deformities. Available at http://www.orthopectus.com.br/ffaq.htm. Accessed 2006.

  19. Haller JA Jr, Kramer SS, Lietman SA. Use of CT scans in selection of patients for pectus excavatum surgery: a preliminary report. J Pediatr Surg. Oct 1987;22(10):904-6. [Medline].

  20. Haller JA, Colombani PM, Humphries CT, et al. Chest wall constriction after too extensive and too early operations for pectus excavatum. Ann Thorac Surg. Jun 1996;61(6):1618-24; discussion 1625. [Medline].

  21. Haller JA, Scherer LR, Turner CS, Colombani PM. Evolving management of pectus excavatum based on a single institutional experience of 664 patients. Ann Surg. May 1989;209(5):578-82; discussion 582-3. [Medline].

  22. Hebra A, Jacobs JP, Feliz A, Arenas J. Minimally invasive repair of pectus excavatum in adult patients. Am Surg. Sep 2006;72(9):837-842. [Medline].

  23. Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg. Feb 2000;35(2):252-7; discussion 257-8. [Medline].

  24. Marusch F, Gastinger I. [Life-threatening complication of the Nuss-procedure for funnel chest. A case report]. Zentralbl Chir. Nov 2003;128(11):981-4. [Medline].

  25. Ohno K, Morotomi Y, Nakahira M, et al. Indications for surgical repair of funnel chest based on indices of chest wall deformity and psychological state. Surg Today. 2003;33(9):662-5. [Medline].

  26. Ravitch MM. Pectus excavatum. In: Congenital Deformities of the Chest Wall and Their Operative Correction. Philadelphia, Pa: WB Saunders Co; 1977.

  27. Robicsek F. Surgical treatment of pectus excavatum. Chest Surg Clin N Am. May 2000;10(2):277-96. [Medline].

  28. Shamberger RC. Congenital chest wall deformities. Curr Probl Surg. Jun 1996;33(6):469-542. [Medline].

  29. Tschirkov A, Baev B, Iliev R. Simultaneous pectus and open heart surgery. Chest Surg Clin N Am. May 2000;10(2):405-13, viii-ix. [Medline].

  30. Tsirikos AI, McMaster MJ. Congenital anomalies of the ribs and chest wall associated with congenital deformities of the spine. J Bone Joint Surg Am. Nov 2005;87(11):2523-36. [Medline].

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Further Reading

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Keywords

pectus excavatum, congenital chest wall deformity, sunken chest, pectus, Marfan syndrome, Poland syndrome, minimally invasive repair of pectus excavatum, MIRPE, Nuss technique, open Ravitch technique for repair of pectus excavatum, mitral valve prolapse, scoliosis, carinatum, pectus posture, bone and cartilage overgrowth, sternal turn-over operation, pectus carinatum, pectus deformity, back pain

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Contributor Information and Disclosures

Author

Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Girish D Sharma, MD, Associate Professor, Department of Pediatrics, Rush University Medical Center, Rush Children's Hospital; Director of Pediatric Pulmonary Section and Rush Cystic Fibrosis Center
Girish D Sharma, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Royal College of Physicians of Ireland
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Heidi Connolly, MD, Associate Professor of Pediatrics and Psychiatry, University of Rochester; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center
Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD, Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center
Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Merck Honoraria Speaking and teaching

 
 
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