Current management of pectus excavatum

Pectus excavatum (PE) is one of the most common anomalies of childhood. It occurs in approximately 1 in every 400 births, with males afflicted 5 times more often than females. PE is usually recognized in infancy, becomes much more severe during adolescent growth years, and remains constant throughout adult life. Symptoms are infrequent during early childhood, but become increasingly severe during adolescent years with easy fatigability, dyspnea with mild exertion, decreased endurance, pain in the anterior chest, and tachycardia. The heart is deviated into the left chest to varying degrees causing reduction in stroke volume and cardiac output. Pulmonary expansion is confined, causing a restrictive defect. Repair is recommended for patients who are symptomatic and who have a markedly elevated pectus severity index as determined by chest X-ray or computed tomography scan. Repair using the highly modified Ravitch technique is usually performed after the age of 8 years. The optimal age for repair is between 12 and 16 years. Repair can be performed on adults with similar good results. Recent modifications in the Ravitch technique remove minimal cartilage and routinely use a temporary internal support bar for 6 months. Operation rarely takes more than 3 hours, and hospitalization rarely exceeds 3 days. Pain is mild and complications are rare, with 97% of patients experiencing a good to excellent result. The new minimally invasive Nuss repair avoids cartilage resection and takes less operating time, but is associated with more severe pain, longer hospitalization and a higher complication rate, with the bar remaining for 2 or more years. This technique is less applicable to older patients and those with asymmetric deformities. Long-term follow-up will be necessary to determine which operation may be best for any specific patient.