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Evolving management of pectus excavatum based on a single institutional experience of 664 patients
J A Haller1, L R Scherer, C S Turner
1Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Insights
Pectus excavatum surgery in childhood is recommended to prevent chest compression and cardiac issues. Early repair, ideally between ages 4-6, ensures normal thoracic growth and positive outcomes.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Congenital Chest Wall Deformities
Background:
- Pectus excavatum is often treated surgically only in teenagers for cosmetic reasons.
- Current beliefs delay surgical intervention, potentially missing critical developmental windows.
Purpose of the Study:
- To advocate for early surgical repair of pectus excavatum in childhood.
- To highlight the benefits of early intervention for thoracic growth and cardiopulmonary function.
- To present an effective surgical technique and patient selection criteria.
Main Methods:
- Utilized preoperative CT scans for deformity assessment and patient selection.
- Employed pulmonary function studies during exercise to identify respiratory dysfunction.
- Performed surgical repair involving costal cartilage removal, sternal osteotomy, and internal rib support.
- Implemented a temporary substernal bar to prevent recurrence in adolescents.
Main Results:
- Follow-up of 664 patients over 1-40 years.
- Achieved 95% excellent long-term results.
- Reported only 5% mild to moderate recurrences.
Conclusions:
- Early surgical repair of pectus excavatum (ages 4-6) is crucial for normal thoracic development and preventing cardiopulmonary complications.
- The presented surgical technique offers excellent long-term outcomes with low recurrence rates.
- Timely intervention before the pubertal growth spurt is key to reversibility and optimal results.
Abstract:
Most pediatricians and family physicians believe that children with pectus excavatum require surgery only for cosmetic indications and then only in teenagers. We believe pectus excavatum should be repaired in childhood (1) to relieve structural compression of the chest and allow normal growth of the thorax; (2) to prevent pulmonary and cardiac dysfunction in teenagers and adults; and (3) to obviate the cosmetic impact that may cause a child to avoid sports and gymnastics. Preoperative CT scans now help select those children who need repair to prevent progressive deformities. Pulmonary function studies during vigorous exercise can document respiratory dysfunction in teenagers. These features are reversible if repair is completed before the pubertal growth spurt. The ideal age for repair is 4 to 6 years, which permits enough emotional maturity for a positive hospital experience and avoids later psychological effects. Repair at an earlier age has no operative advantages. Our operative technique consists of the removal of three to four overgrown costal cartilages, repositioning of the sternum with a transverse osteotomy, and internal support using the child's lowest normal ribs, avoiding any prosthetic support. To prevent recurrence in teenagers, we add a temporary bar beneath the sternum to prevent depression of the sternum from the weight of the chest-wall muscle mass. Six hundred sixty-four patients have been followed for 1 to 40 years; 95% have excellent long-term results and only 5% have mild to moderate recurrences. Our current techniques of patient selection and surgery will be presented.