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Updated: Jan 8, 2026

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

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Published on: June 20, 2018

Low interobserver agreement among expert surgeons using a common morphological classification for pectus excavatum.

Donají Rodríguez-Ortiz¹, Luzia Toselli², Gaston Bellia-Munzon²

¹Clínica Mi Pectus, Buenos Aires, Argentina. Av. Cramer 4602, Capital Federal, Buenos Aires, C1429AKL, Argentina.

Journal of Pediatric Surgery

|December 13, 2025

Summary

The visual classification of pectus excavatum shows low reproducibility among surgeons. Objective metrics like the Titanic Index are needed for consistent treatment decisions in chest wall malformations.

Keywords:

Interobserver variability Morphological classification Pectus excavatum Titanic index

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Area of Science:

Thoracic surgery
Medical imaging
Surgical outcomes

Background:

The established visual classification for pectus excavatum, introduced in 2006 and revised in 2013, categorizes deformities into three types.
Despite its international popularity, concerns regarding the reproducibility of this classification system persist among clinicians.

Purpose of the Study:

To evaluate the interobserver agreement and reproducibility of the established visual pectus excavatum classification system.
To assess the impact of objective thoracic indices on classification consistency.

Main Methods:

A two-stage comparative study involving blinded assessment of standardized pectus excavatum photographs by thoracic surgeons.
Phase one included six surgeons evaluating 100 cases; phase two involved 17 international experts assessing 10 simplified cases.
Analysis correlated classification agreement with thoracic indices, including the Titanic Index.

Main Results:

Complete agreement among surgeons was low (30% in phase one, 6% in phase two).
High agreement (≥80% observers) was achieved in 49% of cases in phase one.
Cases with higher agreement showed significantly lower Titanic Index values, suggesting localized deformities correlate with better consistency.

Conclusions:

Substantial interobserver variability exists in the visual pectus excavatum classification, even among specialists.
Reliance on surface anatomy alone is insufficient for guiding treatment decisions.
Quantitative imaging indices, such as the Titanic Index, are recommended to improve reproducibility and clinical decision-making.