Have you ever noticed someone whose chest sinks inward in the front, kind of like a funnel? The first time I ever noticed this bony malformation was when I was in high school, and a friend of mine on the soccer team had one. It was called “pectus excavatum,” he told me.
In my thoracic surgery training, I was often called upon to evaluate patients with this chest wall abnormality. As a result, I began to delve deeper into some of the issues that may affect people with this type of defect.
Pectus excavatum is the most common chest wall deformity and results from abnormal development of the sternum and its attachments. Most patients are self conscious about the defect and usually focus on its appearance but because this is usually present for much of a person’s life, symptoms associated with it may not be totally obvious. Individuals affected generally get used to how they feel and try to overcome any limitations to the best of their abilities without even knowing that’s what they are doing. Most patients describe some chest discomfort, shortness of breath when exerting themselves, lack of endurance, or feeling embarrassed in social situations when their shirt is off. It is not uncommon to hear patients say that they have trouble keeping up with their friends during activities, or that they avoid any activities that would require them to take off their shirt in public-such as going to a pool.
Most physicians aren’t even aware that there is an effective treatment for pectus excavatum. In fact, the teaching has been that unless the patient is symptomatic, the surgery is purely cosmetic. When the traditional Ravitch technique - which uses a large incision and then breaks the sternum and the affected ribs, followed by fixing them in a corrected position - was used, this seemed reasonable.
However, over the last 25 years there has been a development of a less invasive means of surgically correcting pectus excavatum called the Nuss procedure (Dr. Nuss in Virginia pioneered the procedure),. This procedure involves placing 1-2 bars across the chest underneath the sternum, to lift and reform the sternum to a more typical appearance. Patients see improvements in the way their sternum looks by the time they awake from anesthesia in the operating room! The bars stay in for 3 years on average before being removed.
Not all patients with pectus excavatum are good candidates for surgery. In order to best determine if surgery is a good option for a person with pectus excavatum, thoracic surgeons at Swedish like to evaluate all who are interested in potentially correcting their pectus in the clinic to determine how the pectus is affecting their life’s activities and then to perform a physical exam. We also will order a CT of the chest to calculate a Haller index which helps to assess how significant is the pectus with respect to its location from front to back, or chest to spine. This is a calculation that determines how much-or little-room there is between the spine and your pectus (or chest) for other organs to occupy-such as your heart.
Our experience thus far has provided those who have undergone the procedure a fresh outlook on how they see themselves. With time we aim for improvements in lung and heart function as these organs regain the room they need to function optimally.