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Surgical Treatment


Surgical treatment of pectus anomalies should be performed by an experienced thoracic surgeon. Many people with pectus anomaly express great frustration when trying to obtain advice from their general practitioners (GP) about what the chest anomaly is and what is the best treatment. A referral to a thoracic surgeon must be made by a GP. An experienced thoracic surgeon will conduct a thorough assessment of the chest anomaly and advise the most appropriate treatment for each individual case.

Pectus correction surgery is usually performed by specialist thoracic surgeons who have obligations to operate on patients with life threatening diseases. Because pectus correction surgery is often viewed as cosmetic surgery, patients often have a long struggle to have their operation performed.

Surgical correction of pectus anomalies can now be performed with low morbidity, low cost, minimal limitation in activity and a high frequency of symptomatic improvement. Fonkalsrud et al (2000) states that more than 97% patients had a very good or excellent result.

Currently the surgical options availalbe in the UK are the Ravitch and Nuss procedures.

Please note, however, any type of surgery leaves a scar, is very painful and complications include wound infections and post-operative pain.

In severe cases, correction may not be total and recurrence can take place.

Information on each of these operations is given below, including the advantages and disadvantages of each procedure.


Procedures:

Ravitch procedure

Nuss Procedure or Minimally Invasive Repair of Pectus Excavatum (MIRPE)

Advantages of the Ravitch and the Nuss procedure

Disadvantages of the Ravitch and the Nuss procedure

Benefits of surgical treatment for pectus anomaly

Risks of surgical treatment for pectus anomaly


Ravitch Procedures (Illustrations)
In the Ravitch procedure, the rib cartilages are cut away on each side and the sternum is flattened so that it will lie flat. One or more bars (or “struts”) may then be inserted to ensure the sternum keeps it shape. This is the procedure we use for complex pectus anomalies and for pectus carinatum. The operation involves making a horizontal cut from one side of the chest to the other. Drains are inserted on each side of the chest to remove any fluid from the surgical site and the wound is closed using dissolvable stitches. If a strut is inserted it is intended to remain in place permanently but may be removed if it causes pain or other problems.

For illustrations, click here.

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Nuss Procedure or Minimally Invasive Repair of Pectus Excavatum (MIRPE)
(Photo Illustrations)
Developed by Dr Nuss in the 1980s, the MIRPE or Nuss procedure involves placing one or two curved steel bars behind the sternum, forcing it back into a more normal shape. Drains are then inserted on either side of the chest to remove any fluid from the surgical site. This procedure can only be used for pectus excavatum. In children, the bar is removed after two years once permanent reshaping has occurred. In adults, the bar is currently left in place for at least three to five years. Some patients prefer to keep the bar permanently as it reduces the risk that their pectus anomaly will come back.

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What are the advantages of the Ravitch procedure and the Nuss procedure?

Advantages of the Ravitch Procedure:
  • It is a tried and tested method for correcting pectus anomaly. Research shows that 97 per cent of patients stated they have very good or excellent results with this procedure.

  • Once the procedure has been performed, it is extremely unlikely that the anomaly will happen again.

Advantages of the Nuss Procedure (minimally invasive repair of pectus excavatum – MIRPE):
  • It is a minimally invasive operation – only four to five small incisions are needed (an incision of four to five centimetres on each side of the chest; two chest drain incisions of one to one and a half centimetres each; and a two centimetre incision below the tip of the sternum).

  • It does not involve cutting or removal of cartilage.

  • There is generally minimal blood loss during the procedure. It is unusual for a patient having this operation to require a blood transfusion.

  • It is generally a quicker operation than the Ravitch procedure.

  • A recent article on the experience of Nuss procedure patients at Royal Brompton showed that 85 per cent thought that their decision to have the operation was the right one.

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What are the disadvantages of the Ravitch procedure and the Nuss procedure?

Disadvantages of the Ravitch Procedure:
  • There is a large incision, although this normally fades to a thin line.

  • The procedure is a more extensive operation than the Nuss technique.

Disadvantages of the Nuss Procedure:
  • As it is quite a new procedure there is not yet reliable data on how well it works in the longer term.

  • Generally the procedure is straightforward but it can sometimes be more difficult to carry out in adults than in children.

  • There are not yet clear guidelines on when to remove the bar in adults. It is possible that the anomaly will reoccur once the bar is removed.

  • Though very rare, injury to the heart when positioning the bar can happen. Your surgeon will use various techniques to minimise this risk and will discuss these with your prior to the procedure.

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What are the benefits of surgical treatment for pectus anomaly?

Surgery will improve the shape of your chest which may improve your self-confidence and self-esteem. Some people who have had the operation say that they also feel physically better following the procedure. But it is important to know that there is no evidence to suggest that pectus correction surgery will reduce any problems with your heart or lungs. It is important to remember that it is not possible for us to say to what extent we will be able to improve the shape of your chest with surgery. Your surgeon will discuss this with you. Though many people will feel more positive about themselves following the corrective procedure, many continue to need and receive counselling and other support for poor self-esteem or concerns over body image.

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What are the risks of surgical treatment for pectus anomaly?

Overall both the Nuss and Ravitch procedures have good safety records. Complications can occur with any surgery, however. For pectus anomaly correction surgery, the specific risks include:
  • Bleeding: Rare for Nuss procedure; unlikely for Ravitch procedure
  • Wound infection: Rare
  • Collection of fluid around one or both lungs (pleural effusion): Rare
  • Air leak from either lung (pneumothorax): Rare
  • Quick healing of the surgical wound, which results in the scar
    being red, thickened and itchy (Keloid scarring): Rare
  • Long term discomfort from the sternal bar: Unlikely
  • Damage to the heart from bar placement: Very rare

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