Pectus excavatum

Congenital deformity of the anterior thoracic wall in which the sternum and rib cage grow abnormally producing a caved-in or sunken appearance of the chest.

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Aetiology

Associated conditions:

• Congenital disorders:
  • Noonan syndrome
  • Marfan syndrome
  • Loeys-Dietz syndrome
• Connective tissue disorders:
  • Ehlers–Danlos Syndrome
• Spinal muscular atrophy
  • Develop pectus excavatum due to their diaphragmatic breathing

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Clinical features

• Sunken appearance of the sternum (HALLMARK)
• Cup-shaped concavity, involving the lower end of the sternum (M/C form)
• Lower-most ribs may protrude (“flared ribs“)
• May be symmetric or asymmetric
• Chest and back pain
• Severe cases:
  • Mitral valve prolapse

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Diagnosis

Imaging:

Chest X-ray or CT-scan

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Management

Conservative treatment:

• Excercise

Magnetic mini-mover procedure (3MP)

Technique used to correct pectus excavatum by using two magnets to realign the sternum with the rest of the chest and ribcage

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Vacuum bell (treatment by cup suction) +  physiotherapy

Surgical management: Ravitch technique

• Two-stage procedure:
  • Creating an incision along the chest through which the cartilage is removed and the sternum detached
  • Small bar is inserted underneath the sternum to hold it up in the desired position.
    • Bar is left implanted until the cartilage grows back (~6 months), then removed in an OPD procedure

Nuss procedure

• Two-stage procedure:
  • Slipping in ≥ 1 concave steel bars into the chest, underneath the sternum
    • Bar is flipped to a convex position so as to push outward on the sternum, correcting the deformity.
  • Bar usually stays in the body for 2-5 years
    • Removed through OPD procedure when the bones have solidified into place

Robicsek procedure

• Single-stage procedure:
  • Pectoralis major muscles then detached from the sternum
  • Using the upper limit of the sternal depression as a guide, the deformed cartilages are removed one-by-one, using sharp and blunt dissection.
  • Lower tip of the sternum is then grabbed with a towel-clip and, using blunt dissection, is freed of tissue connections with the pericardium and the pleura.
  • Sternum is then forcefully bent forward into a corrected position.
    • To keep the sternum elevated, a piece of mesh is placed under the mobilized sternum and sutured under moderate tension bilaterally to the stumps of the ribs.
  • The pectoralis muscles are united in front of the sternum and the wound is closed.