Advances in the management of pectus deformities in children

Abstract

Pectus excavatum (PE) and pectus carinatum (PC) are relatively common deformities involving the anterior chest wall, occurring in 1:1000 and 1:1500 live births, respectively. While the etiology remains an enigma, the association of pectus deformities with other skeletal abnormalities suggests that connective tissue disease may play a role in their pathogenesis. Clinical features of these deformities vary with severity, as determined by the Haller index and Backer ratio, but frequently include cardiac and respiratory abnormalities. Importantly, there exist profound psychosocial implications for children afflicted with these deformities, including but not limited to feelings of embarrassment and maladaptive social behaviors. These debilitating characteristics have prompted the development of novel medical and surgical corrective techniques. The correction of pectus deformities reduces the incidence of physiological complications secondary to chest wall malformation, while simultaneously improving body image and psychosocial development in the affected pediatric population. The Ravitch (open) and Nuss (minimally invasive) procedures remain the most frequently employed methods of pectus deformity repair, with no difference in overall complication rates, though individual complication rates vary with treatment. The Nuss procedure is associated with a higher rate of recurrence due to bar migration, hemothorax, and pneumothorax. Postoperative pain management is markedly more difficult in patients who have undergone Nuss repair. Patients undergoing the Ravitch procedure require less postoperative analgesia, but have longer operation times and a larger surgical scar. The cosmetic results of the Nuss procedure and its minimally invasive nature make it preferable to the Ravitch repair. Newer treatment modalities, including the vacuum bell, magnetic mini-mover procedure (3MP), and dynamic compression bracing (DCB) appear promising, and may ultimately provide effective methods of noninvasive repair. However, these modalities suffer from a lack of extensive published evidence, and the limited number of studies currently published fail to adequately define their long-term effectiveness.