General and Thoracic Surgery Pectus Excavatum Surgery
General and Thoracic Surgery Pectus Excavatum Surgery

What Is Pectus Excavatum?

If your child develops a sunken chest — referred to as pectus excavatum — chances are that another family member has had the congenital condition too. While pectus excavatum causes are unknown, the condition tends to run in families; 25 percent of patients discover a family history of others with “funnel chest” (also known as caved-in chest).

The surgical experts at Children’s Mercy Kansas City are recognized leaders in repairing pectus excavatum. Our surgery success rate is 99 percent.

The condition is the most common deformity in children’s chest walls and can become visible (the only actual pectus excavatum symptoms) anytime from infancy through puberty. It occurs when several ribs and the sternum (breastbone) don’t grow normally, causing the sternum to be pressed inward and resulting in a depression that is visible when looking at your child’s chest. The depression can range in size and depth, being deeper on one side, causing the breastbone to be curved and, in severe cases, pushing the sternum to nearly touch the spine.

Most kids aren't bothered by having a concave chest until they begin their growth spurt. At that point, severe cases of pectus excavatum deformity may require minimally invasive surgery. Mild pectus excavatum often can be improved with exercises to increase upper-body strength and improve posture.

Pectus Excavatum Surgery

Doctors began using open surgery to correct the condition in the early 1900s. Eighty years later, Donald Nuss, MD, a Norfolk, Va., doctor, devised an approach that was less invasive. Since then, the general surgeons at Children’s Mercy have modified the Nuss procedure. In 1999, they began using a procedure that involves small incisions — only 1.5 inches long — on each side of a child’s chest. Doctors then insert a steel bar that has been curved to fit under the concave sternum and around the front of the chest. The bar helps reshape the chest as the child grows. After about three years, the bar is removed in a same-day procedure. This pectus excavatum treatment is highly effective; less than 1 percent of children will develop the condition again.

What to Expect Before Surgery

The first step, before surgery, is a CT (CAT scan) of your child's chest to measure the indented chest depression and see whether the heart or lungs are crowded. The CT scan is not painful and simply requires your child to lie still for about 5-10 minutes while a series of pictures are taken.

Because pectus excavatum surgery cost can be very expensive, your insurance company may require additional testing before approving your child's surgery, therefore, we recommend checking with your insurance company. Unfortunately, many insurance companies don’t begin the precertification process that notifies you of required additional testing until shortly before before your child’s scheduled surgery date. This can create difficulties if you want to be able to plan for the surgery to correct an inverted chest condition ahead of time. Be prepared in case your insurance company doesn’t initially approve the surgery. The appeal process can be lengthy and may require the surgery date to be postponed and rescheduled.

Exercises

We’ll give you a list of pectus excavatum exercises after the CT scan to help strengthen the chest muscles. Your child will need to perform these exercises after surgery, too. Other helpful tips are to practice deep breathing and work to maintain a "military" posture (with shoulders back and the spine in straight alignment).

Here are exercises guides you can follow at home:

Medications

Your child also will need to begin taking a laxative (MiraLAX) three days before surgery (as well as after) because pain meds will otherwise cause constipation. The recommended dosage is 1 capful, twice a day. The medication has no taste and dissolves easily in water, juice or tea.

The medication necessary to manage pain after the surgery is only available in pill form. If your child struggles to swallow pills, he or she will need to learn how before surgery. A good technique is to practice using Tic Tac breath mints and water.

Learn more about what to expect during and after surgery at Children's Mercy.

What to Expect After Surgery

Doctors will cover your child’s incisions with outer bandages, which you can remove two days after the surgery. Beneath the dressings will be white steri-strips. Do not remove these; they will curl up and fall off on their own as the incisions heal. If the steri-strips are still in place a week after the surgery, you may remove them by rubbing gently with a washcloth while bathing. 

Your child will not need any stitches removed because doctors will have closed the incisions using dissolving stitches beneath the skin.

The incisions will be pink and gradually fade over the next year. Notify your child's doctor if the incisions become red, begin to swell or start to drain.

You’ll also need to continue giving your child a laxative until your doctor indicates it is no longer needed.

Pain Management

Cryoablation is a new modality of pain management for patients undergoing bar placement to repair pectus excavatum repair. In the operating room, the surgeon will freeze 4 intercostal nerves on each side prior to placing the bar. This will temporarily decrease pain transmission through these nerves. The full effect may take 12-24 hours for optimal pain control. The cryoablation will last between 2-3 months. Patients may experience some skin numbness to chest wall. The numbness should resolve within 3 months when the nerve regenerates. 

Patients will most commonly receive cryoablation, unless the surgical team recommends pain management with a PCA or epidural. Either pain management modality will be co-managed with the anesthesia pain management team. The patients will go home with oral pain medications to continue during their recovery.

When cryoablation works well, most patients are able to go home the day after surgery. Standard post-operative course has been for 4-6 days in the hospital for pain management.

Follow-up Appointments

Your child’s doctor will want to see him or her 2-4 weeks after the operation, 3 months afterward and then annually until it is time for the bar to be removed. It is important to keep these appointments so doctors can regularly monitor your child's condition. If an appointment is not scheduled when you leave the hospital, please call the Kansas Surgery Clinic (913) 696-8570 or the Adele campus (816) 234-3199 to set one up.

Limiting Your Child’s Activity

Your child will need to avoid physical education class and sports for the first 1-3 months after surgery to make sure the bar in his or her chest doesn’t become dislodged. After that length of time, your child can participate in whatever activities are comfortable except for any type of contact or action sports.

Also, your child should not lift anything that weighs more than 25 pounds during the first three months after surgery. 

After your child gets approval from the doctor, usually after the three-month mark, your child should begin practicing the same exercises for the chest strengthening that he or she had been doing before surgery.

Contact sports (such as football or wrestling), however, should continue to be avoided until least 6 months after surgery. After that time, your child could begin these activities again, but most doctors recommend waiting longer due to the risk of the chest bar rotating or other problems developing that could require additional surgery. (It’s up to you and your child to assume the risk for these types of activities).

Returning to School

Usually children need to be home for about 1-2 weeks after surgery. Your child can return to school when his or her energy level and pain control permits.

Walking up or down stairs is allowed anytime. But, as mentioned, your child must avoid physical education class and even recess for the first one to three months. Also avoid carrying heavy books. Talk to your child’s teachers about leaving books in the classroom so your child won’t need to carry them.

Children’s Mercy will provide paperwork with instructions about these activities when your child is discharged from the hospital.

Traveling After Surgery

Your child can travel after surgery as soon as he or she is comfortable enough to have an enjoyable trip. If traveling by airplane, you may want to take along a form from your doctor in case there questions from airport security agents. It is also a good idea to wear a medical bracelet or necklace with an inscription stating “STEEL BAR IN CHEST.” You can find these at identifyyourself.com.

Additional Concerns

Immediately after or anytime during your child’s recovery, you should call your child's surgeon if:

  • The incision becomes red, swollen, very painful or begins draining.
  • You think the bar has become dislodged (the chest changes shape or your child has been hit forcefully in the chest).
  • You have questions or concerns.
  • Your child is still having difficulty having bowel movements after an enema.

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