台灣漏斗胸(凹胸)病友協會

Mini Review

A Look at the History of Surgery for Pectus Excavatum


Chih-Chun Chu (朱志純)


Formos J Surg 2011;44:1-5


Pectus excavatum is the most common deformity of the anterior wall of the chest, in which several ribs,costal cartilages and the sternum grow abnormally and produces a caved-in appearance of the chest. PE is usually considered to be cosmetic; however, depending on its severity, the deformed chest wall can compress the heart and reduce the thoracic volume, and impair cardiac and respiratory function, distort spine curvature, and cause pain in the chest.
A review of the literature shows that the first record of pectus excavatum was probably written in the 16th century by Johan Schenck (1531-1590). Bauhinus (1594)1 described a case in which the patient suffered from shortness of breath and cough as a result of severe pectus excavatum. In 1820, Coulson2 cited a family including three brothers with a funnel chest. In 1872, Williams3 reported a patient born with a pectus excavatum whose father and a brother also suffered from the same condition. Ever since, the reported cases have gradually increased, but treatment before the 20th century was limited to fresh air, breathing exercises and lateral pressure on the chest, all of which probably exerted no substantial beneficial effect. During those early days, technology of surgery and anesthesia was unable to overcome lung collapse during thoracic surgery, and the progress in treatment of pectus excavatum remained stagnant until early 20th century. Meyer in 19114 removed the first, second and third costal cartilages of a patient with pectus excavatum, but apparently did not attained the desired effect. Sauerbruch in 1931,5 performed surgery on a patient with pectus excavatum suffering from severe dyspnea in a negative pressure chamber wherein he removed a part of the anterior chest wall which included the fifth to the ninth costal cartilages, as well as a segment of the adjacent sternum. After the procedure, the patient was able to work, and even married three years later. It is difficult to imagine how science and technology at the time was able to complete such a type of operation. In the 1920’s, he had already advocated bilateral removal of costal cartilages and sternum transection in order to raise the anterior chest wall. After the procedure, according to Sauerbruch the patient had to stay in bed for external traction to hold the anterior chest wall in position for 6 weeks or more. Although the process was very harmful, the technology provided a method of treatment that had not been achieved before, and it soon gained popularity in Europe and the United States.

Fig 1. Compare before (A) and afte (B) Nuss procedure for pectus excavatum, the new technique leaves no surgical scar on the anterior chest wall

In 1939, Ochsner and DeBakey6 published their experience with the Sauerbruch's operation. In the same year, Lincoln Brown7 also published the experience with two of his patients and theorized that the funnel chest is caused by the short diaphragmatic ligaments and the continuous pull of the diaphragm. Adopting the theory and to avoid external retraction after operation, Ravitch modified the operation by complete mobilization of the sternum from its surrounding tissues, with transection of all sternal attachments, including the intercostal bundles, rectus muscles and diaphragmatic attachments. This surgical technique eliminated the need after surgery of an external device to lift the sternum. This is the current socalled traditional surgery most commonly referred to as the Ravitch procedure. This procedure avoid the external retraction but had a higher recurrence rate, and the concept of internal support merged. In 1956, Wallgren and Sulamaa10 introduced for the first time the concept of internal support technology.
They used a stainless steel bar pushed through the sternum to lift the depressed chest wall from the inside. In 1961, Adkins and Blades11 using a similar concept,placed the steel bar beneath the sternum, rather than through the sternum.
In 1958, Welch12 modified the Ravitch procedure by not cutting through all the intercostal bundles and rectus muscle attachments and obtained good results. Pena was greatly disturbed by the idea of resecting the rib cartilages of young children. Haller14 also published a report using the Ravitch procedure, but stated also that the chest wall loses its elasticity, thus affecting the respiratory function (acquired asphyxiating chondrodystrophy). Therefore, he advocated to decrease the amount of cartilage resected for surgical correction of pectus excavatum.
Wada in 1961 reported a corrective operation for the funnel chest wherein the sternum is turned over resulting from a convex to a concave shape. The above-mentioned surgical procedure is usually performed through a vertical midline incision or a bilateral submammary incision, and thus in addition to leaving an unsightly scars, the procedure easily causes the anterior chest wall to lose its organizational flexibility with a high recurrence rate.
In 1986, while using the Ravitch procedure, Donald Nuss was struck with the flexibility of the rib cartilages and instead of removing it, he took advantage of its flexibility and malleability. He used a U-shaped stainless steel bar passed through small incisions on both sides of the chest, and traversing between the pericardium and the sternum. Under thoracoscopic guidance, the strut could be easily passed through the retrosternal space, and also behind the sternum without injuring the heart or lungs. The strut was then flipped to elevate the depressed thoracic wall. After ten years of closed-door study, Nuss reported this new technique for correcting pectus excavatum in 1998. As a result, without resection of costal cartilage or ribs, no sternal wedge resection, a revolutionary change in pectus excavatum surgery occurred, and the treatment for pectus excavatum officially enters the era of minimally invasive surgery (Fig 1). The simple design of the Nuss procedure provides a universal way to correct pectus excavatum for different types and age ranges (Fig 2) of patients. The author has experienced patients from age 2 to age 48 with excellent results. Because of its simplicity, the Nuss procedure leaves much room for personal style and surgeons can gradually develop their individual style and characteristics.
Compared with traditional open surgery, the Nuss procedure provides a lower recurrence rate, less injury, better results, and a wide range of indications for different type and severity of pectus excavatum. Some severe complications, such as accidental penetration into the lung or heart, have been reported in performing the Nuss procedure, but under the direct vision of thoracoscopy, such complications are almost entirely avoidable. The prophylactic use of antibiotics and stabilizers certainly reduces the complications of implant infection and displacement of the the strut.
In failed Ravitch or sternum turn over cases, revision has been made using the Nuss procedure that demonstrated good results (Fig 3 & 4).
In 2005, Nuss was invited to Taiwan where he introduced the innovated surgical operation. So far, Taiwan has had more than five hundred patients that have undergone the Nuss procedure. As with other surgery, the treatment of pectus excavatum is geared towards the development of minimally invasive surgery. The Nuss procedure has been carried out under the guidance of thoracoscopy in our series of 304 cases and is proved to be safe mostly with satisfactory results. No life-threatening complications were encountered. The incidence of minor complications, such as displacement of the struts, wound infection, unsatisfied chest contour, and pneumohemothorax are totally less than 6%, and only 5 cases (less than 1.6%) need a second operation. It is probably safe to predict that minimally invasive surgery will be the mainstream in the treatment of pectus excavatum. 



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