Surgical treatment of complex pectus excavatum in children: a case series

BACKGROUND: Pectus excavatum is the most common developmental defect of the anterior chest wall, occurring in children with a frequency of 1:300 to 1:1000. The widespread use of the minimally invasive and highly effective Nuss procedure for thoracoplasty has solved most of the problems inherent in previously applied treatment methods. However, there are particular deformities where the classical application of this method does not yield good cosmetic and functional results.

AIM: This study aimed to analyze the results and demonstrate the technical approaches to thoracoplasty for complex forms of pectus excavatum.

METHODS: Based on the analysis of experience of more than 600 operations over a 20-year period in children with pectus excavatum who underwent surgery using classical and modified Nuss techniques, 13 (2.2%) children with complex deformities were identified. They were divided into four groups: group 1, children aged 15–18 years with an absolutely rigid chest and grade III severity of deformity (p-5); group 2, children with asymmetric deformity and elements of hemithorax hypoplasia (p-4); group 3, children with connective tissue dysplasia and pectus excavatum manifesting from the first months of life, leading to severe impairment of respiratory and cardiac function by age 3–5 years (p-2); group 4, children with profound canyon-type deformity of the manubrium and body of the sternum (p-2). When treating patients in these groups, various surgical techniques complementing the classic Nuss procedure were used.

RESULTS: To achieve good results in children of the first group, transverse and longitudinal partial sternotomy with chondrotomy of the two most deformed ribs during thoracoscopy was added to the Nuss procedure. In group 2, the bar was positioned based on multidetector computed tomography data to determine the optimal location for the metal implant. Children in group 3 underwent surgery in two stages starting at age 5 years. In group 4 patients, correction was achieved using two bars. While surgery for typical pectus excavatum took 15–18 minutes, for complex forms it lasted approximately 30–40 minutes. Good long-term results with complete correction of the deformity were achieved in 12 of 13 patients.

CONCLUSION: Complex pectus excavatum in children is rare. Its correction requires an individualized approach to the timing of surgery, the number of metal implants used, and the points of their insertion into the chest.