Helping Families Decide
Study gives Pediatric Surgeons Objective Guidelines for Advising Parents on Pectus Surgery
by Lindy Keane Carter
The surgery to correct pectus excavatum (a congenital chest wall deformity in which abnormal growth of the ribs and the sternum produces a “caved-in” chest in children and adolescents) has undergone a revolution since 1996 when the minimally invasive approach was introduced. André V. Hebra, M.D., Chief of the Division of Pediatric Surgery at MUSC Health, began offering this procedure in 1998. Several years later, Hebra and Donald Nuss, M.D., the Virginia surgeon who pioneered the approach that now bears his name, began evaluating and reporting on its outcomes and addressing some of its risks and complications. They introduced the routine use of thoracoscopy to guide the insertion of the corrective bar between the sternum and the heart, developed ways to better stabilize the bar to minimize migration and flipping, and recognized that the surgery should not be done on pre-pubescent children because of the risk of pectus recurrence.
As the operation became safer and outcomes improved, demand grew. The number of cases worldwide increased from about 200 per year in 1998 to more than 2,000 per year in 2002. Still, controversy simmered over the true benefits of the operation. Surgeons sought an objective measure of the deformity that would help them advise parents who were wavering about what could be viewed as elective surgery and that would persuade insurance companies that were increasingly refusing to cover it.
In 2001, Hebra and Robert E. Kelly Jr., M.D., from Children’s Hospital of The King’s Daughters in Virginia developed a ten-year study of 327 pectus surgery patients at 11 medical centers. All were evaluated pre-operatively and one year post-operatively with computed tomography (CT), pulmonary function tests, and body image survey. The CT scans provided the patient’s Haller index, the objective measure of the severity of the deformity; a score greater than 3.2 is considered significant.
The final report, published in the December 2013 Journal of the American College of Surgeons,showed that surgical correction on those patients with a Haller index of 4 or greater improved pulmonary function and total lung capacity. In a smaller subset of patients who underwent testing during exercise (stress test), the investigators were able to demonstrate significant improvement in oxygen delivery by the heart and improved exercise tolerance.
“This study is the first conducted on a large number of children with pectus excavatum that validates the fact that correction of the deformity is not just cosmetic improvement,” says Hebra. “Now, we can give parents the objective assessment in support of surgical intervention and we can predict the impact the operation will have on improving cardiopulmonary function. If the pectus is mild but the parents still want corrective surgery, we can delineate realistic outcomes and manage expectations.”
Hebra has lectured extensively in the U.S. and abroad on the treatment options, risks, benefits, and outcomes of pectus surgery. These findings provide important guidelines for the management of pectus to physicians throughout the world.
MUSC Children’s Hospital is a destination center for pectus excavatum and pectus carinatum (another common chest wall deformity). For more information, go to the Chest Wall Deformity Center.
Figure above: CT scan demonstrates compression of the lungs and complete shift of the heart into the left side of the chest. The sternum is almost touching the spine.