Surgical Options for Adults with Pectus Excavatum
For adults seeking treatment, two primary surgical approaches are available, both adapted to address the greater rigidity of the mature chest wall. The choice of procedure depends on the severity of the deformity, patient preference, and the surgeon's expertise.
The Modified Nuss Procedure (MIRPE)
Originally developed for pediatric patients, the minimally invasive Nuss procedure has been successfully modified for adults. This approach is often favored for its smaller incisions and reduced surgical trauma compared to the open Ravitch procedure. However, modifications are necessary for the less pliable adult chest.
- Technical Adaptations for Adults: To overcome chest wall stiffness, surgeons use techniques like forced sternal elevation, multiple support bars, and medial fixation to prevent bar rotation.
- Procedure Overview: A curved steel bar is inserted through small incisions on either side of the chest, threaded under the sternum, and then flipped to push the breastbone forward. The bar remains in place for approximately two to three years before a second, minor outpatient procedure is performed to remove it.
The Modified Ravitch Procedure
This open surgical technique involves a larger, central chest incision and is sometimes considered for older patients with very rigid or complex deformities.
- Technical Adaptations for Adults: The procedure involves removing the deformed cartilage connecting the ribs to the sternum. The sternum is then elevated and secured with a small, temporary metal bar or mesh supports, which are typically removed after 6 to 12 months.
- Procedure Overview: Unlike the Nuss bar, which is removed after years, the Ravitch support bar is typically removed within one year, and sometimes permanent fixation with plates and screws is used.
Comparison of Nuss vs. Ravitch Procedures in Adults
| Feature | Modified Nuss Procedure (MIRPE) | Modified Ravitch Procedure |
|---|---|---|
| Invasiveness | Minimally invasive; small lateral incisions | Open surgery; larger central chest incision |
| Recovery Time | Often slightly shorter initial recovery; bars remain in longer | Longer initial recovery due to cartilage removal |
| Chest Wall Flexibility | Highly dependent on specialized techniques for rigid adult chests | Open access allows for direct remodeling of the chest wall |
| Pain Management | Can be significant initially due to pressure; managed with epidurals, cryoablation, and oral medications | Manageable with oral pain medications and local nerve blocks; pain is more similar to other major chest surgery |
| Risk Profile | Higher potential for bar migration or rotation without proper fixation | Risks include infection, pneumothorax, and scarring |
| Long-Term Hardware | Bars are removed in a later, separate procedure | Support can be removed earlier or involve permanent plates/screws |
The Adult Patient's Experience: Symptoms and Evaluation
Adults with pectus excavatum may present with symptoms that have either progressed or only recently become noticeable. The greater rigidity of the chest wall can increase cardiac compression and respiratory limitations over time.
Cardiopulmonary and Psychological Effects
- Physical Symptoms: These can include decreased exercise tolerance, shortness of breath, chest pain, palpitations, and chronic fatigue, especially with exertion. Many adults who were asymptomatic in their youth find symptoms become more prominent later in life.
- Psychological Concerns: The visual appearance of the chest can significantly impact an adult's self-esteem and body image, leading to social anxiety and withdrawal. For some, this cosmetic distress is a primary motivator for surgery.
Preoperative Evaluation
Before surgery, adults undergo a thorough evaluation to assess the severity and impact of the condition. This typically involves:
- Imaging: A chest CT scan or MRI to measure the Haller index (which quantifies severity), visualize the deformity, and assess potential cardiac compression or displacement.
- Cardiopulmonary Testing: A pulmonary function test and echocardiogram evaluate heart and lung function, which can be restricted by the deformity.
- Exercise Testing: Cardiopulmonary exercise testing helps quantify the physiological impact and track improvements after surgery.
Recovery and Long-Term Outcomes
Recovery from adult pectus excavatum surgery is a significant process, and pain management is a crucial component due to the greater forces required to reshape the rigid chest. Advancements like cryoablation, which freezes the intercostal nerves, have drastically improved postoperative pain control and shortened hospital stays.
- Hospital Stay and Initial Recovery: Patients typically stay in the hospital for 3 to 5 days, though this can vary. Initial recovery involves restricted movement to protect the repair.
- Full Recovery and Return to Activity: Full recovery can take several weeks to months, with a gradual return to normal activities. Contact sports and strenuous exercise are typically restricted for months to years, depending on the procedure.
- Excellent Long-Term Results: Studies show excellent long-term patient satisfaction and cosmetic results in adults who undergo surgery. Many patients report significant improvement or complete relief of cardiopulmonary symptoms, leading to a much-improved quality of life.
Conclusion
Yes, it is possible to get pectus excavatum surgery later in life, and for many adults, it is a life-changing procedure. While the surgery and recovery may be more intensive than in adolescents, modern modifications to procedures like the Nuss and Ravitch have made successful outcomes achievable. Adults who experience significant cardiopulmonary symptoms, cosmetic concerns, or body image issues can find substantial relief through surgical correction. Consulting with a cardiothoracic or pediatric surgeon experienced in adult chest wall deformities is the first step towards determining the right treatment plan. With proper evaluation, advanced pain management, and specialized surgical techniques, age is no longer a major barrier to addressing pectus excavatum effectively.
Columbia University Department of Surgery: Correcting Chest Wall Abnormalities in Adults
