(funnel chest)

The most common chest wall defects: 1/400 births; it is more common in boys than in girls. It is usually isolated and without objective functional impact although some a discomfort during exercise to the effort is possible. The perceived prejudice is essentially esthetic; some patients complain of exercise-induced asthma or pain. It would be due to excessive length of chondrosternal cartilage but some cases are the result of chronic respiratory efforts ( sternal retraction) in infancy.

The severity of the deformity is assessed by calculating the Haller index on a chest scan that also evaluates the compression and the displacement of the cardiac cavities (mostly the right ones) and the lungs. The Haller index is calculated by measuring in cm and at the level of the pectus: the width of the thorax between the costal walls and the height of the thorax between the anterior part of the vertebra and the posterior part of the sternum. The deformation is severe if the ratio of the width/height measured is > 3. One can also measure the depth of the pectus with a caliper: > 2.5 cm deep is a factor of severity. Mitral valve prolapse is often associated.

Surgical correction is easier before ossification is complete (puberty) but should not be performed too early (not before the age of 4 years) to avoid harming the secondary ossification nuclei (which could cause later a thoracic dystrophy with a restrictive syndrome).

Two surgical techniques can be used to correct pectus excavatum. The conventional technique (Ravitch procedure) resects chondrosternal cartilage at the level of maximal sternal deformation to straighten the sternum in hypercorrection and fix it.  Postoperative management is often difficult because of severe pain, and its interference with breathing: atelectasis and pneumonia are the most common complications.

A less invasive technique (Nuss procedure) consists in introducing a convex metal bar under the sternum through  2 small lateral chest incisions. The bar is left in place for 2 years before being removed surgically. The esthetic result is comparable to the classic method, as are the rate of complications, postoperative pain and duration of hospitalization. Postoperative pain is often even more severe than after the Ravitch technique.

The risk of post-operative recurrence is more important in the presence of connective tissue disease such as Marfan's, Ehlers-Danlos or Loeys-Dietz syndrome.

Anesthetic implications:

echocardiography, see the chest CT scan; pulmonary function tests: restrictive syndrome ? In case of connective tissue disease, assess its specific implications.

In case of surgical correction of the chest deformation (or removal of hardware): blood should be cross-matched (risk of sudden hemorrhage by vascular or myocardial injury), arterial line. Either selective intubation of the lungs, or thoracoscopy with capnothorax. Risk of compression/stretching of the brachial plexus: careful positioning, preferably with the arms alongside the body ! In case of epidural block, catheter insertion at the level of Th5-6 or Th6-7 seems optimal. In case of hypotension after the positioning of the Nuss rod under thoracoscopy that does not respond to vascular filling, the following possible diagnoses should be excluded: a pneumothorax, a hemothorax (intercostal or large vessel injury), a cardiac or hepatic injury, or kinking of the inferior vena cava following traction on the pericardium (reversible when the rod is reversed).

If an external cardiac massage is necessary, it is important to bear in mind that the heart is displaced to the left and caudally, compared to normal, both before and after the repair of the pectus excavatum with a Nuss rod: the thoracic compression on the inferior third of the sternum can thus be less efficient than expected.

Moreover, it is advised to avoid a displacement of the sternum, for a distance greater than one third of the chest height at each compression, as there is a risk a damage to the underlying organs.

Post-operative analgesia is difficult to manage; it should be multimodal often associating a thoracic epidural catheter for 48-72 h and intravenous PCA.

References : 

-        Kelly RE Jr. 
Pectus excavatum: historical background, clinical picture, preoperative evaluation and criteria for operation. 
Semin Pediatr Surg 2008; 17:181-93.

-        Huddleston CB. 
Pectus excavatum. Semin Thorac Cardiovasc Surg 2004; 16:225-32.

-        Iida H. Surgical repair of pectus excavatum. 
Gen Thorac Cardiovasc Surg 2010; 58:55-61

-        Robicsek F, Watts LT, Fokin AA. 
Surgical repair of pectus excavatum and carinatum. 
Semin Thorac Cardiovasc Surg 2009; 21:64-75.

-        Hebra A. 
Minimally invasive repair of pectus excavatum. 
Semin Thorac Cardiovasc Surg 2009; 21:76-84.

-        Nasr A, Fecteau A, Wales PW. 
Comparison of the Nuss and the Ravitch procedure for pectus excavatum repair: a meta-analysis. 
J Pediatr Surg 2010; 45:880-6. 

-        Mavi J, Moore DL. 
Anesthesia and analgesia for pectus excavatum surgery. 
Anesthesiology Clinics 2014 ; 32 : 175-84. 

-        Muhly WT, Beltran RJ, Bielsky A, Bryskin RB, Chinn C et al.
Perioperative management and in-hospital outcomes after minimally invasive repair fo pectus excavatum: a multicenter registry report from the Society for Pediatric Anesthesia improvement network.
Anesth Analg 2019; 128: 315-27.

-        Lai SW, Rothenberg SS.
Culture of safety and error traps in pediatric thoracoscopy.
Semin Pediatr Surg 2019 ; 28 : 178-82

-        Jang Y-E, Park J-B, Kang C-H, Park S, Kim E-H et al.
Cardiopulmonary resuscitation in pediatric pectus excavatum patients: where is he heart?
Pediatr Anesth 2020; 30:698-707.

Updated: August 2020