March 17, 2000 (Washington) -- Parents of babies born with a sunken breast bone, a condition called funnel chest, are often told that the deformity will improve with age and shouldn't cause the child any heart or lung problems. But that advice is frequently wrong, and many children who could benefit from corrective surgery -- and who do better when they have the procedure before adolescence -- are being denied treatment, according to some surgeons.
Successful surgical repair for funnel chest, technically termed pectus excavatum, has been practiced for more than 50 years, and a new technique was developed about 10 years ago. A study in the March issue of the journal Annals of Surgery shows that nearly 400 patients who had the surgery at UCLA Medical Center did extremely well. The lead author of the study, who performed most of the surgeries himself, tells WebMD he hopes it will spur more surgeons and pediatricians to recommend this procedure to appropriate patients.
"We hope that publishing a report with a large number of patients with excellent results, no major complications, and an average hospital stay of three days, will cause this to be considered more frequently for repair," says Eric Fonkalsrud, MD, a professor of surgery at the UCLA School of Medicine.
Estimates vary, but pectus excavatum, or funnel chest, is thought to occur in one of every 600 to 2,000 newborns. It is caused by an overgrowth of cartilage between the sternum and the ribs, which causes the bone to turn inward. Only 15% undergo surgery to repair the sunken grooves and concave appearance that mark their bodies, usually for life. Many children will start to experience symptoms around school age, and often they complain of shortness of breath and reduced endurance. Many are extremely self-conscious about their appearance, don't participate in sports, and will not wear bathing suits; boys often refuse to go shirtless. The disorder is twice as common in men than women and can run in families.
Of the patients who underwent surgical repair for pectus excavatum at UCLA from January 1969 through November 1999, 97% had very good or excellent results. They ranged in age from 2 to 53; nearly 80% were males. Prior to surgery, almost all patients had some displacement of the heart to the left side and reported mild to severe decreased stamina and exercise endurance.
Fonkalsrud and his colleagues performed the repair using a technique developed more than 50 years ago. The procedure, performed under general anesthesia, takes about three hours and involves removing cartilage overgrowth from affected ribs at the connection point to the sternum, with a steel rod or strut placed across the chest to support the top of the sternum and then wired to surrounding ribs. The inpatient stay for the procedure averaged just over three days.
All the patients had remarkably good outcomes on a variety of measures and developed few complications. Many were able to participate in sports activities, such as running, swimming, and basketball, even before the metal bar was removed, the authors write, and all of those who had reported limitations in stamina and endurance before the surgery "experienced marked improvement within four months" after surgery. Many who reported a lot of respiratory problems found those dissipated, as did asthma symptoms in some patients. Out of 90 patients who had heart murmurs before the surgery, 74 improved so much that the murmurs could no longer be heard.
There were no deaths from the procedure, and complications were relatively rare, with 97% judged to have a very good or excellent result from the surgery.
"Most patients are ... advised by well-meaning family physicians or pediatricians that the deformity will improve with age, that it will not affect heart or lung performance, that it is primarily a cosmetic problem, and that surgical repair is minimally effective, and unnecessary," the authors write. "It is clear that each of these views is incorrect."
"I think this is a good article; it gets the word out that the Ravitch procedure is a safe operation with very good results. It's really the gold standard," says Paul M. Colombani, MD, chief of pediatric surgery at Johns Hopkins University in Baltimore. Colombani, also a professor of pediatric surgery at Hopkins' School of Medicine, notes that he has performed more than 1,000 such surgeries with equally good outcomes. However, he sometimes operates on people whose earlier pectus excavatum repair was bungled by less-experienced surgeons. He was not involved in the study but reviewed it for WebMD.
However, Colombani says that he no longer uses this technique. For the last two years, he has been using a surgical procedure developed by Donald Nuss, MD, a pediatric surgeon with Children's Hospital of the King's Daughters in Norfolk, Va. In this procedure the bar remains in place for two years before being surgically removed.
Colombani, who counts himself as one of the few surgeons who has experience with both techniques, reports being "very pleased" with a modified Nuss method. He says it produces a better appearance in patients, although he does not consider it to be minimally invasive, as promoted by Nuss.
"There is a lot of misinformation out there about the Nuss procedure," he says, but he adds that he considers this procedure to be superior because, among other reasons, it is quicker, and he suspects it ultimately may result in fewer recurrences of the deformity, compared to the Ravitch procedure. However, because he has only done the surgery for two years, none of his patients has had the bar removed yet.
But another surgeon, while praising the study as providing a useful benchmark to compare outcomes of newer surgical procedures such as the Nuss procedure, noted that all the measures of improvement were subjective. Objective confirmation of such improvements are difficult to obtain, and whether they exist at all is "debatable," R. Lawrence Moss, MD, tells WebMD. Moss, an assistant professor of surgery and pediatrics at Stanford University School of Medicine, also reviewed the study for WebMD.
"These are excellent results from a very well-respected group, and anything new that comes out is going to have to meet this," Moss says. "Even though this is a major operation, they've shown it has low morbidity. Patients and referring physicians think this operation is riskier than it is."
He adds that he does not assess functional changes in his patients postoperatively and views the purpose of the surgery to correct a physical deformity. "These are not nose-jobs or breast implants," Moss says. "This is reconstruction of a chest that is not normal."
Fonkalsrud and his colleagues report that they are "awaiting with enthusiasm" more results on the Nuss procedure to get a true picture of recurrence and complication rates.
Regardless of which procedure is used, Colombani agrees with Fonkalsrud that physicians and the public need to be better informed about the repair options for funnel chest, and he argues they should both be strongly dissuaded from the false belief that the condition is simply "cosmetic."
"Many of these patients are sedentary and they avoid sports because they don't feel good," says Colombani. "When you fix them it's kind of like a new lease on life for them."
- When babies are born with a sunken breast bone, called funnel chest or pectus excavatum, many physicians tell the parents it is a primarily cosmetic problem that will improve with age, but this may not be the case.
- Surgical repair of funnel chest can be successful, improving endurance and even asthma symptoms in some patients.
- Many children who are born with this condition can be self-conscious about their appearance and unwilling to participate in sports activities -- another reason why surgery should be considered.