Advances in the Care of Patients With Chest Wall Deformities

Every year Nationwide Children’s Hospital sees several hundred children and adolescents with chest wall deformities.

Common Chest Wall Conditions

Two of the most common chest wall diagnoses are pectus excavatum (sunken chest) and pectus carinatum (pigeon chest).  These conditions can cause a variety of symptoms, and for many children the physical appearance can be a major concern.

Pectus carinatum occurs when the sternum and ribs grow outward, causing an abnormal protrusion of the chest. Prevalence of pectus carinatum is estimated to be 1 in 1,000 to 1,500. The condition can usually be corrected by a brace that provides pressure on the sternum to place it back into normal alignment. Bracing is extremely successful in patients who wear the brace regularly. While there aren’t typically medical reasons to fix pectus carinatum, most patients find psychologic improvement and improved self-esteem.

Pectus excavatum is more common, occurring in between 1 in 400 and 1 in 1,000 live births. In contrast to pectus carinatum, pectus excavatum can compress the heart and lungs causing medical symptoms, in addition to cosmetic concerns.

Modern studies consistently find that the heart and lungs’ ability to tolerate exercise improves after surgical correction of severe defects. At least 12 studies with more than 500 patients all demonstrate improvement in cardiopulmonary exercise testing after surgery.

Bracing options for excavatum are typically only useful for mild defects in younger patients. The results are quite varied, but bracing may be an option for a select group of patients.  Surgical options, especially for patients with a severe defect and symptoms, may be recommended. The signature surgical approach to excavatum is, the Nuss procedure. The Nuss procedure places a metal bar behind the sternum and functions to push this outward.  At Nationwide Children’s Hospital, this is almost always performed using a minimally invasive approach, with very small incisions.

Improving Surgical Outcomes: Shortening Average Lengths of Stay From 10 Days to 1 Night

One of the best advances in pectus surgery has been improvement in pain management. Even with minimally invasive approaches, pain after a Nuss procedure usually required patients to remain in the hospital for up to a week. In the last 10 years, however, intercostal nerve cryoablation has significantly improved pain control after surgery. Performed during the Nuss procedure, intercostal nerve cryoablation requires no additional incisions. Nerves that send pain signals to the front of the chest are frozen, causing them to be numb for several weeks and minimizing pain after surgery.

To improve recovery further, the team at Nationwide Children’s Hospital utilizes an Enhanced Recovery After Surgery (ERAS) protocol. This pathway ensures patients recover as quickly and safely as possible.  Medications are given to prevent nausea from anesthesia. Pain medications, nerve blocks and cryotherapy all minimize the number of opioids used and mitigate their side effects. We allow patients to ambulate and eat quickly after they awake from surgery. With this protocol, most patients only require one night in the hospital after surgery.

Personalized Care for Each Patient

These recent advances have taken a surgery that was once avoided due to fear of post-operative pain and made it an approachable option for many patients. Most patients report improvement in breathing, exercise tolerance and self-esteem. However, the decision to repair a chest wall deformity is highly individualized. Experts in the chest wall clinic discuss all options and help families make the best decision for each patient.

References:

1. Sutyak KM, Hebballi NB, Bidart Y, Joly JM, Broussard M, Christensen H, Mendenhall J, Jayarajan N, Anderson I, Young Y, Taylor L, Little D, Tsao K. Is it time to expand the surgical criteria? The psychosocial impact of pectus excavatum in pediatrics. Surgery. 2025 Sep;185:109546.
2. Eldredge RS, Sabati A, Ochoa B, Viswanath V, Khoury E, Rassam K, Ostlie DJ, Lee J, McMahon L, Notrica DM, Padilla BE. Cardiopulmonary impact of the minimally invasive repair of pectus excavatum in pediatric patients: A prospective pilot study. Journal of Pediatric Surgery. 2025 Apr;60(4):162177.
3. Belgacem A, Abane C, Tricard J, Felix P, Lavrand F, Laloze J, Lopez P, Bothorel P, Auditeau E, Fourcade L, Ballouhey Q. Sternal advancement surgery for pectus excavatum: a systematic review and meta-analysis of cardiac and respiratory function outcomes. Journal of Thoracic Disease. 2025 Jul 31;17(7):4897-4908.

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