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Surgical Experience, Expertise Lead to Strong Outcomes for Patients with Severe Pectus Excavatum

Cincinnati Children’s is one of the highest-volume centers in the United States for pectus excavatum (PE) repair, with strong surgical and clinical outcomes. In recent years, the number of adults seeking care at the center has been on the rise. Of the 188 PE surgeries performed at Cincinnati Children’s in 2018, 16% were on patients age 18 or older, including some in their late 30s.

“Since PE is largely a pediatric condition, pediatric surgeons are more familiar with the condition than adult-care providers,” says Rebeccah Brown, MD, co-director of the Chest Wall Center at Cincinnati Children’s. “This makes experienced pediatric surgeons well-suited to treat both children and adults with PE, but you can’t approach surgery on an adult the same way as you would on a child. For example, you have to consider other comorbidities that kids don’t have. And you may need to use more complex techniques to raise the chest wall, since in many cases the chest wall is less flexible in adults.”

To ensure they provide optimal care to adults, Brown and her colleagues sought out additional training at Mayo Clinic in Phoenix, Ariz., where they learned from world-renowned thoracic surgeon Dawn Jaroszewski, MD. One technique they adopted through that experience is the use of the Rultract surgical retractor to lift the sternum away from the heart and provide a clear plane to insert the pectus bars. “Now I would never do a PE surgery any other way, even when correcting a minor defect,” says Brown, who has been performing PE surgeries for more than 20 years.

One patient’s experience

A recent case demonstrates the importance of experience and surgical expertise in treating adult patients with PE. The patient, Felix Skeens, came to the Chest Wall Center on his 18th birthday in November 2018, seeking treatment for a severe, symmetric cup-shaped pectus deformity involving the inferior half of his sternum.

Brown knew from the physical exam that Skeens would benefit from surgery, and subsequent test results provided confirmation. Skeens’ cardiac MRI results were definitive: His Haller index was 6.7 (normal is 2.5-2.7), and he performed poorly on the cardiopulmonary exercise test. His pulmonary function test showed a mild obstructive defect.

Surgery took place five days after Skeens’ high school graduation, in May 2019. Brown suspected that the surgery would be particularly complex due to the fact that Skeens, who had been born at 23 weeks gestation, had had neonatal chest tubes. “We accessed the chest wall through the right chest and put a scope in, and noticed a lot of adhesions up to the chest wall and mediastinum,” Brown said. “This required careful dissection of the scar tissue to view the heart and sternum.”

Brown used a Nuss procedure to insert three bars, providing the support needed for Skeens’ deep defect and tall stature. While the Nuss procedure is inherently painful, and more so in adults than in children, the pain team effectively managed Skeens’ pain using a multimodal approach. This included epidural analgesia for the first 48 hours, muscle relaxants, non-steroidal anti-inflammatory drugs and other holistic therapies. Despite the pain associated with the procedure and activity restrictions for 12 weeks, Skeens says he was thrilled with the results.

“I used to feel like something was always pushing on my lungs, but now I feel great and I can breathe way better. I don’t have any more chest or back pain,” says Skeens, who is now a college freshman and planning to become a nurse. “But I guess what’s really amazing to me is that when I see myself in the mirror, I’m just so happy about how I look. It’s given me a lot of confidence.”

To discuss a patient with pediatric surgeons at the Chest Wall Center, call 513-803-1062 or email chest-wall-center@cchmc.org.

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