Pectus Excavatum Repair in Adults: Indications and How To Do It

Gender differences in objective measures of adult patients presenting for pectus excavatum repair

BACKGROUND

Women have a reported incidence of pectus deformities 4-5 times less than men. Gender differences have not been well studied.

METHODS

A retrospective review was performed of adult patients (≥18 years) who underwent a pectus excavatum repair at Mayo Clinic in Arizona (January 1, 2010-December 31, 2019).

RESULTS

In total, 776 adults underwent pectus repair with 30% being women. Women presented older (mean age 35 vs 32 years, p=0.007) and more symptomatic. Despite this, women performed better on cardiopulmonary exercise testing (higher VO2 max and O2 pulse). Women had more severe deformities (Haller index 5.9 vs 4.3, p<0.001). However, in 609 patients undergoing attempted primary minimally invasive pectus repair, intraoperative fractures/osteotomies occurred equally between genders with the majority occurring in patients ≥30 years of age (11.5% in ≥30, 1.7% in <30, total 7%). Women were also less likely to require 3 bars for repair (12% vs 42%, p<0.001). Hospital length of stay and postoperative complication rates were not significantly different. Postoperatively women reported a greater daily intensity of pain, but only on the initial postoperative day used significantly more opioids than men. Cardiopulmonary exercise testing in 142 patients undergoing baseline and postoperative evaluation at bar removal showed equal and significant benefits in both genders.

CONCLUSIONS

Women presented for pectus excavatum repair older and with greater symptoms and severity. Despite this, women required fewer bars, with no significant differences in length of stay or complications. Cardiopulmonary benefits of repair were significant and equal for both genders.

Nuss procedure in the adult population for correction of pectus excavatum

Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.