Pectus Excavatum: Which Patients Need Corrective Surgery?

New study can aid clinicians in determining when surgery is most likely to help.

Traditionally, we have reassured parents of children with pectus excavatum that this common chest wall defect is primarily cosmetic. Occasionally, we need to evaluate children with more severe defects for pulmonary or cardiac complications and refer them for surgical repair. When surgical repair is beneficial has long been a topic of controversy.

In a study recently published in Pediatrics,¹ Kelly and colleagues looked at physical and psychosocial quality of life after surgical repair of pectus excavatum. Over a 5-year period, a research coordinator administered a validated questionnaire by telephone to patients at 11 pediatric centers and to their parents, before and 1 year after surgical repair. For children under the age of 8 years, only the parents completed the questionnaire.

Patients were excluded if they had other chest wall defects; previous chest surgery; congenital heart disease; or surgical risk factors, such as a bleeding disorder.Altogether, 274 parents and 247 patients completed the presurgical and postsurgical questionnaires. The patients were asked questions about body image issues related to the pectus excavatum and about physical difficulties such as chest pain, trouble exercising, shortness of breath, and fatigue. The version administered to the parents asked about emotional difficulties related to the pectus excavatum, social self-consciousness, and physical difficulties.

Among the answers to questions that parents and patients gave before surgery, no significant differences correlating with the anatomical severity of the chest wall defect (as measured by CT scan) were noted: patientswith less severe defects had perceived difficulties that were similar to those described by those with more severe defects.

A year after surgery, the patients reported significantly fewer body image concerns and physical difficulties than they had before surgical repair. Parents also reported significant improvements a year after surgery concerning their child’s physical difficulties, social selfconsciousness, and emotional functioning. The authors concluded that anatomical severity is less useful as a measure of the need for surgical referral than are a patient’s perceived emotional and physical difficulties.

Of note, the study by Kelly and colleagues only included patients who had defects that warranted referral and CT scans. Although severity may not have played a role in that population in determining the degree of difficulty caused by a patient’s pectus excavatum, the authors did not evaluate patients with pectus excavatum who were merely monitored by their pediatrician without referral. Also, the patients and parents in the Kelly study may have reported more perceived presurgical difficulties in an unconscious attempt to rationalize their decision to proceed with surgery.

Despite these limitations, the Kelly study can help us pediatricians be more aware of potential problems that our patients with pectus excavatum may have. Rather than dismissing this lesion as purely cosmetic, we should assess both the emotional and physical impact that the defect has on the child. Although a surgical referral may not be medically indicated in many children with pectus excavatum, an exploration and understanding of patients’ fears and perceived concerns may help us better determine which management strategy will truly meet their needs best.