HCA Midwest Health - September 08, 2017

Can sunken chest surgery be performed on adults?

There have been many changes over the years in both the understanding and treatment of pectus excavatum (sunken chest)—most recently in the availability of surgery for adults with sunken chest right here in the Kansas City region.

So if you were diagnosed with pectus excavatum before the 1990s, it might be time to take another look at how it may be impacting your health and whether treatment is an option.

About Sunken Chest

Like a lot of conditions, pectus excavatum (sunken chest) can range from mild to severe. It’s a condition present from birth but it usually doesn’t cause problems until bone growth spurts during adolescence.

The chest area, holding the heart, lungs and other body tissue, is surrounded by the ribcage – attaching to the spine in the back and the sternum (breastbone) in the front. The breastbone is usually positioned so there is a slight dip in the middle of the chest. But if that dip is abnormally deep, it can affect how well the heart and lungs function.

Changing Views on When to Treat Sunken Chest

For years, pectus excavatum was considered to cause emotional distress, but no physical problems. Children that did not experience heart-related complications from their sunken chest were not treated. This is partly because treatment involved complex, often painful surgeries with long recovery times—not something that any doctor (or parent) is looking to do for a child without significant symptoms.

Through research and better understanding of pectus excavatum, that is no longer the case. While mild cases of sunken chest are still considered cosmetic, doctors are more aware of how moderate to severe pectus excavatum can affect the patient through adulthood.

Symptoms may be obvious, such as shortness of breath or chest pain. Or, they may be less noticeable, such as tiring easily or not being able to “keep up” during play or athletics.

Better understanding is one of two main reason that pectus excavatum is more commonly treated in adolescents today. The other is a major advancement in treatment options called the Nuss Procedure.

Minimally Invasive Sunken Chest Surgery (The Nuss Procedure)

Prior to the late 1990s, the only treatment for pectus excavatum was the Ravitch Procedure—a long incision is made to access the breastbone and chest area. Deformed cartilage is cut away and the breastbone is repositioned, sometimes supported with metal struts or mesh supports. The implants are then removed in a second surgery about a year later—after the cartilage grows back together to support the new position.

The Nuss Procedure is a minimally-invasive surgery named after the physician who pioneered it in the 1980s. It requires a smaller incision than the Ravitch Procedure, and the surgeon doesn’t cut into any bone or tissue with the Nuss Procedure—making it a popular alternative.

During a Nuss Procedure, small incisions are made on the chest and under each arm. Using specialized tools and a camera to view inside the chest cavity, a curved metal bar is threaded under the breastbone to raise it to a more normal position. The bar is left in place for two to three years, supporting the breastbone until the body’s bones and cartilage can adjust to the new position.

The success and complication rates of the two procedures are similar. The main advantages of the Nuss Procedure are smaller scars and shorter recovery time for the initial surgery. Nuss also does not carry the risk of one rare, but significant complication of the Ravitch Procedure called “chest wall constriction”—when the chest wall is not able to continue to grow after surgery.

The Nuss Procedure in Adults

Until recently, the Nuss procedure was rarely performed on adults. And, if it was, patients needed to travel out of state to three hospitals that perform some limited procedures in adults. One of these is the Children’s Hospital of the King’s Daughters in Norfolk, Virginia. But performing procedures on adults in a children’s hospital has its own challenges. That’s why pediatric surgeon Corey Iqbal, MD originally hesitated to perform the procedure on adults.

“There is anxiety working on adults in a children’s hospital,” said Dr. Iqbal. “What if there is a complication? Is there the experience in place to take care of it in an adult patient.”

Then Dr. Iqbal joined the HCA Midwest Health team at Overland Park Regional Medical Center, where he had the support of a surgical team experienced in adult care—including nurses, surgical assistants and anesthesiologists. Not to mention the post-surgical services to see patients through the next two to three years of follow-up until the support bar is removed.

“There’s a strong continuum of care in place,” said Dr. Iqbal, “and a patient-focused mission that makes it possible for me to confidently offer this procedure to adult patients.”

Which is precisely what happened earlier this year, when Dr. Iqbal performed the first Nuss Procedure on an adult at Overland Park Regional Medical Center. Dustin Lurvey’s sternum was so sunken that it pressed against his heart and lungs. He struggled to breathe whenever he exercised and he could see his heartbeat through his skin. As a child, he was treated for asthma because doctors didn’t connect his symptoms to his sunken chest.

After the Nuss procedure, at 38, Dustin’s chest is flat for the first time in his life. It will take some time for the other benefits to kick in, like more comfortable breathing. It’s a long journey, but one Dustin is grateful to finally be on. Dustin’s journey was recently featured in the Kansas City Star.

Reevaluating Your Sunken Chest Options

Dustin Lurvey’s journey to a Nuss Procedure began when he got a fresh opinion on whether his pectus excavatum was severe and causing symptoms during a visit with his new primary care physician. That doctor recognized a significant sunken chest and referred Dustin to HCA Midwest Health, where he eventually met Dr. Iqbal.

If you are looking for a second opinion or in need of a primary care physician or specialist, call 1-800-386-9355 — HCA Midwest Health’s free 24-hour helpline (closed Thanksgiving Day, Christmas Day, and New Year’s Day). You can also visit My Midwest Physician to find a physician or make an appointment.