Disease Description (Causes and Symptoms)
- Definition: Pectus excavatum is a chest wall deformity in which the sternum is sunken inward and is the most common of the chest wall deformities. The incidence in Korea is estimated to be approximately 1 in 1,000 people.
- Causes and pathophysiology: The exact cause is unknown, but it is explained as inward depression of the sternum caused by overgrowth of the cartilage connecting the lower sternum and adjacent ribs, which pulls the sternum inward. Some cases may be associated with a genetic predisposition or specific genetic syndromes (Marfan syndrome, Turner syndrome, etc.), metabolic diseases (rickets), or skeletal diseases (osteogenesis imperfecta). If the depression is severe, the sternum becomes closer to the heart, and compression or displacement of the heart and partial compression of the lungs may lead to decreased lung volume.
- Main symptoms: In most mild cases, there are few or no symptoms, but moderate or more severe cases may cause shortness of breath during exercise, chest pain (at the costochondral junction), and easy fatigue. Rarely, palpitations, cosmetic concerns regarding the chest, and accompanying scoliosis may occur. Symptoms may worsen when lung inflammation or asthma is also present.
- Diagnostic findings: Chest CT (or chest X-ray) is used to assess the pattern of sternal depression (symmetric/asymmetric), changes in the position of the heart and aorta, and decreased distance between the sternum and spine. Functional effects are evaluated with cardiopulmonary function tests (echocardiography and pulmonary function tests). The Haller index (the ratio of the transverse diameter of the chest to its anteroposterior diameter) is frequently used to assess severity (generally, values >3.25 are referenced as a criterion for severe disease).
Treatment Methods
- Conservative treatment
- In mild cases, symptoms are managed through observation and exercise therapy (chest wall strengthening and breathing exercises).
- A non-surgical approach may be considered when there is no major impact on cardiopulmonary function and cosmetic concerns are mild.
- Surgical treatment (indications: decreased cardiopulmonary function, significant exercise limitation, severe cosmetic concerns, etc.)
- Nuss procedure (currently widely used minimally invasive remodeling procedure): A customized metal bar is inserted beneath the sternum to correct its position. Advantages: small incisions, shorter operation time, and relatively less bleeding and pain. Disadvantages: the bar must be removed after the fixation period (usually 2–3 years), long-term follow-up is required, and long-term outcomes continue to be reported.
- Ravitch procedure (traditional open-chest surgery): Resection of deformed costal cartilage and repositioning of the sternum. It is used selectively in recent years because it may weaken the chest wall and leave a large scar.
- Silicone implant insertion: A cosmetic filling procedure (filling the depressed area). It is intended to improve appearance rather than symptoms and does not resolve cardiopulmonary compression.
- Medication: There is no specific drug treatment. Analgesics for postoperative pain control and antibiotics to prevent infection may be used.
- Postoperative care: Chest physiotherapy (breathing exercises), gradual increase in activity, regular imaging/functional tests, and determination of the timing of bar removal (usually 2–3 years).
- Complications and precautions: Possible complications include surgery-related infection, bar displacement or breakage, pneumothorax in the pleural cavity, bleeding, chronic pain, and recurrence. Silicone implantation carries a risk of long-term foreign-body reaction and infection. Cardiopulmonary function should be evaluated before surgery (echocardiography and pulmonary function tests).
Checklist Before an Outpatient Visit (Including Example Questions)
- Items to prepare
- A list of current medications (including anticoagulants and antiplatelet agents) and allergy history
- Records of previous surgeries and hospitalizations, and family history (chest wall deformities and genetic syndromes)
- Existing imaging materials (chest X-rays and CT scans) and test results (echocardiography and pulmonary function tests)
- Symptom records: activity level when shortness of breath occurs (e.g., how many floors of stairs can be climbed), location, nature, and frequency of chest pain, and changes in fatigue during exercise
- Front, back, and side photographs of the chest (useful for cosmetic consultations)
- Tests that may be performed during an outpatient visit
- Chest CT or X-ray, echocardiography, pulmonary function tests, and, if necessary, an exercise stress test
- Examples of frequently asked questions during an outpatient visit (for patients to check themselves)
- When did the symptoms begin? Have they gradually worsened?
- How severe is the shortness of breath during daily activities or exercise?
- Does the pain worsen with specific movements or breathing?
Examples of General Questions to Ask the Doctor
- Is this condition serious enough to require surgery? (What are the indications for surgery?)
- What surgical method do you recommend, and what are its advantages and disadvantages?
- What is the expected recovery period after surgery, and when can I return to daily activities?
- What is the likelihood of surgical complications (infection, bar displacement, and recurrence), and how can they be prevented and managed?
- What tests should I undergo before and after surgery?
Examples of Condition-Specific Questions
- Based on the degree of my sternal depression (such as the Haller index on CT) and my cardiopulmonary function results, which treatment (observation vs. Nuss vs. Ravitch) do you recommend?
- If I undergo the Nuss procedure, how is the timing of bar removal determined? How high is the risk of recurrence after removal?