Surgical treatments for pectus excavatum

Pectus excavatum is characterized by a depression (sunken appearance) of the anterior (front) chest wall (sternum and lower costal cartilages); it is the most common chest wall defect. The frequency ranges from 6.28 to 12 cases per 1000 around the world. It is generally regarded as a genetic condition, based on the fact that it is usually present in several members of the same family and is often associated with other genetic diseases; however, its causes remain in debate. To what degree the disorder affects the individual's life is variable, some will live a normal life and others can have physical and psychological symptoms such as: precordial pain after exercises; problems with pulmonary and cardiac function; shyness and social isolation.

Many types of non-surgical treatments have been tried, among them there are physical and respiratory exercises and different methods or devices to put pressure on the elevated parts of the chest wall or do traction in the depressed parts. Despite these different options of conservative treatment, the widespread treatment is that of surgical correction. For many years the surgical correction was based on the resections of the deformed costal cartilages (which aim to extend the ribs forward and contribute to the elasticity of the walls of the thorax (area between abdomen and neck)) and the placement of a support behind of the externum to move it forward. Since 1997 a new surgical technique became available, the externum is displaced forward by the placement of a metal bar behind it, the bar is placed by video-assisted throat surgery and the costal cartilage is resected. However, there is a debate if one surgery is better (reach a better result with less complications) than the other. To clarify this question we performed a systematic review, but, no trials were eligible for inclusion. We conclude that, there is no evidence to decide what is the best surgical procedure to treat pectus excavatum.

Authors' conclusions: 

There is no evidence from randomized controlled trials to conclude what is the best surgical option to treat people with pectus excavatum.

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Background: 

Pectus excavatum is characterized by a depression of the anterior chest wall (sternum and lower costal cartilages) and is the most frequently occurring chest wall deformity. The prevalence ranges from 6.28 to 12 cases per 1000 around the world. Generally pectus excavatum is present at birth or is identified after a few weeks or months; however, sometimes it becomes evident only at puberty. The consequence of the condition on a individual’s life is variable, some live a normal life and others have physical and psychological symptoms such as: precordial pain after exercises; impairments of pulmonary and cardiac function; shyness and social isolation. For many years, sub-perichondrial resection of the costal cartilages, with or without transverse cuneiform osteotomy of the sternum and placement of a substernal support, called conventional surgery, was the most accepted option for surgical repair of these patients. From 1997 a new surgical repair called, minimally invasive surgery, became available. This less invasive surgical option consists of the retrosternal placement of a curved metal bar, without resections of the costal cartilages or sternum osteotomy, and is performed by videothoracoscopy. However, many aspects that relate to the benefits and harms of both techniques have not been defined.

Objectives: 

To evaluate the effectiveness and safety of the conventional surgery compared with minimally invasive surgery for treating people with pectus excavatum.

Search strategy: 

With the aim of increasing the sensitivity of the search strategy we used only terms related to the individual’s condition (pectus excavatum); terms related to the interventions, outcomes and types of studies were not included. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, LILACS, and ICTPR. Additionally we searched yet reference lists of articles and conference proceedings. All searches were done without language restriction.

Date of the most recent searches: 14 January 2014.

Selection criteria: 

We considered randomized or quasi-randomized controlled trials that compared traditional surgery with minimally invasive surgery for treating pectus excavatum.

Data collection and analysis: 

Two review authors independently assessed the eligibility of the trials identified and agreed trial eligibility after a consensus meeting. The authors also assessed the risk of bias of the eligible trials.

Main results: 

Initially we located 4111 trials from the electronic searches and two further trials from other resources. All trials were added into reference management software and the duplicates were excluded, leaving 2517 studies. The titles and abstracts of these 2517 studies were independently analyzed by two authors and finally eight trials were selected for full text analysis, after which they were all excluded, as they did not fulfil the inclusion criteria.

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