Pectus Excavatum

Pectus excavatum, the most common chest wall deformity (1:400–1000 births, 4:1 male predominance), presents with cardiopulmonary symptoms—fatigue, dyspnea, chest pain—in roughly two-thirds of patients, though the clinical significance remains debated [e305-c1,c6,e990-c18]. Cardiac compression reduces right ventricular ejection fraction (<50%) in ~15% of cases, with stroke-volume limitation during exercise; repair improves cardiac output by 24–30% [e305-c12,e692-c2,c4,e688-c7,c8,e1017-c7,c8]. Pulmonary function averages one standard deviation below predicted (85–90% FVC), correcting post-operatively [e305-c11,c12,c13]. Haller index >3.25 (transverse/AP diameter ratio) defines severity, though barrel chests require correction or depression indices (>10%, >0.2 respectively) [e305-c7,c8,c9,e692-c7,c8]. Surgical indications demand ≥3 of 6 criteria: Haller >3.2, PFTs <80%, cardiac abnormalities, symptoms, progression, or psychosocial distress . The Nuss procedure—minimally invasive bar placement—is the gold standard, ideally performed ages 11–15 during puberty to minimize recurrence (<1.2%) when bars remain 2–3 years [e305-c17,c18,c34,c35,e423-c15,c16]. Intercostal nerve cryoablation (T3–T7, 2-minute cycles) has revolutionized pain control, reducing length of stay from 4–5 days to 1–2 days and opioid use by >70%, though 10–23% develop transient hypoesthesia and older patients (>21y) show higher neuropathic symptom rates [e305-c29,e5806-c6,c7,e5422-c14,e8729-c6,c7,c8,c9,e10345-c15,c17,c18]. Bar displacement (2.7–11% historically) is mitigated by medial stabilizer placement, pericostal sutures, and bridge techniques [e305-c29,c30,e6277-c5,c14,e9184-c5,c6]. Revision cases—30% of some practices—stem from technical failures (bar rotation, lateral stripping) or open-repair malunion; forced sternal elevation, multiple bars, and limited osteotomies address rigid adult chests [e689-c1,c4,c7,c8,e1016-c1,c4,c7,c8]. Vacuum bell therapy achieves correction in young (<11y), flexible patients with mild defects (<1.5cm) but requires 2h twice-daily wear for a year [e305-c36,c37,e10345-c24,c25,c26,e10404-c5,c6,c7]. Pectus carinatum responds to dynamic compression bracing (85% compliance, 6–20 months) in two-thirds of patients, reserving surgery for failures [e305-c39,e423-c23,c24,e990-c26,c27]. Connective tissue disorders (Marfan 5.3%, hypermobile Ehlers-Danlos common) warrant cardiac screening and may predict chronic pain [e305-c2,e423-c5,e10345-c3,c4,e1018-c8,c14,c25,c26,c27].