| Dr L M Darlong |
The Nuss procedure is a surgical technique for correction of pectus exacavatum, a congenital chest wall deformity caused due to abnormal development of ribs, cartilage or breast bone. In pectus excavatum or funnel chest, the breast bone is depressed leading to sunken or caved chest appearance. It is one of the most common congenital deformities of the anterior wall of the chest. It can either be present at birth or develops during puberty. What causes this condition is not known, though 40 per cent cases have hereditary association. It is more common in males. While we don’t have Indian figures on the occurrence of pectus excavatum, the Western incidence is 1 in 500 to 1000 live births. Besides pectus excavatum other deformity which are less common are pectus carinatum/pigeon chest in which the chest protrudes out and defects in which both defects exist.
In the Indian context, pectus excavatum is considered a cosmetic problem, which is not true. Even serious cases of pectus excavatum may not threaten life, but it affects heart and lung functioning as there is not enough room for these organs to develop due to the sunken chest. This can be physically disabling for the patient and may manifest in heart problems indicated in the symptoms like shortness of breath, low tolerance for exercise and chest pain. Mild breathing difficulties and frequent, long-lasting colds may result from less severe forms.
| Nuss procedure at Fortis Noida |
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Fortis Noida performs advanced Nuss procedure using technique of pectoscopy and crane lift. It has the “chest wall deformity clinic” specifically for such cases and deals with both domestic and international patients. The clinic deals with pectus excavatum, pectus carinatum combine deformities and chest wall deformities arising from trauma/ tumours. The clinic deals with pectus deformity in all age group from children, teenagers and adults. Chest wall deformity clinic provides
The centre employs the following technique for safety and result
The “chest wall deformity clinic” has an online query site at http//www.pectusindia.com through which outstation domestic and international patients are screened to confirm their diagnosis. Online review of pectus questionnaires, clinical images and radiological images help us in planning the management of such patients Such cases are planned keeping in view their schedule like school vacation for children, college holidays for teenagers. |
Nuss procedure is a minimally invasive procedure that aims to force the sternum forward and hold it there with the help of a steel bar. It is based on the principle of bone and muscle remodelling along the rigid framework provided by the steel bars which lifts the breast bone to overcome the defect. In this procedure, small incisions of 2.5 cm are placed on each side of the chest, under each arm. Long-handled tools and a narrow fibre-optic camera are inserted through the incisions. A curved metal bar is threaded under the depressed breastbone, to raise it into a more normal position. In some cases, more than one bar is used based on the extent of deformity and age of the patient. The bars are removed after two to three years. Bar removal procedure is done through the original small incisions of previous surgery on either side of the chest. The surgery corrects the cosmetic deformity boosting the patient’s self-confidence and improving heart and lung physiology.
The dictum for the time of surgery is “the earlier the better”.
The ideal age for pectus excavatum surgery is three years using the Nuss procedure. At this age the bones are soft and can be easily remodelled with less pain. Moreover by the time, the child is five years of age and ready to go to school, the bar is ready to be removed and avoids psychosocial implication from peer group in their class.
The early correction of sunken chest avoids physiological effect on heart and lung functioning and psychosocial implications of the defect. The chest wall remodelling effects of the bar allows it to grow as a normal chest.
In India there is absence of dedicated clinics for repair of sunken chest. The medical community also has less awareness on the management of sunken chest. It is usually perceived as a cosmetic deformity. As a result, parents seeking advice of the correction of this condition in their children are often asked to live with it. This results in the loss of precious time because correcting sunken chest is more advantageous in kids with Nuss procedure.
| Case study: | ||
| Fortis Noida operated on a three-year old child in July 2012. She is doing well, her brother no longer teases her as the dent on her chest is gone, the parents say her posture has improved and she is more social now and goes for swimming too. Her bar will be removed by the age of five years, and with her deformity corrected she will attend school free of psychological and physiological implication which would not have been the case if it was left untreated.
Similarly, the hospital has operated on teenagers who were left untreated during childhood and continued suffering psychological trauma with physiological limitation due to the deformity. With the help of internet such young, aware, educated net-savvy individuals were able to locate the hospital and get their pectus deformity corrected. In adults too people in their 30’s have had their pectus deformity corrected mainly due to its psychosocial impact. Cost to patients Cost of treatment varies from Rs 2 to 3 lakhs depending on the number of Nuss bars used and the age of the patient. The younger the patient the lesser the cost due to less hospital stay. |
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| 1. Pectus excavatum showing depressed breast bone compressing the underlying heart and lung. | 2. Crane lift device attached to deformity. | 3. Crane lifting of the deformity |
| 4. Pectoscopy creation of space for bar placement | 5. Pectus tunneloscopy bar placement | 6. Nuss bar before fixation |
| 7. Nuss bar after fixation and correcting defect | ||