Sunken Chest Now Treated by Gentler Surgery

NORFOLK, Va. —  Carden McKinley used to have a depression in his chest so deep that a bar of soap fit in it.

The 10-year-old boy suffered from a congenital condition called pectus excavatum, or sunken or funnel chest, which occurs in about one child in 1,000.

Pectus can cause chest pain and breathing problems because the sternum turns inward, crowding the heart and reducing lung capacity. Carden also had asthma attacks.

Although surgery is needed only in more severe cases, the operation that has been available since 1910 to correct pectus is brutal.

A doctor slices open the child’s chest, removes the ribs, cuts out a piece of the breastbone, elevates the breastbone and replaces the ribs. In the 1950s, doctors also began inserting a steel bar to support the breastbone.

Dr. Donald Nuss, a pediatric surgeon, decided there had to be an easier way.

He devised a technique that involves cutting small holes on either side of the chest and pulling through a stainless steel bar beneath the breastbone and ribs.

The curved bar “pops” out the depression. It is not visible from the outside and stays in place for about two years. The bar is removed as an outpatient procedure.

Nuss and his associates at Children’s Hospital of the King’s Daughters have performed the surgery about 120 times since 1987.

His patients have included Carden, who had his surgery a year ago. Carden’s two older brothers also had pectus and underwent Nuss’ procedure in the spring.

“I never would have done the other surgery. There was no way,” said their mother, Lona McKinley, 40. The older technique seemed too grisly, she said, and would have left their chests rigid, making it unsafe for the boys to play sports.

After amassing 10 years of data that he believes proves the success of his technique, Nuss began telling other doctors about the surgery.

In May 1997, he presented his work at an American Pediatric Surgery Assn. meeting. His paper was published in April this year in the association’s peer-reviewed Journal of Pediatric Surgery, and the procedure was featured in a recent presentation at the Clinical Congress of the American College of Surgeons, held in Orlando, Fla.

At least 50 surgeons from other institutions have come to Norfolk to learn from Nuss how to perform the surgery. And children have come to Children’s Hospital of the King’s Daughters from as far away as Maine, Florida and Kansas for the procedure.

Nuss’ procedure has several advantages over the old technique, said Dr. Deborah Billmire, a pediatric surgeon at St. Christopher’s Hospital for Children in Philadelphia who has observed Nuss perform the surgery and has performed the technique herself.

“It has superior cosmetic results, it has shortened healing time and it takes quite a bit less time to do,” she said.

The older surgery took three to six hours, and some children lost so much blood they needed transfusions. Recuperation took three to six months, and the patient was left with a large scar. Sometimes the ribs didn’t grow back properly, causing breathing problems.

Nuss’ procedure takes 45 minutes and leaves two small scars under the armpits. Complications are minimal, Nuss said.

The child spends four to five days in the hospital and, after discharge, can slowly resume normal activity. Most children return to school after two weeks with only minor restrictions.

After a month, the patient may return to regular activity--including sports. Carden pitched on his school’s baseball team in the spring. His 11-year-old brother, Philip, is playing ball this fall, and his 14-year-old brother, Harrison, has resumed playing golf.

“They’re 110%,” their mother said, noting that Carden hasn’t had an asthma attack since the surgery.