Surgical treatment of severe pectus excavatum in an adolescent: a case report

BACKGROUND: Pectus excavatum is a malformation characterized by deformities of the cartilaginous parts of the ribs and sternum of varying severity and accounts for 75%–91% of all chest wall deformities. Surgical treatment of pectus excavatum in children remains an urgent issue, despite the considerable number of existing surgical correction techniques. These techniques are not universally applicable, especially for asymmetric and rigid forms, requiring ongoing modification and improvement.

CASE DESCRIPTION: A 17-year-old patient underwent surgical correction of a severe pectus excavatum complicated by a history of cardiac surgery, namely, median sternotomy and mitral valve prosthesis placement. The surgical procedure involved the release of major vital anatomical structures, the use of an external fixation device providing high corrective force during surgery, and gradual intraoperative correction under cardiac function monitoring.

DISCUSSION: Correction of severe pectus excavatum following prior median sternotomy is associated with a high risk of complications, including fatal events such as asystole or massive hemorrhage. In such cases, a minimally invasive thoracoplasty with an additional subxiphoid approach and sternal elevation using an external fixation device is recommended. Conventional sternal elevation techniques (e.g., bone hooks, sutures, and clamps) have been found to be not advisable for pronounced rigid deformities owing to the risk of sternal injury. Moreover, isolated thoracoscopy using the standard MIRPE technique does not ensure the integrity of intrathoracic structures, and traditional bar-flipping maneuver for immediate and forced correction of pectus excavatum is inappropriate.

CONCLUSION: Patients with pectus excavatum exceeding the threshold for severe deformity, particularly those with previous cardiac surgery, require a treatment different from standard thoracoplasty. The presented approach, involving the release of major vital anatomical structures and gradual intraoperative correction under cardiac monitoring with an external fixation device, is recommended for managing such complex clinical cases.