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Purpose: The etiology of pectus excavatum (PE) has not been clarified. In 1944, Sweet (Sweet RH. Pectus excavatum. Ann Surg 1944;119:922-934) mentioned about the possibility of the overgrowth of costal cartilage being involved. However, no additional report that supports his hypothesis is available. In this study, we investigated whether the overgrowth of costal cartilage was an actual cause of PE through measurement of the costal cartilage length in PE patients and healthy controls., Materials and Methods: We investigated the length of the fifth and sixth costal cartilages and ribs in PE patients from reconstructed images of 3-dimensional computed tomography. To examine the relative costal cartilage length, we calculated the C/R ratio, defined as the quotient of the costal cartilage length divided by the adjacent rib length, and compared it between PE patients and healthy controls., Results: In PE patients, the C/R ratios were not larger than in healthy controls at any level. At the left sixth, the C/R ratio was significantly smaller in patients than in the healthy control group., Discussion: The results revealed that, in PE patients, relative costal cartilage lengths were not longer than in healthy controls. We conclude that the overgrowth of costal cartilage is not the etiology of PE., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Purpose: The cause of pectus excavatum has been hypothesized to be overgrowth of the costal cartilage. According to this theory, the length of costal cartilages must be longer in the side of deep depression in asymmetric patients. To challenge this hypothesis, we measured the lengths of ribs and costal cartilages and investigated lateral differences., Subjects and Methods: Twenty-four adolescent and adult patients with asymmetric pectus excavatum (14-30 years of age) with no history of surgery were investigated in this study. The fifth and sixth ribs and costal cartilages were individually traced to measure their full lengths on 3-dimensional computed tomographic (CT) images. As an index of asymmetry, sternal rotation angle was measured in the chest CT images. Patients with a 21 degrees or greater angle of sternal twist were designated as an asymmetric group and those with an angle of smaller than 20 degrees as a symmetric group. Lateral differences in the fifth and sixth costal and costal cartilage lengths were compared between the groups., Results: On comparison of the costal and costal cartilage lengths in the asymmetric group, the right fifth ribs and costal cartilages were significantly shorter than the left (P = .02 and .03, respectively), and right sixth ribs were also significantly shorter than the left (P = .004), but right sixth costal cartilages were not (P = .31). In the symmetric group, the lengths of the left and right fifth ribs and costal cartilages were showing no significant difference (P = .20 and P = .80, respectively), and those of the sixth ribs and costal cartilage were also showing no significant difference (P = .97 and P = .64, respectively)., Discussion: The ribs and costal cartilages on the right side with severer depression were significantly shorter or not different than those on the contralateral side. Based on these findings, the theory of costal cartilage overgrowth is contradictory. The etiology of asymmetric chest deformity should be reevaluated.

Background: Objective assessment of the chest in patients with pectus excavatum after the Nuss procedure has not been published. This study evaluated the results of the Nuss procedure using computed tomographic (CT) index (CTi)., Methods: We have performed the Nuss procedure in 382 patients since 1998, and 150 patients who underwent bar removal were included in this study. Computed tomographic scans were obtained before the Nuss procedure and after bar removal, and then preoperative CTi (pre-CTi) and postoperative CTi (post-CTi) were calculated. Computed tomographic scans of 62 age-matched patients without chest deformity were collected as controls. Patients were divided at 10 years of age into the younger and older groups, and groups with mild and severe deformity were defined using a pre-CTi value of 5 as border. These CT indices were compared and statistically analyzed., Results: Mean pre-CTi in all cases was 5.97 +/- 3.31 and improved to 3.08 +/- 0.64. Postoperative CTi was not significantly different from that of the control (2.47 +/- 0.32, P = .17). In the group with mild depression, pre-CTi was 4.15 +/- 0.62, and post-CTi was 2.88 +/- 0.50. Preoperative CTi in the group with severe deformity (7.44 +/- 3.82) improved to 3.25 +/- 0.69. Postoperative CTi values between the severe and mild groups were not significantly different (P = .75). Computed tomographic index of the young group improved from 6.20 +/- 3.58 to 2.93 +/- 0.49 and in older group from 5.50 +/- 2.64 to 3.40 +/- 0.79. These 2 post-CTi values were not significantly different (P = .73)., Conclusion: Postoperative CT scan could provide objective evaluation of sternal elevation. Mean CTi after the Nuss procedure was statically equivalent to that of the control cohort. Good sternal elevation can be achieved with the Nuss procedure regardless of the severity of chest depression or age.

Aim: Bone scintigraphy was performed to elucidate the effects of the Nuss procedure for pectus excavatum on the bony thorax., Methods: Eight boys and 6 girls (5 - 24 years of age) underwent bone scintigraphy, using (99m)Tc-HMDP. Eleven patients were studied 5 to 21 days after the Nuss procedure; 6 were studied 20 to 24 months after the operation before bar removal. Three of 14 were studied twice after the Nuss procedure and before bar removal., Results: In the early postoperative phase, RI accumulation was found at the sternum and ribs in only 1 of 6 patients under 9 years of age, whereas in all 5 older patients, RI had accumulated at the sternum. Scintigrams before bar removal revealed, regardless of age, hot spots at the lateral ribs in contact with the bar and at the costochondral junctions where the bar passed through the intercostal spaces. Furthermore, chest roentgenograms showed the deformed lateral ribs in contact with the bar., Conclusions: The Nuss procedure creates minute fractures at the sternum and the ribs, especially in older patients. The bar deforms the ribs and restrains the growth of the thorax. Furthermore, it constantly rubs against the ribs and can therefore cause late complications. Bone scintigraphy may determine the appropriate timing for bar removal.

Background: We summarized our experience of the Nuss procedure for pectus excavatum with comparison by age and uncommon complications., Methods: Twenty-three patients underwent the Nuss procedure. Their age ranged from 3 to 19 years old. The outcome was compared between two groups divided by age: teenagers (> or = 13 yrs old, n = 5, Group 1) and younger patients (n = 18, Group 2)., Results: Cosmetic results were significantly better, and the operating time and postoperative hospital stay in Group 2 were significantly shorter than in Group 1. Complications were more frequently seen in Group 1 than in Group 2. In all three younger patients whose bars were removed after 2 years, the ribs holding the bar were deformed. Uncommon complications occurred in two cases. In one case, pneumothorax occurred due to laceration by a fragment of wire after 12 months, and the fragment fell into the thoracic cavity. In another case, pneumothorax occurred due to injury by the port of a thin thoracoscope., Conclusion: The teenaged patients had more complications and poorer cosmetic results. Therefore, this operation should be performed before the teenage years. In younger patients with rapid growth, the bar should be removed less than 2 years to prevent restriction of costal growth.

Purpose: We examined the surgical indications for funnel chest, taking psychological factors into consideration., Methods: We assessed 36 young people with funnel chest who were seen as outpatients, including 31 boys and 5 girls aged from 1 to 22 years old. Respondents were asked whether they suffered psychological distress, and if they wanted surgery. The severity of the deformity was evaluated using the Vertebral Index (VI) and the Frontosagittal Index (FSI) calculated from chest roentgenograms., Results: The VI in 11 patients without distress (23.7 +/- 4.1) was lower than that in 25 patients with distress (32.8 +/- 8.2), and the FSI in the patients without distress (33.5 +/- 5.3) was higher than that in the patients with distress (23.6 +/- 8.6). The VI in 19 patients who did not want surgery (26.9 +/- 7.9) was lower than that in 17 patients who did (33.5 +/- 7.5), and the FSI in the patients who did not want surgery (30.4 +/- 8.1) was higher than that in the patients who did (22.4 +/- 8.1). The distressed patients suffered many psychological problems, such as being the object of bullying., Conclusion: The severity of the deformity affected the patient's psychological state. We consider that a VI >28 or an FSI <28 are indications for surgery, based on the mean VI + SD and the mean FSI-SD of patients not suffering distress.

Forty-seven children with funnel chest (FC) who underwent sternal elevation and 210 normal children were examined to determine the indications for surgical treatment using the vertebral index (VI) and frontosagittal index (FSI). In normal children VI gradually increased and FSI gradually decreased with age. Both indices changed significantly at 3 years of age. Although the VI of FC patients decreased significantly from 33.8 +/- 7.6 (n=40) to 24.4 +/- 3.9 (n=38) postoperatively (P < 0.0001), it was significantly larger than that of normal children over 3 years of age (20.2 +/- 2.2, n=150) (P < 0.0001), and although the FSI of FC patients increased significantly from 22.0 +/- 7.0 (n=40) to 34.5 +/- 6.5 (n=38) postoperatively (P < 0.0001), it was significantly smaller than that of normal children over 3 years of age (41.1 +/- 4.0, n=150) (P < 0.0001). Since many patients had a thin and flat chest despite excellent correction, their postoperative indices were not normal. There was a correlation between VI and FSI in normal children and a high degree of correlation between VI and FSI both before and after operation in FC patients. We conclude that a VI of more than 27 and/or a FSI of less than 29 are indications for surgical treatment based on the mean VI + 3SD and FSI - 3SD of normal children over 3 years of age. These values are almost equal to the mean VI - SD and FSI + SD of patients with physical, cosmetic, and/or psychological disturbances. However, it is not necessary to measure both indices simultaneously. Postoperative VI and FSI did not always reflect the degree of chest-wall depression in FC patients because of their flat chests.