International survey on the management of pectus excavatum: is there a consensus?

Abstract

Purpose: Pectus excavatum (PE) is the most common congenital chest wall deformity. While often perceived as a cosmetic issue, PE can impair cardiopulmonary function. Surgical correction has evolved from the Ravitch procedure to the minimally invasive Nuss technique, which offers reduced surgical risks and improved postoperative outcomes. However, diagnostic and therapeutic variability persists, highlighting the need for expert consensus.

Methods: A 31-question web-based survey was distributed to CWIG members and PE specialists between November 2024 and January 2025. The survey explored five key domains: demographics, preoperative evaluation, surgical indications and timing, operative technique, and postoperative management. Responses from 100 international surgeons were analyzed.

Results: The most common indications for surgery were severe deformity (88.9%), Haller index > 3.25 (78.8%), psychosocial distress (77.8%), and symptoms (77.8%). Technique selection was influenced by prior surgery (48%) and surgeon experience (45.9%). For complex cases, 90.8% preferred the double-bar technique. Most surgeons removed the bar within 2-3 years (86.6%). Postoperative pain was primarily managed with oral analgesics (64.6%) and IV pumps (47.5%). Early complications included pneumothorax (68.1%) and infections (62.8%); bar displacement (78%) was the most frequent late complication.

Conclusion: Despite widespread adoption of the Nuss procedure, significant variation remains in PE management. These findings emphasize the need for standardized, evidence-based guidelines to optimize patient outcomes.