Less intrusive surgical options are changing the lives of South Africans with sunken chest deformity..

“More than a decade after the first minimally invasive Nuss procedure was performed in South Africa, the general public and many doctors in South Africa are still not aware that there is a considerably less invasive treatment — which does not involve cutting through the chest wall cartilage, or resection of tissue – available to correct more serious cases of sunken chest deformity, medically known as pectus excavatum.”

So says cardiothoracic surgeon, Dr Ivan Schewitz, who was speaking at the recent historic 20th Congress of the Chest Wall International Group (CWIG), which was attended by delegates and speakers from around the world.

Dr Schewitz, who practices at Netcare Waterfall City Hospital in Midrand, noted that in South Africa, only the traditional open chest surgery used to treat this condition seems to be known. However, it can take patients many months to recover from this major operation, the Ravitch procedure, which also leaves considerable scarring on the chest.

Doctors are reluctant to refer patients for major procedure

“Many doctors are therefore reluctant to refer patients with even the most serious sunken chest deformity for treatment. Parents are often also unwilling for their children to go through such a major operation. This can be tragic as pectus, which usually starts to become evident in the early teens, can develop into much more than simply an aesthetic problem, and in serious cases can result in a range of debilitating symptoms,” added Dr Schewitz.

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Minimally invasive Nuss procedures demonstrated at workshop

Dr Schewitz, who performed the first local Nuss procedure in Johannesburg in 2008 and headed the local organising committee of the congress, demonstrated the minimally invasive technique by performing four procedures at Netcare Waterfall City Hospital at a workshop held as part of the congress.

The procedures were streamed live to more than 130 delegates including some of the world’s leading paediatric and cardiothoracic surgeons, with lively interaction and discussions between the surgical team in theatre and delegates. Among the delegates were 25 registrars, or trainee specialists, who were sponsored by CWIG to attend the congress and greatly benefitted from the educational demonstration.

Dr Schewitz explains that pectus excavatum may be mild, moderate or severe

Whether or not a repair procedure is appropriate will depend on each individual case. In more severe cases, however, the breastbone can go on to place such pressure on the heart and lungs that it severely limits the physical activities of these growing and developing teenagers. In addition, the sunken chest often results in the individual suffering psychologically, experiencing “devastating self-esteem and confidence problems”.

Whether or not a repair procedure is appropriate will depend on each individual case.

“The Nuss procedure involves temporarily placing curved metal bars behind the sternum to lift it to a normal position. It has been used to correct the deformity in at least 100 000 patients around the world since it was first developed by South African-born Professor Donald Nuss, and we were greatly honoured that he travelled from the United States to attend the 2019 congress,” said Dr Schewitz.

The congress, a joint meeting of CWIG, the South African Thoracic Society (SATS), and the Allergy Society of South Africa (ALLSA), was hosted in Pretoria and had the theme “Challenging Beliefs”.

Who is Professor Nuss?

Now retired and an honorary president of CWIG, Professor Nuss started his career in Cape Town, and qualified as a paediatric surgeon at Red Cross Children’s Hospital. He developed the procedure that has been named in his honour at Children’s Hospital of The King’s Daughters, in Norfolk, Virginia, in the United States. The intricate Nuss procedure usually takes approximately two hours to complete, and is internationally regarded as the gold standard in the treatment of appropriate patients with more serious sunken chest.

Interviewed during his visit to South Africa, Professor Nuss said that it was wonderful to be in South Africa again, and have the privilege of attending the CWIG congress. “I was particularly impressed by the pectus workshop, and by Dr Schewitz’s commitment to impart his considerable experience of this condition and in the Nuss procedure to his colleagues, which will hopefully inspire some of them to also train in it,” he noted.

“While this treatment option has caught on around the world, the uptake in South Africa has unfortunately been slower”

Uptake of the procedure has been slow in SA

“While this treatment option has caught on around the world, the uptake in South Africa has unfortunately been slower, with Dr Schewitz being one of the few surgeons to offer the procedure. One of the challenges is that while this approach offers a real solution for identified patients with more severe pectus, it is tricky to master and I think for this reason many surgeons here have avoided training in it.

“Training workshops such as the one done by Dr Schewitz are therefore critical in making this option more accessible to people with the condition in South Africa. It is also imperative to raise awareness of this minimally invasive option among the general public, GPs and specialists who may be consulted by patients living with complications because of the condition not having been treated.”

How did Dr Nuss develop the procedure?

Asked how he had come to develop the procedure, Professor Nuss said that he noted that pectus, which occurs among all population groups, although more so in some than others, was devastating for many young people and he felt that there must be a better solution to treating the condition than by means of the more traumatic Ravitch approach.

“I fully agree with Dr Schewitz that those who develop more severe pectus should be treated by the best means available for the particular patient. The signs of the condition become increasingly evident from puberty and into the teenage years, with the chest wall steadily and alarmingly collapsing as the youngster grows.

“Individuals with developing pectus should be assessed as soon as possible and, if necessary, undergo a correction procedure so that the strain on their organs can be relieved and their quality of life and self-esteem can be restored. In other words, we want these young people to thrive rather than having to grow up with this potentially debilitating condition,” concluded Professor Nuss.

Signs and symptoms of pectus excavatum

Dr Ivan Schewitz has extensive experience in the treatment of children, teenagers and adults with pectus excavatum. He says that while the condition is usually mild at an early age, it tends to progress rapidly during the pubertal growth spurt giving rise to a variety of symptoms.

The decision regarding whether to treat the patient with a vacuum bell device, or to offer surgical correction depends on whether the patient has severe symptoms, whether the condition is progressing and on the results of a chest CT scan showing heart or lung compression, lung functions tests and ultrasound of the heart.

He advises that the signs and symptoms of more severe cases of pectus excavatum can include:

  • Difficulty breathing, which can severely hamper physical activities and exercise
  • Tiredness
  • Chest pain
  • A rapid heartbeat or heart palpitations
  • Frequent respiratory infections
  • Coughing and wheezing, often diagnosed as asthma

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