Pectus excavatum: Out of Africa – evolution, outcomes, and global implications of minimally invasive repair

INTRODUCTION

Pectus excavatum is characterized by posterior displacement of the sternum and adjacent costal cartilages, resulting in a concave anterior chest wall. It occurs in approximately 1 in 1,000 live births and shows a male predominance. While mild deformities may be asymptomatic, moderate to severe cases are increasingly recognized as having significant physiological and psychological consequences.^[1]

Historically, surgical correction involved extensive resection of the costal cartilages and mobilization of the sternum. Over the last three decades, advances in minimally invasive surgery have transformed the management of chest wall deformities, culminating in the widespread adoption of the Nuss procedure [Box 1].^[1-6]

HISTORICAL EVOLUTION OF SURGICAL TECHNIQUES

Early surgical philosophy advocated radical resection of abnormal cartilages (Ravitch-type procedures). This approach carried significant morbidity and often resulted in chest wall rigidity.

A pivotal shift occurred when Donald Nuss demonstrated that correction could be achieved without resection, using internal bracing to remodel the flexible chest wall. Importantly, Nuss was African-born, from KwaZulu-Natal, South Africa, and trained at the University of Cape Town – an often under-recognized African contribution to global surgical innovation.

THE NUSS PROCEDURE

Technique

The Nuss procedure involves thoracoscopic passage of a curved metal bar beneath the sternum [Figure 1]. The bar is rotated to elevate the depressed sternum and stabilized laterally. No cartilage resection or sternal osteotomy is required.^[1,2]

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Figure 1: Procedure and eversion of the sternal depression with a metal bar. The curved grey arrow indicates the clockwise rotation of the Nuss bar from (a) the inverted position to the (b) final position, thereby correcting the pectus excavatum deformity.

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TECHNICAL REFINEMENTS

A number of technical refinements have significantly improved the safety, reproducibility, and applicability of the Nuss procedure. The use of multiple bars has enhanced correction in patients with rigid or asymmetric deformities, while sternal elevation techniques,^[6] including crane-assisted methods, have reduced the risk of cardiac injury during substernal dissection. Advances in thoracoscopic visualization have improved intraoperative precision, and modern bar stabilization strategies have reduced displacement rates. These developments, together with refinements in anesthetic techniques and standardized postoperative care protocols, have contributed to improved overall outcomes and reduced complication rates.

COST-ADAPTED MODIFICATIONS IN RESOURCE-LIMITED SETTINGS

In South Africa and similar resource-constrained environments, pragmatic adaptations of the Nuss procedure have enabled safe and cost-effective implementation without compromising clinical outcomes. These include same-day hospital admission and a reduction in routine pre-operative investigations, with non-contrast expiratory computed tomography (CT) serving as the primary imaging modality. The use of laryngeal mask anesthesia simplifies perioperative management, while the avoidance of routine epidural analgesia and urinary catheterization reduces both cost and procedural invasiveness. Early mobilization protocols and expedited discharge pathways further enhance efficiency and resource utilization, making the procedure more accessible in low- and middle-income settings.

POSTOPERATIVE PAIN MANAGEMENT

Postoperative pain management following minimally invasive repair has evolved considerably over time. Early reliance on systemic narcotics proved frequently inadequate for controlling the significant discomfort associated with substernal bar placement. The introduction of thoracic epidural analgesia represented a major advance, offering effective pain control but at the cost of technical complexity and potential complications. Subsequent adoption of intravenous and patient-controlled analgesia strategies reduced epidural-related risks while maintaining acceptable analgesia. More recently, intercostal nerve cryo-analgesia^[7] has emerged as the preferred modality in many centers, providing prolonged and targeted pain relief, markedly reducing opioid requirements, and facilitating early mobilization. This technique has been transformative, enabling discharge within 48–72 h in a large proportion of patients.

FUNCTIONAL OUTCOMES

COMPLICATIONS

Early experience with the Nuss procedure identified several complications, including bar displacement, recurrence, infection, hemothorax, and hypersensitivity reactions such as nickel allergy. However, advances in surgical technique, improved bar design, and more refined patient selection have significantly reduced the incidence of these adverse events. Contemporary large institutional series report recurrence rates below 2% and excellent long-term outcomes in more than 90% of patients when the procedure is performed in experienced centers.^[1]

DISCUSSION

The management of pectus excavatum has evolved from radical resection surgery to a minimally invasive, physiology-preserving approach. This transition reflects broader trends in thoracic surgery toward reducing tissue disruption while improving functional outcomes. The Nuss procedure represents the culmination of this evolution and has fundamentally altered the standard of care.^[1,2,9]

A critical advance has been the recognition that pectus excavatum is not merely a cosmetic condition. Contemporary imaging and functional studies consistently demonstrate right heart compression, impaired diastolic filling, and reduced stroke volume in patients with moderate to severe deformities. The immediate restoration of cardiac geometry following sternal elevation provides compelling physiological evidence for surgical correction and explains the rapid symptomatic improvement reported by many patients.

Minimally invasive repair offers clear advantages over traditional open techniques. Avoidance of cartilage resection and sternal osteotomy preserves chest wall compliance and reduces long-term rigidity, particularly important in younger patients. Large institutional series report excellent or good outcomes in over 90% of patients – approaching 95% in high-volume centers – when the procedure is performed in experienced hands with complication rates that compare favorably to historical open repairs.^[10,11]

Despite its conceptual simplicity, the Nuss procedure is technically demanding. The proximity of the bar to vital structures necessitates meticulous technique, thoracoscopic visualization, and secure stabilization. Technical refinements, including sternal elevation and improved bar fixation, have significantly enhanced safety. These considerations underscore the importance of structured training and mentorship, ideally within specialized chest wall centers. Such training is increasingly available in Africa, enabling safe dissemination beyond high-income settings.

Post-operative pain management remains a key determinant of outcome. While thoracic epidural analgesia improved early results, it introduced logistical complexity and risk. Intercostal nerve cryo-analgesia has emerged as a particularly effective alternative, providing prolonged analgesia, reducing opioid requirements, and facilitating early mobilization and discharge. This has had important implications for patient satisfaction and healthcare resource utilization.

The applicability of minimally invasive repair in resource-limited settings is of particular relevance. Through pragmatic modifications – limited pre-operative investigations, simplified anesthesia, and cost-effective analgesia – the procedure can be performed safely without compromising outcomes. This is especially significant given the African origins of the Nuss procedure, yet persistent inequities in access to modern chest wall surgery across the continent.

This review is limited by its narrative design and reliance on observational series rather than randomized trials. Nevertheless, the consistency of outcomes across centers and over time supports the safety, efficacy, and durability of minimally invasive repair. Future work should focus on long-term functional outcomes, refinement of patient selection, and broader data collection from low- and middle-income countries.

In summary, minimally invasive repair of pectus excavatum represents a paradigm shift in thoracic surgery, combining physiological restoration with reduced morbidity. That this innovation originated from an African-trained surgeon underscores both its historical significance and the imperative to ensure global access to modern surgical care.

CONCLUSION

Minimally invasive repair of pectus excavatum represents one of the most important paradigm shifts in modern thoracic surgery. The transition from radical resection to internal bracing has improved functional outcomes, cosmetic results, and patient safety.

That this innovation originated from an African-trained surgeon is both historically significant and symbolically important. The Nuss procedure is now the global gold standard and should be accessible wherever trained thoracic surgeons practice – including across the African continent.