Funnelling the funnel chest debate into evidence-based care: current landscape of pectus excavatum surgery

Surgery for pectus excavatum (PEx) has been a topic of controversy and much debate in recent years. In the UK, in particular, the National Health Service (NHS) England decommissioned surgery in 2019, which led to widespread outcry regarding access to care, culminating in a House of Commons debate [1]. The fallout from this has been significant both in the UK and further afield. Through defunding of service or confusion regarding the indications and efficacy of surgery, patients with PEx have been neglected.

But what does the evidence show? A National Institute for Health and Care Excellence (NICE) technology appraisal in 2009 looking at published studies and contemporary data found both open (Ravitch) and minimally invasive (Nuss) surgery for PEx to be safe [2]. Multiple cohort studies and a recent systematic review have shown clear benefits in terms of quality of life and psychological benefits following surgery [3]. However, the physiological benefit of surgery is less clear and has been difficult to objectively quantify [3]. This is in part due to the fact that the cardiopulmonary effects of PEx have not been well elucidated. It is generally accepted that sternal compression impairs right ventricular filling, which limits the patient’s ability to increase their stroke volume in response to exercise, thereby reducing maximum cardiac output, leading to symptoms of exercise intolerance and dyspnoea. Using resting variables to assess this dynamic compromise has not proven helpful; however, cardiopulmonary exercise testing (CPET) provides a better assessment of this, and several recent studies have demonstrated improvement following repair. The largest of which, published in 2022 by Jaroszewski et al. [4] found significant improvement in oxygen consumption and oxygen pulse (P < 0.001) in 130 patients undergoing CPET preoperatively and 3 years post Nuss repair, just prior to bar removal. It is important to note, however, that these demonstrated improvements in exercise testing indices have not yet been well correlated with patients symptoms. This makes their clinical significance uncertain in terms of meaningful outcomes for patients.

Clarity is needed. We commend the multidisciplinary approach taken in the new pectus care guidelines recently published in this journal [5]. These consensus guidelines come from the wide range of specialist societies that deal with PEx, including patient advocacy groups. It summarizes the evidence to date on PEx treatment and makes best practice guidelines for the investigation and management of patients with pectus deformities. CPET is advised as a routine assessment for patients with physiological symptoms, and it supports the recommendation for surgical repair in patients with severe PEx deformity and symptoms that are attributable to cardiac compression. Based, in part, on these guidelines, a Pectus MDT has been established in the UK for selection of patients with PEx who may benefit from surgery.

One stated limitation of these guidelines is the lack of high-quality evidence to guide decision-making—this, however, may soon change. The National Institute for Health Research (NIHR) in the UK has recently awarded funding for a randomized trial of surgery versus no treatment to restore cardiopulmonary function in severe PEx—The RESTORE Trial (NIHR158749) [6]. This will be the first randomized trial in PEx and aims to compare 200 patients with severe PEx (i.e. Haller index >3.25) and physical symptoms attributable to PEx, randomized to either surgery or delayed surgery at 1 year. The primary outcome will be patient-focused; change in the Short Form Health Survey (SF36v2) physical function questionnaire, with secondary outcomes being CPET variables (VO_2max and oxygen pulse), health-related quality of life measures and acceptability (Nuss questionnaire). This will be the first trial to assess patients’ symptoms and quality of life measures alongside cardiopulmonary function and should help establish the minimally clinically important differences for improvements in these indices following repair.

The ability to recruit such a trial, controlled with delayed surgery, is perhaps a silver lining of the current access issues in the UK. Recruiting commenced in August of this year, with 1-year results to be reported in 2027 and the final 3-year results in 2029. This well-considered, planned and funded trial will hopefully provide an answer the question mark over surgery that has been a barrier to care for patients’ with PEx for the last 5 years.

Regardless of the outcomes of this trial, questions will remain about the timing for surgery and its indication for less anatomically severe ‘cosmetic’ cases but potentially psychologically distressing pectus defects as well as the use of secondary, defect-filling approaches with implants. Certainly, however, the landscape of PEx surgery may soon change with debate finally beginning to funnel in the direction of evidence-based case.

Conflict of interest: Professor Karen C. Redmond is chair of SCTS Pectus Working Group and co-chair of the SCTS Thoracic Working Group.

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