Pectus Excavatum is a congenital deformity where the ribs and sternum grow abnormally forming a caved-in chest wall. In most patients, the only symptom is the cosmetic indentation of the chest although, in more severe cases, there can be respiratory problems and chest pain. Surgery involves placing titanium bars beneath the ribs and sternum to push the chest back out.

The deformity caught national attention in January 2020 when the BBC published an article[1] featuring a patient who had been refused surgical intervention, which she says has left her with pain and breathing difficulties. On the other hand, the article also speaks to a patient who had operative intervention and is now hospitalised, in severe pain, and waiting for a revision.

The article may have been published in response to NHS England’s 2019 report on limiting surgical intervention for Pectus Excavatum, which concluded that “there is not enough evidence to routinely commission the intervention”[2]. In most patients, surgery does primarily have a cosmetic benefit although some argue that there can also be a functional benefit, including better cardiac function and stamina[3]. However, the flipside is that some think that the alleviation in symptoms is because their confidence improves, and they become more active.

A concern for the NHS is the high rate of surgical failure. In one retrospective review of all their surgical patients (39) between 2009 and 2014, a Trust found that 31% were identified as having the system “fail before removal”[4]. This means that the bars either broke or became loose before they could improve the patients’ deformity and had to be removed. NHS England’s report found a slightly lower instance of failure for surgical implants (21%) and c.5% for minimally invasive procedures[5].

Where the system does fail, patients often succumb to chronic pain. The surgery itself therefore presents a risk of claims for the NHS, which may be liable for failure of the implants, either through s.2(3) of the Consumer Protection Act 1987[6]; because the patient was not properly warned of the risk of failure; or because it isn’t clear whether their injury resulted from system failure or negligent implantation.

Case Law

There have been no judgments concerning surgical intervention for Pectus Excavatum, but several cases have been settled out of court[7]. Of the settlements we have seen reported in the UK:

Injuries

The injuries alleged are the same: patients are left suffering from psychiatric injury, chronic pain and requiring revision procedures due to the surgery failing.

Allegations

The allegations often fall into two themes:

1. Failure to appropriately consent for the procedure, including providing full information on the alternatives, likely benefits, risks and postoperative pain; and/or
2. Negligently performing the surgery, including using bars that were known to break or fail.

Since February 2019, the NHS has significantly limited the use of surgical intervention for Pectus Excavatum and NHS Guidance is now that surgery should only be performed where there is a clear physiological need, although with the associated risks this need needs to be very carefully investigated and evidenced.  For example, doctors must ensure that patients are fully informed of all the material risks associated with the surgery, as well as the alternative options and likely benefits. Clinicians should clearly document what was discussed and follow up with a clinic letter reiterating what patients can expect from the procedure.  Patients with Pectus Excavatum are often paediatric, and many suffer from psychological problems relating to low self-esteem and body image[8]. It is therefore also important to ensure expectations are carefully managed and parents or carers are involved. To achieve this, a multi-disciplinary approach may be helpful with input from psychologists and social workers.

If surgery proceeds, to try and ensure evidence of appropriate bar insertion, detailed operation notes and imaging can assist. Furthermore, where patients do suffer a surgical failure (i.e. where the bar breaks or moves), it can be tricky to identify. Clinicians expect patients to experience a significant level of postoperative pain but again, where reported pain seems unusually intense, imaging should quickly be arranged to identify the cause and clear documentation and follow up provided.

[1] See Gilbody-Dickerson (2020) Sunken chest syndrome: ‘I’m being strangled inside’ https://www.bbc.co.uk/news/uk-england-devon-50551265

[2] NHS England (2019) Clinical Commissioning Policy: Surgery for Pectus Deformity, 170113P

[3] See Maagard M et al. (2016) Improved cardiac function and exercise capacity following correction of pectus excavatum: a review of current literature, The Annals of Cardiothoracic Surgery; 5(5): 485-492

[4] Muthialu N, McIntyre D, McIntosh N, Plumridge J, Elliott MJ (2019) Disturbingly high fracture rate of STRATOS bars in pectus corrections, European Journal of Cardiothoracic Surgery; 55(2): 300-303

[5] NHS England (2019) Clinical Commissioning Policy: Surgery for Pectus Deformity, 170113P: 13

[6] See https://www.russell-cooke.co.uk/settlementforpectusexcavatum/

[7] See X v Oxford University Hospital NHS Trust (2017)

[8] Steinmann C, Krille S, Mueller A, Weber P, Reingruber B, Martin A (2011) Pectus excavatum and pectus carinatum patients suffer from lower quality of life and impaired body image, European Journal of Cardiothoracic Surgery; 40(5): 1138-45