Pediatric surgeon repairs 38-year-old's sunken chest
Dustin Lurvey is feeling pretty good for a guy with a steel bar inside him, pushing out his ribcage.
Before he had the bar surgically inserted a month ago, Lurvey lived 38 years with a dent in the middle of his chest that formed a funnel shape with the surrounding pectoral muscles. His sternum pressed against his inner organs, and when he exercised he struggled to breathe and could watch his heart beat through his skin.
Lurvey’s midsection is still tender from the surgery, and the bar will stay in for at least two years as his ribs, muscles and cartilage conform to their new shape. But his chest is now flat, and to Lurvey, that’s worth it.
“I’m doing better than I ever have,” he said.
The surgery is called the Nuss procedure, and it’s usually done on children and teenagers. If Lurvey’s continues to be a success, it will open up a new world of comfortable breathing and shirtless confidence for other adults like him.
It will also open up a new market for Corey Iqbal, the pediatric surgeon who performed it at the Overland Park Regional Medical Center.
Sunken chest, known medically as pectus excavatum, is a congenital condition that happens in about one of every 1,000 people. Mild cases are typically just cosmetic, but severe cases restrict the heart and lungs. That can lead to heart palpitations, chest pain, respiratory infections and difficulty exercising.
The Nuss procedure has gained favor since the 1990s because it’s less invasive than previous techniques. But it’s traditionally not done on adults because fully developed chests are less pliable. Pushing out an adult ribcage takes more force, and for years surgeons feared adult chests were more likely to sink back into their original form once the internal brace is removed.
That’s beginning to change. In 2014 a team of researchers from the University of Pennsylvania’s Perelman School of Medicine published a review of a long list of studies on pectus excavatum surgery. Their conclusion: While it’s easier to do the Nuss procedure on younger patients, the studies show it’s safe and effective on adults — at least in the short-term. Study on long-term effects was lacking.
But it’s still hard for adults to find a place that will do the surgery, especially in the middle of the country.
Truman Medical Centers surgeon James Stewart performs a modified version of an older surgery, the Ravitch procedure, that includes removing some cartilage and bracing the sternum with a metal strut. The Perelman School review found the Ravitch procedure had slightly lower complication rates in adults.
“Much better results in adults, but more involved,” Stewart said via email. “I am the only surgeon in the region that operates on adults for this.”
Iqbal said he’s aware of two hospitals that regularly perform the Nuss procedure on adults: Children’s Hospital of the King’s Daughters in Norfolk, Va., where Donald Nuss pioneered it, and the Mayo Clinic’s Arizona branch, where Dawn Jaroszewski is considered an expert in the field. It’s also available to adults at Columbia University in New York City.
Washington University in St. Louis says that although the Nuss procedure “can be successfully performed in the adult with excellent results,” it’s usually done on children. St. Luke’s in Kansas City, though nationally known for its cardiovascular department, doesn’t perform it on adults. A spokesman for the University of Kansas Health System said the system had one doctor, Emmanuel Daon, who did five of them last year.
Even at the hospital in Virginia, any patient older than 25 has to get special permission from the hospital administration before the surgery is scheduled.
But Iqbal, the director of pediatric and fetal surgery at Overland Park Regional, said the administrators there are fully on board and he’s ready to start offering the procedure to adults in Kansas City and beyond.
“There’s a lot of people living with this who don’t realize there are options,” said Iqbal, who estimated he could do up to 20 adult procedures a year, depending on demand. “Even better for this region, is now you don’t have to go to Scottsdale, you don’t have to go to Virginia, we can do it right here. We have the technical know-how, and we’ve got all of the adult specialists.”
Before this year, Lurvey, a father of two young boys who works at the Apple Store in Leawood, was among those who didn’t know surgery was an option. He had lived with the dent in his chest for as long as he could remember.
“When I was young, I was told, if it doesn’t grow out, tough luck, it’s a cosmetic issue,” Lurvey said. “There’s no heart complications, there’s nothing to worry about.”
Iqbal said that’s not unusual. Pectus excavatum was long viewed as a condition that caused emotional distress, but no physical problems.
“We’re finding out that’s not true,” Iqbal said.
Lurvey played several sports as a kid but couldn’t train hard without getting so winded he felt physically ill. He also noticed that his heart pressed up so closely against his chest that he could actually watch his skin pulsate with each beat.
“I was like, ‘That’s not normal,’ ” Lurvey said.
His childhood doctors diagnosed him with asthma and bronchitis and prescribed inhalers that had little effect. Lurvey eventually accepted that nothing would change.
But in January, Lurvey saw a new primary care doctor in Olathe for a regular checkup. The doctor pressed her index finger in the depression in his chest, all the way to the first knuckle. She started asking him whether he ever had trouble breathing, or chest pains, especially when exercising.
“I was answering yes to all of these questions,” Lurvey said.
The doctor performed a breathing test and found that Lurvey’s lung capacity was 20 percent less than the average male his age, even though he was active and otherwise seemed to be in good shape. She ordered a CT scan so she could measure the extent of Lurvey’s pectus excavatum using the Haller index, a ratio of the width of his chest compared to the distance between his spine and sternum.
A normal Haller index is about 2.5. Anything above 3.25 is considered a serious deformity. Lurvey’s Haller index was 5.8.
Lurvey’s doctor referred him to a cardiology team within the HCA Midwest Health system for possible reconstructive surgery. But they didn’t have experience correcting pectus excavatum. So they referred him to Iqbal.
When Iqbal saw Lurvey’s scans and his Haller index, the doctor knew immediately he would be a candidate for surgery.
“The highest I’ve ever seen is 7.4, but 5.8 is getting up there,” Iqbal said. “And you can really appreciate on that CT scan the amount of compression on the heart and lungs.”
Most insurance plans cover the Nuss procedure, which costs $40,000 to $60,000, if the patient’s Haller score is above 3.25 and there’s impairment of the heart and lungs.
Iqbal, who previously worked at Children’s Mercy Hospital, had done the Nuss procedure more than 50 times on kids. His experience with adults was limited to two special cases, a 31-year-old and a 25-year-old. Still, he was confident he could do it for Lurvey, in part because he’s now in an HCA Midwest Health medical system with nurses, surgical assistants and anesthesiologists who are experienced in adult procedures.
“In terms of what it takes for me as a surgeon to get the bar in place, the steps are the same, whether it’s a 16-year-old or a 38-year-old,” Iqbal said. “Where the anxiety came in in the previous adults I operated on was being in a freestanding children’s hospital. I worried that if this 31-year-old has a complication, who’s going to take care of that?”
Iqbal’s confidence was contagious. Lurvey, who had never had surgery before, said he knew Iqbal had little experience operating on adults but trusted him.
“I had no doubt whatsoever,” Lurvey said. “I was more nervous for being under” anesthesia.
Iqbal said he pulled together the surgical team in short order and once he got started, the surgery itself took less than an hour.
Lurvey said feeling the bar inside him is still bizarre, but he passed his two-week and one-month followup exams with no issues and he’s almost weaned off his post-surgical pain medicine.
In the wake of the successful surgery, Iqbal said the cardiologists he works with already have a couple other patients they plan to refer to him. Not everyone with a sunken chest will qualify, based on their Haller index, and not everyone who qualifies will want to do it. It’s a painful procedure, and in about 5 percent of all cases — adult and pediatric — the chest sinks in again once the bar is removed.
But Lurvey is regaining his range of motion and is looking forward to warmer weather. He’s always been self-conscious about going swimming, and he and a couple other dads with sunken chests who go to the community pool regularly have a sort of informal support group.
“I can’t wait to see those guys this summer at the pool and be like, ‘Look, I’ve got a normal chest; I’ve got pecs for the first time,” Lurvey said. “Jokingly, but seriously: My life’s completely changed.”