20 years clinical application of the vacuum bell for conservative treatment of pectus excavatum-past, present, future.

Background: For decades, open surgical repair was the only available method to treat pectus excavatum (PE). In 1998 Donald Nuss described first time a minimally invasive repair of pectus excavatum (MIRPE), and today MIRPE is performed with increasing frequency worldwide. However, despite its minimally invasive approach, with the widespread use of MIRPE the character and number of complications have increased. 20 years ago, non-surgical measures such as vacuum bell therapy (VBT) were introduced as a useful complement for specific treatment of PE patients. However, until today there are no existing validated guidelines concerning VBT. Methods: The study includes the results of an online survey submitted to the members of Chest Wall International Group (CWIG), a selective review of the English spoken current literature with focus on VBT and an analysis of our own previous studies concerning VBT. Results: Seventy-two percent of the CWIG members practicing in 47 different institutions confirmed to use VBT for PE patients. Furthermore, within the last 10 to 15 years an increasing number of studies were identified reporting on successful use of VBT for PE. However, a recently published study stated that the effect of VBT is predominantly because of thickening of the chest wall by increasing pre-sternal adipose tissue. There was one study comparing VBT to MIRPE but no randomized and/or prospective studies comparing conservative treatment Conclusions: Non-operative treatment of PE with VBT proved to be safe and a potential alternative to surgical repair in carefully selected PE patients. Patient's age at diagnosis and severity of the PE represents relevant variables to decide which kind of therapy might be successful to correct PE. Especially in PE patients under the age of 10 years, VBT seems to represent the first step of specific therapy.