Robert Kelly

442 timestamped statements across 3 collections — auto-found in recorded discussions, each timestamp jumps to the exact moment.

Pectus Excavatum · guest expert Single Ventricle / HLHS · guest expert

Featured diaries

▶ Ep 11 · 4:04
A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
quote · Pectus Carinatum
▶ Ep 20 · 4:04
A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
quote · Pectus Excavatum
▶ Ep 30 · 4:04
A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
quote · Single Ventricle / HLHS
▶ Ep 30 · 4:04
A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
quote · Single Ventricle / HLHS
▶ Ep 11 · 40:04
Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum.
quote · Pectus Carinatum
▶ Ep 20 · 40:04
Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum.
quote · Pectus Excavatum

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Pectus Carinatum 126 entries

Chest Wall Deformities with Dr. Robert Kelly

▶ Ep 5 · 1:33
quote When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression. ↗
▶ Ep 5 · 1:33
clinical Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally not occurring at rest but with exertion. ↗
▶ Ep 5 · 2:55
clinical Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker. ↗
▶ Ep 5 · 3:44
quote It's probably uh. Productive to have the patient stand first. Uh, if you have a mirror in the room, have the patient, uh, watch himself in the mirror, uh, and ask the patient to take several deep respirations and watch the motion of the chest with respiration ↗
▶ Ep 5 · 4:04
clinical In a normal chest, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner). ↗
▶ Ep 5 · 4:19
quote The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner. ↗
▶ Ep 5 · 4:29
clinical In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath the xyphoid pulls back towards the spine. ↗
▶ Ep 5 · 6:05
epidemiological In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis. ↗
▶ Ep 5 · 6:36
clinical When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first. ↗
▶ Ep 5 · 8:39
epidemiological In the multi-center study of pectus excavatum at 11 centers, roughly 2/3 of patients had symptoms of easy fatigability, shortness of breath, or chest pain. ↗
▶ Ep 5 · 9:44
clinical The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine; an index greater than 3.25 indicates severe pectus excavatum. ↗
▶ Ep 5 · 10:09
clinical The Kansas City group recognized that in a patient with a barrel chest, the Haller index underestimates the depth of the depression because the AP diameter is increased, and they advocate an alternative index comparing the AP distance at the depression to the normal lateral chest. ↗
▶ Ep 5 · 12:53
epidemiological Mitral valve prolapse is present in about 14% of pectus excavatum patients, compared to about 1% in young patients generally. ↗
▶ Ep 5 · 13:37
epidemiological On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted). ↗
▶ Ep 5 · 14:15
clinical Patients with pectus excavatum came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored through surgery. ↗
▶ Ep 5 · 14:37
clinical Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is seen in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected. ↗
▶ Ep 5 · 15:05
clinical Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems. ↗
▶ Ep 5 · 15:11
guideline Surgical indications for pectus excavatum include at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests <80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, and major psychosocial issues related to body image. ↗
▶ Ep 5 · 16:47
clinical The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty (ages 11-13 for girls, a year or two older for boys). ↗
▶ Ep 5 · 17:02
clinical Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed. ↗
▶ Ep 5 · 17:29
clinical Some Asian groups, particularly in Korea (Dr. Park), operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results. ↗
▶ Ep 5 · 17:55
quote It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period. ↗
▶ Ep 5 · 18:32
quote The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people. ↗
▶ Ep 5 · 18:32
clinical The hard part of pain management is not to relieve the pain, but to relieve the pain without obliterating consciousness, which requires feedback from the patient. ↗
▶ Ep 5 · 19:13
quote We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it ↗
▶ Ep 5 · 20:03
clinical About half of pectus excavatum patients don't have their usual appetite after surgery, while about half eat very well. ↗
▶ Ep 5 · 20:46
guideline For the first month after pectus excavatum surgery, patients should only walk and do activities of daily life; beginning at 1 month they can liberalize physical activities; by 3-6 months they can do pretty much any activity except those where they know they'll get a blow to the chest. ↗
▶ Ep 5 · 21:09
quote I had a fellow who was a boxer who wanted to know if it was OK to go back to boxing. It's not OK to go back to boxing. We've just tried to make the chest very nice, and we don't want somebody pounding his fist into it. ↗
▶ Ep 5 · 21:40
clinical The Allergies test developed in Canada includes all components of the stainless steel bar, and patients have reacted against a number of minor components including nickel, chromium, and cobalt. ↗
▶ Ep 5 · 22:17
clinical Titanium bars must be bent at the factory and have to be ordered in advance; they are currently much more expensive than stainless steel bars. ↗
▶ Ep 5 · 22:45
clinical The likelihood of transfusion in Nuss procedure is exceedingly low. ↗
▶ Ep 5 · 23:29
clinical Measuring the bar length from mid-axillary line to mid-axillary line and subtracting an inch is one method that works very well. ↗
▶ Ep 5 · 24:43
guideline It should be standard practice in patients with any difficulty in visualization to use some technique of sternal elevation during Nuss procedure. ↗
▶ Ep 5 · 24:43
quote I think it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation. ↗
▶ Ep 5 · 26:02
quote The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it. ↗
▶ Ep 5 · 26:02
clinical The most important part of the Nuss procedure, whatever techniques are used, is that the surgeon sees the tip of the introducer at all times—not just knowing it's in there somewhere, but actually seeing it—to minimize the likelihood of injuring the heart. ↗
▶ Ep 5 · 28:54
clinical The bar must be positioned medial to the pectus ridge so there is a rib providing counterforce; if placed very laterally, only the intercostal muscles prevent movement and they will strip or rip under the load. ↗
▶ Ep 5 · 28:54
quote If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right. ↗
▶ Ep 5 · 30:07
clinical In patients who are growing, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so they are generally placed on only one side. ↗
▶ Ep 5 · 30:39
clinical If a patient is over approximately 6 feet 2 inches tall, the chances of needing two bars are almost 100%. ↗
▶ Ep 5 · 33:03
epidemiological In multiple series, short-term complications of the Nuss procedure are few and intervention has been infrequent. ↗
▶ Ep 5 · 33:14
epidemiological In a series of past 2000 Nuss procedures, about 2.7% of patients required some sort of revision for bar displacement. ↗
▶ Ep 5 · 33:28
clinical The incidence of bar displacement has been cut to about half (approximately 1.35%) by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures. ↗
▶ Ep 5 · 33:43
clinical Most bar displacement now occurs due to some kind of marked force or trauma rather than spontaneous displacement. ↗
▶ Ep 5 · 34:13
epidemiological Bar allergy occurred in a little less than 1% (0.9%) of patients; screening for metal allergy has been performed since 2004 and has dramatically decreased the incidence. ↗
▶ Ep 5 · 34:27
epidemiological About 6.4% of pectus excavatum patients had clinical or patch test evidence of metal allergy. ↗
▶ Ep 5 · 34:40
epidemiological Wound infection occurred in 2.3% of patients, with more than 2/3 being superficial or cellulitis. ↗
▶ Ep 5 · 35:07
epidemiological Recurrence after Nuss procedure occurred in about 1.2% of patients. ↗
▶ Ep 5 · 35:16
opinion Why recurrence happens after pectus excavatum surgery is still poorly understood; it can occur even when the bar is left in for 3 years. ↗
▶ Ep 5 · 36:39
guideline The bar should remain in place for at least 2 years before removal, with preference for closer to 3 years than 2 years. ↗
▶ Ep 5 · 37:19
epidemiological In a study from Saint Etienne, France published in Journal of Pediatric Surgery, vacuum bell treatment was effective in pretty much eliminating pectus excavatum in 23 of 73 patients. ↗
▶ Ep 5 · 37:58
clinical In patients who are young (under approximately 10 years old), the vacuum bell can be very effective in lifting the chest up. ↗
▶ Ep 5 · 39:06
clinical In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore movement of the chest wall, and patients will have some restrictive process from scarring. ↗
▶ Ep 5 · 40:04
epidemiological Brace therapy for pectus carinatum is successful somewhere between 2/3 and 3/4 of the time. ↗
▶ Ep 5 · 40:27
opinion Because any operation carries more morbidity than almost any brace, it's hard to say one shouldn't start with brace treatment for most patients with pectus carinatum. ↗
▶ Ep 5 · 40:46
quote I had a patient who was from the juvenile detention home. He had various behavioral problems, and he looked me in the eye and said, I'm not going to wear that thing. And I said, I believe you. ↗
▶ Ep 5 · 41:23
clinical Marcello Ferro's dynamic compression system brace solved two patient objections: it is comfortable (pressure can be adjusted) and it's concealable under even an opaque close-fitting t-shirt. ↗
▶ Ep 5 · 42:00
epidemiological The Ferro brace works approximately 3/4 of the time in Dr. Kelly's experience. ↗
▶ Ep 5 · 42:43
clinical Most patients with pectus carinatum do not have symptoms, but there is a small subset who complain of pain and exercise limitation who should be considered for operation. ↗
▶ Ep 5 · 43:13
clinical The reverse Nuss operation (Abramson procedure) works well in pectus carinatum patients with a flexible chest. ↗
▶ Ep 5 · 43:43
opinion There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch. ↗
▶ Ep 5 · 44:52
epidemiological There is a family tendency in pectus deformities in approximately 40% of patients, but the majority still don't have a family history. ↗

Chest Wall Deformities with Dr. Robert Kelly

▶ Ep 11 · 1:33
quote When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression. ↗
▶ Ep 11 · 1:33
clinical Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest. ↗
▶ Ep 11 · 2:55
clinical Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker. ↗
▶ Ep 11 · 4:04
quote A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner. ↗
▶ Ep 11 · 4:04
clinical In patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration. ↗
▶ Ep 11 · 4:29
quote What one will frequently see in Pex excavatum is that the depressed area of the chest is absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath and sucks in air, the xyphoid pulls back towards the spine. ↗
▶ Ep 11 · 4:29
clinical In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath. ↗
▶ Ep 11 · 6:15
quote In our series of patients, uh, at this point we've evaluated more than 4000 people for pectus excavatum, and just over 25% of them have had scoliosis. ↗
▶ Ep 11 · 6:15
epidemiological In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis. ↗
▶ Ep 11 · 6:36
clinical When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon. ↗
▶ Ep 11 · 8:39
epidemiological In the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain. ↗
▶ Ep 11 · 9:44
clinical The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus. ↗
▶ Ep 11 · 10:09
host_summary The Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant. ↗
▶ Ep 11 · 12:53
epidemiological Mitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population. ↗
▶ Ep 11 · 13:37
epidemiological On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted). ↗
▶ Ep 11 · 14:15
clinical In both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery. ↗
▶ Ep 11 · 14:37
clinical Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected. ↗
▶ Ep 11 · 15:05
clinical Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems. ↗
▶ Ep 11 · 15:11
guideline Dr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image. ↗
▶ Ep 11 · 15:35
clinical Around the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct. ↗
▶ Ep 11 · 16:47
clinical The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that. ↗
▶ Ep 11 · 17:02
clinical Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed. ↗
▶ Ep 11 · 17:29
host_summary Some Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results. ↗
▶ Ep 11 · 17:55
quote It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period. ↗
▶ Ep 11 · 18:32
quote The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people. ↗
▶ Ep 11 · 18:49
clinical Dr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback. ↗
▶ Ep 11 · 19:13
quote We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it. ↗
▶ Ep 11 · 19:39
clinical Dr. Kelly's center has not used epidurals for pectus excavatum surgery for several years. ↗
▶ Ep 11 · 19:47
clinical Postoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery. ↗
▶ Ep 11 · 20:46
clinical For the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest. ↗
▶ Ep 11 · 21:37
clinical The Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance. ↗
▶ Ep 11 · 22:17
opinion Titanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate. ↗
▶ Ep 11 · 24:43
guideline For Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other. ↗
▶ Ep 11 · 24:43
quote At this point it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation. ↗
▶ Ep 11 · 24:57
clinical Sternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify. ↗
▶ Ep 11 · 26:02
clinical The most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low. ↗
▶ Ep 11 · 26:02
quote The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it. ↗
▶ Ep 11 · 26:43
clinical To prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib. ↗
▶ Ep 11 · 27:32
clinical For Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus. ↗
▶ Ep 11 · 27:39
clinical In post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient. ↗
▶ Ep 11 · 28:54
clinical The bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load. ↗
▶ Ep 11 · 28:54
quote If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right. ↗
▶ Ep 11 · 30:07
quote In patients who are growing, the stabilizers, which will be encased by scar can cause a wasp waste effect if they're put on both sides. So we generally favor putting them on only one side of the bar. ↗
▶ Ep 11 · 30:07
clinical In growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar. ↗
▶ Ep 11 · 30:39
clinical Patients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation. ↗
▶ Ep 11 · 31:17
clinical The Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities. ↗
▶ Ep 11 · 32:02
clinical Postoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines. ↗
▶ Ep 11 · 33:03
host_summary In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent. ↗
▶ Ep 11 · 33:14
epidemiological In Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures. ↗
▶ Ep 11 · 33:43
clinical Most bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents. ↗
▶ Ep 11 · 34:13
epidemiological Bar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy. ↗
▶ Ep 11 · 34:40
epidemiological Wound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle. ↗
▶ Ep 11 · 35:07
epidemiological Recurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years. ↗
▶ Ep 11 · 36:33
clinical Dr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal. ↗
▶ Ep 11 · 37:19
host_summary The vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients. ↗
▶ Ep 11 · 37:49
clinical Dr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up. ↗
▶ Ep 11 · 39:06
clinical In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial. ↗
▶ Ep 11 · 40:04
quote Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum. ↗
▶ Ep 11 · 40:04
opinion Because brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients. ↗
▶ Ep 11 · 41:23
clinical Dr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands. ↗
▶ Ep 11 · 42:35
clinical Candidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing. ↗
▶ Ep 11 · 43:13
clinical The reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest. ↗
▶ Ep 11 · 43:43
host_summary There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch. ↗
▶ Ep 11 · 44:52
epidemiological There is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history. ↗
Pectus Excavatum 64 entries

Chest Wall Deformities with Dr. Robert Kelly

▶ Ep 20 · 1:33
quote When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression. ↗
▶ Ep 20 · 1:33
clinical Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest. ↗
▶ Ep 20 · 2:55
clinical Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker. ↗
▶ Ep 20 · 4:04
quote A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner. ↗
▶ Ep 20 · 4:04
clinical In patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration. ↗
▶ Ep 20 · 4:29
clinical In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath. ↗
▶ Ep 20 · 4:29
quote What one will frequently see in Pex excavatum is that the depressed area of the chest is absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath and sucks in air, the xyphoid pulls back towards the spine. ↗
▶ Ep 20 · 6:15
epidemiological In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis. ↗
▶ Ep 20 · 6:15
quote In our series of patients, uh, at this point we've evaluated more than 4000 people for pectus excavatum, and just over 25% of them have had scoliosis. ↗
▶ Ep 20 · 6:36
clinical When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon. ↗
▶ Ep 20 · 8:39
epidemiological In the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain. ↗
▶ Ep 20 · 9:44
clinical The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus. ↗
▶ Ep 20 · 10:09
clinical The Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant. ↗
▶ Ep 20 · 12:53
epidemiological Mitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population. ↗
▶ Ep 20 · 13:37
epidemiological On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted). ↗
▶ Ep 20 · 14:15
clinical In both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery. ↗
▶ Ep 20 · 14:37
clinical Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected. ↗
▶ Ep 20 · 15:05
clinical Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems. ↗
▶ Ep 20 · 15:11
guideline Dr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image. ↗
▶ Ep 20 · 15:35
clinical Around the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct. ↗
▶ Ep 20 · 16:47
clinical The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that. ↗
▶ Ep 20 · 17:02
clinical Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed. ↗
▶ Ep 20 · 17:29
clinical Some Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results. ↗
▶ Ep 20 · 17:55
quote It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period. ↗
▶ Ep 20 · 18:32
quote The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people. ↗
▶ Ep 20 · 18:49
clinical Dr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback. ↗
▶ Ep 20 · 19:13
quote We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it. ↗
▶ Ep 20 · 19:39
clinical Dr. Kelly's center has not used epidurals for pectus excavatum surgery for several years. ↗
▶ Ep 20 · 19:47
clinical Postoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery. ↗
▶ Ep 20 · 20:46
clinical For the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest. ↗
▶ Ep 20 · 21:37
clinical The Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance. ↗
▶ Ep 20 · 22:17
opinion Titanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate. ↗
▶ Ep 20 · 24:43
guideline For Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other. ↗
▶ Ep 20 · 24:43
quote At this point it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation. ↗
▶ Ep 20 · 24:57
clinical Sternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify. ↗
▶ Ep 20 · 26:02
clinical The most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low. ↗
▶ Ep 20 · 26:02
quote The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it. ↗
▶ Ep 20 · 26:43
clinical To prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib. ↗
▶ Ep 20 · 27:32
clinical For Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus. ↗
▶ Ep 20 · 27:39
clinical In post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient. ↗
▶ Ep 20 · 28:54
quote If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right. ↗
▶ Ep 20 · 28:54
clinical The bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load. ↗
▶ Ep 20 · 30:07
quote In patients who are growing, the stabilizers, which will be encased by scar can cause a wasp waste effect if they're put on both sides. So we generally favor putting them on only one side of the bar. ↗
▶ Ep 20 · 30:07
clinical In growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar. ↗
▶ Ep 20 · 30:39
clinical Patients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation. ↗
▶ Ep 20 · 31:17
clinical The Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities. ↗
▶ Ep 20 · 32:02
clinical Postoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines. ↗
▶ Ep 20 · 33:03
epidemiological In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent. ↗
▶ Ep 20 · 33:14
epidemiological In Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures. ↗
▶ Ep 20 · 33:43
clinical Most bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents. ↗
▶ Ep 20 · 34:13
epidemiological Bar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy. ↗
▶ Ep 20 · 34:40
epidemiological Wound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle. ↗
▶ Ep 20 · 35:07
epidemiological Recurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years. ↗
▶ Ep 20 · 36:33
clinical Dr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal. ↗
▶ Ep 20 · 37:19
clinical The vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients. ↗
▶ Ep 20 · 37:49
clinical Dr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up. ↗
▶ Ep 20 · 39:06
clinical In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial. ↗
▶ Ep 20 · 40:04
quote Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum. ↗
▶ Ep 20 · 40:04
opinion Because brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients. ↗
▶ Ep 20 · 41:23
clinical Dr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands. ↗
▶ Ep 20 · 42:35
clinical Candidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing. ↗
▶ Ep 20 · 43:13
clinical The reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest. ↗
▶ Ep 20 · 43:43
opinion There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch. ↗
▶ Ep 20 · 44:52
epidemiological There is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history. ↗
Single Ventricle / HLHS 252 entries

Chest Wall Deformities with Dr. Robert Kelly

▶ Ep 17 · 1:33
clinical Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally not occurring at rest but with exertion. ↗
▶ Ep 17 · 1:33
quote When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression. ↗
▶ Ep 17 · 1:33
clinical Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally not occurring at rest but with exertion. ↗
▶ Ep 17 · 1:33
quote When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression. ↗
▶ Ep 17 · 2:55
clinical Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker. ↗
▶ Ep 17 · 2:55
clinical Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker. ↗
▶ Ep 17 · 3:44
quote It's probably uh. Productive to have the patient stand first. Uh, if you have a mirror in the room, have the patient, uh, watch himself in the mirror, uh, and ask the patient to take several deep respirations and watch the motion of the chest with respiration ↗
▶ Ep 17 · 3:44
quote It's probably uh. Productive to have the patient stand first. Uh, if you have a mirror in the room, have the patient, uh, watch himself in the mirror, uh, and ask the patient to take several deep respirations and watch the motion of the chest with respiration ↗
▶ Ep 17 · 4:04
clinical In a normal chest, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner). ↗
▶ Ep 17 · 4:04
clinical In a normal chest, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner). ↗
▶ Ep 17 · 4:19
quote The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner. ↗
▶ Ep 17 · 4:19
quote The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner. ↗
▶ Ep 17 · 4:29
clinical In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath the xyphoid pulls back towards the spine. ↗
▶ Ep 17 · 4:29
clinical In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath the xyphoid pulls back towards the spine. ↗
▶ Ep 17 · 6:05
epidemiological In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis. ↗
▶ Ep 17 · 6:05
epidemiological In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis. ↗
▶ Ep 17 · 6:36
clinical When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first. ↗
▶ Ep 17 · 6:36
clinical When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first. ↗
▶ Ep 17 · 8:39
epidemiological In the multi-center study of pectus excavatum at 11 centers, roughly 2/3 of patients had symptoms of easy fatigability, shortness of breath, or chest pain. ↗
▶ Ep 17 · 8:39
epidemiological In the multi-center study of pectus excavatum at 11 centers, roughly 2/3 of patients had symptoms of easy fatigability, shortness of breath, or chest pain. ↗
▶ Ep 17 · 9:44
clinical The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine; an index greater than 3.25 indicates severe pectus excavatum. ↗
▶ Ep 17 · 9:44
clinical The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine; an index greater than 3.25 indicates severe pectus excavatum. ↗
▶ Ep 17 · 10:09
clinical The Kansas City group recognized that in a patient with a barrel chest, the Haller index underestimates the depth of the depression because the AP diameter is increased, and they advocate an alternative index comparing the AP distance at the depression to the normal lateral chest. ↗
▶ Ep 17 · 10:09
clinical The Kansas City group recognized that in a patient with a barrel chest, the Haller index underestimates the depth of the depression because the AP diameter is increased, and they advocate an alternative index comparing the AP distance at the depression to the normal lateral chest. ↗
▶ Ep 17 · 12:53
epidemiological Mitral valve prolapse is present in about 14% of pectus excavatum patients, compared to about 1% in young patients generally. ↗
▶ Ep 17 · 12:53
epidemiological Mitral valve prolapse is present in about 14% of pectus excavatum patients, compared to about 1% in young patients generally. ↗
▶ Ep 17 · 13:37
epidemiological On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted). ↗
▶ Ep 17 · 13:37
epidemiological On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted). ↗
▶ Ep 17 · 14:15
clinical Patients with pectus excavatum came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored through surgery. ↗
▶ Ep 17 · 14:15
clinical Patients with pectus excavatum came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored through surgery. ↗
▶ Ep 17 · 14:37
clinical Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is seen in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected. ↗
▶ Ep 17 · 14:37
clinical Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is seen in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected. ↗
▶ Ep 17 · 15:05
clinical Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems. ↗
▶ Ep 17 · 15:05
clinical Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems. ↗
▶ Ep 17 · 15:11
guideline Surgical indications for pectus excavatum include at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests <80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, and major psychosocial issues related to body image. ↗
▶ Ep 17 · 15:11
guideline Surgical indications for pectus excavatum include at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests <80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, and major psychosocial issues related to body image. ↗
▶ Ep 17 · 16:47
clinical The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty (ages 11-13 for girls, a year or two older for boys). ↗
▶ Ep 17 · 16:47
clinical The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty (ages 11-13 for girls, a year or two older for boys). ↗
▶ Ep 17 · 17:02
clinical Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed. ↗
▶ Ep 17 · 17:02
clinical Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed. ↗
▶ Ep 17 · 17:29
clinical Some Asian groups, particularly in Korea (Dr. Park), operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results. ↗
▶ Ep 17 · 17:29
clinical Some Asian groups, particularly in Korea (Dr. Park), operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results. ↗
▶ Ep 17 · 17:55
quote It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period. ↗
▶ Ep 17 · 17:55
quote It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period. ↗
▶ Ep 17 · 18:32
quote The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people. ↗
▶ Ep 17 · 18:32
quote The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people. ↗
▶ Ep 17 · 18:32
clinical The hard part of pain management is not to relieve the pain, but to relieve the pain without obliterating consciousness, which requires feedback from the patient. ↗
▶ Ep 17 · 18:32
clinical The hard part of pain management is not to relieve the pain, but to relieve the pain without obliterating consciousness, which requires feedback from the patient. ↗
▶ Ep 17 · 19:13
quote We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it ↗
▶ Ep 17 · 19:13
quote We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it ↗
▶ Ep 17 · 20:03
clinical About half of pectus excavatum patients don't have their usual appetite after surgery, while about half eat very well. ↗
▶ Ep 17 · 20:03
clinical About half of pectus excavatum patients don't have their usual appetite after surgery, while about half eat very well. ↗
▶ Ep 17 · 20:46
guideline For the first month after pectus excavatum surgery, patients should only walk and do activities of daily life; beginning at 1 month they can liberalize physical activities; by 3-6 months they can do pretty much any activity except those where they know they'll get a blow to the chest. ↗
▶ Ep 17 · 20:46
guideline For the first month after pectus excavatum surgery, patients should only walk and do activities of daily life; beginning at 1 month they can liberalize physical activities; by 3-6 months they can do pretty much any activity except those where they know they'll get a blow to the chest. ↗
▶ Ep 17 · 21:09
quote I had a fellow who was a boxer who wanted to know if it was OK to go back to boxing. It's not OK to go back to boxing. We've just tried to make the chest very nice, and we don't want somebody pounding his fist into it. ↗
▶ Ep 17 · 21:09
quote I had a fellow who was a boxer who wanted to know if it was OK to go back to boxing. It's not OK to go back to boxing. We've just tried to make the chest very nice, and we don't want somebody pounding his fist into it. ↗
▶ Ep 17 · 21:40
clinical The Allergies test developed in Canada includes all components of the stainless steel bar, and patients have reacted against a number of minor components including nickel, chromium, and cobalt. ↗
▶ Ep 17 · 21:40
clinical The Allergies test developed in Canada includes all components of the stainless steel bar, and patients have reacted against a number of minor components including nickel, chromium, and cobalt. ↗
▶ Ep 17 · 22:17
clinical Titanium bars must be bent at the factory and have to be ordered in advance; they are currently much more expensive than stainless steel bars. ↗
▶ Ep 17 · 22:17
clinical Titanium bars must be bent at the factory and have to be ordered in advance; they are currently much more expensive than stainless steel bars. ↗
▶ Ep 17 · 22:45
clinical The likelihood of transfusion in Nuss procedure is exceedingly low. ↗
▶ Ep 17 · 22:45
clinical The likelihood of transfusion in Nuss procedure is exceedingly low. ↗
▶ Ep 17 · 23:29
clinical Measuring the bar length from mid-axillary line to mid-axillary line and subtracting an inch is one method that works very well. ↗
▶ Ep 17 · 23:29
clinical Measuring the bar length from mid-axillary line to mid-axillary line and subtracting an inch is one method that works very well. ↗
▶ Ep 17 · 24:43
quote I think it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation. ↗
▶ Ep 17 · 24:43
guideline It should be standard practice in patients with any difficulty in visualization to use some technique of sternal elevation during Nuss procedure. ↗
▶ Ep 17 · 24:43
quote I think it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation. ↗
▶ Ep 17 · 24:43
guideline It should be standard practice in patients with any difficulty in visualization to use some technique of sternal elevation during Nuss procedure. ↗
▶ Ep 17 · 26:02
quote The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it. ↗
▶ Ep 17 · 26:02
clinical The most important part of the Nuss procedure, whatever techniques are used, is that the surgeon sees the tip of the introducer at all times—not just knowing it's in there somewhere, but actually seeing it—to minimize the likelihood of injuring the heart. ↗
▶ Ep 17 · 26:02
quote The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it. ↗
▶ Ep 17 · 26:02
clinical The most important part of the Nuss procedure, whatever techniques are used, is that the surgeon sees the tip of the introducer at all times—not just knowing it's in there somewhere, but actually seeing it—to minimize the likelihood of injuring the heart. ↗
▶ Ep 17 · 28:54
clinical The bar must be positioned medial to the pectus ridge so there is a rib providing counterforce; if placed very laterally, only the intercostal muscles prevent movement and they will strip or rip under the load. ↗
▶ Ep 17 · 28:54
quote If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right. ↗
▶ Ep 17 · 28:54
clinical The bar must be positioned medial to the pectus ridge so there is a rib providing counterforce; if placed very laterally, only the intercostal muscles prevent movement and they will strip or rip under the load. ↗
▶ Ep 17 · 28:54
quote If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right. ↗
▶ Ep 17 · 30:07
clinical In patients who are growing, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so they are generally placed on only one side. ↗
▶ Ep 17 · 30:07
clinical In patients who are growing, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so they are generally placed on only one side. ↗
▶ Ep 17 · 30:39
clinical If a patient is over approximately 6 feet 2 inches tall, the chances of needing two bars are almost 100%. ↗
▶ Ep 17 · 30:39
clinical If a patient is over approximately 6 feet 2 inches tall, the chances of needing two bars are almost 100%. ↗
▶ Ep 17 · 33:03
epidemiological In multiple series, short-term complications of the Nuss procedure are few and intervention has been infrequent. ↗
▶ Ep 17 · 33:03
epidemiological In multiple series, short-term complications of the Nuss procedure are few and intervention has been infrequent. ↗
▶ Ep 17 · 33:14
epidemiological In a series of past 2000 Nuss procedures, about 2.7% of patients required some sort of revision for bar displacement. ↗
▶ Ep 17 · 33:14
epidemiological In a series of past 2000 Nuss procedures, about 2.7% of patients required some sort of revision for bar displacement. ↗
▶ Ep 17 · 33:28
clinical The incidence of bar displacement has been cut to about half (approximately 1.35%) by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures. ↗
▶ Ep 17 · 33:28
clinical The incidence of bar displacement has been cut to about half (approximately 1.35%) by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures. ↗
▶ Ep 17 · 33:43
clinical Most bar displacement now occurs due to some kind of marked force or trauma rather than spontaneous displacement. ↗
▶ Ep 17 · 33:43
clinical Most bar displacement now occurs due to some kind of marked force or trauma rather than spontaneous displacement. ↗
▶ Ep 17 · 34:13
epidemiological Bar allergy occurred in a little less than 1% (0.9%) of patients; screening for metal allergy has been performed since 2004 and has dramatically decreased the incidence. ↗
▶ Ep 17 · 34:13
epidemiological Bar allergy occurred in a little less than 1% (0.9%) of patients; screening for metal allergy has been performed since 2004 and has dramatically decreased the incidence. ↗
▶ Ep 17 · 34:27
epidemiological About 6.4% of pectus excavatum patients had clinical or patch test evidence of metal allergy. ↗
▶ Ep 17 · 34:27
epidemiological About 6.4% of pectus excavatum patients had clinical or patch test evidence of metal allergy. ↗
▶ Ep 17 · 34:40
epidemiological Wound infection occurred in 2.3% of patients, with more than 2/3 being superficial or cellulitis. ↗
▶ Ep 17 · 34:40
epidemiological Wound infection occurred in 2.3% of patients, with more than 2/3 being superficial or cellulitis. ↗
▶ Ep 17 · 35:07
epidemiological Recurrence after Nuss procedure occurred in about 1.2% of patients. ↗
▶ Ep 17 · 35:07
epidemiological Recurrence after Nuss procedure occurred in about 1.2% of patients. ↗
▶ Ep 17 · 35:16
opinion Why recurrence happens after pectus excavatum surgery is still poorly understood; it can occur even when the bar is left in for 3 years. ↗
▶ Ep 17 · 35:16
opinion Why recurrence happens after pectus excavatum surgery is still poorly understood; it can occur even when the bar is left in for 3 years. ↗
▶ Ep 17 · 36:39
guideline The bar should remain in place for at least 2 years before removal, with preference for closer to 3 years than 2 years. ↗
▶ Ep 17 · 36:39
guideline The bar should remain in place for at least 2 years before removal, with preference for closer to 3 years than 2 years. ↗
▶ Ep 17 · 37:19
epidemiological In a study from Saint Etienne, France published in Journal of Pediatric Surgery, vacuum bell treatment was effective in pretty much eliminating pectus excavatum in 23 of 73 patients. ↗
▶ Ep 17 · 37:19
epidemiological In a study from Saint Etienne, France published in Journal of Pediatric Surgery, vacuum bell treatment was effective in pretty much eliminating pectus excavatum in 23 of 73 patients. ↗
▶ Ep 17 · 37:58
clinical In patients who are young (under approximately 10 years old), the vacuum bell can be very effective in lifting the chest up. ↗
▶ Ep 17 · 37:58
clinical In patients who are young (under approximately 10 years old), the vacuum bell can be very effective in lifting the chest up. ↗
▶ Ep 17 · 39:06
clinical In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore movement of the chest wall, and patients will have some restrictive process from scarring. ↗
▶ Ep 17 · 39:06
clinical In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore movement of the chest wall, and patients will have some restrictive process from scarring. ↗
▶ Ep 17 · 40:04
epidemiological Brace therapy for pectus carinatum is successful somewhere between 2/3 and 3/4 of the time. ↗
▶ Ep 17 · 40:04
epidemiological Brace therapy for pectus carinatum is successful somewhere between 2/3 and 3/4 of the time. ↗
▶ Ep 17 · 40:27
opinion Because any operation carries more morbidity than almost any brace, it's hard to say one shouldn't start with brace treatment for most patients with pectus carinatum. ↗
▶ Ep 17 · 40:27
opinion Because any operation carries more morbidity than almost any brace, it's hard to say one shouldn't start with brace treatment for most patients with pectus carinatum. ↗
▶ Ep 17 · 40:46
quote I had a patient who was from the juvenile detention home. He had various behavioral problems, and he looked me in the eye and said, I'm not going to wear that thing. And I said, I believe you. ↗
▶ Ep 17 · 40:46
quote I had a patient who was from the juvenile detention home. He had various behavioral problems, and he looked me in the eye and said, I'm not going to wear that thing. And I said, I believe you. ↗
▶ Ep 17 · 41:23
clinical Marcello Ferro's dynamic compression system brace solved two patient objections: it is comfortable (pressure can be adjusted) and it's concealable under even an opaque close-fitting t-shirt. ↗
▶ Ep 17 · 41:23
clinical Marcello Ferro's dynamic compression system brace solved two patient objections: it is comfortable (pressure can be adjusted) and it's concealable under even an opaque close-fitting t-shirt. ↗
▶ Ep 17 · 42:00
epidemiological The Ferro brace works approximately 3/4 of the time in Dr. Kelly's experience. ↗
▶ Ep 17 · 42:00
epidemiological The Ferro brace works approximately 3/4 of the time in Dr. Kelly's experience. ↗
▶ Ep 17 · 42:43
clinical Most patients with pectus carinatum do not have symptoms, but there is a small subset who complain of pain and exercise limitation who should be considered for operation. ↗
▶ Ep 17 · 42:43
clinical Most patients with pectus carinatum do not have symptoms, but there is a small subset who complain of pain and exercise limitation who should be considered for operation. ↗
▶ Ep 17 · 43:13
clinical The reverse Nuss operation (Abramson procedure) works well in pectus carinatum patients with a flexible chest. ↗
▶ Ep 17 · 43:13
clinical The reverse Nuss operation (Abramson procedure) works well in pectus carinatum patients with a flexible chest. ↗
▶ Ep 17 · 43:43
opinion There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch. ↗
▶ Ep 17 · 43:43
opinion There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch. ↗
▶ Ep 17 · 44:52
epidemiological There is a family tendency in pectus deformities in approximately 40% of patients, but the majority still don't have a family history. ↗
▶ Ep 17 · 44:52
epidemiological There is a family tendency in pectus deformities in approximately 40% of patients, but the majority still don't have a family history. ↗

Chest Wall Deformities with Dr. Robert Kelly

▶ Ep 30 · 1:33
clinical Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest. ↗
▶ Ep 30 · 1:33
quote When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression. ↗
▶ Ep 30 · 1:33
quote When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression. ↗
▶ Ep 30 · 1:33
clinical Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest. ↗
▶ Ep 30 · 2:55
clinical Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker. ↗
▶ Ep 30 · 2:55
clinical Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker. ↗
▶ Ep 30 · 4:04
quote A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner. ↗
▶ Ep 30 · 4:04
quote A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner. ↗
▶ Ep 30 · 4:04
clinical In patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration. ↗
▶ Ep 30 · 4:04
clinical In patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration. ↗
▶ Ep 30 · 4:29
clinical In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath. ↗
▶ Ep 30 · 4:29
quote What one will frequently see in Pex excavatum is that the depressed area of the chest is absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath and sucks in air, the xyphoid pulls back towards the spine. ↗
▶ Ep 30 · 4:29
clinical In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath. ↗
▶ Ep 30 · 4:29
quote What one will frequently see in Pex excavatum is that the depressed area of the chest is absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath and sucks in air, the xyphoid pulls back towards the spine. ↗
▶ Ep 30 · 6:15
quote In our series of patients, uh, at this point we've evaluated more than 4000 people for pectus excavatum, and just over 25% of them have had scoliosis. ↗
▶ Ep 30 · 6:15
quote In our series of patients, uh, at this point we've evaluated more than 4000 people for pectus excavatum, and just over 25% of them have had scoliosis. ↗
▶ Ep 30 · 6:15
epidemiological In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis. ↗
▶ Ep 30 · 6:15
epidemiological In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis. ↗
▶ Ep 30 · 6:36
clinical When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon. ↗
▶ Ep 30 · 6:36
clinical When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon. ↗
▶ Ep 30 · 8:39
epidemiological In the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain. ↗
▶ Ep 30 · 8:39
epidemiological In the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain. ↗
▶ Ep 30 · 9:44
clinical The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus. ↗
▶ Ep 30 · 9:44
clinical The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus. ↗
▶ Ep 30 · 10:09
clinical The Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant. ↗
▶ Ep 30 · 10:09
host_summary The Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant. ↗
▶ Ep 30 · 12:53
epidemiological Mitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population. ↗
▶ Ep 30 · 12:53
epidemiological Mitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population. ↗
▶ Ep 30 · 13:37
epidemiological On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted). ↗
▶ Ep 30 · 13:37
epidemiological On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted). ↗
▶ Ep 30 · 14:15
clinical In both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery. ↗
▶ Ep 30 · 14:15
clinical In both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery. ↗
▶ Ep 30 · 14:37
clinical Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected. ↗
▶ Ep 30 · 14:37
clinical Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected. ↗
▶ Ep 30 · 15:05
clinical Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems. ↗
▶ Ep 30 · 15:05
clinical Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems. ↗
▶ Ep 30 · 15:11
guideline Dr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image. ↗
▶ Ep 30 · 15:11
guideline Dr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image. ↗
▶ Ep 30 · 15:35
clinical Around the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct. ↗
▶ Ep 30 · 15:35
clinical Around the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct. ↗
▶ Ep 30 · 16:47
clinical The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that. ↗
▶ Ep 30 · 16:47
clinical The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that. ↗
▶ Ep 30 · 17:02
clinical Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed. ↗
▶ Ep 30 · 17:02
clinical Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed. ↗
▶ Ep 30 · 17:29
clinical Some Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results. ↗
▶ Ep 30 · 17:29
host_summary Some Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results. ↗
▶ Ep 30 · 17:55
quote It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period. ↗
▶ Ep 30 · 17:55
quote It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period. ↗
▶ Ep 30 · 18:32
quote The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people. ↗
▶ Ep 30 · 18:32
quote The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people. ↗
▶ Ep 30 · 18:49
clinical Dr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback. ↗
▶ Ep 30 · 18:49
clinical Dr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback. ↗
▶ Ep 30 · 19:13
quote We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it. ↗
▶ Ep 30 · 19:13
quote We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it. ↗
▶ Ep 30 · 19:39
clinical Dr. Kelly's center has not used epidurals for pectus excavatum surgery for several years. ↗
▶ Ep 30 · 19:39
clinical Dr. Kelly's center has not used epidurals for pectus excavatum surgery for several years. ↗
▶ Ep 30 · 19:47
clinical Postoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery. ↗
▶ Ep 30 · 19:47
clinical Postoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery. ↗
▶ Ep 30 · 20:46
clinical For the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest. ↗
▶ Ep 30 · 20:46
clinical For the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest. ↗
▶ Ep 30 · 21:37
clinical The Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance. ↗
▶ Ep 30 · 21:37
clinical The Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance. ↗
▶ Ep 30 · 22:17
opinion Titanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate. ↗
▶ Ep 30 · 22:17
opinion Titanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate. ↗
▶ Ep 30 · 24:43
guideline For Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other. ↗
▶ Ep 30 · 24:43
guideline For Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other. ↗
▶ Ep 30 · 24:43
quote At this point it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation. ↗
▶ Ep 30 · 24:43
quote At this point it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation. ↗
▶ Ep 30 · 24:57
clinical Sternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify. ↗
▶ Ep 30 · 24:57
clinical Sternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify. ↗
▶ Ep 30 · 26:02
quote The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it. ↗
▶ Ep 30 · 26:02
clinical The most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low. ↗
▶ Ep 30 · 26:02
clinical The most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low. ↗
▶ Ep 30 · 26:02
quote The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it. ↗
▶ Ep 30 · 26:43
clinical To prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib. ↗
▶ Ep 30 · 26:43
clinical To prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib. ↗
▶ Ep 30 · 27:32
clinical For Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus. ↗
▶ Ep 30 · 27:32
clinical For Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus. ↗
▶ Ep 30 · 27:39
clinical In post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient. ↗
▶ Ep 30 · 27:39
clinical In post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient. ↗
▶ Ep 30 · 28:54
clinical The bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load. ↗
▶ Ep 30 · 28:54
quote If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right. ↗
▶ Ep 30 · 28:54
clinical The bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load. ↗
▶ Ep 30 · 28:54
quote If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right. ↗
▶ Ep 30 · 30:07
quote In patients who are growing, the stabilizers, which will be encased by scar can cause a wasp waste effect if they're put on both sides. So we generally favor putting them on only one side of the bar. ↗
▶ Ep 30 · 30:07
clinical In growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar. ↗
▶ Ep 30 · 30:07
quote In patients who are growing, the stabilizers, which will be encased by scar can cause a wasp waste effect if they're put on both sides. So we generally favor putting them on only one side of the bar. ↗
▶ Ep 30 · 30:07
clinical In growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar. ↗
▶ Ep 30 · 30:39
clinical Patients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation. ↗
▶ Ep 30 · 30:39
clinical Patients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation. ↗
▶ Ep 30 · 31:17
clinical The Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities. ↗
▶ Ep 30 · 31:17
clinical The Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities. ↗
▶ Ep 30 · 32:02
clinical Postoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines. ↗
▶ Ep 30 · 32:02
clinical Postoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines. ↗
▶ Ep 30 · 33:03
host_summary In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent. ↗
▶ Ep 30 · 33:03
epidemiological In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent. ↗
▶ Ep 30 · 33:14
epidemiological In Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures. ↗
▶ Ep 30 · 33:14
epidemiological In Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures. ↗
▶ Ep 30 · 33:43
clinical Most bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents. ↗
▶ Ep 30 · 33:43
clinical Most bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents. ↗
▶ Ep 30 · 34:13
epidemiological Bar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy. ↗
▶ Ep 30 · 34:13
epidemiological Bar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy. ↗
▶ Ep 30 · 34:40
epidemiological Wound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle. ↗
▶ Ep 30 · 34:40
epidemiological Wound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle. ↗
▶ Ep 30 · 35:07
epidemiological Recurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years. ↗
▶ Ep 30 · 35:07
epidemiological Recurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years. ↗
▶ Ep 30 · 36:33
clinical Dr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal. ↗
▶ Ep 30 · 36:33
clinical Dr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal. ↗
▶ Ep 30 · 37:19
clinical The vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients. ↗
▶ Ep 30 · 37:19
host_summary The vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients. ↗
▶ Ep 30 · 37:49
clinical Dr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up. ↗
▶ Ep 30 · 37:49
clinical Dr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up. ↗
▶ Ep 30 · 39:06
clinical In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial. ↗
▶ Ep 30 · 39:06
clinical In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial. ↗
▶ Ep 30 · 40:04
opinion Because brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients. ↗
▶ Ep 30 · 40:04
opinion Because brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients. ↗
▶ Ep 30 · 40:04
quote Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum. ↗
▶ Ep 30 · 40:04
quote Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum. ↗
▶ Ep 30 · 41:23
clinical Dr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands. ↗
▶ Ep 30 · 41:23
clinical Dr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands. ↗
▶ Ep 30 · 42:35
clinical Candidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing. ↗
▶ Ep 30 · 42:35
clinical Candidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing. ↗
▶ Ep 30 · 43:13
clinical The reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest. ↗
▶ Ep 30 · 43:13
clinical The reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest. ↗
▶ Ep 30 · 43:43
host_summary There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch. ↗
▶ Ep 30 · 43:43
opinion There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch. ↗
▶ Ep 30 · 44:52
epidemiological There is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history. ↗
▶ Ep 30 · 44:52
epidemiological There is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history. ↗