Chest Wall Deformities with Dr. Robert Kelly
With Dr. Robert Kelly · hosted by Dr. Todd Ponsky · StayCurrentMD
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
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.
Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.
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.
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.
In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.
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.
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.
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.
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.
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).
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.
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.
Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.
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.
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.
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.
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.
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.
Dr. Kelly's center has not used epidurals for pectus excavatum surgery for several years.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Most bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
There is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history.
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.
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.
In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent.
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.
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.